HomeMy Public PortalAbout5258 SERENO DR_Electrical__ WOVER S COMPENSATION DECLARATION 200019 DPW(1291) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate o/ consent to sell insure 76,1M
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 Se 380 Lab C) /y.
Policy h 21��1- Umpany�'1 1 = FOR APPLIGNI TO faLL IN ADDRESS Z `! 0
Cemfied copy is hereby furnished NO EACH E
J New Ree Family
Bldgs 8�ql�' _ a LOCALITY G
❑ - .Ceruf*d copy b filed with the cou build i 1 8 2 Fatuity Sq FI S
department Q MUIti IBnuty Sq Ft NEAREST
CROSS ST o
Date <�'� /�ApPlican Residential Swimming Poole A S SS PAGE I PUCEL
i CERTIFICATE OF EXEMPTION FROM WORKERS OWeta Roc _Light_Sw OWNER
I NER on A/
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COMPENSATION INSURANCE lICud
(Thin section need not G completed If the work Involved by the Fust,20 ` NAIL v
permit Ii for one hundred dollen(7100)or leu) Teal No Add 9Dnal ADDRBBS ✓ a N �.
I certify that In the Performance of the work for which this permit CITU 1 Tel 6Q7�
is Issued I shall not employ any person in any manner so as to
31
become subject to the Workers Compensation Laws Lighting Flatures Mrst 20 PI-AN
CHECK
APPLICAM
Total No Additional
ADDRESS
Dote ` Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If eller making this Certificate of CITU TN rid
Exemption you should become subject to the Workers Compensation OTHER APPIJANCES NOT OVER 3 HP
provisions of the Labor CodPERMITe you must forthwith comply with each Power Apparatus 8 Large Appliances
provisions or this permit shall be deemed revoked
LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 310 t0lncl
(commencing with Section 7000) of Division 3 of the Business and CITY .7
Professions Code and my license is in full force and effect Over 10 to 50 Ind }
LICENS
_�a`7 Over 50 to 100 Incl REO NUMBER I (im �0 t1
Lltenae NumbB(� O) (0 ' LIC CI Over 100 DISTRICT NO / PR iED BY'
JIA Services Swbd MCC 8 Panelboerde • G Q
Comre I�� ' Et�e 0 399 Amp Under 600 V DAre O
❑ I am exempt under Sec 400 10DO Amp Under 600 V VALIDATION 0
Over 1000 Amp or Over 800 VLU
FINAL (L
B 8P C for this reasonBY
BRANCH CIRCUIT FEES rn
Dale 1S4 or 20A 120V Lighting or Recap) i Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ ExemplKvl for Rep Mem) Electti
ISA 20e Branch Caourts
A 2DBV To 277V Ughong Br Cecitis 2
SINGLE HOME OWNER BUILDER ILY DECLARATION Temp Power PoleBAppunenenures ACCT.v rn
I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Cncuit 1.49
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits MM
Code) I 1 ITEMS
❑ I m owner of the properly will do the wok and the structure Misc Condore 8 Conductors _
is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule)_ TOTAL 221 . 49
and Professions Code) PON. ^^ DECK
ECD 221.*�'
CONSTRUCTION LENDING AGENCY Cfle9n>z BOO
I hereby affirm that there is a construction lending agency for the 1"09n�
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total) /
Qv C)
PLAN CHECKING FEE OD00-0001 5/'2'5/4,
Lender s Name
PERMIT ISSUING FEE 44?9 1 AM 440
Lentler a Address
I certify that 1 have read this app icahon and under penalty of pugury state TOTAL FEE
that the above information is comect I agree to comply vnth all County
oWmencee end State lower u ti Elect nig end hereby euthova '
represent lives of t1 o r upon a elKrve-mentwned propery
for i tion pu a SEE REVERSE FOR EXPLANATORY LANGUAGE
D RE OF P DATE