HomeMy Public PortalAbout10828 DAINES DR_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 81 C APPLICATION
1p 1pl ICA TION COR PERMIT
1 hereby affirm that I have a certificate of consent to self CE818 (2-801 P9 Ir If- L PY 1 tl r f'C Ir IG YY IVY Y n
mss.e,jr>r scertificate of Workers'Compensation Insurance,of
` HEATING-VENTILATING-AIR- CONDITIONING _ IILJII
a certified copy thereof(See. 3800,Lab. C.)`
Policy No. Company°. - -
❑ Certified copy is hereby furnished. . - COUNTY OF LOS ANGELES - BUILDING AND SAFETY
❑ Certified copy is filed.with the county building inspection FOR APPLICANT TO FILL IN _ BUILDING
'department: - ADDRESS /p$a2 S 9 ���1 -1'f•!t
Daly ,Applicant. - (PRINT OR TYPE ONLY) _
. .. LOCALITY --PLC L%(TY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. ,TYPE OF APPLIANCE OR EQUIPMENT FEE - I
COMPENSATION INSURANCE NEAREST
CROSS ST.
(This section-need not be'completed-if-'the workinvolved , 'ABSORPTION UNIT, BTU- - - - - E L�../�ry 7 O by the permit is for one hundred dollars ($100) or leo.) I - DISTRICT NO. - PRODEssED,. U
I certify that in the performance o,I the work for which this AIR HANDLING UNIT,CFM. O cc
D
permit is.issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compen 'boo-Laws.' BOILER, BTU • ~
try- APPROVALS DATE /I INSVECTDR'S SIGNATURE W
Date./6-2-SO Applicant_Q�SI� COMPRESSOR, BTU ROUGH �� �1 r �e..a-��J N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM 'FINAL �' �� Z
Exemption, you, should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-- - EVAPORATIVE COOLER VALIDATION
with' comply :with such provisions. or this permit shall,he
deemed revoked. -U RNACE: FAU— GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
—
I 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. 77 rte.
License,Nu/m/l1ber_✓>�IIl� _ Lia Class_'_ f
Contractmya¢g_�I_, Date -
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a.registered professional .engineer Plan cheek fee 25%of above. -
acting in my professional capacity (Section 7051.. Bus- ,1-
iness and Professions Code)- PERMIT ISSUING FEE $
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER BUILDER DECLARATION - PLAN CHECK APPLICANT !� ,
1 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 CITY ,. TEL. NO. -
structure is not intended or offered for sale (Section
7044, Business and Professions-Code).
❑ C/
I, as owner of the property, am exclusively contracting OWNER WPW L L.
with licensed contractors to construct the project - MAIL x214?ti3A
(Section 7044, Business and Professions Code). ADDRESS JJO�� G //A/IJ�„S
:CIT yl TELL NO. # sic le s A )
CONSTRUCTION that there LENDING AGENCY /cM�CE L�r_T _
I hereby perform that [here is a construction lending agency CONTRACTOR - q C 2,-'.,27.00
for the performance ce of the work for which. this permit is LES., —f 4 �J.�f L'OJ✓S? a
issued 'Sec. 3097.Civ.C.).
Lender's Name ADD RESS�p / -*- 27,00l6 ,,'
Lender's Address CITY A 2e 6-P) A TEL. NO.S74- 1(.o 1 3 1 0.'0 2'-' 8 0
I certify that I have read this application and state that theSTATE LIC.
above information is correct.I agree to comply with all County LICENSE NO, o51 Som-r7� CLASS Fes '
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE.REVERSE I-OR EXPLANATORY LANGUAGE -
County to enter upon tire above-mentioned property for
ills
Ppp-e[io11 Pu^P�oses.
af�o � !0`.2-£rd
Signature of Permittee Dale - - ,
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 9611120001
BUILDING AND SAFETY / I SNC•%s .'ELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID– BUILDING ADDRESS:
TR: 10260 LT: 19 ' 10828 DAINES DR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802918
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8573-016-001 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D3 LOCALITY: ,TEMPLE CITY
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: EXPI S ON:
TOTAL FEES 81.75 11/12/96 TC 1 1/ /97
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: -
ZONE NANCY TR NANCY ZONE TRUST (818) 448-9440-
10828 DAINES DR "2",
1 1914
TEMP 917802918 DESCRIPTION OF WORK
REPLACING EXISTING ROOF TOP HEATIN IN& A/C
APPLICANT: TEL. NO:
ROYAL PLUMBING HEATING 8 A/C (818) 793-5943-
156 N. HILL ST. &EL Ab—.^� SPECIAL CONDITIONS:
PASADENA,CA 91106
CONTRACTOR: TEL. NO: / . APPROVALS DATE INSPECTOR SIGNATURE
ROYAL PLUMBING,AIR CONDITINIONING, (818) 793-2300- vA
156 N. HILL AVENUE LIC. NO FA /IA L FURNACE
PASADENA, CA 91106 700466 ®J P/� 1
COMBUSTION AIR OPENINGS
i
ARCHITECT ORENGINEER: TEL. NO: D CTiWORK
LIC. NO: itii;i AC/COMPRESSOR
THERMOSTAT
PUBLIC WORKS I
FIREIDAMPERS �
O 0 `^ SMOKE DETECTIONEDEVICES
S
..I COMMERCIAL HOOD
0 O�
rvrce
REPORT ID: DPR264 ROUTE TO: BS0508