HomeMy Public PortalAbout10155 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364C 46DPW 9,69 ' APPLICATION FOR- PERMIT 11 "E GREEN
• 76A3 •
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.)
P❑ollcy No. Company COUNTY OF-LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY,DIV.
Certified copy is hereby furnished
❑ Certified copy.Is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING gip/ - QnrJ� '
''department. Y g p (PRINT OR TYPE-ONLY) ADDRESS �;
Date Applicant LOCALITY 7 ZL C17
- - - NO TYPE OF APPLIANCE OR EQUIPMENT FEE ,
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST J��J •J ✓� '
COMPENSATION INSURANCE" Cz
ROSS ST
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOKPAGE PARCEL.
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY ,
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. ��
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after makiAg 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 t
LICENSED CONTRACTORS'DECLARATION FLOOR BTU •-'VALIDATION' _
1i
: I hereby affirm that I am licensed.under provisions of Chapter 9 SUSPENDED UNIT ;y:.l.:I ,•a
(commencing with Section 7000) of Division 3,of the"Business and, HEATER: WALL
Professions Code,and my license Is in full force and effect Lj it_I
License Number Lic Class_
T+iii; - 30 s 4.- f a
Contractor Date CHECK " =j='`'-j O
' U
CH check fee _ t:^i+
I am exempt under Sec. Aill 1E O
B.&P.C.for-this reason ` PERMIT ISSUING-FEE $ ¢O I--
Date:• EI — ' ii 9 y W
TOTAL FEE'. 'J i_t_ ;E# 4_l
CL
Signature C
rc. z_. ..
OWNER-BUILDER DECLARATION PLANCHECKAPPLICANT *^''') Z
I hereby affirm'that'I am exempt from the Contractor's License Law NAME ,
for,the following reason (Section.7031.5, Business and Professions
-Code): ADDRESS ,
IyX{I I, as owner of the property, or-my employees with wages
as their'sole compensation, will do the work and the CITY TEL NO
structure Is not Intended or offered for sale'(Section'7044,
Business and Professions Code). NER i1/
❑ I, as owner of the property, am exclusively contracting MAIL -
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code);
CONSTRUCTION LENDING AGENCY CIC TEC.'NO
I hereby affirm that there Is a construction lending agency for CONTRALTO ,
the performance of the work for which this permit Is issued
(Sec 3097,Civ:C.). ,
ADDRESS
Lender's Name _
CITY TEL.NO
Lerider's Address STATE LIC.
I,certify that I have read this application and state that the above- LICENSE NO. CLASS
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
propert for inspection purposes:- SEE REVERSE FOR EXPLANATORY-LANGUAGE.•. ,
S,GNATURE OF APPLICANT OR AGENT DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0801030005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS:
ITR: 16957 LT: 132 I 1 10155 BOGUE ST 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA'917802703
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: - 1
18586-019-015 101 PERMIT ISSUANCE FEE 27 75 I THOMAS PAGE: 597 GRID: B3 LOCALITY: TEMPLE CITY, Cl
102 COMPRSR < 100 KBTU 1.00 COM 27.00 1 1
1TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
130 AIR INLETS/OUTLETS 9 00 UNI 39.15 101/03/08 SR 07/01/08 1
I 141 VENTILATION FAN 2.00 FAN 31.50 1
10WNER: TEL. NO: I TOTAL FEES 152.40 IFINAL DAT,.E�^� FINAL BY: CODE: 1
IKIM, JASON (626) 203-9193- 1
110155 BOGUS ST I
ITEMP 917802703 I IDE CRIPTION OF WORK 1
(INSTALL AIR CONDITIONING D HEATING SYSTEM
(APPLICANT: TEL NO:
I I
ICHO CHAN (818) 957-7364- 1
13557 ENCINAL_AVE. ISPECIAL CONDITIONS:
IGLENDALE, CA 91214 I
1CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE
ISUPER AIR REFRIGERAION (213) 952-2171- 1 1 I
13557 ENCINAL AVENUE LIC. NO 1 JFAU/WALL FURNACE 1 1
IGLENDALE CA 91214 682906 C20
(COMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER: TEL. NO" 1 IDUCT WORK I I
1 -
LIC. NO: 1AC/COMPRESSOR 23k
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I ITHERMOSTAT I" 1
I I IFIRE DAMPERS I
I ISMOKE DETECTION DEVICES
I I I I I I
I I ICOMMERCIAL HOOD I
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I IREPORT ID- DPR264 ROUTE TO: BS0508 1 I