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HomeMy Public PortalAbout5100-5102-02 1/2 SERENO DR_Electrical__ WOkKERS'COMPENSATIONDECLARATION 784883 CE (280) APPLICATION FOR ELECTRICAL PERMIT •i I hereby a7firm that I have a s'Co certificate of consent nsur to self COUNTY OF LOS ANGELE 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 J Policy No Company` New Residential Bldgs & ols EACH NO FEE A DRESS 0 M, S EN Certified copy Is hereby furnished i &2 Famdy,Sq Ft /,*ra0 S — 1__3rL LOCALITYFARE �M ` Certified copy Is filed with the county budding inspection Multi family Sq Ft CROSS ST g department Residential Swimming Pools OWNER OR ) y.. FIRM NAME . 5 N 0J eLo r Date Applicant Outlets Ret;_Light_Sw MAIL �t First 2ADDRESS V-3 C)3 �7 o CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional - ��/i COMPENSATION INSURANCE CITTY cSA✓V Tat N a (This section need not be completed if the work involved APPLICANT O by the permit Is fa one hundred dollar ($100) or less) Lighting Fixtures First 20 ADDRESS (C�1 Total No Additional 2 1 certify that in the performance of the work for which this CITY Tel No 0 permit Is Issued, I shell not employ any person in any manner Fixed Appliances Not Over 1 HP PERMIT (� a0 as 10 bac m0 a bject to the Workers CO entail Laws Range_Heater D W PP M CANT H . W `• Oven — Dryer_W M ADDRESS 0 7" 2 Date? pplrcan[ Top _ FAU _W H CITY � Tel N Hood — Fan _Other_ NOTICE TO APPLICANT If, after making this Certificate of Dlsp _ Room Air Cond— N E OR `/© Exemption, you should become subject to the Workers' RE NUMBE pi's-9 Class Compensation'prowsions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO P CES ED BY with comply with such provisions or this permit shall be ' i` deemed revoked Size&Type HP,KW,KVA or KVA /j-` df� r ' Up to 11nc1 FINAL Over 1 to 101ricl DATE VALIDATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl 1 hereby affirm that I am licensed under provuiom of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 7000)of Division 3 of the BusrBY Over 100 tins and Professions Code and my license is in full force and , effect - Services ��� q J License NumbedLic Class 0 0200 Amp Under 600 V i 201 1000 Amp Under 600 V Contractor C Pa QI KC - Date AF O Over 1000 Amp or Over 600 V F HOMEOWNER BUILDER DECLARATION Temp Power Pole&Appurtenances i`I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit T�sense Law for the fallowing reason (Section 7031 5, Busi- Additional Sign Branch Circuits �ness and Professions Code) ' Misc Conduits&Conductors ' ^ ❑ 1, as owner of the property will do the work and the Other (See Complete Fee Schedule)— 1 2- structure structure Is not intended or offered for sale (Section 7044, Business and Professions Code) 1 o d-�19-0 CONSTRUCTION LENDING AGENCY �1 1 hereby affum that there it a construction lending agency 0 0 0 4 2 0�((� for the performance of the work for which this permit Is , Issued(Sec 3097,Civ C) PERMIT FEE (Sub-Total) 01731 -90 rf 31 -AXJ Lender's Name PLAN CHECKING FEE (One Fourth Permit Feel � Lender s Addreu PERMIT ISSUING FEE 1 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 representatives oft County to enter u on throe enhone properq ^ tp n� pG ses , r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date _ IF WORKERS'COMPENSATIONDECLARATION 76A683 ; CEEOeG f2 801 APPLICATION FOR ELECTRICAL PERMIT ` t I herby 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 11 a /'� ' a cbehfted copy thereof(Sec 3800,Lab C) 6: �s Company FOR APPLICANT TO FILL IN JOB ADDRESS&�O d S �NO PolicyNo Com an New Residential Bldgs &P s EACH NO FEE ❑ Certified copy is hereby furnished 1 &2 Family.Scl Ft aWo — $ 20 = LOCALITY ❑ Multi family St1 Ft Certified copy ss filed with the county budding inspection CROSS ST 5' department Residential Swimming Pools OWNER OR /�� 1 - FIRMNAME fi/ kLk. Date Applicant Outlets Rec_Light_Sw = MAIL 013 First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITYS Jf) Tel No,.1'j 36 ' } COMPENSATION INSURANCE PLAN CHECK a (This section need not be completed If the work Involved i APPLICANT f0 3 by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS Total No Additional 1 certify�thst in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No O permit a issued I shall not employ any person in any manner PERMITU so as to become subject to the Workers' Compensation Laws Range_Heater_D W APPLICANT /` rn d /� Oven _ Dryer_W M ADDRESS Dj ' Cn Dete "–"�--Applicant c G Top _ FAU _WH _W H _ ` Z p Hood _ Fen _Other_ CITYAJor Tel No NOTICE TO APPLICANT r r f2a m'— Disp _Room Air Cond_ L N OR Exemption, you should become subject to the Workers' REG NUMBE Clap Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliences DISTRICT NOP Type deemed revoked ED BY with comply with such provisions or this perms shall be Size&THP,KW KVA or KVA " 7 3 Up to 1 Incl Over 1 to 10 Incl FINA DATE Over 10[0 60 incl LICENSED CONTRACTORS DECLARATION ^/ �f ��/ VALIDATION T I hereby affirm that I em licensed under provisions of Chapter Over 50 to 10D Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Buin Over 100 BY near and Professions Code,fand my license Is in full force and effect Services n -200 Amp Under 600 V License Numbe,3_7L a_V Lic Class ` L _ �r rO 201 1000 Amp Under 600 V Contractor`.,E qA c. L�s d Date?—3/—,i7y Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances r r AFI hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 'License Law for the following reason (Section 7031 S, Busy Additional Sign Branch Circuits , d ness and Professions Cade) ' ` Mist: Conduits&Conductors ❑ I,i,as owner of the property, will do the work and the Other (See Complete Fee Schedule)— structure is not intended or offered for sale (Section 7044, Business 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 PERMIT FEE (Sub-Total) issued(Sec 3097,Civ C) - - • • • • •'t/ Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) I i .Y• • �.1'(� Lender a Address PERMIT ISSUING FEE ` I certify that I have read this application and state that the TOTAL FEE above information a correct 1 agree to comply with all County Of 31 _9V ordinances and State laws regulating Electrical wiring, and ' hereby authorize repr sentetives of this County to enter upon I the above mention, ProPertY r inspection pure SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date