HomeMy Public PortalAbout5039 CAMELLIA AVE_Mechanical__ wbRIERS'COMPENSATIONDECLARA-nON APPLICATION FOR P�RMIT
.I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A36sC
❑pcyI6 C4:G; /d �9Z y ,��/( f�I �-ete(g>v. to;et)
IP�oIIi No. Com SibPe/'i Qu UiC�tlOsY� r
Certlfled copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certlfled copy is filed with the county.building Inspec-. FOR APPLICANT TO FILL IN B IILDING 3 (� C!
tion department. /',' (PRINT OR TYPE ONLY) ADDRESS
Date Appllcant LW I �$ L LOCALTY
NO. TYPE OF APPLIANCE OR EQU I PMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' QST
COMPENSATION INSURANCE CROSS�•"
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTUFo sTaicT No. PROS ev
the permIlt Is for one hundred dollars (:100)or less.) v
AIR HANDIJtJG UNIT,CFM a
I cerllfy that In the performance of the work for which this 1 0
permit Is Issued, I shall not employ any.peIn any manner
w as to become subject to the Workera�Compensation Laws.Compensation BT0 APPROVus DATE I RTECTOR-S SIGlaTU RE
Date Anpllcont- / -COMPRESSOR, BTU V ROtr
NOTICE TO APPLICANT: if, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Worken'
Compensation provisions of the Labor Code, you must forth- EYAPORATiVE 030 ER VALIDATIO
with comply with such provisions or this permit shall be
deemed revoked. , FURNACE: FAUYm
LICENSED CONTRACTORS DECLARATION FLOOR BTU O '�
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 WAIL
and Professions Code,and my license Is In full force and effect. d
Lic�14Ve4X/VSVC
Number/.< �� d-+� Llc. Class �—.�- UU 0
Coor Date ad
❑ I am exempt under Sec. sL
Plan check fee + 5,B.BP.C. for this reason' Z
PERMIT ISSUING FEE;
Date. TOTAL FEE 33337 35.75
Signature '
OWNER-BUILDER DECLARATION PLAN CNECY APPUCANT 1 1TENS
I hereby affirm that I am exempt from the Contractor's License —.c c
Law for the following reason (Section 7031.5, Business and NAME TOTS 1-13
Professlons Code):
❑ I, as owner of the property, or my employees with
ADDRESS GfiE��'. 35.7
wages as their tole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CITY TEL NO.
704", Business and Profemlons Code).
OWNER
❑ I, os owner of the property, am exclusively contracting MIJL 03OLr-LW 2'14/8.
with licensed contractors to construct the project (Sec-
Ilan 7W", Business and Professions Code). SS 1230 1 r
CONSTRUCTION LENDING AGENCY -re
NO. -3
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit is Issued OONTRACTOR 'IC
(Sec. 3097, Cly. C.).
ADDRESS d I
Lenders Name ac
Lenders Address C"� TEL NO,�,
STATE !7 f ^ UC.
I certify that I have read this application and state that the LKINSE NO. (- (p of G CLASS
above Information Is correct. 1 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 loe-mentlohed property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,Ie(1 .-a- -z J q — F /
Slgm"r+of Appllcant cr Agent Die //,
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COUNTY OF LOS ANGELES TEMPLE CITY 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUBAS ME 0508 0407120004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
L E GAL ID: --7nS PAID BUILDING ADDRESS:
TR: 141+67 LT: 27 5039 CAMELLIA AV
FEE DESCRIPTION: QUANTITY: LIOM: AMOUNT: TEMP CA 917803854 _
ASSESSOR INFORMATION NLMER: MEAREST CROSS STREET: LA ROSA
8589-014-014 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TE14PLE CITY, C
30 AIR INLETS/OUTLETS 1.00 UNI 4.35
41 VENTILATION FAN 1.00 FAN 15.75 .
TOTAL FEES 47.85 07/12/04 JK 01/08/05
KIO HSU, HUEI CHING (626) 285-9112-
5039 CAMELLIA AV
TERP 917803854 OF WORK
EXTEND DUCK WORK TO THE NEW ADDITION
APPLICANT: TEL. NO:
SAME AS 06MER
SPECIAL DITIONS:
CONTRACTOR: TEL. WO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO
ARCHITECT OR ENGINEER: TEL. NO: DUCT 6K)R-K
LIC. N0:
FIRE DAMPERS
SMOKE DETECTION DEVICES
REPORT ID: DPR264 ROUTE TO: BS0508
COUNL'Y OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1210260004•
BUILDING AND SAFE'T'Y / LAND DEVELOPMENT TE2GgE CITY CA 91780
PHONE: (626) 285-0488 ETT:
LEGAL ID: FEES PAID 13UILD12JG ADDRESS:
TR: 14467 LT: 27 _ - 5039 CAMELLIA AV.
FEE DESCRIPTION: QUANTITY: DOM: AMOUW: T'E1P CA 917803854
ASSESSOR INFORMATION NUI-SER: NEAREST CROSS STREET: '
8589-014-014 01 PERMIT ISSUANCE FEE 27.80 THOMA$ PAGE: 597 (I7ID: A4 LOCALI7.'Y: TEMPLE CITY CA
02 COMPRSR < 100 SBTU 1.00 COM 27.00
TEnmNr: 08 FURN7LCE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PIAN BY:
54 NO PERMP $224.70 MIN 342.20 342.20 10/26/12 SR
TOTAL FEES 424.00
OYBiER: TEL. NO: FINAL DATE FINAL BY: CODE:
5YU LUO (626) 226-9112-
5039039 CAMELLI?. AV ►y�,'.1/� `� IV
TEMP 917803854 _ DESCRIPTION OF STORE
HVAC REPLACEMENT .
APPLICANT: TEL. NO:
LIU, NORMAN (626) 579-1559-
10932 GRAND AVE SPECIAL CONDITIONS:
TEXPLE CITY CA 91780
NPRACtOR: - TEL. NO: OVALS DATE
NORMAN LSO (626) 579-1559-
10932 GRAND AVENUE LIC. NO FAU 'pAL.L, FURNACE
TEMPLE CITY, CA 91780 559374
COI]�USTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. PO: _ DUCT WORK '
LSC. NO: - AC/COMPRRSSOR
T11ERM)STAT
_
FIRE' DAMPERS
SMO DETECTION DEVICES
COMMERCIAL HOOD
i
i
REPORT ID: DPP264 ROUTE TO: RS0508