HomeMy Public PortalAbout5926 ENCINITA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION ]6A36640 PW 9/89 APPLICATION FOR PERMIT �� � GREEN
I hereby affirm that I have a certificate of consent to self insure,
or a certificale 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 NG
ADDRESS
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 ASSESSOR /��/
(This section need not be completed If the work involved by the MAP BOOK 1j Q / PAGE' PARCEL /
-permit Is for one hundred dollars($100)or leas.) AIR HANDLING UNIT,CFM
DISTRICT NO, PROCEaaEC 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 Xb� C 'Cfl �'w�
become subject to the Workers'Compensation Laws.
COMPRESSOR,STU
APPROVALS OATE 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
provisions of the Labor Code, you must forthwith comply with such FINAL _ 416
provisions or this permit shall be deemed revoked. FURNACE: FAU - GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU .
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED�UNIT /
(commencing with Section 7000)O1 Division 3 of the Business and : WALL (o
,Professions Code,and my license is in full force and effect. '
License Number Lic.Class j
Contractor Date !Tf:Mi („)
❑ I am exempt under Sec. - Plan check fee - i 1ITAL 52 - 05 Q
B.&P.C.for this reason -PERMIT ISSUING FEE rr .r 5c°tl , U
Date: TOTAL FEE OZ d 5 a?i•I ]E °f=1 d
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - �' Z
hereby affirm that i am exempt from the Contractor's License Law NAME
for-the following reason (Section 7031.5. Business and Professions
Codex ADDRESS - _,1:{
El 1 11.
I, as owner of the property, or my employees with wages
as their sola 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
❑ . 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS.
lion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEMa86- 03
I hereby affirm that there is a constructionper[ending agency for CONTRACTOR �� � D
the performance of the work for which thissperIs issued
(Sec. 3097, Civ.C.). - - - -
ADDRESS
Lender's Name -
- CITU 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 4_
and State laws relating to building construction,and hereby authorize -
representatives of this County to enter upon the above-mentioned -
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
/h/TiYlIA HdniLJ - .. .
SIGNAID E Gi APPLmANT OR AGENT 7 AT
COUNTY OF IAS ANGELES TEMPLE CITY 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1111210006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-:0488 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 379 BE: .001 UN: .002 1 5926 ENCINITA AV
IEEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917801931
ASSESS0R INFORMATION NUMBER I NEAREST CROSS STREET:
18587-001-018 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: S3 LOCALITY: TEMPLE CITY, Cl
1 141 VENTILATION FAN 3.00 FAN 47.50
TENANT: I TOTAL FEES 75.30 JISSUED ON: PROCESSED BY: PLAN BY:
1111/21/11 SR
OWNER: TEL. NO: FINAL DATE FIN BY: CODE:
1ZHANG, XUAN (626) 757-6685- �)D _p L?N
19168 LAS TUNAS DRIVE /
TEMP 917801931 1 IDESCRIPTION OF WORK
I 1 ITHREE VENTILATION FANS
(APPLICANT: TEL. NO:
IPUN, PETER (626) 572-9181- 1 1 1
12714 STINGLE AVE I SPECIAL CONDITIONS:
IROSEMEAD CA 91770 1 1
(CONTRACTOR: TEL. NO: I 1APPROVA1,S DATE INSPECTOR SIGNATURE
IS P CONSTRUCTION (626) 572-9181- 1 1
12714 STINGLE AVENUE LIC. NO 1FAU/WALL FURNACE
ROSEMEAD, CA 91770 642751 B
ICOMBUSTION AIR OPENINGS
I
ARCHITECT OR ENGINEER: TEL. N0: IIDUCT- WORK
I LIC. NO: I 1AC/COMPRESSOR
I THERMOSTAT
I 1
I I (FIRE DAMPERS I I 1
1 ISMOKE DETECTION DEVICES
(COMMERCIAL HOOD 111
11 1 I I I 11
1 11 I I I 11
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�.,1 ,IREPORT ID: DPR264 ROUTE TO: BS0508 I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
.. DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1203120044
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 2B5-0488 EXT:
(LEGAL ID: FEES PAID I BUILDING ADDRESS:
ITR: 6561 LT: 379 BL: .001 UN: .002 1 5926 ENCINITA AV
IEEE DESCRIPTION: QUANTITY: UOM: AMOUNT: I TEMP CA 917801931
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
8587-001-018 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: T3 LOCALITY: TEMPLE CITY, Cl
102 COMPRSR < 100 KBTU 1.00 COM 27.00 1
(TENANT: 106 FURNACE/HEATER <100 1.00 UNI27.00 ISSUED ON: PROCESSED BY: PLAN BY:
130 AIR INLETS/OUTLETS 9.00 UNI 39.60 103/12/12 SR
TOTAL FEES 121.40 1
OWNER: TEL. NO: I FINAL DATE FINAL BY: CODE:
ZHANG, XUAN (626) 757-6685- 1 1 _
19168 LAS TUNAS DRIVE
(TEMP 917801931 IDESCRIPTION OF WORK
INEW A/C COOLING/HEATING UNIT
APPLICANT: TEL. N0:
PUN, PETER (626) 572-9181-
12714 STINGLE AVE SPECIAL CONDITIONS:
ROSEMEAD CA 91770
CONTRACTOR: TEL. NO: IAPPROVALS DATE INSPECTOR SI NATURE
J P CONSTRUCTION (626) 572-91.81-
12714 STINGLE AVENUE LIC. NO FAU/WALL FURNACE
ROSEMEAD, CA 91770 642751 A `
I
COMBOSTION AIR OPENINGS
OPEN INGS�
I I I
ARCHITECT OR ENGINEER: TEL. N0: I iDUCT WORK
LIC. NO: I
IAC/C^MPRESSOR
ITHERMOSTAT
I
I II 1FIRE DAMPERS i 11 I
I ISMOKL DETECTION DEVICES
CONPAERCIAL xooD I I I
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I I I I 11 11
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(REPORT ID: DPR264 ROUTE T0: 850508
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