HomeMy Public PortalAbout10608 DAINES DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C APPLICATION
py� py p� I� PERMIT I hereby affirm that I have a certificate of consent to self CE-818 (2-80). Ar r L IC P"1 1 ION FOR Ir G Y"'(M IT
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.) _
Policy No. Company COUNTY OF LOS AN ELES� ' NG AND SAFETY
Certified copy is hereby furnished.
I] Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN WILDING jQ
department. AODAESS
Date Applicant (PRINT OR TYPE ONLY)
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST y
(This section need riot be completed if the work in°'olved ABSORPTION UNIT, BTU CROSS ST. - ti O
.by the permit is for one hundred dollars (5100). Or less.) DISTRICT NO. PROCF^'ED�' U
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
Y� OU� APPROVALS DATE INSPEC➢R'SSIGN nT nE w
Date Applicant COMPRESSOR,BTU-- ROUGH p/ h
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM
Exemption, you should become subject to the Workers' FINAL
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
-
I hereby affirm that 1 am licensed Under provisions of Chapter / HEq TE R: SUSPEN DEO UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- 'WALL �QD c700
ness and Professions Code, and my license is in full force and r—
effect.
License Number Lic.Class
Contractor Date �1
I am exempt from the licensing requirements as I am a C',
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
t Lic.or Reg.No. Date TOTAL FEE 7 -
HOME OWNER-BUILDER DECLARATION
PLAN CHECK APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME _
License Law for the following reason (Section 1031.5, Busi
nnees///s and Professions Code): ADDRESS
'�( 1, as owner of the property, will do the work and the '
_I~structure is not intended or offered for sale (Section CITY TEL. NO. 29 JS O ) A
7044. Business and Professions Code).
❑ OWNER A r"/J # °.° °;° 4 �
1, as owner of the property. am exclusively contracting
with licensed contractors to construct the project MAIL ,�( 7T�
(Section 7044,Business and Professions Code). ADDRESS �0l' L A .21°,°.3 7.Q 0
CONSTRUCTION LENDING AGENCY CITY I C - TEL. NO. C j((Z 7701 'e e e 3 7,0 0:60.
I hereby affirm, that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR 8 0 ) 8 1
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS '
Lender's Address CITY TEL.NO.
I certify that I have read this application and state that the [LICENSE
STATE LIC.above information is correct. I agree to comply with all County NO. CLASS - -
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Count to enter rpo re above-mentioned property for -
insp,c on rpos / ,3 J ,rl ..
I
Signature of Permittee Date
COUNTY OF IAS ANGELES TEMPLE CITY q 0508 t . MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0911100023
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID_ FEES PAID BUILDING ADDRESS:
ITR: 9690 LT: 80 BE: .001 UN: .002 10608 DAINES DR
IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT: ( TEMP CA 917802814
1ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
18586-030-021 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, Cl
1 102 COMPRSR 1 100 KHTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER 1100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 81.75 11/10/09 SR 11/10/10
OWNER: TEL. N0: IPINAL DATE FINAL BY: CODE:
SELTMAN HOBBY (626) 442-7281-
110608 DAINES DR I ' 1 'v
ITEMP 917802814 I (DESCRIPTION OF WORK 1
I I IC/O A/C AND HEATING 1
APPLI CANT: TEL, N0:
AIA—TRO (626) 357-5311-
11630 S. MYRTLE AVE. SPECIAL CONDITIONS:
MONROVIA, CA 91016
I
(CONTRACTOR: TEL. No : JAPPROVALS DATE INSPECTOR SIGNATURE
(AIR—TRO (626) 357-5311-
11630 S. MYRTLE LIC. NO FAU/WALL FU
RNACE
MONROVIA, CA 91016 25822SC20 ' r
GGMBDSTIDN AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK
I I
LIC NO: I IAC/COMPRESSOR
(THERMOSTAT I
1FIRE DAMPERS
I I SMOKE DETECTION DEVICES 1
COMMERCIAL HOOD
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1
I 111 111 I II II
11 I' ADDITIONAL DATA ON FILE
IRE PORT ID: DPR264 ROUTE TO: BSO508