HomeMy Public PortalAbout9071 EMPEROR AVE_Mechanical__ �. ERS'COMPENSATION DECLARATION to self / AlPLICATION FOR PERMIT
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CE-818(REV 10/81)
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Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING A 4D SAFETY
Certified copy is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department /,//(/y��t �� ADDRESS 6
771
Date Applicant t'►''7")�1 ' iw" (PRINT OR TYPE ONLY)
LOCALITY
NO TYPEOF APPLIANCE OR EQUIPMENT FEE lid
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 PR 56ED BY
the permit is for one hundred dollars ($100)or less ) — C j
I certify that In the performance of the work for.which this AIR HANDLING UNIT CFM ` Vx
permit Is Issued, 1 shall not employ any person In any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws APPROVALS DATE NSP! OR S SIGNATURE
DateTMd& Applicant COMPRESSOR BTU 3 .Cj ROUGH
NOTICE T 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 VALIDATION
with comply with such provisions or this permit shall be _
deemed revoked FURNACE FAURAVITY �)
LICENSED CONTRACTORS DECLARATION FLOOR BTU (�
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPEND UNIT'
(commencing with Section 7000) of Division 3 of the Business HEATER WALL
and Professions Code,and my license is In full force and effect
License Number Llc Class O
u
Contractor Date DC
❑ jam exempt under Sec W
V
Plan check fee a
B &P C for this reason
Date Z
PERMIT ISSUING FEE a
Signature TOTAL FEE d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME
Professions Code) I
`' ❑ I, as owner of the property, or my employees with ADDRESS n
wages as their sole compensation,will do the work and CITY TEL NO :20 7 Q n
5
the structure is not intended or offered for sale(Section
7044, Business and Professions Code) �
OWNER tJ �y #�• opo e o 8
1, as owner of the property, am exclusively contracting
P�Iwith licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS qO17 ��,o C� r- , 0 _
pp,,
CONSTRUCTION LENDING AGENCY CITY TEL NOd fgl,2
1 hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit is Issued CONTRACTOR
(Sec 3097, Civ C ) _
ADDRESS
Lender's Name
CITY TEL_NO
Lender's Address
I 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 jaws relating to building construction,
and hereby authorize represe t tives of this County to enter J
upon the�e-mentio � erty for Inspectio` purposes SEE REVERSE FOR EXPLJANATORY LANGUAGE
/ - "Z- ��
Signature or Agent Agent Date
COUNTY OF'LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1205210006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL IDFEES PAID BUILDING ADDRESS
I 9071 EMPEROR AV
ON FILE IFEE DESCRIPTION QUANTITY UOM AMOUNT SGAB CA 917752016
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET ROSEMEAD
15382-011-018 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID H1 LOCALITY TEMPLE CITY, Cl
I _141 VENTILATION FAN 1 00 FAN 15 80
(TENANT I TOTAL FEES 43 60 JISSUED ON PROCESSED BY PLAN BY
105/21/12 SR
OWNER TEL NO
IFINt D E FINAL BY CODE
IGHABOUR WAGDY R,ANAAM S (626) 482-2433-
19071 EMPEROR AV
SGAB 917752016 IDECRI TION OF WORK
IRE LACE VENTILATION FAN FOR BATHROOM REMODEL
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(APPLICANT TEL NO
ISAME AS OWNER -
SPECIAL CONDITIONS I
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ICONTRACTOR TEL NO I (APPROVALS DATE INSPECTOR SIGNATURE I
ISAME AS OWNER I
I LIC NO I FAU/WALL FURNACE
ICOMBUSTION AIR OPENINGS
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(ARCHITECT OR ENGINEER TEL NO IDUCT WORK I
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I LIC NO I IAC/COMPRESSOR
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(FIRE DAMPERS I I I
ISMOKE DETECTION DEVICES
ICOMMFRCIAL HOOD
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IREPORT ID DPR264 ROUTE TO BS0508
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