HomeMy Public PortalAbout5719 ENCINITA AVE_Mechanical__ WORKER'S.I have
a certificate
DECLARATION 26.A364 DPW 9/89 - APPLICATION FOR PERMIT L��ME GREEN
70A 6
1 hereby off i'(n That I have a certificate of consent,to self insure, �T
or a certificate of worker's Compensation Insurance, or a Conti HEATING -VENTILATING-AIR CONDITIONING ylLl'I
copy thereof(Sec.3800 Lab.C.)
Policy No.(]gs1.123°Co-mlpany C A� 0 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnis�ed
/� ,J� BUILDING p AE '
❑
Certified copy is filet/the nspection - FOR APPLICANT TO FILL IN ADDRESS S7 I A.1 ,LJ r f•ti /•
department (PRINT OR TYPE ONLY) /
DateA cant LOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICJr NEAREST OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This s tion neetl not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit 19 for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM
� nl$iRILT NO. PROCESSED 8Y
)1Cerhfy 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. 7 �� O O� v
COMPRESSOR,BTU L '
/ �I r�'_ (( APPROVALS DATE INSPECTOR'S SIGNATURE
Data y—,` � W Applicant COLH r`r�L.� L��NnT/ Cie jCc W VENTILATION SYSTEM
NOTICE TO APPLICANT: It, after making this Certificate of ROUGH
Exemption,you should became subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY (o6.
LICENSED CONTRACTORS DECLARATION / FLOOR BTU VALIDATION
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: WA L
Professions Code,and my license is in full force and effect. /
$
1
J O
License Number �'��� lDC Lie.Class — 7,0 ACCT.t
ContractorCUt�II�T 6P1144TiZ Date `�' 6 - D 3303 114'.10 O
❑ Plan check fee 1 ITEMS U
I am exempt under Sec. 4- O
B.aP.C.for this reason PERMIT ISSUING FEE $ p TOTAL '11 _ 10 0
Date: TOTAL FEE CHECK 114.10 W
a
Signature - CHANGE •00 0-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions D 0flflntl
000-0001' 6! 696
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages 6769 1 AM 9�10.
as their sole compensation, will do the work and the CIN TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). - OWNER U 1.f ;
❑ I, as owner of the property; am exclusively contracting MAIL n
with licensed contractors to construct the project (Sec. ADDRESS q N - tJr
tion 7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY CIN I K ? errTEL.NO. /1
I hereby affirm that there is a construction lending agency for CONTRACTOR CO C' i NTQOt� D
the performance of'the work for which this permit is issued
(Sec.3097,Civ. C.). )
ADDRESS
Lender's NameJ
CITY A TEL.NO.
Lender's Address fes- r, I
I certify that I have read this application and state that the above L CENSE NO. 4 10 te l 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 ..r inspection rpoSes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OR AG IT I I DA
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 9811060007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ON FILE 5719 ENCINITAAV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802418
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LIVE OAK
5387-018-015 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY
30 AIR INLETS/OUTLETS 6.00 UNI - 26.10
TENANT: TOTAL FEES 53.85 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
11/06/98 UT 11/06/99
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
CHAVEZ JULIAN E;KATHLEEN K - --T r OZ
5719 ENCINITA AV `,
TEMP 917802418 DESCRIPTION OF WORK
HEATING AND AIR CONDITIONING
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
OS P�GELES C
CONTRACTOR: TEL. N0: O��T APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. O: DUCT WORK
LIC. NO: 1111111 AC/COMPRESSOR
THER14OSTAT
C � pO = �AVQRKS FIRE DAMPERS
v l SMOKE DETECTION DEVICES
8 COMMERCIAL HOOD
Coe �ot�
c Service VA
REPORT ID: DPR264 ROUTE TO: BS0508