HomeMy Public PortalAbout5266 SERENO DR_Electrical__ • WO that I SCOMPENSATION DECLARATION 260019 DPW(+29+) APPLICATION FOR ELECTRICAL PERMIT 11
. I hereby affirm that have a'cart10cete of consent to Self insure 79A68
or a cadlllcate of Worker a Compensation Insurance or a candled COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereol(Sec 3800 Lab C)
Policy N42_/__L1 IAZornpany FOR APPI-ICANT TO RLL IN JJ B K O
Certified copy Is hereby'furnished NO EACH FEE
New Residents]Bldgs 8 PP!P m LOCALITY�G Certified copy re filed with the count uIM11 1&2 Family Sq Fl e��) — S
IF
department _ Muttl family Sq Ft Ns9�
Date 2.f �� Applicant Residential Swimming Poole AS9EBSOR „(
MAP BOOT( PAGE PARCEL
CERTIFICATE OF EXEMFTK)N FROM WORKERS Outlets Ret —Light_S. OWNER OR
COMPENSATION INSURANCE ITRMNAME
(This section need not be completed It the work Involved by the Fust 20 MAIL
permit Is Tor one hundred dollars($100)or leas) Total No Additional ADDRESS
I certify that In the performance of the work for which this permit CrTY +
Is Issued I shall not employ any person-in any manner so as to
become subject to the Workers Compensation Laws Lghhng Fixtures First 20 PPU(A�
Total No Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY TN No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PERMrt 1 �� G
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APPLICA T
' LICENSED CONTRACTORS DECLARATION Sze 3 Type HP KW KVA or KVAR ADDRESS77/6 R e-
I hereby affirm that I am licensed under provisions of'Chapler B Over 3 to 101nc1
(commencing with Section 7000) of Division 3 of the Business and CITYT 21
Professions Code +aU�n7d�V�my license Is In full force and effect Over 10 to 50 InLOEN
d C� C^/ }
— Over 50 to 100 Ind REG NUMBEFJ:�O 0 1&1
Ucenee Num : ' ` LIc CIa,���0
11 ��� / )�a Semce, Swbd MCC a Panelboerds
Canr I�S IA /' e e. K+ —7� 0 399 Amp Under 000 V FINAL
❑ - DATE / ` _ Q
am exempt under Sec 400 1000 Amp Ulider 800 V DN' VALIDATION , V
Over 1000 Amp or Over 600 V PWAL W
B$P C for this reason - BRANCH CIRCUIT FEES By - C/)
Date ISA or 20A 120V Lighting or Recept Z
Signe tits 1 To 10 Branch Circuits
71 To 40 Branch Circuits
41❑ Exemptwn for Reg-MamVV t-Elect 15A 20A 20 To 277Vfi More �iits Its
SINGLE FAMILY Temp Power Pole d Appurtenances - - 2
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ACCTeA
I hereby affirm that I em exempt from the Contractors License Lew �p
If
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits ' 3 (amu•lj
Gods) -
❑ I as owner of the property will do the work and the structure Mlsc Conduits 8 Conductors AA,�'�1 IT+G11+�f8 15 C
Is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) TOTAL 228 . 1-J
and Professions Code) _
CACK 228.15
CONSTRUCTION LENDING AGENCY CHANE •�)
I hereby affirm that mere m a construction lending agency for the
performance of the work for which this permit is Issued (Sec 3097 PERMIT FEE (Sub Total) =51 - -
Civ C)
PLAN CHECKING FEE 0000-0001 5/25/93
Lender Name
• PERMIT ISSUING FEE �� 9936 1 AM 9:43
Lender a Address - --
I certify that I neve read this application and under penalty of purlury elate TOTAL FEE a� 0.
that the above informal Ie correct agree to comply with all County -
ordmanceaandStetelawsr leu E tical wiring and hereby authorize
repress t le e n the above mentioned property, -
fo I Pu SEE REVERSE FOR EXPLANATORY LANGUAGE
Tt/E DF pAiE