HomeMy Public PortalAbout9943 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89
76A364C 'APPLICATION FOR PERMIT LICE GREEN
76A3 - '
I hereby affirm that I have a certificate of consent to self Insure,. .
or a certificate of-Worker's Co npensation Insurance, or a certified' -,HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
'. P❑olicy No Company` COUNTY OF'LOS ANGELES" DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.`.
Certified copy is„hereby furnished.
❑ Certified-co is filed with the county buildin 'ins ection FOR APPLICANT'TO FILL'IN BUILDING 2. '
PY 9 P ADDRESS • J
- -department. (PRINT•OR TYPE ONLY)
Date' ApplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT, .-a - FEE c
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
_-COMPENSATION INSURANCE i 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($100)or,less.)• AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, (,shall not employ'any person in any manner so as to BOILER,BTU y
become sub' t to the Workers' Compensation Laws
/+ COMPRESSOR,BTU
APPROVALS - ',DATE INSPECTOR'S SIGNATURE
Da V L Apphca VENTILATION SYSTEM
NO E TO APPLICANT: If,,after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you-must forthwith comply with suctr FINAL —uICA
provisions or this permit shall be deemed revoked. ' 'FURNACE. FAU Y y0. VALIDATION .
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I:am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 70 00) of Division 3 of the Business and. WALL
Professions Code,and my license is in full force.and effect
JL
LicenseNum*4 �- / Lic Class 2� 33031fIttFo•1�
CL
Contractor^ Date 1, ITEM O
Iff
Plan check fee �I�i A j. m U
I am 'exempt under Sec. .-; 65
BAP C.for this reason PERMIT ISSUING'FEE'$ C.HECK 0
Date. TOTAL FEE �p lJ CHAN aE ri ; w
Signature 0-
PLAN CHECK APPLICANT In
OWNER-BUILDER DECLARATION i i Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , I E013C 301,�� 6/VS.-�' _
for the following reason (Section 7031.5; Business and Professions hhiq i o sit
Code) ADDRESS �{ 4� i A i 1 L•3:
❑ 1, as s owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL NO.
structure isnot intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am'exclusively contracting' MAIL L/
,with licensed contractors to construct the project (Sec- ADDRESS'
tion 7044, Business and Professions Code): CITY �� 32
CONSTRUCTION,LENDING,AGENCY
hereby affirm that there`is a construction lending agency for
ow
the,performance of the work for which this permit:is issued; CONTRACTOR
(Sec-3097;Civ.C.)'. _
ADDRESS
Lender's Name
' CITY ` L �'',S�O7” -
Lender's Address STATE / LIC.
I certify that Lhave read this application and state that the above LICENSE NQf� ! T Ej CLASS C Z
'information is correct: I agree-to comply with all County the
And State laws relating to building construction,and hereby authorize
representatives of this County-to enter upon the a-me tinned ^
proper r in ection rpipses r
�� •�� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG E OF APPLICANT OR AGENT D E
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1106010007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID
1BUILDING ADDRESS:
TR- 16557 LT: 5
9943 BOGUE ST
1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802632
ASSESSOR INFORMATION NUMBER. I1 NEAREST CROSS STREET- BROADWAY
18588-014-022 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
1 130 AIR INLETS/OUTLETS 1.00 UNI 4.40
1TENANT: 131 AIR INLETS/OUTLETS 1.00 SQ 37 00 (ISSUED ON: PROCESSED BY: PLAN BY:
141 VENTILATION FAN 2.00 FAN 31.60 106/01/11 SR 1
1 147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 1 1
1OWNER: TEL. NO: I TOTAL FEES 127.80 1FINAL DATE FINBY: CODE: 1
1VEENSTRA BARBARA J (626) 286-5330- 1 1 _f� B
19943 BOGUE ST 1
1TEMP 917802632 1 IDESCRIPTION OF WORK
1 1ALTERATION OF EXIST DUCT SYSTEM, 1 AIR INLET AND 2 1
I iVENTILATION FANS
1APPLICANT: TEL NO:
1FIEL, JIM (626) 222-8803- 1
1SPECIAL CONDITIONS:
I I I I
1CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
1FIEL, JIM (626) 222-8803- 1
1 LIC. NO 1 1FAU/WALL FURNACE 1
NONE 1
1
1 1 1COMBUSTION AIR OPENINGS
1ARCHITECT OR ENGINEER: TEL. NO: 1 1DUCT WORK I I I
1MUTKA, JASON (951) 235-0276- 1
1 LIC. NO- 1 IAC/COMPRESSOR 1 1 1
1 NONE I
1
-i 1THERMOSTAT 1 1
1 i (FIRE DAMPERS
1SMOKE DETECTION DEVICES I
1COMMERCIAL HOOD 1 I
1 I I I I I
I
I I I I
1 1 I I I I
1 I I I I I
I I II I I
1 I I I I I
1 1 I I I I
I I I I I I
(REPORT ID: DPR264 ROUTE TO: BS0508 1 1
I I I I I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS - - ME 0508 1210230030
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: i FEES PAID
BUILDING ADDRESS:
ITR: 16557 LT: 5 I 9943 BOGUE ST
IFEE DESCRIPTION., QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802632 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18588-014-022 101 PERMIT ISSUANCE FEE'.', 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I -'"'147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 I I
(TENANT: 154 NO PERMT $224.70 MIN 342.20 342.20 (ISSUED ON: PROCESSED BY: PLAN BY:
- TOTAL FEES 397.00 110/23/12 SR
(OWNER: TEL. NO: j 1FINAL D TE FI Y: CODE: I
1VEENSTRA BARBARA J (626) 840-7177- 1 1
19943 BOGUE ST i I I
1TEMP 917802632 1 IDESCRIPTION OF WORK I
I I IC/O INCREASE TWO S/A DUCTS
I I I I
(APPLICANT: TEL. NO: I I I
IGROSENBACH, PHILLIP (626) 358-0022- 1 1 I
11310 S MYRTLE AVE 1 1SPECIAL CONDITIONS: I
(MONROVIA, CA 91016 I 1 I
I I
I I '
1CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
1GENERAL HEATING AND A C INC (626) 358-0022- 1 1 I
11310 S MYRTLE AVE LIC. NO 1 IFAU/WALL FURNACE 1 1 I .
1MONROVIA CA 91016 469166 1 1 1 I I
ICOMBUSTION AIR OPENINGS I I
ARCHITECT OR ENGINEER: TEL. NO: i (DUCT WORK I I I
LIC. N0- I JAC/COMPRESSOR
I I I
ITHERMOSTAT I I I
I I I
IFIRE DAMPERS -1-1 I
I I I
I ISMOKE DETECTION DEVICES
I ICOMMERCIAL HOOD 1
I I I
I I I I I I
I I I I I I
s'
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I IREPORT ID: DPR264 ROUTE TO: BS0508 I I I I
I I I I I I