HomeMy Public PortalAbout5260 SERENO DR_Electrical__ ,YVOthat I S COMPENSATION DECUBATION 72D-00195AM DPW„2 a„ APPLICATION FOR ELECTRICAL PERMIT
I Hereby efhrm theft have a certificate of consent to sell insure 1sAaQ3
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
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PoplIicy/rOs'�LL— mpalliJ FOR APIiIUCAKT TO FlLL IN ADDRESS �l e� /.A 1110
(pL -Cerhhed copy is hereby fuer ied New.Residential Bldgs & NO EACH FE
1 6 2 Femtl FV.20 — 5 y $ LOCALITY
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❑� Cem6etl copy is bled rnih the co ug i y t _
family Sg Ft NEAREST L e
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D1d Applies MAP BOOK PAGE PARCEL
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CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _Light_Siv _ t OVINER OR
COMPENSATION INSURANCEFIRM
(This section need not be completed if the work Involved by the First 20 r NAA. 3 ,11 t
permit Is for one hundred dollars(5100)or lase) Total No Additional ADDRESS
Er.57I certify that In the performance of the work for which this permit C rilfi> TaAK97711
is issued I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers Compensation Laws Lighung Fixtures Fust 20 APPLCART
Total No Additional
ADDRESS
Dere Applicant RESIDENTIAL APPLIANCES 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 PERMfT
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APP- 1
LICENSED CONTRACTORS DECLARATION Size a Type HP KW KVA or KVAR ADDRE
I hereby affirm thet'l em licensed under provisions of Chapter 8 Over 3fo 10 Ind
(commencing with Section 7000)of Division 3 of the Business and CITY 9
Professions Code and my license is in full force and effect Over 10 to 50 Ind
3v1 SE OR }
C.' ( Over 50 to 100,Incl REO NUMBS Claim, C—/10a
Over 100 DISTRICT W SSED BY
CENO
License Numbs Lic Claes ,{ V
C SIH �1" Services Swod MCC 8 Penelboerds I D t/ � cc
Contractor J Dete 0 389 Amp Under 600 V FINAL //,`�
❑ I am exempt under Sec 400 1000 Amp Under 600 V DATl(/- "Q VALIDATION V
Over 1 ODO Amp or Over 600 V FINAL W
B aP C for this reason BY IL
BRANCH CIRCUIT FEES 2 C0
Date 15A or 20A 120V Lghung or Recept M T _ Z
1 To 10 Branch CircuitsL
Signature 11 To 40 Branch GrcWb —
23
41 Or More Branch crams 4.45
Ex
❑ emption for Rep Meinl Eled ISA 20A 20BV To 277V Lighrng Br Circuits
SINGLE FAMILY Temp Power Pole 8 Appurtenances TOTAL ,�� _
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that I em exempt from the Contractors License Law
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits MILK 234.45
Code) FLwIrc
❑ I as owner of the property will do the work and the structure Msec Condwts 6 Conductors OCI
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
and Professions UCTI 0000-0O1 5/25/93
CONSTRUCTION LENDING AGENCY �1p w�,I �•i
1 hereby affirm that there is a construction lending agency for the 9928 1 AM 9:40
performance of the work for which this permit is issued(Sec 3D97 PERMTF FEE (Sub Totaq
CY C) -
PLAN CHECKING FEE
Lender a Name
PERMIT ISSUING FEE a5
Lender s Address
I corON that I have reed this epplicaBon and under penalty of pur(ury elate TOTAL FEE
that the above information is correct I agree ly wrh all County
oreinancoaentl Stat r n ncelerebyauthonze
rapreeenletrves is t r upoZhv7n � tl propertyfor InSEE REVERSE FOR FJ(PLANATORY LANOUAf7E
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