HomeMy Public PortalAbout5313 CLOVERLY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I' have a certificate of consent to self �
insure, or a c�tificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec 3800, Lab C ) 76A364C
1 20 0046 DPW 9/88
Policy No Company
i is Ceritified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
t
, a r
Certified copy is filed with the'county building mspec- t- FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS
(PRINT OR TYPE ONLY)
Date f Applicant i LOCALITY L /
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
F CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST . L
COMPENSATION-INSURANCE " CROSS ST
(This section need not be completed if the work involved by n ABSORPTION UNIT BTU DISTRICT NO 1 r PROCESSED BY t
ti the permit is for one hundred dollars'($100) or less)
I'certrfy Thar in AIR HANDLING UNIT CFM O'
the«performance of the work for which this •`
permit Is issued, I shall not employ any person in any manner r
so as to bec e- bled fo the Work s Compe On Laws BOILER BTU \\ APPROVALS DATE INSPECTOR S SIGNATURE
` Date Applican COMPRESSOR BTU " w ROUGH
NOTICE O PPLICANT If,'after'mak g this Certificate of VENTILATION SYSTEM FINAL Lrcp
"Exempt on, you should become subject to the Workers `
«. Compensation provisions of the Labor Code, you must forth-, EVAPORATIVE COOLER VALIDATION {
with comply a with such provisions or,this permit shall be deem- ,
t ed revoked v'. r , FURNACE FAU GRAVITY / -
LICENSED CONTRACTORS DECLARATION v FLOORS BTU -
x I hereby affirm that I am licensed under provisions.of Chapter 9 HEATER SUSPENDED UNIT
—
(commencing witli Section,7000)of Division 3 of the Business y_ WALL -- "
anVofessions Crode�,and
my Iiceetnse is in full force and effect l�r�� kc e
Llc'nse Number �+ Lic Class ® - O«
Contractor a'/�S' l 0
' ' ❑ I am exempt under Sec' " O
Plan check fee _ v
B 8P C for this reason W
CL
PERMIT"ISSUING FEE $ Z
' ' , D TOTAL FEE
Signature ��
OWNER- ILDER DECLA'RATION PLAN CHECK APPLICANT w'
I hereby affirm that I am exempt,from the Contractor s License
Law for,the following reason (Section-7031 5, Business and NAME - -
Professions Code) _ < a
I as owner of the,property, or my employees with " ADDRESS -
wages as their sole compensation, will do the work and
the struCITY TEL NOcture is not intended or offered for sale (Section -
7044 Business and Professions Code) Com►(
OWNER �� �i— W 1� 5C7 �t
❑ �:L,
I, as owner of the property, am exclusively contracting
-with-licensed contractors to construct the project (Sec- "IL � ���i'�
^ tion 7044, Business and Professions Code) ADDRESS ��7 i
CONSTRUCTION LENDING AGENCYCITY l' TEL NO IT1-1"1 At- 1 55 . 00
I hereby affirm that there is a construction lending agency for L � b 9 '/C
the performance of the work for which this permit is issued CONTRACTOR 7
(Sec 3097, Civ C ) _ pop.
/ /
ADDRESS QQC//
Lenders Name � �/
Lender's Address CITY L NO
/ter s�d�'► TEi li l]1]—ijijilr4 '4 t J',,STATE LIC
€S
I certify that I have read this application and state that the 1' I ENSE NO & CLASS C--zC)
above information is correct I agree to comply with all,County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this to enterupon the above-mboned property for mspe t�unt
urposes '>
• �( SEE REVERSE FOR EXPLANATORYLANGUAGE "
_ � r
Signatur of Applicant or Agent Acte �s
' COUNTY OF LOS ANGELES TEMPLE CITY - # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1205170008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 -
PHONE (626) 285-0488 EXT
ILEGAL ID - 1 FEES PAID BUILDING ADDRESS
I ON FILE - _ I 1 5313 CLOVERLY AV 1
I IFEE DESCRIPTION QUANTITY UOM AMOUNT 1 TEMP CA 917803106 - I
(ASSESSOR INFORMATION NUMBER I 1 - NEAREST CROSS STREET 1
18590-004-012 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID J4 LOCALITY TEMPLE CITY Cl
1 102 COMPRSR < 100 KBTU 1 00 COM 27 00
(TENANT 108 FURNACE/HEATER <100 1 00 UNI 27 00 11SSUED ON PROCESSED BY PLAN BY
I TOTAL FEES 81 80 105/17/12 SR 1
I I I ( I
(OWNER TEL NO 1 IFINAL DATE FILqAI,,BY CODE 1
ICHEN, JIANG (626) 614-0586- 1 1r
15313 CLOVERLY AV _ I o
(TEMP 917803106 1 - IDESCRIPTION OF WORK 1
I (REPLACING A/C & HEATER ONLY NO DUCTS 1
I I I I
[APPLICANT TEL NO I
IGONZALEZ, FELIPE (626) 482-3176- 1 1 I
12648 E WORKMAN AVE - _ 1 _ , ISPECIAL CONDITIONS I
IWEST COVINA CA 91791 1 1
I
ICONTRACTOR TEL NO 1 I ATTROVATISDAT INSPECTOR JIGNATURE
ITEMP AIR SYSTEM (626) 482-3176- 1 1 1
12648 E WORKMAN AVE #3001 LIC NO I 1FAU/WALL FURNACE I 1
(WEST COVINA, CA 91791 807933 1 I I I
I 1 - ICOMBUSTION AIR OPENINGS I -
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[ARCHITECT OR ENGINEER TEL NO 1 IDUCT,WORK I I I
AC/COMPRESSOR 1 1
1 f LIC NO 1 � I
1 I THERN,OSTAT
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I IFIRE,DAMPERS 1 1 1
1 I (SMOKE DETECTION DEVICES I I
I COMMERCLAL HOOD
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I I* ADDITIONAL DATA ON FILE 1 I 1 I
1 [REPORT ID DPR264 ROUTE TO ES05O8 1 1 1
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