HomeMy Public PortalAbout4935 ARDSLEY DR_Mechanical__ WORKERS"COMPENSATION DECLARATION � nn p
I hereby affirm that have-pa certificate of consent to self 6=dI�I�L� CA u PON .FOR PUNT
insure,.or a certificate of'Workers' Compensation Insurance, HEATIMG VENTILATING - AIR CONDITIONING. '
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C .
CE'-818(REV. 10/81)
Policy No. Company
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 ������yj �l/ �►sig
Tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant - LOCALITY ' !$
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE '
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST flGxiF fL!/
(This section need not be completed if the work involved by.'- ABSORPTION UNIT, BTU DISTRICT NO., PROCESSED BY
the permit is for one,hundred dollars ($100)or less.) . L^ S
I certify that in the perform ce of therw rk for which this AIR HANDLING UNIT, CFM
permit is Issued,:l shall not e loy-any p r n in any anner. gOILER,.BTU l/
so as to bec•orhe subject.to:the rkers' pensatio Laws, APPROVALS DATE IN P R's SIGNAT rzE
s COMPRESSOR, BTU ROUGH ✓ i
Dat �+�'" Applican - -- -
NOTICE TO APPLICANT: If, after making this Certi tate of VENTILATION SYSTEM FINAL ✓
Exemption, you should become subject to the Workers'
Compensation provisioris of the.Lcbor Code,-you must forth-. EVA PORATIVE'COOLER AL ATI
with complywith.such,provisions:or this'permit shall be
deemed revoked: FURNACE: EAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I.herebyoffirrri-that Lam licensed under provisions of Chapter 9T HEATER: SUSPENDED—UNIT—
'(commencing
USPENDEDUNIT'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my'license is ihfull force and effect. d
0 License Number Lic. Class
6W i r �.
ContractoO
r Date
❑ I am exempt.under Sec. U
U
LU
Plan check fee a
N
B.&P.C. for this reason
PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE. 02 ;27 b 4,io A
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT" # o o,o 0 0'8
I hereby affirm that I am exempt from the Contractor's License
Low'for the following reason (Section 7031'.5, Business and NAME I '. D 'I o:® 205 0
Professions Code'): _
❑ I,, as owner of the property, or my employees with ADDRESS 3Sf 51. 2'0 j 0
0 0 o v
wages as their sole compensation,will do the work and q
the structure is not intended or offered for sale(Section CITY Pr TEL. NO ' � —� O 8J 1 ,�8 7
7044, Business and Professions Code): OWNERPp�JIttl&' 1tAl2,9jN&7zN `
I, as owner of the property, am exclusively contracting '
with' licensed contractors to construct the project(Sec- MAIL PAVE
tion 7044; Business and Professions Code). ADDRESS ,'�l///��� -�"�
CONSTRUCTION LENDING AGENCY CITY -� � ty/ - --TEL NO � •��G�
I hereby affirm that there is a construction lending agency for r
IV
the performance of the work for which this permit is issued CONTRACTOR
(Sec..3097, Civ. C.). A -
ADDRESS40)
Lender's Name b
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that.the LICENSE NO. -. CLASS ?'
ove infor ati s correct..l agree to comply with all County t �
rdinances a d State laws relating to building construction, 4' a., 6
nd h�, orize.%pr sentatives of this County to enter r
pon the b entio roperty fo inspectjon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or e t Date - -
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 _ MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1005040018
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626)285-0488 EXT:
ILEGAL ID: FEES PAID 1 BUILDING ADDRESS:
ITR: 14647 LT: 19 I 4935 ARDSLEY DR
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917803804 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
I
18590-018-010 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, Cl
102 COMPRSR < 100 KBTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: 1
I 130 AIR INLETS/OUTLETS 14.00 UNI 60.90 105/05/10 SR 1
1 154 NO PERMT $224.70 MIN 257.00 257.00 I I
(OWNER: TEL. NO: I TOTAL FEES 399.65 IFI AL DATE FINA B.Y CODE: 1
14935 AGTON, DAN (949) 551-5075- i i t�)--I
(u ).
14935 ARDSLEY DR y 1 7 r,
ITEMP 917803804 IDESCRIPTION OF WORK
I ( IREPLACE FURNACE 90,000 BTU & A/C 4 TON ON ROOF + 14 DUCT
IRUNS IN SAME EXACT LOCATIONS
1APPLICANT: TEL. NO: 1
(SERVICE CHAMPIONS (714) 777-7777- - I
122911 SAVI RANCH PWY 1 ISPECIAL CONDITIONS: I
IYORBA LINDA 92887 1
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
ISERVICE CHAMPIONS HEATING AND A,C (714) 777-7777- I 1 I
122911 SAVI RANCHY PKWY LIC. NO I IFAU/WALL FURNACE 1
IYORBA LINDA, CA 92887 799170 C20 I
ICOMBUSTION AIR OPENINGS I I
(ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK I
LIC. NO: 1 JAC/COMPRESSOR
I ITHERMOSTAT
IFIRE DAMPERS I I
I 1 ISMOKE DETECTION DEVICES I I I
I I JCOMMERCIAL HOOD I
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I IREPORT ID: DPR264 ROUTE TO: BS0508 I 1 I