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Home My Public Portal About4923 SERENO DR_Electrical__ TION WORKERS COMPENSATIONacertificate of corse _ '°�' '°'B' APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a cerbficote of consent to self �� m1we or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec 3800 Lab C ) I a Policy No Company FOR APPLICANT TO FILL IN JOB ADDRESS Z 0 Ys� Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO❑ FEE _'F/L Certified ropy is filed with the county building inspec- 18 2-Family Sq Ft : — f LOCALOCALITY -E PE.-E C( tion department Multi-family Sal Ft — C PSS TT UwFm- 4zuso, I okINS' Date Applicant Residential Swimming Pools - FIRMENAME CiKi"oPija ( CERTIFICATE OF EXEMPTION FROM WORKERS MAIL I Outlets Rec_Light_Sw ( COMPENSATION INSURANCE ADDRESS � VV- (This section need not be completed R the work Immlved by First 20 '`' the porntit Is for one hundred dollars($100)or loss) 1 Total No AdditionalCITY _ _ Tel No 63 I certify that in the performance of the work for which this PLAN CHECK permit n rssued I shall not employ any person in any manner APPLICANT so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS JJ -?- s Total No Additional Date p—L" Applicant " � CITY- Tel No Fixed Appliances Not Over I HP PERMIT OTI pt TO APPLICANT If after nakngt i to Certificate of APPLICANT Exemption you should become'subject to the Workers' Range_ Heater_D W __ Compensation provisions of the Labor Code, you must forth Oven _ Dryer _ W M — ADDRESS ` with comply with such provisions or this permit shall be _ deemed revoked Hood _ Fan _Other_ CITY Tel No LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Dnp _ Room Au Cond REG NUMBER Clan (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCESSED and Professions Code,and my license is in full force and effect /� p� d Size 8 Type HP KW KVA w KVAR `7 i 0 Q O License Number Lic ClassU Up to 1 Incl FINAL 1 Over 1 to TO Incl DATE VALIDATION 0 Contractor Date Over 10 to 50 Incl FINAL ❑ 1 am exempt under Sec Over 50 to 100 Inc BY 1 (0 6 n B 8P C for this reason 100 N reason ► _ _ Dote Services, Swbd , MCC 8 Ponelboords O ,o—20 '�3 ,�J,✓� le 0 -200 Amp Under 600 V T Cl"/' Signature 201 - IODO Amp Under 600 V :Z lox 7A CC. •L/R CI r7 20 J N i� Over 1000 Amp or Over 600 V I ❑ Exemption for Reg Mont Elect .1 Z;5=r / r�Ey �!s V o ppu SINGLE FAMILY Temp Power Pole 8 Appurtenances 0-�.F', 2 7 2 3 A A r HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 6 2i�S(r1t L VVV I hereby affirm that I am exempt from the Contractor s License �. • • •�. 2 Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits , ,ens Code) r= 2 . . 25 5 0 . . . I as owner of the property will da the work and the Misc Conduits 8 Conductor Other (See Complete Fee Schedule)_ ► 2 5 �i structure is not intended or offered for sole (Section 7044 Business and Professions Code) 0 61 3—8 3 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE - (Sub Total) - - _ (Sec 3097 Civ C ) PLAN CHECKING FEE-• _ _ Lender s Name PERMIT ISSUING FEE Lender s Address I certify that I have read this application and state that the TOTAL FEE .� above information is correct I agree to comply with all County ordinances and State jaws regulating Electrical wiring and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes Go. ,l5'4-813SEE REVERSE FOR EXPLANATORY LANGUAGE OP'. tu a of Paris mee Date WORKER S COMPENSATICIN DECLARATION 1 200001139 DPW(12 91) 1 here*atirril•lhat I have a ceutd7Cate of cpnsent to self Insure APPLICATION FOR ELECTRICAL PERMIT or ace;tf tato of Worker s�Gompensaton Insurance or a candied COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy therecf,(S9c•3800 Lab_ C) ' Policy No I Company f-04i A=T TO F IN ADDRESS EcnmnoD i Cl Cemf�ied copy is hereby/umishetl T r New Residential Bldgs 8 PoNe_ ., / NO EACH FEE. LOCAUTY / i 1 8 2 Family Sq Ft ❑ Certlied copy a filed with the county bwkhng inspection departmem _ Mulb family Sq Ft DST a Date Applicant h A Residents!Swimming PooSESSOR I MAP BOOK PAGE OI PIiPCQ/ 1 CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light Sw — o�NER oR COMPENSATION INSURANCE MAIL NAME Y Fast io _ MAIL (Thli tIs for need not be completed 0 the work Involved by the Total No Atltlrticnal ADDRESS permit It for one hundred dollars(3100)or lets) I certify that in the performance of the work for which this permit CITY 02/C Cl TN a Is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws I Lighkng Fixtures First 20 PLAN CHECK APPucu+T Total No Additional • ADDRESS Dote ApplwamRESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO APPLICANT If after making this Certimete of : CRY Ttl No Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP PERMIT provisions othe eCode you must forthwith comply with such Power Apparatus 8 Large Appliances, APPLICANT provisions orr this permit shell be deemed revoked Zol LICENSED CONTRACTORS DECLARATION ' Sae 8 Type HP KW KVA or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 1 . Over 310 10 Ind(commencing with Section 7000)of Division 3 of the Business and CITY TO W Professions Code and my license is in full force and effect Over 10 to 50 Ind Over 50 to 100 Incl REG NUMBER O� d License Number Lx Clem luJ Over 100 DISTRICT No SED BY Q • ,' ; - Services Swbd MCC 8 Panelboerda Q Contractor _ Date 0 399 Amp Under 600 V FINAL A(C t,i O 400 1000 Amp Under 600 V a.,1.,-.1,.., rr 11'�ff ❑ I aril exempt under Sec r "�, DATWN 2�}.V Over 1000 Amp or Over 800 V Rppy, B 8P C for this reason - ' BRANCH CIRCUIT FEES BY V�} i I�S a /� fA Date 15A or 20A 120V Ughiwg or Recap T01 AL 295 - 05z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circvus - (HEC h �.05 41 Or❑ —Exemption for Reg Meint-Elect r 15A 204 2D8V To 277V L Mare r Cry�u (HANGE .00 SINGLE FAMILY Temp Power Polo 8 Appurtenances HOME OWNER BUILDER DECLARATION n Y I hereby affirm that I am exempt from the Contractor a License Law sign with One Brarlcli Circuit CIUCk�0001 1U/_}/g4 for the following reason (Section 7031 5 Business and Professions Addhonal Sign Branch Circuits Code) Th E 1 All °:IJI) YLI as owner of the property will do the work and the structure Mist Conduits 8 Conductors _ is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) .,and Professions Code) - CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total) Civ C) PLAN CHECKING FEE _ Lender a Name / PERMIT ISSUING FEE Lender a Address I I cmIrty,Moet I have read this application and under penalty of pur)ury state TOTAL FEE 9 Q that the above mformatoll is correct I agree to comply with an County - ordinencesandlStetelawsregulaung Electncal wiring and hereby authonze roWemmetwm of this Caumy to ante upon the above menboned property •- t for O purpose° SEE REVERSE FOR EXPLANATORY LANGUAGE Ao aieNATURE OF PEROTTTEE DAM i . ,