HomeMy Public PortalAbout9945 DAINES DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT .
I hereby affirm that I_haa`ve certificate of consent to self3 '
insure, or a ,ertiflcate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING ,
or a certified copy,thereof (Sec 3800, Lab C.) 76A364C
20-0046 DPW 9788. ?Policy No No PC991357company Republic Irid.
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY ;
®,,Certified copy is filed with the county bylhg inspec- FOR APPLICANT TO FILL IN BUILDING
Tia epart e� r. - ADDRESS 9945' Daines Drive
(PRINT OR TYPE ONLY)
Dote ApplicantLOCALITY -Temp le'C i ty, CA - ,'
NO TYPE OF APPLIANCE OR EQUIPMENT- 'FEE
CERTIFICATE OF EXEMP F"EtRS!!!'
'' NEARESTCOMPENSATIO INSUCROSS ST Baldwin
ABSORPTION UNIT, BTU
(This section need not be completed if the work involved by V DISTRicT No POC SSED BY '
the•permit i0or one'hundred dollars ($100)or less.)
I,certifythat 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 APPROVALS DATE TOR'S SIGNATURE
Dare A i COMPRESSOR, BTU' =�hrDnn" 1 00 ROUGH
pplicant
NOTICE TO APPLICANT If, afier"makin this Ceitlficate of - FINAL
9 VENTILATION SYSTEM
Exemption,''you should "become subject to
'the Workers'
Compensation provisions-of the Labor Code, you'must•forth- " EVAPORATIVE COOLER V D T164'
with comply•with such provisions or this permrt'shdll be deem,•
ed-revoked ' 7' FURNACE FAU X GRAVITY
4=
LICENSED.CONTRACTORS DECLARATION I FLOOR BTU' 1:2100-
Thereby affirm that I am licensed under provisions of Chapter,9 SUSPENDED UNIT
x HEATER y�ALL - ^
(commenting with Section 7000)of'Division 3 of the"Business
-and Professions Code,and'my license is imfull force and effect. 9 Inlets & Out lets $2. 1 00 L-
License N 7 U1751 L r C-20 a0
Contractor, Datelas GC
❑ I'a7.
empt under c �, , • ` O
Plan check fee u
B&P C for tliis'reason r, d
Date '- PERMIT ISSUING FEE $ 13 00 z '
` TOTAL FEE 55 00
Sign6ture =
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
C-
�----I hereby-offirm-that•i•am•exempt•from•the• ontractor's'Licen`se- a
Law for the following reason (Sect16n,7031 5, Business'and ' NAME, '
Professions Code) -
❑ --I, as owner of the property, or, my employees with ADDRESS`
wages as their sole compensation, will do the'work and i'•i<�f..T°g
CITY_•_ TEL NO
-the structure is not-intended-or offered for sale(Section` cc
7044, Business and Professions Code) 3307 F.s°l3l,j
OWNER .'James,
Belk a -
❑ as,owner_of the,property, am exclusively,coniractmgSJ
with licensed contractors to construct the project (Sec MAIL' 4
Tion 7044, Business and Professions Code) r• ADDRESS- 9945-Da•ines Dr,- TOTAL ,I 55 . 00
CONSTRUCTION LENDING AGENCY CITY Temple City TEL NO 2g7•-3671 , I(I-
I hereby affirm that there'is a construction lending agency for ` CHECK
the performance of the work for which this permit is issued,, CONTRACTOR Bryant Heating'& A/C ® ►.HOIGE °01-1
(Sec 3097,•Civ C )
ADDRESS 13
Lender's Name 50`E, La`s'Tunas
'CITY San Gabriel TEL No 286-1141 00010- 1 5f YK
Lender's Address c-f ts° r
I cern that I have read this'application and state that The I��•�, 7°
STATE LIC "
certify pp LICENSE•NO 221751 CLASS C-20
above'rnformation is correct•I agree to comply,with all County
ordm ces and State la s relating to building construction,
an er y_aut on a esentatives of this County to enter
un the e �propert' inspection purpos s '' - "' •" - •"- ,• ^' -^' � - ,
,SEE REVERSE FOR EXPLANATORY LANGUAGE _»
Sign ur f App scant or A t Date �5
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME'0508 0611020012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE- (626) 285-0488 ERT
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 13805 LT 51 9945 DAINES DR
FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802639
ASSESSOR INFORMATION NUMBER. NEAREST CROSS STREET BALDWIN
8588-016-026 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE: 597 GRID: A3 LOCALITY. TEMPLE CITY, C
30 AIR INLETS/OUTLETS 1 00 UNI 4 35
TENANT _ - 47 ALTER EXIST DUCT SYS 1 00 SYS 27 00 ISSUED ON: PROCESSED BY PLAN BY EXPIRES ON
TOTAL FEES 59.10 11/02/06 JK 05/01/07
OWNER. TEL NO FINAL DTE 'BY.— ---- ---- -- CODE:
BELKNAP JAMES G;ELIZABETH L (626) 287-3671—
9945 DAINES DR bi P1
TEMP 917802639 SCR ION OF WORK
ALTERATION OF EXIST DUCT SYSTEM
APPLICANT. TEL. NO
PENDLEBURY (626) 355-7797-
370 W SIERRA MADRE SPECIAL CONDITIONS
SIERRA MADRE 91024 '
CONTRACTOR TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
JORDAN, PAUL (626) 285-7609-
9945 DAINES DRIVE LIC. NO FAU/WALL FURNACE
TEMPLE CITY, CA 91780 NONE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER TEL NO: DUCT WORK
PENDLEBURY, THOMAS (626) 355-7797-
370 W SIERRA MADRE BLVD. LIC NO: AC/COMPRESSOR
SUITE D C11097
SIERRA MADRE CA 91024 THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
is
REPORT ID: DPR264 ROUTE TO BS0508