HomeMy Public PortalAbout9821 DAINES DR_Mechanical__ WORKER'S COMPENSATION'DECLARATION' v 20-0046 DPW 9/89;
76A364C•- "APPLICATION.. FOR. •PERMITUME , '
vl hereby�afftrm that I'have a certificate of consent to self insure; _ ,:GREEN: ,
or a certificate of•Worker's Compensa{iori Insurance, or.a c lifted HEATING.-VENTILATING :AIR'CONDITIONING
cdpy.thereof.(Sec. 3500 Lab. C.) r ,
Policy
No. Company COUNTY'OF LOS.ANGELES' ' `DEPT OF,PUBLIC WORKS BUILDING AND SAFETY DIV. M Ll
/❑. Certified copy is hereby furnished.
•. :.. � ., � BUILDING
❑' 'Certified copy is filed with the county building inspecti FOR APPLICANT?TO'FILL IN ADDRESS �.0�'1`
',department; ,:: " (PRINT OR TYPE,ONLY)' „
f•�,; .. - ._ �LOCALI,TY� .- f /, Q -
Date �- 1 3 � I /l Applicant ''.. Com(.
I NO. TYPE OF APPLIANCE OR EQUIPMENT. . FEE
CERTIFICATE OF EXEM.TF' 'ION FROM WOR rFs& NEAREST
' ', i.. �,C.,'_' r , CROSS ST.
'. COMP.ENSATIOWINSURANCE , .; ABSORPTION UNIT,BTU
This-section need not be com leted If the work Involved b the ' ASSESSOR
( ._ ,. P- , Yi : - MAP BOOK' . �'s�Z.QJ PAGE /, .PARCEL D3
permit is for'one'hundred'dollars(5100)-or less.) AIR HANDLING UNIT„CFM '
DISTRICT NO: PROCESSED BY '
I certify that JQ,the performance of.the,work for which this,permlt
is issued, I shall not`employi any,person'in.any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. .. (jL _
. o
COMPRESSOR,BTU •f.,,,;'•;'
_ ”'•APPROVALSOATE`` INSPECTOR'S SIGNATURE
Date Applicant -" VENTILATION SYSTEM:; I _
NOTICE TO APPLICANT: If,-_after making this Certificate of ROUGH'^
Exemption,you should'become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of'the Labor Code,' ou must'forthwitli comp1 with such FINAL
proyisionsor this permit shall be deemed revoked.';::- FURNACE: FAU GRAVITY
LICENSED,CONTRACTORS DECLARATION+r' FLOOR BTU' ' " " .VALIDATION
1 hereby,affirm that`I am licensed under provisions of Chapter 9. SUSPENDED UNIT
(commencing with Section 7000) of;Division 3'of the'Business and HE ; WALL'
Profession's.Code,and my'licenseis'in'full*force and effect: _ s s'
/ n � 'ia, •7
Licerise.Number LG('S %�' •S Lic.Class '; " �. •, L - }
' Contracto Date
❑ s Plan checklee C�
`. .I-am exempt under:Sec:
B.&P.C.forthis`reason ' " PERMIT ISSUING FEE$ `3�7 1(�Q,�.t�'�
�:, w
Date: TOTAL FEE'; �, 1'ITEIS W
a
Signature _ ___—a' •f!)
OWNER-BUILDER DECLARAT N PLAN CHECK APPLICANT'"'1� _ TOTAL 'i� .� Z
I.hereby'affWn that I am exempt from'the'Contractor's License'Law NAME ' CHECK
.for the following.,reason (Section 7031:5, Business and Professioris
}Code): .?
ADDRESS
I;as owner'of the property;or my employees with'wages
.'.t..
:,as'their sole'compensatlon, will 'do the work grid the':" CITY TEL•.NO: ���11 �r�I�y�t
structure is not intended or.offered for•sale (Section-7044; VV"VtJV 1
y
u Business and Professions,Code):.: k OWNER ._ t 0 i� " �l.�ii' ,_ij
❑ ' I,:•.as owner�of-the property,, am exclusively:con'tracti'ng 47785' 1:. , t MIO:ter+,"
MAIL i r
with,.licensed contractors to:construct the;:project (Sec'- ADDRESS-
tion 7044, Business and,P.rofessions Code).. " f 17
CITYf! NO: 1
_
'CONSTRUCTION.LENDING AGENCY_ n. a I eL
�reby affirm_that tHere is a construction lending agency'for_,
r Work for which,this.perm Is issued CONTRACTO
the;pe formance of the wo o p 'C3?r`t. , i• 'r.
:(Sec;.3097;'Civ.C:):
�` -
;r' CITY• Q i /TEL.NO. 43 •�'ZS ;
Lender's Address STATE
certify^that I have read this application and state that the above LICENSE N0. (p L, CLASS r�
'information is correct. I agree to'comply,'with all County ordinances•, „
and State laws relating to bu' ng construction,and hereby authorize ;
representatives of this Co to enter'upon the above-mentioned'..
property for inspection p oses. ^
SEE REVERSE'FOR EXPLANATORY LANGUAGE
TURE'OF APPLICANT OR AGENT DATE. r 't
COUNTY OF LOS ANGELES- TEMPLE.CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1204180022
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA ,91780 -
PHONE: (626) 28570488 EXT:
LEGAL ID: I _ '• FEES' PAID' I BUILDING ADDRESS: I-
ITR:- 13805- LT: 64 9821 DAINES DR
I - IFEE DESCRIPTION: QUANTITY:' DOM: AMOUNT: ( TEMP CA 917802637
(ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: BALDWIN
18588-016-039 101 PERMIT 'ISSUANCE FEE 27.80' ( THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE. CITY, Cl
I 130 AIR INLETS/OUTLETS 1.00 UNI 4.40 I
ITENANT: - 141 VENTILATION FAN - - 1.00 FAN 15.80 11SSUED ON: PROCESSED BY: PLAN BY: - -I
I I TOTAL FEES 48.00 104/18/12 SR 1
(OWNER: TEL. NO: I IFINAL DATFIN BY-
CODE: 1
ICONWAY JOHN F;VIRGINIA D (626) 286-3913-
19821
86-3913-19821 DAINES DR
ITEMP 917802637 . . IDESCRIPTION OF WORK - I
I 11 AIR INLET AND 1 VENTILATION FAN
(APPLICANT: . . TEL. NO:
ITSAI, WILLY (626) 281-5726- _
I I ISPECIAL CONDITIONS:
I
(CONTRACTOR: TEL. NO: 1 - - (APPROVALSDATE. INSPECTOR SIGNATURE
_
IPARTAIN CONSTRUCTION (626) 281-5726- - 1 - ' I
1326 BELLA VISTA LIC. NO 1 IFAU/WALL FURNACE I I I
IMONROVIA,- CA 91016 - - 950949 B
I - I 1COM13USTION AIR OPENINGS I I I
(ARCHITECT- OR ENGINEER: 'TEL. NO: I IDUCT WORKI I I
I I
ITSAI,- WILLY (626) 281-5726- 1 1 -1-1 1
1236 S ATLANTIC BLVD LIC. NO:. , I IAC/COMPRESSOR (
JALHAMHRA CA 91803 950949 -B
I ITHERMOSTAT
I I - - I
IFIRE DAMPERS I I' I
I I I
I ISMOKE DETECTION DEVICES I I'
I I (COMMERCIAL HOOD I I I
i
I I I I I I
I 1µ ADDITIONAL DATA ON FILE I I I I
I I I I I I
1. IREPORT ID: DPR264 ROUTE TO: BS0508
I I I I I I