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Home My Public Portal About4967-4969 SERENO DR_Electrical__ ERS COMPENSATION DECLARATION 76Ai 10/61 APPLICATION FOR ELECTRICAL PERMIT .I Grimm that I have a certhcate of consent to self macre, CE 80130 or a certdcate of Workers Compensation Insurance, or a certified COUNTY OF LOS ANGELES + BUILDING AND SAFETY Copy dersol(Sec 3800 Lab C) Panty NO Con P,, FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby tumished New Resdenbal Bldpe 8 Fools EACH NO FEE ADDRESS ❑ Certified copy a filed with the county building nspechan i S 2-Fainly Sq Ft $ — $ L0CALIT`f�� department Multi-tamely Sq Ft — NEAREST Sr Date Applicant Residential Swimming Poole -CROSS1 OWNER OR G _ FHM NAME CERTIFICATE OF EXEMPTION FROM WORKERS MAIL , COMPENSATION INSURANCE Outlets Rec— Lght — Sw ADDRESS SO (This section need not be completed d the work Im ohed by the First 20 permlt Is for one hundred doll($100)ter leas) Total No Additional CITY I certify that in the Performance'of the work for whch the permit PLAN CHECK Is issued I shall not employ arty person in am, manner so as to < �J�T become subject to the�W/lx7kers Comps t Lewy < Lighting Fixtures First 20 ADDRE Date // / /Anplca I // Total No Adddiorusl CITU NOTICE O CANT N a making ffiis CertArcate of Fixed Appkances Not Over 1 HP pER� Exemption you should become subject to the Workers Compensation Range_ Heater= DW /r prowsons of the Labor Code you must forttmath comply with such Oven _ Dryer_ W M _ ADDRE piowsora or the pemut shall be deemed revoked - . Top — FAU _ WH _ LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY TG- Tel I hereby affirm that I am licensed under provisions of Chapter a Dap — Room Air Card LICENSE OR C1®e (wmmencmg with Section 7000)d Drva 3 of the Busness and REG fR BER professions Code and my license is in full force and effectDISTRICT NO PR Power Apparatus 8 Large Appliances OLE BY 0 y' Sae d Type HP KW KVA o KVAR � D I I License,Number L,, Close tip to 1 Intl FlNAL [,7r� Over 1 to 10 hit VALIDATD Canhactar Date Over 10 to 50 Ind ❑ I em exempt under Sec Over 50 to 100 Inc Fl SAP forthe rowan Over 100 ' IL N Date Sery es Swbd,MCC E mp Panelboards Z 0- 200 AUnder 600 V ✓ A S 3 7.6 A -, Sgeture 201 - IOGO Amp Under 600 V 9 . 0 . 9,. 2 ElExemption Over 1000 Amp or Over 800 V ler Reg Ment Elect 1 - - 4(150 SINGLE DECLARATION FAMILY .Temp Paver P06 8 Appurtenances - e • • 4 Q 5 0 0 HOME ONTJ I hereby affirm that I am exempt from the Contractor License Law Si&+vnlh One Branch Cineol for the follovwrig reason(Section 7031 5,Busauess and Protaaacra Additional Sign Branch Circuits I 1, 17t-87 Code) ' 1 IZ3 Mac Conduits s Corducton ' .ie I as oyer of the property \cell do the work(Section and the structure Oder(Sea Complete Fee Schedule) Is not fasted or peered for sale (Sedan 7044 Busneae , ad Professore Code) ' CONSTRUCTION LENDING AGENCY I hereby affirm that there is e Construction lading agency for the ' performance of the work ler which the pennn a issued(Sac 3097 PERMIT FEE (Sub-Total) Civ C) PLAN CHECKING FEE " Lenders Name ' PERMIT ISSUING FEE Lendera Address L I cerhfY that I have read the applcabw and state that the above TOTAL FEE Information is correct I agree to comply with all County ordinances and State laws regulating Electrical winng and hereby authorae ' representatives of the Carry to enter upon the above-mentioned properly br�psapcUm purposes ' SEE REVERSE FOR EXPLANATORY LANGUAGE S��of Permrnee/Permmee Dal 7 r � ' r WORKERS'COMPENSATIONDECLARATION 76A663 (2 80) APPLICATION FOR ELECTRICAL PERMIT {� LJI hereby affirm that I have a certificate of consent to self COUNTY,OF LOS ANGELES BUILDING AND SAFETY Insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800 Lab C) Polity No Company FOR APPLICANT TO SILL IN JOB ADDRESS New Residential Bldgs &Pools EACH NO FEE IJ Certified copy is hereby furnished 1 &2-Family,Sci Ft $ — S LOCALITY ftARtST❑ departed copy a fil♦ed with the county building inspectionMulti family Sq Ft on CROSS ST department Residential Swimming Pools OWNER OR �7 T FIRM NAME �// Date Applicant Outlets Rea F Light SW ADDRESS E 7 .S/v First 20 CERTIFICATE OF EXEMPTION FROM WORKERS Total No - Additional CITU l .- Tel No C COMPENSATION INSURANCE } PLAN CtiECK IL (This section need not be completed if the work Involved APPLIC O by the permit Is for one hundred dollars (SI00) or less) Lighting Flxtur Flrat 20 ADDRESS O i Additional Total No I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel O Permit a issued, 1 shall not employ any person in any manner PERMIT ~ so as to become subject to the Workers' Compensation Laws Range_Heater_D W APPLICANT l IUyI Open p D er_W M ADDRESS H Date Applicant Top F _W H Z Hood F _Other_ CITU el NOTICE TO APPLICANT If after making this Certificate of Disp nom Air Cond_ ICENS R Exemption, you should become subject to the Workers' REG NUMBER Claaa Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO P ES D B with comply with such provapons or this permit shall be / deemed revoked Size&Type HP KW KVA,or KVA D� Up to 1 Incl s ga FINAL LICENSED CONTRACTORS DECLARATION Over I to 10 'IDATE 'Over 10 m BOInncl If VALIDATION 1 hereby affirm that I am licensed under provistuna of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Bus, Over 100 BY ness and Professions Code, and my license n in full for" and , effect ( Services License Number LIc Class 0 200 Amp Under 600 V ' .201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION _ Temp'Power Pole&Appurtenances - Sign with One Branch Circuit 0 2 1 U,4 A 1 hereby affirm that 1 am exempt from the 031Contractor'5us, Additional Sign Branch Circuits License w for the following reason (Section 7031 5 Bw ness an ofesaom Cade) � •'• • o • '2 Mac Conduits&Conductors as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2 ' 3 Q 9 Q structure is not intended or offered for sale (Section e • • ,3 Q 9 7044,Business and Professions Code) i - CONSTRUCTION LENDING AOENCY , 1 hereby affirm that there is a construction lending agency 1 2'02-8 for the performance of the work for which this permit Is PERMIT FEE (Sub-Total) Issued(Sec 3097 Civ C ) Lender s Name PLAN CHECKING FEE (One-Fourth Permit Fee)) Lenders Address PERMIT ISSUING FEE , I certify that 1 have reed this application and state that the TOTAL FEE above information u correct I agree to comply with all County , ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon ) the abovetinned pro y for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee , Dalre r ` WORKERS'COMPENSATIONDECLARATION 76A663 APPLICATION F R ELECTRICAL PERMIT � CE AOBG (2 80)I hereby affirm 'that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or - a certified copy thereof(Sec 3800 Lab C) FOR APPLICANT TO FILL IN• JOB- /C� S�/2F_.Va y71s Policy No Company EACH NO FEE ADDRESS New Residential Bldgs St Pools _ _ Certified copy is hereby furnished t 1 &2 Famdy,Sci Ft S — $ LOCALITY �� [� �- t 7—C , Certified copy n filed with the county building inspection Multi family Sri Ft NtAHUb CROSS S7 department ' Residential Swimming Pools OWNER OR T i rI FIRM NAME Date ` Applicant Outlets Rec_LightSw _ MAIL i first 20 ADDRESS S��s.� r�J CERTIFICATE OF EXEMPTION FROM WORKERS' Total No r Additional CIT : /rf L'� L//lel No ZP7 y�77Z COMPENSATION INSURANCE 0. ` PLAN C ECK 8 (Thu section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS APPLICANT by the permit as for one hundred dollars ($100) or leas) Additional Cr O Total No ' CITY Tel No h 1 permit that m the performance of the work for which this Fixed Appliances Not Over 1 HP U permit n issued. I'ahall not employ any person m any manner PERMIT W so as to become iublect to the Workers' Compernation laws Range_ Heater_D W _ APPLICANT N _ Oven — Dryer_W M _ qD DR ES9 in Date Applicant Top _ FAU _W H _ Hood _ Fen _Other_ CITU T ' NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ LICENSE Exemption you should become subject to the Workers' REG NUMBER Class Compensation provisions of the Labor Code,you must forth Power Apparatus& Large Appliances DISTRICT No J PROCE ED BV with comply with such provisions or this permit shall be /vim Cl/F deemed revoked Size&Type HP,KW, KVA,or KVA Up to 1 Incl FINAL Over 1 to 10 InCI DATE p LICENSED CONTRACTORS DECLARATION VALIDATION .. Over 10 to BO Incl I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Bmi Over 100 BY nas and Profasiorhs Code and my license is in full force and effect Services License Number Lac Clem 0 200 Amp Under 600 V 201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V i HOME OWNER BUILDER DECLARATION _ Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 9 1 3 5 1 A License Law for the following reason (Section 7031 S, Bust Additional Sign Branch Circuits_ _ nos en Profastom Code) - 1 11 i # • • • • • 2 Misc Conduits&Conductors 1, as owner of the property will do the work and the Other (See'Complete Fee Schedule)— 2 e e 1 9.50 structure ti not intended or offered for sale (Section _ 7044, Business and Professions Code) a e e 1 9 5 0 H CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0'9 28-81 - for the performance of•the work for which this permit is PERMIT FEE (Sub-Total) / issued(Sec 3097,Civ C) _ S Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) - t Lender s Address PERMIT ISSUING FEE 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 laws regulating Electrical wiring, and ' hereby authorize repraentstiva of this County to enter upon - thImpaction purposa SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date