HomeMy Public PortalAbout6149 ENCINITA AVE_Mechanical__ .WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self ,
insuiti`or a certificate of Workers' Compensation Insurance, ]aA364C HEATING - VENTILATING - AIR CONDITIONING y
ora certified copy thereof (Sec. 3800, Lab. C.)
10-0046 DPW 9/88'
Policy No.�Company
❑• .4er!Kied copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY -
- Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /` In F ICE ! -r^
lion department. . (PRINT OR TYPE ONLY) ADDRESS —I y G!`7 9
Date Applicant LOCALITY 7FIM Lr' C11 T
•, 'NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1L..5-'1rY 6��V / /vim
CERTIFICATE PENSATIONOF'EXEMPTION FROM WORKERS' - NEAREST
-COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCE55ED BY
the permit is for one.hundred dollars ($100) or less.) .
I certify that in the Performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not eIn person in any m nner
so as to becomesubjectto the rker Compensation LOWS. BOILER, BTU h APPROVALS DATE INSPECTOR'S SIGNATURE
9—I3'0COMPRESSOR, BTU �3`6�0`�0 ROUGH . 8
Date Applicant
NOTICE TO APPLICANT: If, after-ma g this Certificate of _ VENTILATION SYSTEM. .FINAL It " �'
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth. EVAPORATIVE COOLER VA IDA ION
with compiywith'such provisions.or this permit shall be deem-
. s ed revoked. - .'' FURNACE: FAU GRAVIZV�(r
LICENSED CONTRACTORS DECLARATION FLOOR
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
•
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and
m license is in full force and effect. _
License Nu Ger • �-• / Lia Class —w-/J�L D 1
114
Contractor `' -
OF
I am exe pt under Sec.
Plon check_fee
W
8.8PCL
.C. fI.oP ihis•redson. t PERMIT ISSUING FEE $ W
' • Date: Z
Signature TOTAL FEE
'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _
I hereby affirm that I am exempt from'the Contractor's License �'+ -
Low for the following reason (Section J031.5, Business and 'NAME /170f�/0
Professions Code): /��, , '
F-1 1, as owner of the property, or my employees.with ADDRESS-CS L W' -`-00TH14L #1 5 .. 8
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section CITY �v� - TEL. NO. Y� Y ACCT.a
7044, Business and Professions Code).. OWNER
I, as owner of the property, am exclusively contracting "t - - J`r07 -""�'--" -"-s+O SCI
with licensed contractors to construct the project (Sec- MAIL ESS V/`/Y 9 �j-7Y/ 1 ITEMS
tion 7044, Business and Professions Code). ADDR
CONSTRUCTION LENDING AGENCY TOTAL "/-�
CITY = -7 TEL. NO. _ --,d VSO
I hereby affirm that there is a construction lending agency for [� -TI/
the performance of the work for which this permit is issued CONTRACTOR CHECK 1 I �• S !/ � D JO•'C-tO
(Sec. 3097, Civ. C.). C•HANGE
ADDRESS 50 .001
' Lender's Name - ^•�/• � - -
CITY ZVS TEL. NO. 8 '- .. .. .. .._.. . . -..
Lender's Address •� 4
STATE (� / '� LIC. q � - OOOO'0001 9�Id/L,9
fify that have read this application and store that the DCENSE NO. n / CLASS — r 5678 7
bov information is correct. I agree to comply with all County - 1 AM 9C
ordin ries and State to relating to building construction, _
and ereby aulhori e r r eNati es of this County to enter -
up the above-m olio d pro r for inrSpectipu`py,e
1(7y�,„,`(`( CKxI SEE REVERSE FOR EXPLANATORY LANGUAGE
ignaN of Applicant or Agent - Data Os
COUNTY OF LOS ANGELES TEMPLE CITY 4 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1301230010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5904 LT: 288 6149 ENCINITA AV
I �
IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 917801637
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
5384-012-020 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY CAI
1 108 FURNACE/HEATER <100 1.00 UNI 27.00
TENANT: 154 NO PERMT $224.70 MIN 339.60 339.60 JISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES394.40 01/23/13 SR
IOWNER: TEL. NO: IFINAL pATE,� NAy BY: CODE:
CHI CHEN
12312 VIRGINIA ROAD
115ES�CRI'PTION CH WORK
REPLACE EXISTING FURNACE 1
JAPPLICANT: TEL. NO:
I -
JEFF ALBERT (714) 526-6368-
1219 S STATE COLLEGE I ISPECIAL CONDITIONS:
IFULLERTON CA 92831
CONTRACTOR: TEL. NO: 1APPROVALS DATE INSPECTOR SIGNATURE
1ALBERT AIR (714) 526-6368-
11219 S STATE COLLEGE BLVD LIC. NO FAU/W FURNACE /�y�
FULLERTON CA 92831 623420 + ICOMBUSTION AIR OPENINGS P YY V
ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
LIC. NO: 1AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
ISMOKE DETECTION DEVICES
COMMERCIAL HOOD
1 I 11 I I I
1 I I I I I
1 IIII I I � I
+ ADDITIONAL DATA ON FILE
. REPORT ID: DPR264 ROUTE T0: 850508
I