HomeMy Public PortalAbout5104-5104- 1/2 SERENO DR_Electrical__ G 1'
ORE DA 12 E{ APPLICATION FOR ELECTRIC PERMIT
DIVISION OF BUUMING AND SAFM
Deparbn mt of County Engtneft [+
Co=tp of-Lu Angel" BUILDING _!5
WM J PDX, COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T OP Bu1LOIN0 �7
FOR APPLICANT TO FILL IN LOCALITY Tia m r+ - C' IT S�
N
PERMT FEES EAEST AeA3a D
CROSRS ST n.
FEB
NUMBER EACH p�
IKW
HT OUTLETS OWNER /P//�R I�[g"[`x
CEPTACLES --- ADDRESS t-/^;7 7L�I'xan
MAIL
LL SWITCHES
s1,
TOTAL OUTLETS SI ! .S CITY /� ( TEL NO
EC RANGES 25 ELECTRICIAN Pale-a: EL-OCTIT C, SAQ2
EC HEATERS 20 ADDRESS ) N. M2/rc�o A✓F.
EA CITY L 7rm TEL NO D
FIXTURES 5 LICENSE NO O
NUMBER OF LIGHT CIRCUITS DISTRI O GROUP ONE PE{OT FON IN{FER IDX
MB RE E I TB
MOTORS
NUMGER HORSEPOWER FEE INSPECTION RECORD
NEW I NVo HP OVER INC EACH I^ �^
�J A LRSS S 25 \ V
z eo
2 5 100
5 to t HO
_ IS So 250
50 200 1500
MisrNO SIGNS NO TRANS
NO SIGNS NO LAMPS _
FOR EACH PERMIT 00WIRING $100 0
FIXTURES St 00
SUPPLEMENTARY SO _
J� APPROVALS
TOTAL FEE s ✓ v DATE INSPECTOR S SIGNATURE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING 1 l0 SV
ELECTRICAL WIRING
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AMD/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FOW ER
CALIFORNIADESCRR OR THA IPPM THE LEGAL OWNER OF THE ABOVE
1 UTILITYCO NOTIFIE Z� TIS
SIGNATURE
OF PFINAL M
ERMITT E
WILLIAM J FOX. COUNTY ENGINEER t MTY � FEB 9 2 520 D
Lt�O BY
� DEPUTY'
�
i O
WORKERS Ihave COMPENSATION DECLARATIONcorse cl ° APPLICATION' FOR ELECTRICAL PERMIT
hereby affirm that I have a certificate of consent to self ��
ure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELESr DEPT O PUBLICf ORKS
ora certified copyjthereof (Sec 3800, Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished New Residential Bidgs 8 Pools EACH NO FEE ADDRESS '
❑Certified copy is filed with the county building inspec 1 8 2-Family, Sq Ft $ — $ LOCALITY
lion department Multi-family Sq Ft — NEAREST
Date—Applicant Residential Swimming Pools OOWtjERSS ST
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Svv— - ) MAIL
COMPENSATION INSURANCE First 20 ADDRESS 4k 4X33
(This section need not be completed It the work Involved by Total No Additional CIN L - Tel No
the permit is for one hundred dollar($I00)or less )
I certify that in the'performance of the work for which this PLAN CHECK
permit is issued, I shall not employ any person in any mann
so as to become subject to the Worke mpensa n a s Lighting Fixtures First 20 ADDRESS
Additional I
�-�y�--�'/�5— Total No CITY Tel No
Dote�APPbcan -fixed Appliances Not Over 1 HP PERMIT
NOTICE 0 (CANT If, er M.
is rf¢ate
Exemption you should become subj ct to a War rs Range— Hearor—D W _ APPLICATION
Compensation provisions of the Labor C Ou mu Orth Oven — Dryer —W M — ADDRESS
with comply with such provisions or this permit shall be To — FAU —W H —
deemed revoked Hood — Fan —Other— CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
hereby affirm that am licensed under provisions of Chapter 9 sap. _ Room Air Cond R NUMBER Clan
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO P SSED BY >
and Professiorn Code and my license is in full force and effect a_
^� Size 8 Type HP KW, KVA or KVAR ,Z?j� � ' � O
License Number-y"�--'�'--1�'-�Lic Clau —lCJFI - U
Up to 1 Incl NAL
Over 1 to 10 Incl DATE VALIDATION
Contractor to O
❑ Over 10 to 50 Incl FINALlk-
I am exempt under Sec / Over 50 to 100 Inc BY W
D
B 8P C for this reason Over 100 �
D t Service Iboards , Z
2(10 Am Under 600 V
Signature 201 - 1000 Amp Under
F1Exemption1000 Amp or Over 600 V
Ezemption for Reg Mo4 jest
SINGLE FAMILY
HOMEOWNER-BUILDER DECLARATION Temp Power Pole B Appurtenances
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit r _
Low for the following reason (Section 7031 5, Business and \ Additional Sign Branch Circuits
Professions Code) 1 ITEIt:-
❑ 1, as owner of the property, will do the work and the Mlsc Conduits 8 Conducion Ti 11 h1L 31 - 00
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)_
Business and Professions Code) CHECK '1,141
CONSTRUCTION LENDING AGENCY �. C13I 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 PEE � � �I 30IM-0001 12/ 7!9'1
Lenders Name 4353 1 AM 10:2e
" PERMIT ISSUING FEE
Lender a 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 I _
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote ms
t