HomeMy Public PortalAbout4949 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION �E'4 8 8(2 80) A P P L IC A V O N FOR P E R WT ,
I hereby affirm that I have a certificate of consent to pelf i
insure, or a certificate df Workers'Compensation Insurance',,or
ert d///,,,,Op &�r of Sec 3800, HEATING-VENTILATING-AIR-VENTILATING-AIRCONDITIONING` La C
�ol _ C)mpany__ t
Certified copy is hereby furnished "
COUNTY Of LOS ANGELES BUILDING AND SAFETY
hfied copy is filed with the c,ounty ' q inspection ] '
�o a n r W\_ I FOR APPLICANT TO FILL IN ADDRESS DtX
Date_ pircant
ILI (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE`OR EQUIPMENT FEE _
COMPENSATION INSURANCENEAREST
(This section need not be,completed if the work involved ABSORPTION UNIT BTU CROSS ST 0
by the P4rmit is for one hundred dollars ($100) or less) r t 1 DISTRICT NO PROCESS D ev U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner ���j/ {{ Ga 't e Q`
so as//AO become subject to the Worker, a tion aws µ BOILER, BTU /O OU o!O H
l _ _ r , APPROVALS DATE'' INSPECTORS SIGNATURE V
LU
Date_ t�plicant_ x COMPRESSOR BTU — e_� N
ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be v S"7
deemed revoked
FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION BTU
I hereby affirm thatiI am licensed under provisions of ChapterHEATER SUSPENDED UNIT
9 (cojrimencmg with Section 7000)of Division 3 of the Busi WALL
ness and Professions Code and my license is in full force and
effect
License Number �ic�Cl�ss
A
rContrctate __am exempt from the licensing requirements as I am acensed architect or a registered professional engineer ' Plan check fee 25%of`above
cting in my professional capacity (Section 7051, Bus
mess and Pref ss�O.11iCode) i PERMIT ISSUING FEE $
Lic or Reg No DateTOTAL FEE
HOME OWNER BUILDER DECLARATION PLAN CHECK APPLICANT R
I'hereby affirm that I am exempt from the Contractor's NAME
License Law for the following reason (Section 7031 5, Busr `
ness and Professions Code) , , ADDRESS
i, as owner of the property, will do the work and the �'0022A� _
structure is not intended or offered for sale (Section CITY TEL NO o otot•
7044, Business and Professions Code) 4 # } i 4
OWNER w I
I, as owner of the property, am exclusively contracting _ 21°t,2.7 0 0
with licensed' contractors to construct the project MAIL
(Section 7044, Business and Professions Code) 8 ADDRESS IN �_� oo a 270_O4v,
CONSTRUCTION LENDING AGENCY CITY t_ __ _ 016 2'2j-8
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR i
issued(See 3097,Civ C) _ — - - � ,
4
Lender'§Name a ADDRESS
Lender'sAddress CI EL N
I certify that I have read this application and state that the STA LICp
above information is correct I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Hearing, Ventilating and '
Air Conditionmg, and hereby authorise repzesentatives of this SEE°REVERSE FOR EXPLANATORY LANGUAGE `
C in enter upon the above meenti�ohe/d( prop rty for
nsp coon pm �� � I �( (
gnatur of etmi ee Date 1�Yv1 !
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0809160021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID I FEES PAID BUILDING ADDRESS
ITR 11454 LT 14 1 4949 CLOVERLY AV
IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917803811
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET
18590-022-005 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 596 GRID J5 LOCALITY TEMPLE CITY, Cl
102 COMPRSR < 100 KBTU 1 00 COM 27 00
ITENANT 108 FURNACE/HEATER <100 1 00 UNI 27 00 JISSUED ON PROCESSED BY PLAN BY EXPIRES ON
I30 AIR INLETS/OUTLETS 11 00 UNI 47 85 09/16/08 SR 03/15/09
1 TOTAL FEES 129 60 1
1OWNER TEL NO IFIDATE FINAL BY CODE 1
INEVAREZ, RUBEN (626) 287-3974-
14949 CLOVERLY AV
ITEMP 917803811 IDEAPRIPTION AF WORK 1
INEW HVAC SYSTEM & DUCT 11 5 TON 17 SEER 1
I
(APPLICANT TEL NO
IPELL AIR & HEATING, INC (866) 646-8499-
11495 W 9TH ST 201 ISPECIAL CONDITIONS 1
UPLAND CA 91786
I I I I
CONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE
IPELL AIR AND HEATING INC (866) 646-8499- 1
1495 N 9TH ST #201 LIC NO IFAU/WALL FURNACE I
UPLAND CA 91786 848196
COMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER TEL NO IDUCT WORK
I � I
I LIC NO 1 1AC/COMPRESSOR
`
1 � THERMOSTAT I I I
I I
(FIRE DAMPERS
ISMOKE DETECTION DEVICES
(COMMERCIAL HOOD
I � �
IREPORT ID DPR264 ROUTE TO BSO508