HomeMy Public PortalAbout10732 ARROWOOD ST_Mechanical__ s ^WORKERS' COMPENSATION DECLARATION n PPnLL C(�n TION FOR PERM17
•�6laerrby affirm that I have a certificate of consent to self /� (JV
...r!insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING' - AIS COfdDITIOWING
ora ertified copy theresf (Sec. 3800 Lab. C.) 76A364C '
��((�� lj />�Y pv���, CE-_818(REV. 10/81)
-Pblic o. r om an `�li D/��VG(�1 L • .
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
'lF—��/Certified copy is filed with the county buildinginspec- FOR-APPLICANT TO FILL IN BUILDING 32, /n 0
[���i�t1y?��ion depa/rime/(A1t. (PRINT OR TYPE ONLY) ADDRESS 0 7 01W u/O D G[
a'lJ Tel —` —�+ A• licant LOCALITY
PP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
BTU - DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by ABSORPTION UNIT, _
the permit is for one hundred dollars ($100).or less.)
AIR HANDLING UNIT,CFM (f
I certify that in the performance of the work'for which this .. • - _ C
permit is issued, I shall not employ any person in any manner
L?�
so as to become subject to the Workers'Compensation LOWS. �7 BOILER, BTU APPROVALS DATE ws OR'S SIGNATURE
Date Applic6'nt
COMPRESSOR,,BTU ��+ ROUGH
r
NOTICE TO APPLICANT: If, after making.this Certificate 'of VENTILATIONSYSTEM FINAL 1
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: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I'am licensed under provisions of Chapter 9 HEATER: WALL SUSPENDED UNIT
'(commencing with..Section 7000) of Division 3 of the Business �
and Professions Code,and my license is in full fod effect.
� 0.
License Number D3 7`3 Lic. Class u
Contractor C !�- V/V 1,1 -D �0' D
❑ I am exempt under Sec. W
Plan check fee h
'B:BP.C. for this reason . ,
PERMIT-ISSUING FEE $- 6(f z 0;1 ;1,0 A
Date:
Signature TOTAL FEE S # o,u'c,o'o8.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D rI a.io 3 0,5 0
Low for the'following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or 'my employees with ADDRESS o.o-o 3,0.5.0 v
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO. 0 0,7'8:i 8
7044, Business and Professions Code).
' OWNER /l� h
ElI, as owner of the property, am exclusively contracting MAIL ,L '`/��
with licensed contractors to construct the project (Sec- ADDRESS /�°v(0 rn
/p
tion 7044, Business and'Professions Code). {�
CONSTRUCTION LENDING AGENCY. CITY TEL. NO.
hereby affirm that there is a construction lending agency for may,,
the performance of the work for which this.permit is issued CONTRACTOR Gj 11141AA /f� I/ve , - D
(Sec. 3097, Civ. C.). _
ADDRESS 1 �y
Lender's Name �i `
CITY /STATE !�/� TEL. NO��� z
Lender's Address /�� v7
I certify that I have read this application and state that the LICENSE NO. 3'735 CLASS��O` `3� .
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
° and hereby authorize representatives of this County to enter
upon above-mentioned ert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent - Dote - - - '
COITNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1201110010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780_
PHONE: (626) 285-0488 EXT:
ILEGAL ID: 1 FEES PAID I BUILDING ADDRESS: 1
ITR: 17867 LT: 37 1 1 10732 ARROWOOD ST 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917803403 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS.STREET: 1
18574-002-013 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl
I 141 VENTILATION FAN 2.00 FAN 31.60 I
(TENANT: I TOTAL FEES 59.40 (ISSUED ON: PROCESSED BY: PLAN BY: I
1 101/11/12 SR
I I I I
(OWNER: TEL. NO: 1 IF NAL DATE FINAL BY: CODE: I
1HUA, IDAL P -(626) 705-4763- - - I �� -
110732 ARROWOOD ST I1131-
ITEMP 917803403. - I I ESCRIPTION OF WORK 1
ITWO VENTILATION FANS FOR Bv
HROOMS REMODEL
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(APPLICANT: TEL. NO: I I - I
ISAME AS OWNER - I I I
ISPECIAL CONDITIONS: - I
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ICONTRACTOR: - TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
ISAME AS OWNER - I I I
I LIC. NO 1 IFAU/WALL FURNACE I
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I ICOMBUSTION AIR OPENINGS I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I
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I (REPORT ID: DPR264 ROUTE TO: BSO508 I I I I