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HomeMy Public PortalAbout4502 FIESTA AVE_Mechanical__ (2) WORKERS'COMPENSATION DECLARATION 'I'h�reb;faffi•rm that I have a certificate of consent to Self APPLICATION FOR PERMIT isisure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or d certified copy thereof (Sec. 3800, Lab. C.) 76A364C �^��-q�y�/ CE-818(REV. 10/81) P❑olicy,No.� � �Company`J ✓�Y'� /Or_Z� Certified 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 tion department. ADDRESS 3J �i (PRINT OR TYPE ONLY) Dates ? AZ � *Applicanf�`C � ��� LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l• CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (}� � (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM n b I certify that in the performance of the work for which this ✓t�-/ permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers'Compensation Laws. APPROVALS DATE Ey. S SIGNAT E Date Applicant COMPRESSOR, BTU ROUGH — J NOTICE TO APPLICANT: If, after .making this Certificate of VENTILATION SYSTEM FINAL �%- 111 Exemption, you should become subject to the Workers' _ ' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU - GRAVITY 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 and Professions Code,and my license is in full force and effect. /y �� /� lS�j. CL License NumberN� �j v Lic. Class 'ifs' /_/ /` / ( �j �lTw ' Z'959. 1 A U Contractor®— /L �oC �C !/Tdi�,�f!/ ' (� v F-1I am exempt under Sec. o o;0 0 0 8 d Plan check fee y B.&P.C. for this reason' PERMIT ISSUING•FEE $ J o o 3,0,5 0 Z Date: e Signature' TOTAL FEE D © o o 3,0 5 0 r OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License 51 2-8 8 Law for the following reason (Section 7031.5, Business and NAME , Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. ❑ 7044, Business and Professions Code). � � y OWNER .J I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ' MAIL �� , LJ�� tion 7044, Business and Professions Code). ADDRESS /— CONSTRUCTION LENDING AGENCY CITY / Cir TEL. NO. V' 9 - 1 hereby affirm.that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR G ,' (Sec. 3097, Civ. C.). �..J ADDRESS Lender's.Name C•� CITY /!A. p- TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. 72- (�� CLASS above information is correct. I agree to comply with all County - ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0012120004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 12998 LT: 30 4502 FIESTA AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804209 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA 8592-001-045 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 COM 27.00 TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 30 AIR INLETS/OUTLETS 10.00 UNI 43.50 12/12/00 UT 06/11/01 TOTAL FEES 125.25 OWNER: TEL. NO: FINAL DATE FIN BY: CODE: MELOHN;VIVIAN (626) 444-9243- 4502 FIESTA AV 44-r. � TEMP 917804209 DESCRIPTION OF WORK HEATING AND AIR CONDIT 'ONING SYSTEM APPLICANT: TEL. NO: AIR-TRO, INC. (626) 357-5311- 1630 S. MYRTLE AVE. SPECIAL CONDITIONS: MONROVIA, CA 91016 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE AIR-TRO INC. (626) 357-5311- 1630 S. MYRTLE AVE. LIC. NO FAU/WALL FURNACE MONROVIA, CA 91016 258228 C20 COMBUSTION AIR OPENINGS ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK LIC. NO: AC/COMPRESSOR THERMOSTAT FIRE DAMPERS SMOKE DETECTION DEVICES COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508