HomeMy Public PortalAbout5729 ENCINITA AVE_Mechanical__ WORKER'S COMPENSATION-DECLARATION 20-0040 DPW 9189 APPLICATION FOR PERMITUME GREEN
I hereby et firm That I have a"certificate of consent to self insure, 6A364C
or 5,
ertificate of Worker's Compensation Insurance, or a certified _ HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) '
Policy No. Company _ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑.' Certified copy is hereby furnished. .
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN AODBEBs /V N M f
Ake-
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT •FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST _
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL _
permit Is for One hundred dollars($100)or lase.) AIR HANDLING UNIT,CFM
DI6TflICT NO. PRDCESSED BY
I certify That in the performance of the work for which this permit '
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject t0 the Workers' Compensation Laws.
jr COMPRESSOR BTU
APPRWAtS DATE IN61TOR'651GIUTURE
Dale Applicant VENTILATION SYSTEM -
NOTICE APPLICANT: after making this Certificate of ROUGH IV
Exemption,,you should become
subject to the Workers'Compensation EVAPORATIVE COOLER
provisions o/the Labor Code. you-must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. . . FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU t'J(/ VALIDATION .
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_ '
.(commencing with Section 7000) of Division 3 of the Business and HEATER' WALL
Professions Code, and my license is in full force and effect. _. O
V
ACCT..
License Number LID.Class '
D 3303 10E.3.5 y
Contractor Dates 1 ITEMS p
❑ I am exempt under Sec. Plan Check lee TOTAL iAds a Oc
B.BP.C.for this reason PERMIT ISSUING FEE$ Q CHECK 108.85 O
Date: TOTAL FEE CHANGE .00 w
Signature d
PLAN CHECK APPLICANT U)
OWNER-BUILDER DECLARATION 0060—WO Z
I hereby affirm that I am exempt from the Contractor's License Law. NAME D 1 9/22/[9)
for the following reason (Section 7031.5, Business and Professions Ct' 2427 1 AM 8:47
V eJ' ADDRESS i^ )
I, as owner of the property, or my employees with wages til
as their sole compensation, will do the work and the CITY ' TEL.NO. Q/ O
structure is not intended or offered for sale (Section 7044,- V
f 7
Business and Professions Code), OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS T '
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY le 6 TEL.NO. d
I hereby affirm that there is a construction lending agency for CONTRACTOR D
he performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). .-
ADDRESS
Lender's Name
CITY L.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information i correct. I agree to mply with all County ordinances
and State I s relating to buil onstruchon,and hereby authorize
represent i sof this Co ly ante po the above-mentionetl
P
r inspection ur Ses. n Y SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA OFAPPI TOR AGENT DATE �/(J
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHAN',CAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0405260007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488. EXT:
LEGAL ID: EES P D BUILDING ADDRESS: +.-
ON FILE 5729 ENCINITA AV
FEE DESCRIPTION: QUANTITY: UOM: ,AMOUNT: TEMP CA 917802418
ASSESSOR INFORMATION NUMBER: NEAREST..CROSS STREET:
5387-018-013 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, C
41 VENTILATION FAN 1.00 FAN 15.75
TENANT: TOTAL FEES 43.50 ISSUED ON: PROCESSED BY: PLANEXPIRES ON:
05/26/04 VG 11/22/04
OWNER: TEL. NO: FINAL DATF" 9Y: LODE:
TAM, SIMON
5729 ENCINITA AV
TEMP 917802418 D S R P bN Ur•NOR
1 BATH FAN
APPLICANT--. TEL. NO:
PETRA CONSTRUCTION MANAGEMENT INC. (626) 233-8148-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
PETRA CONSTRUCTION MANAGEMENT (626) 233-8148-
2550 W. MAIN ST., #211 LIC. NO FAFA /WA�-
ALHAMBRA, CA 91801 761300 B
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: OL'C WO�r /
LIC. NO: AC/COMPRESSOR !/ -
THEfi OSTTA7
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508