HomeMy Public PortalAbout10644 FAIRHALL ST_Mechanical__ ti WORKERS' COMPENSATION DECLARATION is APPLICATION FOR PERMIT
I hereby affirm that I have a certificate ofconsent to self` r'
Insure, or a certificate of Workers' Compensat,,,or Insurance
or a certif*Sd co , HEATING - VENTILATING - AIR CONDITIONING
copy thereof (Sec 3800, Wjb C�ti 76A364C
r r, " s 20-0046 DPW 9/88 h `
"Policy No Company - * �
Certified copy ds hereby furnished , COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified`copy is filed with The county building rnapec-,t FOR APPLICANT TO FILL IN BUILDING, /
,tion department` d . . ADDRESS' ��lO
u f (PRINT OR TYPE ONLY)
Date Applicant ='� - LOCALITY,
NO TYPE OF APPLIANCE OR EQUIPMENT, FEE'
' CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
Y" COMPENSATION INSURANCE s= e` CROSS ST
-r< (This section need not be completed if the work involved by ' a +ABSORPTION'UNIT BTU DISTRICT NO ^ PROCESSED"BY
the permit is for,ono'hundred"dollars (;100) oreless) `
r 3 , m AIR HANDLING UNIT CFM
-I certify that thew
tperformance of the ork'for which this �J
permit Is issued, I shall not employ any person in any manner
• r so.as to become subject to the Workers Compensation,Laws BOILER BTU ' ( 'APPROVALS DATE INSPECTOR S SIGNATURE ,
i w i COMPRESSOR BTU J 8 1. ',ROUGH y ' ,
Date , Applicant
NOTICE'TO APPLICANT If, 'after'making this Certificate ofr VENTILATION SYSTEM ,FINAL -
Exemption; you should become subject to the Workers'
Compensation provisions of the Ldbor Code, you must forth- EVAPORATIVE COOLER VALIDATION v
with comply with such provisions or this permit shall be deem- ,
ed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 4 FLOOR BTU`
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
—
(commencing with Section 7000)of'Division 3 of the Business ° _ r4 HEATER —WALL
and Professions Code,and my license Is In full force and effect
` a.License Number Llc Class L f
_ a T ® O
U
Contractor Date CC
O
I am exempt under Sec- s U
Plan check fee w, r - W
B&P C for this reason PERMIT ISSUING FEE $ vii
Date - - - '- r T _ - Z
Signature ` f TOTAL FEE y p D ;
OWNER-BUILDER DECLARATION N A ,
PLAN CHECK APPLICANT"
I hereby affirm that I am exempt from the Contractor's License y'
"; `Law for'the6'following reason (Section 7031 51' Business and _ NAME, -�
jProfessions Code)
A x' y ,
ADDRESS U- (7 4r �l4 ,� LL t b
I, as owner of the property, or my employees with r Y
wages as their sole compensation, will do the work and CITY TEL NO " r j AC .� `r
the structure Is not Intended or offered for sale (Section , r ^'+
7044 Business and Professions Code) p ;;3;I7
OWNER
Cas owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL ` �/} I ITEMS
tion 7044, Businessland Professions Code) ADDRESS � o F-( F/-0W Gl4 CITY" �-OTEL NO -`{ _,_
_ CONSTRUCTION LENDING AGENCY ,- r, f r 3I HL � . 00
N��/� 35�� 3U
I hereby affirm that there is a construction lending agency for CHE"*K 77 13 0,
the performance of the work for which this permit is issued CONTRACTOR ` _
(Sec 3097, Civ C ) _ ® v{-Ija3C
ADDRESS -
Lender s Name
r
LendCITY TEL NO
er's'Address 'J
o. STATE a LIC
I certify that I have read this application and state that the LICENSE NO CLASS • ��L, y t ,
above information is correct I agree to comply with all County fi
ordinances and State laws relating to'building construction,
and hereby authorize representatives of this County to enter 1
upon the ve-mentione property for inspe tion urposes - - --
oi C/r . SEE REVERSE FOR EXPLANATORY LANGUAGE };
` V
1_7 /0 s s .. 4 aY , �`
` Signature of Applicant or Agent Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0912210008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
ITR 19189 LT 11 1 10644 FAIRHALL ST I
I IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917804120 I
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET LOWER AZUSA
18585-027-006 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID C4 LOCALITY TEMPLE CITY, Cl
102 COMPRSR < 100 KBTU 2 00 COM 54 00
TENANT106 FURNACE/HEATER <100 2 00 UNI 54 00 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON
1 1 TOTAL FEES 135 75 112/21/09 SR 12/21/10
OWNER TEL NO
ICHAN, DAISY _ 1 IFI AL DATE FINAL BY CODE
110644 FAIRHALL ST I I6�7fp III
1
(TEMPLE CITY CA 91780 1 1DRSC IPTION OF WORK i1
I 1 (DUCTLESS A/C UNIT AND HEATING SYSTEMS (TWO UNITS)
(APPLICANT TEL NO I 1 1
ICHU (626) 581-7738- 1
11830 EWING CT I
I 1SPECIAL CONDITIONS
IHACIENDA HEIGHTS 1
I I I
CONTRACTOR TEL NO1
I (APPROVALS DATE INSPECTOR SIGNATURE 1
IMPACT CONSTRUCTION (626) 821-5308- 1
115902 HALLIBURTON RD 125A LIC NO 1FAU/WALL FURNACE I I
IHACIENDA HEIGHTS CA 91745 479410 B
1 1 (COMBUSTION AIR OPENINGS I 1
(ARCHITECT OR ENGINEER TEL NOI I DUCT WORK
I I I
IARCHIART CORP (626) 581-7738- I
IDBA L J CONSTRUCTION LIC NO I IAC/COMPRESSOR I I
11830 EDWING CT NONE1
1HACIENDA HEIGHTS CA 91748 1 (THERMOSTAT 1 I
1 (FIRE DAMPERS
1 SMOKE DETECTION DEVICES 1 I
I I I I
1COMMERCIAL HOOD
1
I
I I I I
1 (REPORT ID DPR264 ROUTE TO BS0508
I I I I I I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC' WORKS 9701 LAS TUNAS ME 0508 0907220005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS I
ITR 19189 LT 11 1 10644 FAIRHALL ST I
I _IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917804120 1
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET LOWER AZUSA I
18585-027-006 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID C4 LOCALITY TEMPLE CITY, Cl
I 141 VENTILATION FAN 1 00 FAN 15 75
TENANT ITOTAL FEES 43 50 JISSUED ON PROCESSED BY PLAN BY EXPIRES ON
j07/22/09 SR 07/22/10
OWNER TEL NO IF IIIAL DATE FINAL BY CODE
ICHAN, DAISY - I
110644 FAIRHALL ST I D
ITEMPLE CITY CA 91780 D SC IPTION OF WORK
(VENTILATION FAN
1APPLICANT TEL NO
ICHU (626) 581-7738-
I
11830 EWING CT - ISPECIAL CONDITIONS
HACIENDA HEIGHTS I
I �
ICONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE
IMPACT CONSTRUCTION (626) 821-5308-
I15902 HALLIBURTON RD 125A LIC NO IFAU/WALL FURNACE I
IHACIENDA HEIGHTS CA 91745 479410 B
COMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER TEL NO IDUCT WORK
IARCHIART CORP (626) 581-7738- I
I I I
IDBA L J CONSTRUCTION LIC NO IAC/COMPRESSOR
11830 EDWING CT NONE I
HACIENDA HEIGHTS, CA 91748 i ITHERMOSTAT
(FIRE DAMPERS I
(SMOKE DETECTION DEVICES I
(COMMERCIAL HOOD I
I I I I
I I I I
I I I I I I
I I I I I I
I I I I I I
1 I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I
I I I I
I (REPORT ID DPR264 ROUTE TO BS0508 I I 1
I I I I I I