HomeMy Public PortalAbout5957 ENCINITA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT �� � GREEN
I herdby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) '
P y No.to 9 6 Mpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
® Certified copy is hereby furnished.
❑ Certified copy is filed with the county buil 'ng inspection FOR APPLICANT TO FILL IN AooREBfi Cirri/�� C..
department �� A (PRINT OR TYPE ONLY)
Datea�APPlican�c;'s /;,/ LOCALITY./c.,� UKG-J p 17 G,tLiL
NO. TYPE OF APPLIANCE OR EQUIPMENT 4
CERTIFICATE OF EXEMPTION FROM WORKERS' A� r--
NEAREST
COMPENSATION INSURANCE Q(30CROSS ST.
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(3100)or leas.) AIR HANDLING UNIT,CFM
DISTRICT No. PRocssssG 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. OO�COMPRESSOR,BTU APPROVALS GATE INSPECTOR'a SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, aftemaking this Certificate ofROUGH .2
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
44
provisions of the Labor Code, you must forthwith comply with such FINAL _Z
provisions or this permit shall be deemed revoked. < U FAU GRAVITY r.:.�,
LICENSED CONTRACTORS DECLARATION FLOOR B d� VALIDATION.1�'–CI
L hereby affirm that em licensed under provisions at Chapter 9 - SUSPEND UNIT_
'(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL i"�E�`•,
Professions,Code,and my license is in full force and effect.
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License N unit �Lic.Class
ContractaF/"�•�"% `/ Date 0
❑ I am exempt under Sec. Plan Check fee V
CC
B.BP.C.for this reason PERMIT ISSUING FEE $
Date: R' CHECK.
(V(J:�T:: i:I W
TOTAL FEE Y
Signature PLAN CHECK APPLICANT ���t')`j`t ,IIjJ W
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME—t
for the following reason (Section 7031.5, Business and Professions �� J
Code): ADDRESS, �
, d W 1�1(B i–flfil 1 1 yi��>_:
❑ I, as owner of the property, or my employees with wages i'�'� ,,_jar
as their sole compensation, will do the work and the CITY ��-�� TEL.Ng
/z7�ps�r _ qJ
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER —a;l/ IS'
❑ I, as owner o1 the properly, am exclusively contracting i RENIS
MAILi
with licensed contractors to construct the project (Sec /oLS
ADDRESS Ti_ i_
tion 7044, Business and Professions Code). T q
CONSTRUCTION LENDING AGENCY _ TEL. �•7�6'0/Z _ i.HEIi.(=,_ iL'ia Z1-1
I hereby affirm that there is a construction lending agency for CANTRACTOR D
the performance of the work for which This permit Is issued
(Sec.3097,Civ.C.). _
ADDRESSY ���
Lender's Name
CIT -e-,TEL.N ! 21_
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. O` 20 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 Count D enter upon the above-mentioned
property for insp li n p SEE REVERSE FOR EXPLANATORY LANGUAGE
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-SIGNATURL OF APPLICAN I OR AGENT GATE f • ,� -34 . 30
COUNTY OF LOS ANGELES TEMPLE CITY N 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9901 LAS TUNAS ME 0508 1307110021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0486 EXT-
(LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 5904 IT: 383 5957 ENCINITA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: I TEMP CA 917801933
I ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
15384-013-027 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: US LOCALITY: TEMPLE CITY CA
102 COMPEER < 100 KBTU 1.00 COM 27.00
1 TENANT: I TOTAL FEES 54.80 11SSUED ON: PROCESSED BY: PLAN BY:
1 107/11/13 SR
(OWNER: TEL. NO: IFINAL DATE FINAL BY: CODE:
VALAZZA, TONY (818) 378-5295-
15957 ENCINITA AVE
ITEMPLE CITY CA 91780 IDESCRIPTION OF WORK
CHANGE OUT AND REPLACE CONDENSER
APPLICANT: TEL. NO:
KOEPER, ANDREAS (626) 446-7444-
1207 W 13TH ST ISPECIAL CONDITIONS:
UPLAND CA 91786 1
EXPBRER 1 1
CONTRACTOR: TEL. NO: ' / APPROVALS DATE INSPECTOR SIGNATURE
BOWMAN OF ARCADIA (626) 446-7444- 1 I
157 E SANTA CLARA LIC. NOI FAU/WALL FURNACE
1ARCADIA CA 91006 295706 C20 III
COMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
LIC. NO: 1AC/COMPRESSOR
_ ITHERMOSTAT
IFIRE DAMPERS
1 ISMOKE DETECTION DEVICES
COMMERCIAL HOOD
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II III I 1 I II
-" - IREPORT ID: DPR264 ROUTE TO: BS0508