HomeMy Public PortalAbout6116 AVON AVE_Mechanical__ RKERS C0131YENSAT'lON DECLARATION ' CEA 818 (280),
18(2 80) A P P L IC AT 8 O �7 FOR P E R II�%11 0 u
affirm that I have a certificates ofA consent to self i i" s rt
WO�acertificate of Workers Compensation Insurance or
+-� ��~r r
HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 Lab C) } Y
Policy NO Company s
Certified copy is hereby furnished
t COUNTY OF LOS ANGELES BUILDING AND SAFETY `t �
.
❑ Certified C'o'py is filef., iC 0. « �
d with the county building inspection FOR APPLICANT TO FILL IN BUILDING _
t department z '' r . i a.,".
Date Ap_ can`t 4 > ' i w (PRINT OR TYPE ONLY) P ADDRESS
e g m ca ' LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' 4 * NO TYPE OF APPLIANCE OR EQUIPMENT � p FEE}
'"COMPENSATION INSURANCE r r s n NEAREST n� }
CL
(This' section need not be completed if the work involved ' ABSORPTION UNIT BTU CROSS a q0
by the permit is for-one-'hundred dollars($100) oI`less) DISTRICT NOPROCESSED BY U
I certify that m the performance of the workffor which this n « AIR HANDLING UNIT CFM _
permit is Issued' I sR;All not employ any person in any manner O
so as to become subject to the Workers Compensation Laws BOILER BTU f -
) �� �p.
P � � �X1 �IYtB� « 3 t n K APPROVALS DATE ( INSPECT c TUBE
Date� ��sdy[ A plica COMPRESSOR BTUROUGH y
NOTICE TO APPLICANT If after making this°Certificate of ^ r VENTILATION SYSTEM Z
1 Exemption you_ should become subject to the Workers'
FINAL ..t
Compensation provisions of the Labor Code"you must forth ' EVAPORATIVE COOLER { j VALIDATION
with comply with such provisions or this permit shall be a a a
deemed revoked °^r r a i FURNACE FAU BTU GRAVITY—
LICENSED
RAVITY 4 y t
LICENSED CONTRACTORS DECLARATION
I hereby affirm that- am licensed under provisions of Chapter P 'f HEATER r DED- UNIT
9 (commencing with Section-7000) of Division 3 of the Busi i
ness and Professions Code and my license is in full force and
effect x -
n
License Numbe Lic Class
Contractl4 Date b
r "
I am exempt from the licensing requirements as I am a -
licensed architect or a registered professional-engineer Plan check fee 25%of-,above
acting in my professional capacity (Section 7051' Bus
mess and Professions Code) oT7 PERMIT ISSUING FEE $�
Licror Reg No Date i ^ r i , TOTAL FEE
9
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
1 93.5A '
I.-hereby affirm that I am exempt from the Contractor s ` w NAME
License Law for the following riason,.(Section 7031 5` Bust
� s ep p � 0 • 8
ness and Professions Code) ADDRESS "
r
r as towner'of the property will do the work and they r x a e y ` 2101a2050, a,
structure is not intended'or offered for sale-(Section CITY TEL--NO i
7044 Business and Professions Code) I ` OWNER - b `I - �, Ia o o,2 0 5 0 6,
I"aspowner of the property am exclusively pcontracting a i ,f s n 061 8!(
w4 with licensed contractor"'to construct the project MAIL` 4 n r r 1 r
4 (Section 7044 Busmess and Professions Code} 'ADDRESS 17, _ r ,
p it i r CITYS ! i EL NOw2 ^CONSTRUCTION LENDING AGENCY � e,�
I,hereby affirm that there is a construction lending agencye
for the performance of the work for which this permit is CONTRACTO
issued(Sec 3097 Civ C) z ` e
:
Lender s Name _ * ADDRESS
hF
Lender s Address CITY F TEL NO s fti s d
_ �.Oed�S tF
I certify that I have read thisnapplication«and state that the STATELIC
~
above information is correct I agree to comply with all County LICENSE NO CLASS r r A
ordinances and State laws regulating Heating Ventilating and
Air Conditioning a hereby authorize representatives'of this SEE REVERSE POOR EXPLANATORY L\NGUAGE -
Coun to e r upc n the above mentioned property for i
Signature of Permittee r Date '' _ f
s r
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1106130002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285 0488 EXT
ILEGAL ID I FEES PAID BUILDING ADDRESS
ITR 5903 IT 49 1 6116 AVON AV
I IFEE DESCRIPTION QUANTITY DOM AMOUNT SGAB CA 917752606
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET
15386 009 042 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID G2 LOCALITY TEMPLE CITY Cl
I 141 VENTILATION FAN 1 00 FAN 15 80 1
TENANT I TOTAL FEES 43 60 (ISSUED ON PROCESSED BY PLAN BY
106/13/11 SR
OWNER TEL NO I IFI AL DATE FINAL Y CODE I
-INGUYEN -KIM -- (818) 749 8063
6116 AVON AV
ISGAB 917752606 1 ID SCRI TION OF WORK
REPLACE VENTILATION FAN
APPLICANT TEL NO
ISAME AS OWNER
I I ISPECIAL CONDITIONS
ICONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER I
I LIC NO IFAU/WALL FURNACE I I
1 1
I ICOMBUSTION AIR OPENINGS 1
(ARCHITECT OR ENGINEER TEL NO IDUCT WORK
1 1
I LIC NO I IAC/COMPRESSOR 1
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IREPORT ID DPR264 ROUTE TO BS0508
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