HomeMy Public PortalAbout6367 ENCINITA AVE_Mechanical__ o-fl WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT 1�
�Iniure.,"craffirm
certif cathat
te of Workers' Compensation on ent'to Insuran elf J�
bra certified copy thereof (Sec. 3800, Lob. C.) 76A364c HEATING - VENTILATING - AIR CONDITIONING
< 20-0046 DPW 9/88
Policy No Company
Company
Ce.Vified c3py is
.hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
s❑
❑ Certified copy is filed with the county building inspec-• FOR APPLICANT TO FILL IN - BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS6?67 03 ( (�
Date Applicant LOCALITY fN
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. �., %
(Thli section need not be completed If the work'Involved by ABSORPTION UNIT, BTU pISTRICi NO. PR SSED BV
• the permit Is.for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM ,{V-}0 5r O //) 0
' 1 cerllfy that in the performance of the work for'which this -�,/
permit is issued;'Ishall not employ any person in any manner
so as to becomesubject'to the Workers' Compensation Lows. BOILER, BTU i0 APPROVALS DATE INSPECTOR'S SIGNATURE
Date - T "Applic.ril"I dr UTYi.•✓ LVsr COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL -
Exemption, you should become subject to the Workers' -
ff
'Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be deem- -
ed revoked. - FURNACE: FAU C G VIN ff 070
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of.Chapter 9 HEATER: SUSPENDED UNIT— -
(commencing with Section 7000)of Division 3 of the Business WALL
ond.Professions Code,and my license'is in full force and effect.
CL
License Number S J 3 7q*Lic. Class 1C � D O
/Contractor /l9 Yja LalDate / >
d'
❑ '• I am exempt under Sec. 0
Plan check fee u
W
B.BP.C. for this reason. H
• Dat PERMIT ISSUING FEES Z
Signature . ' I TOTAL FEE
OWN -BUILrER DECLAR 'TION PLAN CHECK APPLICANT /i6pli-lu L It 14_1 "
I hereby affirm that I am exempt from th Co rector's License - D
Law for the following reason (Section 7 .5, Business and NAME
Professions Code): r
'.❑ I,'as owner of the property, or my employees with ADDRESS '3 `� IIr7
' � � '
wages os their sole compensation, will do the work and - , . ... ACGT.AT
the structure is not intended or offered for sole(Section CITY TEL NO.. O O
7044, Business and Professions Code). ---""' "----OWNER 3307 54.50
❑ I, as owner of the property, am exclusively contracting - 1 -ITEMS
with licensed contractors to construct the project (Sec- MAR ,y.�-
tion 7044, Business and Professions Code). ADDRESS /// 0 . .._ .TOTAL .54 - 50}'To50
CONSTRUCTION LENDING AGENCY - CITY TEL. NO.• V
I hereby affirm that there is a construction lending agency for . C:HECK. 54.5D
the performance of the work for which this permit is issued CONTRACTORAb r1n On � D -- {:HANUE
(Sec. 3097, Civ. C.).
ADDRESS 6 f 3 d
Lender's Name MpIp p ���/ _ _ _ �1 rr 0r1{
CITY ll TEL. NO r OVNV-��Vt �1�14/vY
Lender's Address'
STA E 9 LIc. 57.57 1 AM °'
1 certify that I have read this application and state that the LICENSE NO. c) , CLASS G�� "-- v.`s`-.
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,'
and here author' representatives of this County to enter
upo above- boned operty for inspection purposes. - - '-
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si6nof Appli 'mor en1 e %
COUNTY OF ,LOS ANGBrIES TEMPLE CITY 4 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1209100021
BUILDING AND SAFETY / LAND DEVELOPMENT _ TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: FEES PAID BUILDING ADDRESS:
�TR: 12115 LT: 20 1 6367 ENCINITA AV
IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT: ( TEMP CA 917801318
(ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
15362-023-012 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY, Cl
130 AIR INLETS/OUTLETS 2.00 UNI 8.80 1
(TENANT: 132 APPL VENT (OTHER) 1.00 UNI 12.90 11SSUED ON: PROCESSED BY: PLAN BY:
141 VENTILATION FAN 2.00 FAN 31.60 107/10/12 SR
147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 1
TOWNER: TEL. N0: TOTAL FEES 108.10 FINAL DATE FINPBY: CODE:
1LIN, DAVID (626) 675-1449- 1 1
16367 ENCINITA AVE I I
1TEMPLE CITY CA 91760 1 DESCRIPTION OF WORK -�
ALTERATION OF EXIST DUCT SYSTEM, 2 AIR INLETS, 2 VENTILATION(
- FANS, AND 1 APPLIANCE VENT
APPLICANT: TEL. NO: T
IKU BY DESIGN, LARRY KU (626) 679-5238-
1828 E. VALLEY BLVD 1 1SPECIAL CONDITIONS: 1
(SAN GASRIEL CA 91776
I
CONTRACTOR: TEL. N0: I JAPPROVALS - DATE INSPECTOR SIGNATURE
1TSH CONSTRUCTION AND DEVELOPMENT (626) 688-6255- 1
15605 TEMPLE CITY BLVD. #B LIC. NO 1FAU/WALL FURNACE �'
TEMPLE CITY, CA 91780 952913-B
COMBUSTION AIR OPENINGS I
T
ARCHITECT OR ENGINEER: TEL. NO: i iDUCT WORK
LIC. NO: IAC/COMPRESSOR
TITHERMOSTAT - �V
I I I
T1 TIFIRE DAMPERS
(SMOKE DETECTION DEVICES
ICoNMERCIAL HOOD
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1REPORT ID: DPR264 ROUTE TO: HSOS08
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