HomeMy Public PortalAbout4847 ARDSLEY DR_Mechanical__ -WORKERS'COMPENSATI04cCLA TION n Pnn C n ftM FOR
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.^I--hereby affirm that I have a certificate"of consent to self G=d lr L� G�1 I1G Ili ISU�IIVII
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab.'C.) 76A364C
CE-818(REV. 10/81) '
Policy No.-Company
a
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
. Certified copy is filed with the county,building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY .
NO. TYPE'OF APPLIANCE OR EQUIPMENT FEE -
C`
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.-7€ G
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSEDsBY
the permit is for one hundred dollars ($100)or less.)
AIR.HANDLING UNIT, CFM ®�
I certify that in the performance of the work for which this _, . -. _ •
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject to the Workers'COmlpe ,nsatlon Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU ROUGH
Dat -`Applicant/ r
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM. FINAL
Exemption,- you should become subject to the Workers'
-Compensation provisions of the'Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply With such'.provisions or,this permit shall be
deemed revoked. FURNACE: EAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER:. SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of'Di.vision 3 of the Business WALL
and Professions Code;and my license is imfull force and effect.
License Number Lic. Class i D
Contractor Date O
aLU
I'am exemptunder Sec. LU
Plan check fee H
B.BP.C. for this reason - PERMIT ISSUING FEE $ Q 2 3:7 9.8z
q
Date:
Signature TQTAL FEE °.
M.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
o pp
p0
I hereby affirm that I am exempt from the Contractor's License
.Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner` of the. property, or myemployees with ADDRESS
wages.asTheir sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY, - TEL. NO.
7044, Business and Professions Code).
_
OWNER.
❑ .I, as owner of the property, am exclusively contracting /F�
with licensed'contractors to construct the project (Sec MAIL -
tion 7044, Business-and Professions Code).- , ADDRESS {
I
CONSTRUCTION LENDING AGENCY CITYTEL. NO.
I hereby affirm that there is a construction lending agency for o !�
the performance of the work for which this permit is issued CONTRACTORD
(Sec. 3097, Civ. C.).
ADDRESSel�,4/. v- s . _
Lender's Name
CITY%`-'�K/ �' TEL. NO
Lender's Address �
I STATE LIC
certify that I have read this application and state that the. LICENSE NO.�/ �r�- CLASSt--W -1 `
above information is correct. I agree.to comply with all County'
ordinances and State laws relating.to building construction,.
and hereby authoriz representatives of this County to enter
uPo abov ntioned property for inspection purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE _
Signature of Applicant or Agent 'Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT -
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0701050001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 14647 LT: 30 . 4847 ARDSLEY DR
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917803802
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY
8590-017-024 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, C
02 COMPRSR c 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 - ISSUED ON PROCESSED BY: PLAN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 4.00 UNI 17.40 01/05/07 JK 07/04/07
TOTAL FEES 99.15 - -
OWNER: TEL. NO: FIATAL fA FINT CODE:
YOUNG ISAAC;ESTHER J (626) 285-8842- 77 l
4847 ARDSLEY DR
TEMP 917803802 - DE CR PTIO OF .WORK
INSTALLATION AIR CONDITION G AND HEATING SYSTEM
APPLICANT: TEL. NO:
PERALTA - (818) 523-3373-
7318 VALIAN AVE SPECIAL CONDITIONS:
VAN NUYS CA 91406
CONTRACTOR:. TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
A & WORKERS ASSOCIATES (818) 982-7904-
13141 HARTLAND ST. LIC. NO FAU/WALL FURNACE
NO. HOLLYWOOD, CA 91605 697160 B
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
LIC. NO: AC/COMPRESSOR
THERMOSTAT
FIRE. DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508 -