HomeMy Public PortalAbout5250 SERENO DR_Electrical__ WORKER I have COMPENSATION DECLARATION �,;DPW(12 el) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm that I have a certlllcate of consent to self insure
or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy t areal 0 Lab C) C 1 �I
Ppd'Lin' � �omparry� �Lfe VNQ IRNI APPLICANT TO RLL M ADDRESS I
/y Certified copy Is hereby furnished New Residential Midge & s�� NO 3 EACH = FEE LOCALITY '
❑,' Carbnetl copy is filed with the ccu but g 1 8 2 Family Sq Ft 5 NEAwEST
department
Muni family Sq Ft CR0996T p
Daltk��`" • ApplKsn
Residential Swimming Pools f.tAP BO K PA3E PM EL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light Sw _ FIRM OWNER OR
/(. 1 Q3/f
t - COMPENSATION INSURANCE Fret 201
(This section need not be completed It the work Involved by the Total No Addn onal ADDRESS
permit is for one hundred dollars(3100)or tau)
I certify that in the performance of the work for which this permit CITUC�bii le TN N
19 Issued I shall not employ any person in any manner so as to Pi A ECK -
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional ADDRESS
Data - Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY Tel No
Exemption you should become Subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP pp��
provisions of the Labor Code you must forthwith comply with such power Apparatus 8 Large Appliances
AD /mss I
provisions or this permit shall be deemed revoked
' ' LICENSED CONTRACTORS DECLARATION Sao&Type HP KW KVA or KVAR ADDRESS 7
I hereby affirm that 1 am licensed under provisions of Chapter 9 Over 3 to 101nd
(commencing with Section 7000)of Division 3 of the Business and C T 2
r k-
Professions Code and my license to in full force and effect Over,10 to 501nd LICE }
/// Over 50 to IDD IrKA qED NUMBER 0 Class _�0 d
Ucense Numbew 3o )�6 I tic Class� Over 1D DISTRICT NOP SSED BY O
(��` CC 11� (� G Services Swbd MCC a Panelboards (��
ContractD...7B` 1�VM 1 �^ aceta v'zx_7 i 0 399 Amp Under ODD DATE
0
❑ I am exempt under Sac 400 IODD Amp Under 600 V VALIDATION W
Over 1 DDD Amp or Over 600 V FINAL '
B&P C for this reason d
BRANCH CIRCUIT FEES BY W
Date 15A or 20A 120V Lighting or Recepl 2
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41❑ Exemption for Reg Maint Elect � ISA 20A 208V To 277VLiLighing
Mae resits
2
SINGLE FAMILY Temp Power Pole 8 Appurtenances,
HOME OWNER BUILDER DECLARATION ACCT.: -
I hereby affirm that I am exempt from the Contractors License Lew Sign with One Branch Circud
for the following reason (Section 7031 5 Business and Professions Acidikooal Sign Branch Circuits 3303 220.E
Code) 1 ITEMS
❑ I as owner of the property will do the work and the structure Mlsc Conduits 8 Conductors �y �f.s +�
is not Intended or offered for sale (Section 7044 Business Other(Sae Complete Fee Schedule) TOTAL LLQ —32
and Professions Code) - ,
' C+E(A 220.32
CONSTRUCTION LENDING AGENCY _ uA`�
I hereby affirm that there is a construction lending agency for the OWE .011
performance of the work for which this permit is Issued (Sac 3097 PERMIT FEE (Sub-Total) �9 ,
Civ C)
PLAN CHECKING FEE OODO-0001 5/25/93
Lander a Name PERMIT ISSUING FEE 9932 1 AM 9.41
Lender a Address �} -
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above Informanon m correct I agree to campy,with all County
ordinances and State laws regulating El ricalw mg and hereby authorize
representatives of th un o r Pon th mantroned property
for I Ion purp Z� /3 SEE REVERSE FOR EXPLANATORY LANGUAGE
IN
agKAlie1E or PEIWTfEE DArS