HomeMy Public PortalAbout4943 FIESTA AVE_Mechanical__ WORKER'S-COMPENSATION DECLARATION 20-0046 DPW 9189
76A364C APPLICATION FOR PERMIT MMA,I herebyaffirm that I have a certificate of consent to self insure,or a certificate of Worker's Compensation Insurance, or a certifiedt
HEATING - VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUIL SS
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSpry
(This section need not be completed if the work involved by the MAPBOOK !J�/v PAGED/ PARCEL
NO. TYPE OF APPLIANCE OR EQUIPMENT' FEE �Jp73
SSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED B
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in'any manner so as to I BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPEC J R'S SIGNATURE /J/
Date App' ant - VENTILATION SYSTEM ,
NOTICE O A I AN If, after g thi rtificate of ROUGH
Exemption,you s uld become subject to the Work s' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwit comply with such FINAL Q
provisions or this permit shall be deemed revoked. i, 'FURNACE: FAU GRAVITY
f/
LICENSED CONTRACTORS DECLARATION FLOOR BTU d VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect. t✓l X.
M q i
J
License Number C4 0141 Lie.Class &" f G D.
Cont ctor ✓ Date
❑ I am exempt u der Sec. Plan check fee V
cc
B.&P.C.for this reason PERMIT ISSUING FEE$ d� O
Date: TOTAL FEE p w
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Signature -} ,s 1 k. a
PLAN CHECK APPLICANT I I E AL �.. c:;. •L. CD
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ADDRESS r•;_
Slit
for the following reason (Section 7031.5, Business and Professions r F
Code): f sWl € ?
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s
I, as owner of the property, or my employees with wages ^�• z
Y
as their sole compensation, will do the work and the CITY TEL.NO. 10117
Ar �=`
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNERTA& O
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS S +
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY _ TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR '
the performance of the work for which this permit Is issuedZETp
(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATELIC. K1
I certify that I have read this application and state that the above LICENSE NO. r4 CLASS
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 psi poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
i
T OF 71T,
014ACENT /ATff
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 9808210023
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 11454 LT: 41 4943 FIESTA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803817
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LOWER AZUSA
8590-019-023 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/NEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
21
30 AIR INLETS/OUTLETS 2.00 UNI 8.70 08/21/98 UT 08/EXPIRES,
TOTAL FEES 90.45
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
TRINH TONY;LAM KELLY 2 /�
4943 FIESTA AV
TEMP 917803817 DESCRIPTION OF WORK
HEATING AND AIR/COND. SYSTEM FOR G ST HOUSE
APPLICANT: TEL. NO:
NGUYEN (626) 918-8906-
1139 GLENVIEW RD. SPECIAL CONDITIONS:
WEST COVINA, CA
CONTRACTOR: TEL. NO: n APPROVALS DATE INSPECTOR SIGNATURE
REACH CONSTRUCTION (818) 282-0042- 1 �1 (%n
90Q
419 N. ATLANTIC BLVD., #207 LIC. NO " FAU/WALL FURNACE
MONTEREY PARK, CA 91754 6957536 (�
!, _)� � COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: � til l G=am DUCT WORK
LIC. N0: �;` �1 � �;j { _- AC/COMPRESSOR
)�AL11. THERMOSTAT
�� �1 �� �� ��f�� ��✓l�� � FIRE DAMPERS
SMOKE DETECTION DEVICES
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COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508