HomeMy Public PortalAbout5262 SERENO DR_Electrical__ WORKER I have PENSATION DECLARATION 76AB63 DPW(12 9+) APPLICATION FOR ELECTRICAL PERMIT IJ
1 hereby elhrm that I have a certificate of consent to Bell insure ��
or a certificate of worker a Compensation Insurance or cenmed COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sac 38 0 Lab C)
Pd CY • 93�,„�, FOR"MCAM TO FILL IN ApOHES9
9 Certed copy m hereby Residential
y lumished New BWga 8 Pools NO EACH, FE bra~0
ifi
1 a 2 Famll FI e� b — E• LOCALITI' G
Jile
❑ Certified copy is filed with the bu mg n y SQ
tef
department ? Multi family Sp Ft — NEAREST
ST ,fir
z �1)134444 Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outleta Rec _LiM_Sw OWNER OR
` COMPENSATION INSURANCE g FlRAI NPA1E /G /
(This motion need trot be completed If the work Involved by the First 20 MAR
per milt Ii for one hundred dollars($100)or lose) Total No Addnonal AODRE95 /it /v
I comfy that in the performance of the work for which this permit CITU T
is issued I shall not employ any person in any manner Bo as to - PLAN CHECK
become sublect,to the Workers Compensation Laws Lighbng Futures First 20 APPLICANT
Total No Addnwnel
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If alter making this Certificate o/ CITY T.I No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must'lorthwith comply with such PERMIT
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APDL / In le C.A
'' UCENSED CONTRACTORS DECLARATION Sao 8 Type HP KW KVA or KVAA ADDRE / Q r
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl K /
Professions Code and my license is In lull force and effect Over 10 to 60 Ind LICE OR REO NUMBER V C)T }
Over 50 to 10D Ind O/ cam. C—I V 4.
O
�m � O I LIC Cities —'O Over+00 dSTRICr NO er U
Services Swbd MCC a Panelboards d/O� Q
Date Jr-21c— 0 390 Amp Under 000 V DAM FINAL
❑ I ern exempt untler,Sec 400 1000 Amp Under 800 V VALIDATION W
ver
O1000 Amp or Over 800 V Ppyy d
B 14P C for the reason BRANCH CIRCUIT FEES ev fn
Date 15A or 211A 120V Ughbng or Recept z
Signature - 1 To 10 Branch Circuits
11 To 40 Branch Circuits
41 Or More Branch Crpgb 2 r
Exemption for Reg Maint Elect 15A MA 208V To Z77V Lighting Sr Circuits
SINGLE FAMILY ` Temp Power Pole 8
Appurtenances
HOME OWNER BUILDER DECLARATION fn,�Y.,CT.ar
I hereby 9111rm that I em exempt from the Contractor a License,Law S'9^wiih One Bre'nch Grcuit � _
for the following reason (Section 7031 5 Business and Professions AdoJ'3v
hunal Sign Branch Circuits W 226.99
Code) 1 ME
❑ I as owner of the property will do the work and the structure Mux Conduits d Conductors
is not intended or offered for sale (Section 7044 Business Other(Sae Complete Fee Schedule) , TOTAL 226 . 89
and Professions Code) CALK 226.99
CONSTRUCTION LENDING AGENCY - Cf>t7rn� LL .00I hereby affirm that there is a construction lending agency for the F4un�
performance of the work for which this permit is issued (Sec 3087 PERMIT FEE (Sub Total /
Civ C)
PLAN CHECKING FEE 0000-0001 5/25/9:
Lender's Name
PERMIT ISSUING FEE aS , 9927 1_ AM 939
Lender a Address /
I carbfy that I have read this app kation and untler penalty of purjury state TOTAL FEE
that the above information is correct I agree to comply with all County _
ordinances and State we rel ladngwrong and
herebyauthonze
represents vee of i o my r the above mentoned property
for i e
on p es SEE REVERSE FOR EXPLANATORY LANGUAGE
s=?-r='3
TUBE OF PERM E DATE