HomeMy Public PortalAbout10558 DAINES DR_Mechanical__ s _ WbRKERs COMPENSATION DECLARATION APPLICATION
PPLIL IC p TION FOR PERMIT
I"}te`reby affi.rri that I have a certificate of consent to self PY P'9 Iltl �N9
insure, oftp certificate of Workers' Compensation Insurance, �aA3a4c - HEATING • VENTILATING - AIR CONDITIONING
or a ceetified copy thereof (Sec. 3800, Lab. C.)
q ^ CE-818(REV. 10/81)
EDI icy No. I�/ � ompany �iTA[ 1 _J iU
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed wit my buil ling pec- FOR APPLICANT TO FILL IN • BUILDING
5 DP
tion department. (PRINT OR TYPE ONLY) ADDRESS ��
DateA licant LOCALITY �� /• •�
NO. TYPE OF APPLIANCE OR EQUIPMENT . FEE c-•
CERTIFICATE OF EMP O OM WORKERS' NEAREST r
• COMPEN ATIO SURANCE, CROSS ST. L
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO, PROCESSED BY
the permit is for one hundred dollars ($100)or less.) a�
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM s
permit is issued, I shall not employ any person in any manner
so as to become,subject to the Workers'Compensation Laws. BOILER, BTU APPROVAtS DATE TOR'S SIGNAT RE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL r
Exemption, you should become subject to the Workers"
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER '- A''DATION
with comply with such provisions or this permit shall be
deemed revoked. _ FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— 0
'(commencing with Section7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. y
' - �� D 9561 A o
License Numbe Lic. Class ,
a�E2✓ANi�5 �iL 6—Ci -He 1
Contract te #,�.� e e 8 O
❑- it-
1 am exempt under Sec. I ,s • - 205 V
Plan check fee 1116
W
B.BP.C. for this reason' .I e - 2 (1510 W
t PERMIT ISSUING FEES
to TOTAL FEE ` ` ` 2255
Signal e -
O � ER DECLARATION PLAN CHECK APPLICANT •0 S,09'-88
hereby firm that I exempt from the Contractor's License D
Law for he followi reason (Section 7031.5, Business and NAME.
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). - -
OWNER , L
I, as owner of the property, am exclusively contracting
El
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY4, G --- TEL. No
I hereby affirm that there is o,construction lending agency for r
the performance of the work for which this permit is issued - CONTRACTOR - /..t$� C D_
(Sec. 3097, Civ. C.). - - -
ADDRESS - r �S+ -
Lender's Nome �J/ Q� _
CITY TEL NO 7C�`- 3/ .
Lender's Address
STATEC.
I certify that I have read this application and stale that the LICENSE NO. 2 CLASS -
above.information is correct. I agree to comply with all County
ordir nd State laws relating to building construction,
and reb authorize re resentatives of this County to enter
ITT above—men, roperty IF Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig Nre Plicant or Agent Date '
COUN?Y OF LOS ANGELES TEMPLE CITY #'0508 MECHAHICAL PERMIT
-- DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0406170010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0438 EXT:
LEGAL ID: I FEES PAID BUILDING ADDRESS:
TR: 7690 LT: 16 UN: .002 10558 DAINES DR
_ FEE DESCRIPTION: ULiANTITY: LOM: AMOUNT: TEMP CA 917802812
ASSESSOR, INFORMATION NUMBER: NEAREST CROSS STREET: PAL MAL
8586-029-024 Oi PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00'COM 27.00
T E NANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED . PL EXPIRES ON:
30 AIR INLETS/OUTLETS 11.00 UNI 47.85 06/17/04 JK 12/14/04
_ TOTAL FEES 129.60
OWNER: TEL. NO: FINAL DAT ryryry BY: CODE:
1055BUDAINESPNE CHARLES F;BROWN GEORGIA E (626) 448-8545- y �I},(
DR
TEMP 917802812 D SCRIPTIO OF\WORK
' 1
INSTALL NEW HVAC
_
APPLICANT: N0: LIVING RM & BEDRM; TTL W!EN DONE:48R/2 3/48A.TH
SAME AS OWNER
SPECIAL CONDITIONS:
CONTRACTOR: TEL. N0: - APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO FRU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER,: TEL. NO: DUCT WORK
LIC. NO: AC/COMPRESSOR
ITHERMOSTA �-
FIRE DAMPERS
SMOKE DETECTION DE ES
COMMERCIAL HOOD
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REPORT ID: DPR264 ROUTE TO: BS0508