HomeMy Public PortalAbout5246 SERENO DR_Electrical__ WORK COMPENSATION DECLARATION 18 (12 9+)
.I hereby el/Inco that
I havehave a certificate of consent to Bell Incurs 78A663APPLICATION FOR ELECTRICAL PERMIT
or a certificate o+Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C) (\�f
Pal 0127 -9 2 Cempgny✓���� VIAL/ FOR APPLICAIR TO FiLL IN JOBooREse5A ,416
IN Certified copy a hereby furnished New Residential Bi 8 NO EACH FEE A00i
❑ Cemlletl copy ar filed with this cou boWi n 1 8 2 Easily Sq Ft
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depart Multi family Sq Ft NEAREST
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CERTIFICATE OF EXEMPTION FROM WORKERS ,
COMPENSATION INSURANCE Outlets qacLight_Sw FIRM URE 10-c- ( J t
(This section need not be completed If the work Involved by the Addi o CRESS A
permit Is for one hundred dollars(5100)or lees) Total No Aust 20 l r �C,
I certify that in the performance of the work for which this permit CITY (e Ns Ei IJ
Is issued I shall not employ any person In any manner so as to PLAN DIEM
become subject to the Workers Compensation Laws Lighting Fixtures Rmf 20 APPLIGNT
Tote]No Adtlttwnal
ADDRESS
Dole ApplesRESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITU Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such AaPLiCANr O cot..
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances
LICENSED CONTRACTORS DECLARATION Sae 8 Type HP KW KVA or KVAR ADDRESS-77/6 ` K y,� a`",
1 hereby affirm that I am licensed under provisions of Chapter 9 04 pvs!3 to 101nc1
(commencing with Section 7000) of Division 3 of the Business and CITY .- $21
Professions Code and my lie""IS In full force and effect Over 10 to 50 Ind LICENSE OR
p Geu fl a
/w I0 Over SO l0 100 Inc] REG NUMBFA
License Number C
I Lo Class —1Over 100 plSrR1OF Np �OV P BY O
tJC. Services Swbd MCC a Panelboarde Q
Canlrecta��`-'I t T�L Data 0 399 Amp Under 800 V RNA ^^ O
❑ I am exempt undo Sec 400 7000 Amp Under 800 V 6-B-
Over 1000 Amp or Over 800 V RNu VALIDATION W
B 8P C for this reasonBRANCH CIRCUIT FEES BY C0
Date ISA or 2DA 120V Lighting or Recepl 2
I To 10 Branch Circuits
Signature 1I To 40 Branch Circuits
41 Or❑ Exemption for Reg Ment Elect 15A 20A 20 VV To 277V UgMning ore Br Com its 2
SINGLE FAMILY Temp Power Pole&Appurtenances ttt.CT.*
HOME OWNER BUILDER DECLARATION Sign with One Braroh Circuit �ry�
I hereby affirm that I am exempt from the Contractors License Law 3M 226.89
for the following reason (Section 7031 5 Business and Professions Adtlaxmal Sign Branch Circuits
Code) -I ITEMS
❑ I ee owner of the property will do the work and the structure Marc Conduits 6 Conductors TOTAL 226- 89 1L �p
is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)— , Tin �.GV
and Professions Code) V �I8y�
CONSTRUCTION LENDING AGENCY 4f➢'W1 .00
1 hereby affirm that there Is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE OOW-0001 5/25/93
LerRlera Name PERMIT ISSUING FEE 9934 1 AM 9�a2
Lender a Address
I oartdy thin I have read thus application and under penally of puqury state TOTAL FEE
that the above Information is comes I agree to comply with all County
odlnancaeand Statelawsregul n El e wiring and hereby authorize
represent tries of thI my t ion t above-mentioned property
fox I P on pure SEE REVERSE FOR EXPLANATORY LANGUAGE
6Mi NRE OF PERM DATE