HomeMy Public PortalAbout5830 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 64 (2 80) �If- IP L� CAT II O U�I FOR II-R E R Il�%U T
I heretiy affirm that I have a' certificate of consent to self
insure, or a certificate'of Workers'Compensation Insurance,or b[ ATING-VENT ILAT8((r G-AOR
Z /7
tifieM thereof(Sec. 3800,
y No. Company COUNTY OF LOS ANGELES BUILDING
122 Certified copy is hereby furnished. ARID SAFETY
-
lLTCertified ropy is filed with the county building inspection BUILDING
ler.^ m.'.•.
FOR APPLICANT TO FILL IN Date _ _g , Applican�� - !�C�Gb T. ADDRESS
G
(PRINT TYPE ONLY}_
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
• _
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATION INSURANCE NEAREST
CROSS ST.\ ►. �LYJ e CL
(This section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) Or less.) DISTRICT NO. ' PROCESSED gY 0
I certify that in the performance of the work for which this AIR HANDLING UNiT.,.CFMr
permit is issued, I shall not employ any person in any mariner ' O Q
so as ' be^ome subject.to the Worker' '—pensation Ltlws. BOILER, BTU I—
"APPROVALS DATE
INSPECTOR'S SIGNATURE
D.r _ Applican _ _ i CL/ - - - - - - - COMPRESSOR, BTU ®O� �� ROUGH 4-*
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 0-13^2�( Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. FURNACE: FAU P4VITY r
LICENSED CONTRACTORS DECLARATION FLOOR:— BTUS_Qd_Z1 � �//
1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED -UNIT
9 (commencing 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 /_L�'c.Class Ci`'-- -
S%I�����f1�
FI am exempt rrom the licensing requirements as I am a - �✓
licensed architect or a registered professional engineer Plan check The '5%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE $
Lie.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
x I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031,5:, Busi-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the --
structure is not intended or offered for sale (Section CITY TEL.NO,
7044, Business and Professions Code).
�3'64t3A
OWNER
I, as owner of the property, am exclusively contracting #,0'0,0 o (I
with licensed contractors to construct the project MAIL
(Section 7044,Business and Professions Code). ADDRESS
2 °;° 8 7 0 0.
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency — o�o o 8 7 Q 0.6
for the performance of the work for which this permit is CONTRACTOR
issued(Sec. 3097,Civ.C.). �L—'l— 1�-,�'�3 -81
Lender's Name ADDRESS 06j� { /
Lender's Address CITY % TEL.NO,Z2!2 3'y
I certify that I have read this application and state that the
STATE LIC:
above information is correct.I agree to comply with all.County LC
ICENSE NO.it r� LASS
ordinances and State laws regulating Heating, Ventilating and.
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter -upon the above-mentioned propert for
insn� .ion pr es. o f
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0901280006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 689 5830 CLOVERLY AV G 1
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802123
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LAS TUNAS 1
18587-012-023 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 1 1
TENANT: 108 FURNACE/HEATER x100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
154 NO PERMT $224.70 MIN 257.00 257.00 101/28/09 SR 07/27/09 1
1 TOTAL FEES 338.75 1 1
OWNER: TEL. NO: (FINAL DATE FINAL 'Y: CODE:
1SUMETHASMORN, SMUTTASMANEE (626) 355-3141-
1701 OAKWOOD AVE. pv
(ARCADIA, CA 91006 (DESCRIPTION F WORK 1
I 1REPLACE ONE 2.5 TON PACKAGED AIR CONDITIONING/HEATING UNIT 1
APPLICANT: TEL. NO:
ILI (626) 679-4949-
1219 1/2 S. BUSHNELL (SPECIAL CONDITIONS:
IALHAMBRA, CA 91801 1 1
I I I I
ICONTRACTOR: TEL. NO: 1APPROVALS DATE INSPECTOR SIGNATURE 1
ISUNCOM (HARRY) SERVICE (626) 679-4949-
1219 1/2 S. BUSHNELL AVENUE LIC. NO IFAU/WALLFURNACE I I I
ALHAMBRA, CA 91801 829980 C20
I (COMBUSTION AIR OPENINGS 1
1ARCHITECT OR ENGINEER: TEL. NO: I (DUCT WORK I I I
1 LIC. NO: 1 1AC/COMPRESSOR J I
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!!{{ (} j pq , ('�'" 1hTHERMOSTAT I
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD 1 1
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1 (REPORT ID: DPR264 ROUTE TO: BS0508 1 1 1
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