HomeMy Public PortalAbout5116 DOREEN AVE_Mechanical__ . WORKER'S COMPENSATION DECLARATION 26W9/e9
fiA3640 APPLICATION FOR PERMIT UME GREEN
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I hereby atfirrQ th;Dl klva a certificate of consent to self insure.
or a ceftificate.of Worker's Compensation Insurance, or a certified HEATING•VENTILATING• AIR CONDITIONING
copy Ahe%gof(Sec�3800 Lab. C.)
P❑alicy No. Company COUNTY OF LOS ANGELES, DEPT OF PUBLIC WORKS BUILDING.AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING .f•��, ' J
❑ Certified copy is filed with the county building inspection FOR APPLICANT INT TPE ONLY) IN ADDRESS �� WIL���/tO �Ci,
department. ( n
� Applicant LOCALITY
Date
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 11
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST -
NEAREST. V✓
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or lase.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY_
I certify that in the performance of the work for which this permit '
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of _ ROUGH
Exemption;you should become subject to the Workers'Compensation EVAPORATIVE COOLER
you must forthwith cpm ...(}
provisions of the Labor Code, y comply with such FINAL
provisions or this permit shall be deemed revoked., FURNA$S��}. FAU_GRAVITY _
LICENSED CONTRACTORS DECLARATION FLOO:* 5-;~ BTU - —51 VALIDATION •i
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL ,
and m license is in full force and effect.
Professions Code, y � �`.tt•,�,:*
License Number Lia Class �' � .� 55117 171.5!
1. ITEMS.... o
Contractor Date - -- '
Plan check fee TOTAL `171 e 37 O
❑. I emexemPl under Sec. 7:5'
- -" It
CHECK 171.37o
B:BF.C.for this reason PERMIT ISSUING FEE $
Date: TOTAL FEE CHANGE GU W
CL
Signature- - (n
I_�)
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT I I � Z
' 0-00G1 ' 1!_„)..193 —
I hereby affirm.that I am exempt from the Contractor's License Law NAME D
for the following reason'(Section 7031.5, Business and Professions 7770 1 AM11:11
Cade: ,
ADDRESS ... .. .___.
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY ,TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). WNER S'T-FvZ `✓L�
❑ I, as owner of the property,'am exclusively contracting MAIL , '� / /A.
with licensed contractors to construct the project (Sec- ADDRESS //¢ ,/•/��i,�eIv ✓�•
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY rg� C (J/ r TEL.NO.
hereby affirm that there is a construction lending agency for CONTRACTOR•
the performance of the work for which'this permit Is issued
(Sec:3097,Civ.C.). -
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I 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 tori pection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C� r�� /-12 —E
51' GNATUflE OF APPLICANT Oa AGENT GATE
COUNTY OF LOS ANGELES TEMPLE CITY N 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1209260008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91760
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID BUILDING ADDRESS:
IBK: 254 PG: 39 PC: 2 1 T 5116 DOREEN AV 91780
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA
(ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET: FREER
I858S-022-045 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Cl
102 COMPEER 1 100 KPTU 2.00 COM 54.00
TENANT: 1
08 FURNACE/HEATER 00 2.00 UNI 54.00 (ISSUED ON: PROCESSED BY: PLAN BY-
130
30 AIR INLETS/OUTLETS 12.00 UNI 52.80 109/26/12 SR
141 VENTILATION FAN 2.00 FAN 31.60 1
TOWNER: - TEL. ITO I TOTAL FEES 220.20 (FINAL DATE FINAL AY: CODE:
TKEY COMMUNITY HORSING 4A Il
15116 DOREEN AV T1�
ITEMP 917803438 1 115ESCRIPTI N OF WORK
(INSTALL 2 A/C AND HEATING UNITS, 12 AIR INLETS AND 2 T
VENTILATION FANS T
((APPLICANT: TEL. NO:
ISCOTT BROWN DESIGN (323) 256-6336- 1 T 1
11444 POPPY PEAK I ISPECIAL CONDITIONS: T
IPASADENA CA 91105 1 1
CONTRACTOR: TEL. NO: T (APPROVALS DATE INSPECTOR SIGNATURE T
IMICHAEL G ROELLE PLUMBING (626) 960-0344- T T
15057 PANTE STREET LIC. NO FAU/WALL FURNACE
TBALDWIN PARK CA 91706 743562BC16 *I
(COMBUSTION AIR OPENINGS T
1
ARCHITECT OR ENGINEER: TEL. NO: iTDUCT WORK
1RAL
HELOU STRUCTUENG (818) 345-7646- _
15585 RESEDA BLVD. 105 LIC. NO:
IAC/COMPRESSOR
TAROANA, CA 91356 NONE I
THERMOSTAT 11
AFIRE DAMPERS
I ISMO KE DETECTION DEVICES I I
(COMMERCIAL HOOD
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* ADDITIONAL DATA ON FILE 11 11
IIT IREPORT ID: DPR264 ROUTE TO: BS0508 11
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