HomeMy Public PortalAbout9511 BLACKLEY ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
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
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NOPROCESSED BY
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH
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 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business HEATER: WALL }
and Professions Code, and my license is in full force and effect. d
O
V
License Number Lica Class , ui
LL
Contractor Date
I am exempt under Sec. Q
Plan check fee oc
8.8P.C. for this reason PERMIT ISSUING FEE $
Date:
TOTAL FEE L++
Signature ►—
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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 my employees with ADDRESS
wages as their sole compensation, will do the work and ' * •
CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). s ' 1
OWNER
❑ I, as owner of the property, am exclusively contracting • • w
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
t
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0601300018
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 17190 LT: 7 9511 BLACKLEY ST •_
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803143
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8590-005-009 01 PERMIT ISSUANCE FEE 27.75 THOMAS.PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C
04 COMPRSSOR > 500 KBTU 1.00 COM 130.95
TENANT: 10 FURNACE > 500 KBTU 1.00 UNI 130.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 10.00 UNI 43.50 01/30/06 JK 07/29/06
41 VENTILATION FAN 3.00 FAN 47.25
OWNER: TEL. NO: TOTAL FEES 380.40 FINAL TE FINAL BY: CODE:
ZHANG, SAM (626) 203-9639- /
9511 BLACKLEY ST
TEMP 917803143 o DES ION OF WORK
INXTAL AIR CONDITIONING AND HEATING SYSTEM
APPLICANT: TEL. NO:
ZHU (626) 203-9639-
556 W. LAS TUNAS DR SPECIAL CONDITIONS:
SAN GABRIEL
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
NOVEL DEVELOPMENT, INC. (626) 202-5448-
319 N. SAN GABRIEL BLVD. LIC. NO FAU/WALL FURNACE
SAN GABRIEL, CA 91775 855491B
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