HomeMy Public PortalAbout6220 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA3818(2-80) A PP UC A U'�IQ V F'®R P E R UVU T
I h$rehy affirm that I have acertifieate of,consent to self
insure oracefiificateof,Workers'Compensationlnsurance,'or , p•1Ej�TIRIG`_yEW-PILAYING-l�l6d CONDITIONINGa certified copy thheii of(Sec 3800,Lab,C)
Policy No/,o!� ACAompanyil
' 1 lG Wed'�;
Certified copy is hereby furnished ' . • :4 COUNTY O'F;WS AiUGE-b S� -L =� BUILDINGAND-SAFETY.= �-
Certified copy u"fited with the county building jape ction
FOR-,AP.PLICANT TO F1LL'INS BUILDING I /
t d�epa�rt9men�t.� c 'ADDRESS
Date) _L_—a L-Applicant (PRINT OR`TYREE.ONLY)
LOCALITY
CERTIFICATE~OF EXEMPTION FROM WORKERS' t NO. TYPE',OF-APPLIANCE OR-EQUIPMENT FEE
COMPENSATION INSURANCE - NEAREST �}
•`(This SeCtlon need not be Completed`lf the'Work involved ABSORPTION UNIT, BTU CROSS ST`. Q d
•by the permit,is for one hundred'-dollars ,($'100)'oi`less.) r " DISTRICT No 'WWWU_ ess�o �Y V`
' .
I
certify,that in thepperformance of the work for.which'this AIR RANDLING,UNIT,CFM 7
,permit is--issueds I•shall not,employ any person m-any manner
-so as»to-become subiect'to the Workers'.Compensation'Laws BOILER,_8TU U
APPROVALS ATE INSPECT 'R'S 3NATURE
-Date Applicant _ COMPRESSOR,BTU Off.
ROUGH'
NOTICE TO-?:PPLICAI T:`If,aftet making`thi's�Certificate of �" VENTILATION•SYSTEM,"' a�' . - Z
•E'zemption, you_ should',becokrne subject 'to the,'Workers' FINAL - ' t
'Compensation pro4rsions^of the"Labor'Code,you must forth- ,: ;
�vtih comply with such'provisions,or this•permit'stia11 We EVAPORATIVE COOLER�• �/ ,LIDa GhJ
deemed_'revoked
FURNACE FAU- �A� lTY �
` •LICENSED'CONTRACTORSDECL'ARATION- FLOOR BTU_ __ '� a
'r I hereby affirm-that I ar•n'licensed under provisions$f Chapter,, -':-,HEATER:. SUSPENDED �'UNIT
(commencing with`Section-7000) of Division 3'of the Busi• WALL '
hess and Professions Code, arid•my`license,is'id full force and
effect. � ;
License Number r�i_� L•ic.,Class �� �i '�.� Q•8-8
# oso;• • � c
Contractor C ��4'i�:+t�► ';Date
I ani•exempt frotri"the licensing requirements as`I am a
licensed archi_tectaor' a registered professwnat engineer Plan Check fee,25%of above: .'�'1i 12 x '
=acting in my professional capacity (Section 7051, Busi 2 Q`�'�,v
]ness and Professions`Code). i= "PERMIT ISSUING FEE $ �� J. i� 9 4
Lw,or Reg:No Date ,' TOTAL FEE
HOME OWNER-BUILDER DEC LAAATION` _
PL4N�;CHECK•4PPL'ICANT
I hereby 'affirm: that�I am-exempt from- the Contraetor's NAM'E',
License Law for the following reason (Section, 7031.5, Busi-
? ne`ss_and'Professions Code). ADDRESS
I, as_owner*of the property.,'wifl Edo the work-and the 1,-
structure is not intended or offered for-sole (Section CITY- �TEL.•NO- F �,
¢7044, Busmess and'Professions C-' r ,•e�� ; ;.> a
�, a 4,,` OWNER "�.,
.I; as„owner of 1:6 property, alit exclusively,contracting -
�nnuh licensed.contract or's to construct `Ithe-. project ' MAIL ” - •
(Section 7044, Business and Professions Code) ADDRESS' - �v(�,(3 �•�ti ��� �_ + ;
CITY,' ° TEL.NO. l
CONSTRUCTION LENDING AGENCY r >Yk �' '(i� l�
a I hereby affirm that there is,a construction lending agency -
for
gencyfor the performance of the work for which this permit' is` CONTRACTOR" �'aitijvd�; IV = -
issued(Sec 3097,Civ,C.). -Lender's-Name f �. ADDRESS a f/�� f r N� f- • "
Lender's•Address y� a.
CITY TEL NO t�/Y`y I Y
I certifythat I have read',this application and•state that,the ` STATE> LIC., ;
above information is correct.I agree to'oomply with all County . LICENSE•NO. � 8 J,/ S: CLASS _
ordinances and-State laws regulating Heating, Ventilating and,.,, �r '
Air Conditioning, and hereby authorize representatives of-this ;SEE REVERSE FOR,EXPLANATORY LANGUAGE d
a County to enter upon the abdve-mentioned property for. ;1
inspection urposes _ -
Sig atureofPermittee Date
* COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0604100008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
-PHONE:--(626)- 285-0488--(626)= -EXT:_
285-0488
`- _ _-` - --- - - --
LEGAL ID FEES PAID BUILDING ADDRESS*
TR: 17179 LT 22 6220 CLOVERLY AV
FEE DESCRIPTION. QUANTITY: UOM: AMOUNT. TEMP CA 917801601
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET:
5385-009-002 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE. 596 GRID J2 LOCALITY TEMPLE CITY, C
02 COMPRSR < 100 KBTU 1 00 COM 27 00
TENANT: 08 FURNACE/HEATER <100 1 00 UNI 27 00 ISSUED ON: PROCESSED BY: PLAN BY EXPIRES ON
30 AIR INLETS/OUTLETS 9 00 UNI 39 15 04/10/06 JK 10/07/06
TOTAL FEES 120 90
OWNER: TEL NO FINAL DATE FINAL BY CODE:
CHASE HELEN L TR CHASE FAMILY TRUST (626) 286-6144-
6220 CLOVERLY AV ✓ /
TEMP 917801601 DESCRIPTION OF WORK
REPLACE AIR CONDITIONING AND HEATING SYSTEM
APPLICANT. TEL NO
ZAMORA (818) 735-7876-
8319 VINEYARD AVE SPECIAL CONDITIONS
RANCHO CUCAMONGA _
CONTRACTOR TEL. NO APPROVALS DATE INSPECTOR SIGNATURE
AMERICAN AIR CONDITIONING (800) 321-9494-
10716 GRAVILLEA LIC NO FAU/WALL FURNACE
INGLEWOOD CA 433868C20 *
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER. TEL NO- DUCT WORK
LIC. NO: AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
* ADDITIONAL DATA ON FILE
REPORT ID DPR264 ROUTE TO: BS0508