HomeMy Public PortalAbout5252 SERENO DR_Electrical__ WORK COMPENSATION DECLARATION 00,0 DPW(+2 9„
I hereby alihm that
I havehave a certificate of consent to Bell m28etria 784883 APPLICATION FOR ELECTRICAL PERMIT
ore certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(SK 3800 Lab,C)I. h _I
Polrq'r COmpan ✓N MR APPLICANT TO FlLL N AOORE59 579
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Ceibhad copy a hereby fumrshed New Residential Bldgs 8 NO EACH FEE LOCALITY' ,
❑ Certified copy Is filed with the coun buddm 1 8 2 Family Sq Ft — $/ S M
department U Mulb family Sq Ft C OSS si ose
Date c.l. f 3 Applicant Residential Swimming Poole ASSESSOR ,
LEAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Ree _Light_Sw FR,ENRjy�E t KO g/
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COMPENSATION INSURANCE
(Thiellon'nesd not W"complstat it the wort Involved by the First ci
permit Is lot one hundred dollen(8100)Or leu) Total No Adtlawnel +' ADORESB � Yw t �fr
I certify that in'the performance of the work for which this permit CT' / Tel 7 /
is Issued I shell not employ any person in any manner so as to PUNS X
become sublect to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT
' Total No Addmonal ADDRESS
Data Applicam 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
provisions of the Labor Code you must forthwith comply with such Power Apparatus 8 Large Appliances APRPLICANT I /fli
provisions or this permit shall be deemed revoked
•LICENSED CONTRACTORS DECLARATION T Size 3 Type HP KW KVA or KVAR ADDRESS fe
I hereby afftrm`that I am licensed under provisions of Chapter 9 Over 3 to 101nc1
(commencing with Section 7000) of Dlvheion3 0l the Business and CITU
Professions Code and my license is in full force and effect Over 10 to 50 Incl LICENSE }
Over 50 to 1011 Ind REG NUMBER
Lkense Number, 3ol 6.1 Lic CIe6e aN1� DISTRICT rq y ED av 0
r SNwces Swbd MCC 6 Panelboerds• Q
ContrecQ I�•s/N t / to •Z.r 9� 0 399 Amp Under 600 DATE O
I errh exempt udder Sec 400 1000 Amp Under BOO V RV 11 VALIDATION Q
Over 1000 Amp or Over 600 V FINAL G.
B 8P C for this reasonBy U)BRANCH CIRCUIT FEES
Date 1 S or 20A 120V Ughung or Recept _ z
1 To 10 Branch Circuits
Signature t t To 40 Branch Grwtls
41 Or More Branch Cucub
❑ Exemption for Reg Mahnt Elect 154 20A—2DBVTo2T7VUotngBr C7rcurts 2
SINGLE HOME OWNER BUILDERILY DECLARATION Temp PowerPale 8 Appunenences ACCT..
I hereby affirm that I am exempt from the Contractor SALicense Law Sign with One Branch Clrwlt �n� 221,49
for the following reason (Section 7031 5 Business and Professions Ackhootal Sign Branch Grcuus 3303 �
Code)
❑ I ae owner of the property will do the work and the structure Mhsc Conduits 3 Conductors _1 I 1 L1 F]
y�p
G�iJ
hs not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule) ► TOTAL 221.49 221rT
and Professions Code) t CHECK Mott?
CONSTRUCTION LENDING AGENCY f LL e00
I hereby affirm that there IS a construction lending agency for the fYBnG
e
performance of the work for which this permit is issued (Sec 3087 PERMIT FEE (Sub—Total)'
Cm C)
PLAN CHECKING FEE OOOO—OMI 5/25/93
Lenders Name PERMIT ISSUING FEE p3 9931 1 Ali 9'41
Lender a Address - Y
1 comfy that I have read this application and under penalty of purjury state TOTAL FEE CA
that the above information Is correct I agree to empty with all County
ordinances entl State le regul ti � I cUicel ng end hereby authorize
repreaentmhvea of ih n h port above-menbaled PropNty
for tin a on pure SEE REVERSE FOR EXPLANATORY LANGUAGE
NATIIHE OR PEIOfTIEE ,WTE