HomeMy Public PortalAbout9822 BROADWAY_Mechanical__ WORKER'S COMPENSATION DECLARATION It
PW 9189' _-APPLICATION FOR �PERII�IT ����- ����IfV
- affirm that 1 have.a certificate of consent to self insure -
oI icate ct Worker:s Compensation Insurance, ar a certified ' - HEATING,-VENTILATING •AIR CONDITIONING
cop .of(Sec. 3800 Lab.C.) -
olicy No. y� �3� Ce pang • COUNTY OF LOS ANGELES DEPT OF'PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ,Certified copy is hereby furnished. - - ('�
Certified copy is flled•with the county building inspection •FOR APPLICANT TO FILL•IN ADDRESSDDRESS n
epadm n1. (PRINT OR TYPE ONLY) A2S 7`J
el& A LOCALITY
A
Date Applicant N0. TYPE OF APPLIANCE OR EQUIPMENT FEE- . ""'
* CERTIFICATE OF EXEMPTI RO ORKERS' NEAREST �AI rA
COMPENSATIONS RANGE• •• CROSS ST. gALD L✓ -/v•
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($100)or less.) AIR HANDLING UNIT,CFM DIsrRICT No. - RRDCESSEO av
I certify that in theperformance of the.work for which this permit
is issued I shall not employ any person in any manner-so as to BOILER,BTU 'I"
become subject to the Workers'Compensation Laws. . O GT U
• "' COMPRESSOR,BTU
APPROVALS DATES NSPECTOR'h.00 ATURE -
Data Applicant - VENTILATION SYSTEM ,
NOTICE TO APPLICANT' It, after.making'lhis Certificate of ROUGH
'Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER - f
provisions of the9.abor Code,.you must forthwith'comply with such FINAL 3— I � •fes-c�"
.provisions or this permit shall be deemed revoked. 'FURNACE:_ < AUul
'GR TV
LICENSED CONTRACTORS_DECLARATION FLOOR BTU VALIDATION•
I hereby affirm that I am.licensed under provisions of Chapter 9' - ENDED - UNIT—_
(commencing with Section.7000)'of Division 3 of the Business and HEATER: SUSPENDED
-
Professions Code; and my license is in full force and effect.
License Number WALL
7�/ 7 JV 2�- Lic.Class e2-0 -
- pp f - - •}
Conlractorrot'le SI �Ui.,S Date 9 ` D 0
❑ D am exempt under Sec Plan check fee
_B.&P.C.for this reason PERMIT ISSUING FE E-$ �3 0
a
Date: - TOTAL FEE Jam'[70 W
Signature O'
PLAN CHECK APPLICANT - _ - �
• OWNER-BUILDER DECLARATION - _ Z
I hereby affirm that I amexemptfrom the Contractor's License Law NAME '7C'C r/ I !�
for the following reason(Section 7031.5, Business and Professions r VJ - -
1 b
Code): • ADDRESS .A� W,�I .2
❑ .I, as owner of the property, oir my employees with wages -
as their sole compensation, will do the work and.the CITYT{:MP
/•
TEL NO.���ddS�
structure is not intended or offered for sale (Section 7044, �� CC 1. ,. I//'"�2 z
Business and Professions Code). OWNER
❑s' C� ,
I, as owner of the property, am exclusively contracting Tljl(al •-nom - 00
MAIL
with licensed contractors to construct the project (Sec- ADDRESS CHECK,'
tion 7044„Business and Professions'Code). - - -
CONSTRUCTION LENDING AGENCY CITY TEL.NO. ' !'.HHf'flI =I
I hereby affirm that there is.a construction lending agency for. CONTRACTOR
the performance of the work for which this permit Is issued
.(Sec.3097, Civ. C.). {'1 _
ADDRESS 307 1/. 1/' J-AGIVT Clio t0D—'.3Doj1
Lender's Name _
. D J'J� • YJ _. "
CITY TEL.NO. 4692 d1
0'0cVc
.Lender's Address STATE —> �'•(')� LIC. - - -
Icertify thaLlhave read this application and state that the`above uCENSENO. S 6 77 V 2 CLnSS I�
information is correct. I agree to comply with all bounty ordinances -
and State laws relating to building construction,and hereby authorize - r
repr entalives of This County tosss,,,enter upon the above-mentioned
pr per for inspectiol rpol ..SEE REVERSE FOR EXPLANATORY LANGUAGE
-Z� 9V
SIGNATIIR FAPPLIC TOR AGENT DATE - '
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0609150001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91980
- PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID - BUILDING.ADDRESS:
TR: 13805 LT: 29 9822 BROADWAY
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA'917802633 ,
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN .
8588-016-004 01 PERMIT ISSUANCE FEE 29.95 THOMASiPAGE: 597_ GRID:'A3 ' LOCALITY::TEMPLE-CITY, C
47 ALTER EXIST DUCT SYS 1.00 SYS 29.00
TENANT: .. TOTAL FEES 54.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
09/15/06 JK 03/14/07
OWNER: TEL, NO: FINAL DAT BY: CODE:
BECKWITH CHARLES E;JOANNE K (626) 287-2820-
9822 BROADWAY
TEMP 917802633 DESCRIPTION OF WOR
ALTERATION OF EXIST DUCT SYSTEM
APPLICANT: TEL. NO:
WENDY WILSON 6 ASSOC. (626) 404-2161-
908 W. SIERRA MADRE SPECIAL CONDITIONS:
SIERRA MADER 91024
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNJTURE
CHARLES MYRICK (818) 391-3610-
1312 HIGHLAND AVE LIC. NO �. FAU/WALL FURNACE
DUARTE, CA 91010 849976 B
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
CAI.CIVIC ENGINEERING (818) 790-0473-
4929 RUPORT LN. LIC. NO: AC/COMPRESSOR
LA CANADA FLINTRIDGE, CA NONE
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMidERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BSOSOB
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1402100022
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 265-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 13805 LT: 29 9822 BROADWAY
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802633
1855E-5OR INFORMATION NUMBER: NEAREST CROSS STREET: BALDWIN
18588 -016-004 01 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, C
102 COMPEER < 100 KBTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN. BY:
30 AIR INLETS/OUTLETS 8.00 UNI 35.20 102/10/14 SR
TOTAL FEES 117.00 1
TOWNER: TEL. NO: FINAL DATE FINpL�Y: CODE:
BECKWITH CHARLES E;JOANNE K 626) 287-2820- (NAL DATE
;INT
9822 BROADWAY
TEMP 917802633 1
IESCRIP'TION OF WORK
HVAC CHANGE OUT AND REPLACEMENT DUCT WORK R-8
(APPLICANT: TEL. NO:
PEIDRA, FERNANDO (909) 575-8192- 1
4650 ARROW HIGHWAY SPECIAL CONDITIONS:
MONTCLAIR CA 91763
C&- j- j-rM 12-
CONTRACTOR:
TEL. NO: IAPPROVAly DATE INSPECTOR SIGNATURE
IHOME PERFORMANCE MATTERS, INC. (909) 992-3214-
1624 FOXPARK DR. LIC. NO FAU/WALL FURNACE
ICLAREMONT, CA 91711 919844
COMBUSTION AIR OPENINGS V
ARCHITECT OR ENGINEER: TEL. NO: (DUCT WORK
LIC. NO: IAC/COMPRESSOR
f ITHERMOSTAT
IFIRE DAMPERS
1SMOKE DETECTION DEVICES 1 1 I
I 1
CGNPSERCIAL HOOD
I
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I j
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I I II I
I
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1 I I I I I
(REPORT ID: DPR264 ROUTE TO: BS0508