HomeMy Public PortalAbout9843 ESTRELLA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION f APPLICATIONFOR -PERMIT
f hereby affirm that I have a certificate of consent to self
insure, or'a certificate of Workers Compensation Insurance, 76A364C HEATING • VENTILATING - AIR CONDITIONING. ,
or a certified copy thereof (Sec. 3800, Lab. (
�'7 OL 3• •_ , - �D 20-0046 DPW 9/88 '
Policy NY s �3 Company - n `
Certified.copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is flied with th ounty b iId i nginspec-
LL FOR APPLICANT TO FILL IN BUDRESS ILDING ''f'I� S EZZA Ail
(PRINT.OR TYPE
ion department ..^^ ONLY) '
AD
Date"�d� -Applicant - LOCALITY—T—e (30C Cl
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF,EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE _ .. _ CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU 70. PROCESE BY '
the permit is for one hundred dollar s'($100) or less.) O Q.
AIR HANDUNG'UNIT, CFM
I certify that in the performanceofthe work for which this
permitis issued,.)shall not employ any person_ BOILER, BTU in any manner, _ -
'
. ' so as to become subject to the Workers'Compensation Laws. APPROVALS' DATE wsP roRIs slcri TURF
' COMPRESSOR, BTU Q O V ROUGHWX
Date 'Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should' become subject'to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER _ VALIDA ION -
with comply with such provisions or this permit shall be deem-
ed revoked. ' FURNACE: -FAuBU ' RAVI Y
^ FLOOR LICENSED
'.I hereby affirm that'l am licensed a nderProv i s i o ns of Chapter 9 HEATER: - SUSPENDED UNIT
- • (commencing with Section 7000)of Divisiod3 of the Business WALL
and Professions'Code,and my license is in full force and effect.
License Number 5'3Lia Class D Is.
SJIO
U
Contractor Date O
.. ❑' •1 am,exempt under Sec. "- ~
Plan check fee _ W
- B.'BP:C. for this reason. - - O H
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE 01 O
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
.1 hereby affirm.that Lam exempt from the Contractor's.License - -
Law for the following reason (Section 7031.5,,Business and NAME
Professions,Cade): - - -
- -
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sale compensation, will do the work and - ANTA
A
the structure is not intended or offered for sale (Section CITY — TEL, NO. - - „ ,.,_, ACCTA - --++�� CCrs••LL
7044, Business and Professions Code). OWNER _ J,V� EM .lV.•JV
❑ 1„as owner of the property, am exclusively'coniracting, - T
with licensed contractors to construct the.project (Sec- MAIL 13 2
5_7-k'T_.LA - 1.1T
tion firm Business and Professions Code). ADDRESS (-r7,,_
TEL-. NO , P��r f•. .
CITY
^ FF v CHECY 30.E
I hereby afflrmOthatRherelis ONa LENDING AoGEendYng agency for TOTAL - 3�v��
the performance of the work for which this permit Is Issued CONTRACTOR— /tn
(Sec. 3097, Civ. C.) p ^
ADDRESS � F� s"1�t... ..
,Lender's Name -
CITY �. G'�` TEL. NO.
Lender's Address QQQd-0001 6/23/39
I certify that I have read this application and state that the STATE LIC. G2-f> - . .... - .
LICENSE NO. I 3� CLASS
4152 1 AMIO:11
above information is correct. I agree to comply with all County _ _
ordinances and State laws relating to building construction,
and hereb authorize representatives of this County to enter
upon the Lvementi ned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of pplicant or Agent .• ,Date. -
.
I*JUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1111210024
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 16712 IT 11 9843 ESTRELLA AV
I IF£E DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917801417 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
15383-023-011 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: Al LOCALITY: TEMPLE CITY CAI
1 141 VENTILATION FAN 2.00 FAN 31.60
1TENANT: - TOTAL FEES 59.40 (ISSUED ON: PROCESSED BY: PLAN BY:
111/21/11 SR
OWNER: TEL. NO: l (FINAL DATE FIN BY: CODE: 1
198 LI, TAM 626) 203-6362- ��f?.
9893 ESTRELLA
ITEMPLE CITY CA 91700 D SCRI TION OF WORK
IVENTILATION FANS FOR TWO BATHROOMS REMODEL
(APPLICANT: TEL. NO:
LEE, RAYMOND (626) 825-2614-
19322 KLINGERMAN ST C ISPECIAL CONDITIONS:
SOUTH EL MONTE 91733 1
I
CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
PAY LEE CONSTRUCTION, INC. (626) 825-2614- 1
9322 KLINGERMAN STREET #C LIC. NO IFAU/WALL FURNACE
ISOUTH EL MONTE, CA 91733 7295168 * 1
(COMBUSTION AIR OPENINGS
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1ARCHITECT OR ENGINEER: TEL. NO: - IDUCT WORK
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LIC. NO: IAC/COMPRESSORI
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IFIRE DAMPERS
ISMO KE DETECTION DEVICES
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jADDITIONAL DATA ON FILE
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RE PORT ID: DPR264 ROUTE T0: 850508 l
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