HomeMy Public PortalAbout5256 SERENO DR_Electrical__ WORKER
t1 have COMPENSATION DECLARATION �,a DPW 112 91, APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of convent to Bell insure
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof Sao 3800 , ��CJJ I r ih p w 1 - �]
Polity 422 pan �` v FOR APPLICANT TO FLL IM DpRE99 S/t 6 eI'q n o
yNaW{I r
Certified �a her furnWted NO EACH FEE r
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copy �Y New Reettlentiel Bldgs 8 LOCALITY
❑ . tCerbfied copy w bled with the coal dtlug 1 8 2 Family Sol Fl 9� _ a• NEAREST ,
_ Muhl family SQ Ft CROSS U
Data AppII� Rmrdentlal Swimming Pools r, ASSESSOR
MAP BOLI( PApE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERSOWNER OR
COMPENSATION INSURANCE - Outlets Rec _Light_Sw FmAI NAME /y l 0 V it-
(This
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(This section need not be completed H the work Involved by the First 20 Mwl $ 6 AI) H
penult Is for one hundred dollen(6100)or leu)
Total No Additional ADDRESS
I certify that in the'perlormance of the work for which this permit CCr /t Tel 6473/
is issued I shell not employ any person in any manner so as to Ab
PSC
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPl1CANT
Total No Additional ADDRESS
Due ` Applicant RESIDENTIAL APPWINCF_S NOT OVER 3 HP
NOTICE TO APPLICANT If alter making this Certificate of CITY Ta 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 PERMIT
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APPLICANT A s/ti 1 �. .-
LICENSED CONTRACTORS DECLARATION` Size 8 Type HP KW KVA or KVAR ADDRESS ,G Gq r
I hereby affirm that 1 em licensed under provisions of Chapter B Over 3 to 10 Incl e
(commencing with Section 7000) of Division 3 of the Business and CITU' 47 Tly522
Professions Code and my license Is In lull force and eflect Over 10 to 60 Ind
LICEN9 aI Q D� �/D a
2 /
Over 50 to 1 b Ind REG NUMBER
Ucanae lNuumbber✓J30 I �/_' Lic Clam`�_� Over 100 DLSTPoCT 1q ` O� P Ep By O
Conlrect� I V�Y •I �'s C��ii�a � 2.�93 0 399 Amp Unde e800 V s Jr (0
FAM Q
GATE {/(�
❑ I em exempt under Sec 400 1000 Amp Under 800 V —C VALIDATION V
Over 1000 Amp or Over 600 V FINAL d
- B 8P C for this reason - BRANCH CIRCUIT FEES BY Cit
Date 1 S or 20A 120V Lighting or Receipt Z
- - 1 To 10 Branch Orcuns
Signature 11 To 40 Branch Circuits -
❑ EF
Exemption for Reg Maint Elect ISA 2DA,208V To 277V L41 LiighMg Ur Cmrts _
7
SINGLE FAMILY Temp Power Pda 8 Appunenencea
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ATtCCTe i
I hereby affirm that 1 em exempt from thehe Contractor a License Law ^'L
for the following reason (Section 7031 8 Business and Professions Additional Sign Branch Circuits .7.]LT.z LJv•
Code)
❑ 25
I as owner of the property will do the work and the structure Mnc Condmro 8 Conductor, 1 ITEM
Is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) , TOTAL 236.25
and Professions Code) CI�CYA ��•+�
CONSTRUCTION LENDING AGENCY _ nzy���E�CI�C
1 hereby affirm that there Is a construction lending agency for the t.i**E OD
performance of the work for which this permit is Issued(Sec 3097 PERMIT FEE (Sub-Total)
Address �Q
Civ C)
Lenders Nesse -
LerMer
PLAN CHECKING FEE 0000000-0001 5/29/93
PERMIT ISSUING FEE J 9930 1 Am 9:41
TOTa3 cp
I cantly t ve that I hareed that application and under penalty of purjury trete AL FEE
that the above mformabon Is carred I agree to cro pl with all County
mcmarwree and State lawn regulating rcal wiring ereby author
representallvm oft n to I ntwed property v
id In on p / SEE REVERSE FOR EXPLANATORY LANGUAGE
61 r DATE