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Home My Public Portal About9723 BROADWAY_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT �� 0-0076A364C that I have a certificate of consent to self insure, `fforker's Compensa'on Insurance, a certified HEATING. VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 b C.) -' Policy ompan Y ' OUNTY OF LOS ANGELES DEPT OF PUALIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. - Certified co Is filed with the c I building ins cticn FOR APPLICANT TO FILL IN BUILDING •�. 3 p�arrt¢�en�py//� y g _ (PRINT OR TYPE ONLY) ADDRESS /J ' 1' 1-V1� 1 pp LOCALITY Date A II orl I NO, TYPE OF APPLIANCE OR EQUIPMENT FEE �� C CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed it the work involved by the ASSESSOR' MAP BOOK PAGE PARCEL .permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT.CFM nISTRICi NO. PgOyE55ED 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 BOIL R,BTU //' become subject to the Workers' Compensation Laws. - O - �` �t COMPRESSOR,BTU APPROVALS OATE INSPE T 'a SIG NATURE 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 / _O V ATION LICENSED CONTRACTORS DECLARATION FLOOR BTU rte' I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. License N bef PA) ✓✓ Lic.Clas �✓ _ Contractif Date40-. D ACCT a O ❑ Plan check fee .a V I am exempt under Sec. 40 3303 „��.90 cc 8.8P.C.for this reason PERMIT ISSUING FEE Dale: _ 1 ITEMS I— TOTAL FEE CJ - - -cxcl' 90 LU Signature TOTAL 7 +�'�+ ® a OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - CHECK °8•9U Z I hereby affirm that I am exempt from the Contractor's License Law NAME DCHANGE .00for the following reason (Section 7031.5, Business and Professions Code): ADDRESS ❑ I, as owner of the property, or my employees with wages ff11 nn �r -t p as their sole compensation, will do the work and the CITY TEL.NO. - 0000—Iwo1 Jh�t /i J6 structure is not intended or offered for sale (Section 7044, 6266 1 AI11t X42 Business and Professions Code). OWNER 1 ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRES tion 7044, Business and Professions Cade). CITY TEL.NO. 1 CONSTRUCTION LENDING AGENCY �" I hereby affirm that there is a construction lending agency for CONTRACTOR the erformance of the work for which this permit Is issued (Secp.3097,Civ.CO. ' ADDRESS _ Lender's Namer CIT I ( TEL.NO. ,. Lender's Address STATE l LIG I certify that I have read this application and state that the above LICENSE 10. CLASS information is correct. J 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 _ prop rty forinspec ion a�p s s. S SEE REVERSE FOR EXPLANATORY LANGUAGE TU rL T A FNT — /•'�/ DA//T-e WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9189 76A364C APPLICATION FOR PERMIT - '�. 1 5. 1 ^1 3. 4"""tttiE I hereby affirm that I have a certificate of consent to self In Sure, 1 �'{)Il ," . or a certificate of Workers Compensation Insurance, or a Certified HEATING • VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab. C.) PDllcy 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 county building inspection FOR APPLICANT TO FILL IN ADDRESS department (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO, TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS SL COMPENSATION INSURANCE 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 (S100)or less.) AIR HANDLING UNIT.CFM DISTRILi No. P30CESSED 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 BOIL R.BTU become subject to the Workers'Compensation Laws. . CO P R.BT APPROVALS DATE INSPECTOR S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If. after making this Certificate of ROUGH Exemption, you should become subject to the WorkersCompensation EVAPORATIVE COOLER provisions of the Labor Cotle, you must forthwith comply with such FINAL i provisions or this permit shall be deemed revoked FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ (commencing with Section 7000) of Division 3 of the Business and WALL Professions Code, and my license is in full force and effect. U License Number Lic.Class D Contractor Date .. . ❑ I am exempt under Sec. Plan check fee LL S.EP.C.for this reason PERMIT ISSUING FEE S Date: TOTAL FEE C Signature - PLAT:CHECK APPLICANT ... - OWNER-BUILDER DECLARATION C I hereby affirm that I am exempt from the Contractor's License Law NAME D for the following reason (Section 7031.5, Business and Professions Code): ADDRESS - LU ❑ I. as owner of the property, or my employees with wanes - 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). OWNER ❑ 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), CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency tar OONi RACTOR the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). ' ADDRESS Lender'a Name CITY TEL NO. - Lender's Address STATE LIG. - 1 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT OR AGENT DATE COUNTY OF LOS ANGELES TEMPLE CITY q 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1203290008 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: (LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 9723 BROADWAY FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803213 1 (ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET: 16568-010-025 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, CI I 141 VENTILATION FAN 2.00 FAN 31.60 1TENANT: ITOTAL FEES 59.40 (ISSUED ON: PROCESSED BY: PLAN BY: 103/29/12 SR 1 10WNER: TEL. NO: EC DATE FINAL BY: CODE: WONDERFUL INVESTMENT INC. (626) 512-5863- ]] W. LAS TUNAS DR. 11 � ARCADIA, CA 91007 DESCRIYTT'ION OF WORK '1{ INSTALL 2 VENTILATION FANS YOR BATHROOMS REMODEL (APPLICANT: TEL. NO: 1SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: JAPPROVALS DATE INSPECTOR SIGNATORE 1SAME AS OWNER - I I LIC. NO IFAU/WALL FURNACE I I I COMBUSTION AIR OPENINGS (ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK LIC. N0: IAC/COMPRESSOR I THERMOSTAT I I I FIRE DAMPERS ISMOKE DETECTION DEVICES COhP]ERCIAL HOOD 1 II 11 I I I I I I II I I I II I I I I I I I I I II I I � 11 II I 1 RE PORT ID: DPR264 ROUTE T0: BS 0508 I I I I