HomeMy Public PortalAbout10832 ARROWOOD ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 76360464CDPW9/89 APPLICATION FOR PERMITLIME 'GREEN.,
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) _ LI
Policy NAQ.AA r- 2L mpany 577t-7ZF d COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN go'RD
E83 8� Z TV�{ft/�����//•^
de rtment. (PRINT OR TYPE ONLY)
Date 6
LOCALITY
NO.plicant i,7
.. � TYPE OF APPLIANCE OR EQUIPMENT FEE. O
-
CER TIFI ATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM -
DISTRICT NO. P CE V
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. lJJ (J
C,
COMPRESSOR,BTU
APPROVALS D E PECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,'you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION IFLOOR BTU VALIDATION
( hereby affirm that I am licensed under provisions of Chapter 9 / HEATER: S A ENDED UNIT—
(commencing
commenciin with Section 7000 of Division 3 of the Business and ( J
Professions Code, and my license is in full force and,effect.
0.1
License Number 3 0 0 �+ic7 y Lic.Class o
Y a.
Contractor 's Date a 0
❑
lam exempt under Sec. Plan.Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ Z5 (os 0
Date: TOTAL FEE SS
Signature W
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
hereby affirm that I am exempt from the Contractor's.License Law NAME , a
for the following reason (Section 7031.5, Business and Professions ACCT.v'
Code): _
ADDRESS 1307 50.75
❑ I, as owner of the property, or my employees with wages qq ITEMS
k�e;�
LEMS
as their sole compensation, will do the work and the CITY TEL.NO. 1 T
structure is not intended or offered for sale (Section 7044, TOTAL
T 1 !C �-
Business and Professions Code). OWNER /`r^ '/�L // Z `LOt{Ate,•• 0 m —�—3
❑ I, as owner of the property, am exclusively contracting MAIL -f •s s�' /�. r•fl �l� 5�I=c
with licensed contractors to construct the project (Sec- ADDRESS 6 3� .y w CP �� t
tion 7044, Business and Professions Code). / t1�13E o�l
CITY C� TEL.NO. Y�y k k a .. ........ .. . .
CONSTRUCTION LENDING AGENCY
I herpeby affirm that there is a construction lending agency for CONTRACTOR
the erformance of the work for which this permit Is issued � � , _ 0 „-3
(Sec.3097,Civ.C.): 101000`U D1 4/26tF 7.?
ADDRESS '6611'r
S// rz . . .. i qf,1
Lender's Name t'�` S A� �+ 35 f t A I 8'-2 13;
rlNd � TEL.NO. (� 2 J_
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO_J//2�0 CLASS 0
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 the above-mentioned
prope for inspection purposes. 41SEE REVERSE FOR EXPLANATORY LANGUAGE
l- NA URE OF APPLICANT OR AGENT DATE
° CZ)U's Y OF LOS ANGELES TEMPLE C..7.T PERMIT
DEP:RTPL
MEN7 OF PUBLIC WORKS 9701 L,".S TULAS 'riE 050: 0408190005
BUILDING A�=G SAFETY / LAND DEVELOPMENT TEME SITY :,'A r1780
PHONE: CL:'.5; 285-0458 EXT:
E[AL ID: --� - FEES PAID —�—.. BUILDINGUFtfa: - - ~-
jTR; 14020 LT: 30 10832 ARROW-014 Si•
IFEE DESCRIPTION: QUANTITY: UOM: ?FiCi'aT: TEMP CA 917003'_:17
i"� �SSOR INFORMATION NUMBER. ��� NEAREST CR-OSS -i
n...�,_
'8'574—O06-008 iui PERMIT ISSUANCE FEE 2;:75 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEiPLE CITY, C
__ 02 COMPRSR < 100 s L•T.U 1.00 COM 7.-00
il'EP.ANT: 08 FURNACE/HEATER <'i';0 1.00 UNI 27.00 ISSUED ON: P R 0 S7 t'Y: PLAN BY: EXP-,rl!:�Gh:;
30 AIR INLETS/OUTL'ETS 7.00 UNI 50.45 08/19/04 %' 02115,05
TOTAL FEES, '17_.20 _
0.?h"2"R: TEL. NO: -_—I FINAL DATE
kU;JFZ IRENE N TR IRErE ri NUNEZ TRUS (818) 444-3840- j ice' D `� -' _---
iT08?2-ARR0WO0D ST P- - " L3
T `-=—
1EM.T' 9/7803517 DESCRIPTIO r O
I LI'l
INSTALL NEW- EAi!`2G ;^!v AIR N ROOF
!APPLICANT: TEL. NO: V
�''OIFORT CLIMATE CONTROL (626) 815-1612"-
W. i—
Mff1U17 . FOOTHILL BL (SPECIAL CONDI"liONS:
USA. CA 91702
I" _ TEL. N07 APPROVALS D.-"-iiE INSPECTOR lGNA U E
- ,,:4T-AC70R:
COf•t;ORT CLIMATE COI!TROL (626) 8'!-r,-
11017' W FOOTHILL BLVD LIC. NO I FAU/WALL FURNACE
i iCi1R , CA 91702 64 i 0hOu I C
(COMBUSTION AIR 0-,-ENI%GS
ITECT OR ENGINES TEL. .,.I IDJC7 WORK `-�-- ' - --____. -__ _ -- --•-
_ I i i
NO: ,ACI;C:IPPRESSO^ i
i I
I !
'IRE DAMPERS
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COMM ERC lAL. HOO5
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ADDITIONAL DATA O! FIL
REPORT iD: DPR264 ROUTE TO: BS0508