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ERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
rm that I have a certificate of consent to self
1,e Z, certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a ca d py thereof (Sec. 3800, Lab. C.) 76A364C
Jv fJ—CE-818(REV. 10/81)
Polify No i�l r Company �r AAe;
PD_Certifiecl copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�r/��{' Certified copy,is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING f�
T tion de artment. ADDRESS �%
_ p�. (PRINT OR TYPE ONLY) C(d Ql
Dat Applicant �' LOCALITY ,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM W KR ERS' NEAREST
COMPENSATION INSURANCE CROSS ST. (i
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROLE BV
the permit is for one hundred dollars ($100)or less.) ,(( o
AIR HANDLING UNIT, CFM
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 become subject to the Workers'Compensation Laws. BOILER, BTU [ APPROVALS DATE NS ECTOR'S SIGNATURE
COMPRESSOR, BTU (J iKROUGH
Date - Applicants
NOTICE TO APPLICANT: If, after making t ' Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject Lfo the Workers'
Compensation provisions of'the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such .provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU CjvezoU
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED ( UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
,� ` >� 376 0
License Numb Lic. Class ,
lbx.
Contractor Date r
3 0
❑ I am exempt u er Sec. UU
Plan check fee
B.&P.C. for this reason PERMIT ISSUING FEE $
Date:
TOTAL FEE
Signature
OW ER-BUILDER LARATION PLAN CHECK APPLICANT
+
1 hereby affirm that I am exem t from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
ri
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,'will do the work and
the structure is not intended or offered for sale(Section CITY, TEL. NO. _.are• -+c'
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contractingMAIL
with licensed contractors to construct the project Sec- ADDRESS (` ` , -+ti - '-s'40-
tion
tion 7044, Business and Professions Code). -`-
CAI
CONSTRUCTION LENDING AGENCY is a%7(`;`; t?'= -e
CITY r - TEL. NO.� /�( 3z r,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued. CONTRACTOR C , P F-r-
(Sec.,3097, Civ. C.).
ADDRESS
Lender's Name' _ +'•-- ;in
CITY ^ TEL. NO. F �'f �3 i W ; J t , ..
Lender's Address 44 -
STATE z LIC. a•M•W i _ PE! ilr;
I certify that I have read this application and state that the LICENSE NO. S CLASS Z
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authggrIze representatives of this County to enter
up the abovefrent oned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-� _ << Y '13 -d
Signature-af Applic ar Agent Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1301020002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID � - BUILDING ADDRESS:
ITR: 45817 LT: 1 UN: 4 5808 CLOVERLY AV B
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: j TEMP CA 917802140
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-012-035 ':01 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CAI
1 i02 COMPRSR < 100 KBTU 1.00 COM 27.00 1
TENANT: I TOTAL FEES 54.80 11SSUED ON: PROCESSED BY: PLAN BY:
101/02/13 SR
10WNER: TEL. NO: FI AL DATE FINAL, CODE:
ANDERSON, JULIE (626) 523-7218-
15808 CLOVERLY AV
(TEMP 917802140 I ID�SCR P-� WORK
IREPLA,,=E AIR CONDITIONING
APPLICANT: TEL. NO: 1
ICHIANG, DAVID TZUN (626) 831-0818-
1131 LIVE AVE 1 (SPECIAL CONDITIONS: 1
ISAN GABRIEL CA 91776
IICONTRACTOR: TEL. NO: A PROVA DATE INSPECTOR SIGNATURE
ALLIANCE ENERGY CO. (626) 831-0818- ..
1131 LIME AVE LIC. NO FAU/WALL FURNACE
ISAN GABRIEL,CA 91776 925226 * __
(COMBUSTION AIR OPENINGS
1ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
I I-
I LIC. NO: IAC/CO.vPRESSOR
1
THERMOSTAT r I
1 IFIRE DAMPERS 1
i I I I I
(SMOKE DETECTION DEVICES
ICOMME3CIAL HOOD
I �* ADDITIONAL DATA ON FILE 1
1 REPORT ID: DPR264 ROUTE TO: BS0508 1 1 1
I_