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HomeMy Public PortalAbout9328 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION -APPUCAYMN FOR PERNT ' I hereby affirm that I have a certificate .of consent to self insure,.or a certificate of Workers' Compensation Insurance, HEATING VENTILATING ­AIR ®N®I4I®��NG or,q certified"copy thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 0014No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified c4y•is.filed with the county building inspec- BUILDING FOR APPLICANT TO FILL IN i tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCAU � �.. CIA•, NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ' CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST \ COMPENSATION INSURANCE CROSS ST. ` (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollops ($100) or less.) I 'certifythat in The erformance of the work for Which this AIR HANDLING UNIT;CFM permits issued; I shall not employ any person in any mannerO ��r�e���> so as.to become subject,to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE • INSPECTOR'S SIGNATURE Date Applicant I COMPRESSOR, BTU ROUGH 2(v y� NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject .to the Workers' Compensation provisions of the Labor Code,.you must forth- EVAPORATIVE COOLER. ALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAUGRAVITY _ LICENSED CONTRACTORS DECLARATION. 1 -FLOOR 7` BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in hull force and effect. CL License Number Lic. Class ' D o Contractor' Date Ot ❑ : I am exempt under,Seca • Plan check fee B.BP.C. for-this reason. H Date: PERMIT ISSUING FEE $ ,✓ Z Signature TOTAL FEE PO OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License D is Law for the following reason (Section 7031.5, Business and NAME a AC Professions Code): T C l ' I, as.owner-'of the property;'or my employees With ADDRESS ;–,•1_ s•_el_R_ wages'as their sole'compensation,will do the'work and C TY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). s •t 'a a � OWNER 3 I j T;.4; , 0', I, as owner of the property, am exclusively.contractingt 101 �r with'licensed contractors to construct the project (Sec- MAILS tion 7044, Business and Professions Code). - ADDRESS . \ r Ch CONSTRUCTION LENDING AGENCY iGE CIT ffV\ \ CAIL. NO. _ '_ t•_'H u I hereby affirm that there is a construction'lending agency for '�J. . the performance of the work for which this permit is issued CONTRACTOR .(Sec. 3097, CIV. C.)'. D 5'-i°_ 3 '1_f Cat`2 d 1,Il lf,l I ILIA i sy, ,, -a; - ADDRESS ' Lender's Name' 3: ri ?*5'- ' CITY TEL. NO. 428•_ Lender's Address — STATE certifythat I have read this application and state that the STATE LIC. PP LICENSE:NO. CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize repre ntativeVin County to enter upon the menti rop tion purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE F � 11 �, V ature of Applicant or Agent Date ©5 COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1105160009 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID I BUILDING ADDRESS: ON FILE 1 9328 DAINES DR 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917803110 ASSESSOR INFORMATION NUMBER: 1 1 NEAREST CROSS STREET: 18588-029-015 101 PERMIT ISSUANCE FEE 27.80' 1 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, Cl I 141 VENTILATION FAN 2.00 FAN 31.60 1 1 1TENANT: 1 TOTAL FEES 59.40 11SSUED ON: PROCESSED BY: PLAN BY: 1 1 105/16/11 SR 1' 1OWNER: TEL. NO: 1 1FINAL DATEINAL BY: CODE: 1 1ABI RACHED SAMIR;YOLLA (626) 794-5220- 1 19328 DAINES DR `1 ITEMP 917803110 1 ID SCRIPTION OF WORK 1 1 1 1VENTILATION FANS FOR BATHROOMS REMODEL 1 I I I I 1APPLICANT: TEL. NO: I IGUIRGUIS, SAMIR (626) 449-6461- 1 1281 N. ALTADENA AVE 1 ISPECIAL CONDITIONS: - 1 IPASEDENA, CA 1 1 ,\ I 1CONTRACTOR: TEL. NO: 1 1APPROVALS DATE INSPECTOR SIGNATURE 1 1ABI-RACHED, SAMIR & YOLLA (626) 794-5220- 1 1 19328 DAINES DRIVE LIC. NO 1 FAU/WALL FURNACE ITEMPLE CITY, CA 91780 NONE 1 1 1 ICOMBUSTION AIR OPENINGS (ARCHITECT OR ENGINEER: TEL. NO: I-DUCT WORK 1 I I LIC. NO: - 1AC/COMPRESSOR 1 1 1 1 1THERMOSTAT 1 I 1 IFIRE DAMPERS 1 ISMOKE DETECTION DEVICES COMMERCIAL HOOD 1 1 I I I I I I I 11 11 I I I 1 I I I I I I I I I I I 1 I I I I I I I I I 1 I 1 I I I I I I I I I I I I I I i I I 1 IREPORT ID: DPR264 ROUTE TO: BS0508 1 1 I I I COMPENSATION DECLARATION jfiA364C PW9f89 4d� PUC�kT*N FOR -pC�G�MT �� 'f hereby (firm that I'"�have a,certificate of consent to self•Insure, . WORKER'S COM or a certl[Ic of Worker s Compensation Insurance, or'a certifiedHEATING- VENTILATING AIR CONDITIONING copy'therewf(Sec.3800 Lab. C.) Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ' ❑ Certified copy is hereby furnished: r ' _ a.•• BUILDING Certified copy is filed-with the county building inspection; FOR APPLICANT TO FILL IN ADDRESS department.w... •' (PRINT OR TYPE ONLY) S Date Applicant NO. •TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALI „(�? \ V .. ` .. . .: . H CERTIFICATE OF EXEMPTION'FROM WORKERS''•'-,. CROSS ST. \'`, COMPENSATIONINSURANCE, NEAREST •, � / ' l,� V e L ABSORPTION UNIT BTU ASSESSOR (This section need'not'be completed'if-the work involved;by the MAP BOOK ��� PAGELocy PARCELO�� permit is for one hundred dollars($100)or less.), r•',,. AIR HANDLING UNIT;CFM' DISTRICT No. • P C ED-BY D (,certify that in',the:performance'of the work for which this permit Is,.issued, I shall not"employ any person+in any manner so as to BOILER,BTU - become subject to-the Workers':Com ppnsation Laws. " COMPRESSOR,BTU' APPROVALS DATE INSPECTOR'S SIGNATURE ate "Applicant - . VENTILATION SYSTEM - - NOTICE+-TO APPLICANT: If, after making this Ceriif,ibate of ROUGH $ TExemption,you should.become subject-to-the Workers Compensation, EVAPORATIVE COOLER' provisions of the Labor."Code, you must-forthwith comply with such" FINAL prowslons or.this permit-shall be deemed,revoked. FURNACE: FAU GRAVITY ;, „ LICENSED CONTRACTORS DECLARATION FLOOR BTU -e VALIDATION.; ~ ,I hereby affirm that I am licensed`uncler.provisions of Chapter, 9 SUSPENDED UNIT (commencing with Section 7000) of:Division 3 of the Business and HEATER: 'WALL Professions Code,and"my license is'in.full force and effect. License Number Lic.Class T `t N I l7 / Y � G - UJ ht '/-�7 rf:^^rte 5 Contractor Date Plan check fee 0: I am exempt under Sec, / &P,C.for this reason !p PERMIT ISSUING FEE$ O Dated Date: g r i-f3_.E TOTAL FEE.. Si nature PLAN CHECK APPLICANT _ _ � :I-c a , OWNER-BUILDER.DECLARATION : ' 7$'t• I hereby affirm that,l.am exempt from the Contractor's License.Law NAME D ' :for-the following reason,(Section 70314 Business and,Professions Code) ADDRESS' ' as:owner ofr the property, or'r my employeeS with wages as their sole compensation;will do the work and the, CITY TEL.NO. , i structure Isnot intended or offered for sale'(Section 7044;. tt Business and;Professions Code). OWNER ET, :'I, as owner`of the property;. am exclusively contractin"g MAIL. with licensedycontractors:to construct the project (Sec-', ADDRESS tion 7044, Business and Professions Code). n CONSTRUCTION LENDING AGENCY CITY r L m 1- ei G TEL. .'1 I.hereby'affirm that"there is a coristruction lending agency for the performance'•of (Sethe.work for which this permit Is Issued CONTRACTOR:p c:3097,Civ. C.).. ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE` ` LIC; certify that 1 have read this application and state that the above LICENSE NO. CLASS information is correct. I,agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this County to enter upon the:above-mentioned property for in ection.-pur' oses. SEE REVERSE FOR EXPLANATORY LANGUAGE gy— A T0XRE OF APPLIC 0 AGENTS DTE