HomeMy Public PortalAbout8628 HALDEMAN ST_Mechanical__ WORKER'S COMPENSATION DECLARATION. 20-0046 DPW 9189 APPLICATION FOR PERMIT
76A364Q ,• IME G�RE ,, �::::.
I hereby,affirm that I have a certificate of consent to self Insure, LEN',
or a certificate•of,Worker's Compensation Insurance,:or a certified - '+;.,'HEATING VENTILATING -AIR CONDITIONING,-'
copy,ther6oYtSec.3600 Lab.C) v'•
;COUNTY OF LOS ANGELES'r'. ^ :- DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV:
P.olicy'No Company; Vt^���N',
❑
rtrfie_d copy is hereby furnished.
�Cgertified co Is filed with the county buildin •Ins ection FOR APPLICANT TO'FILL IN BUILDING'
L(G'•; PY tY 9 P ADDRESS G z SL%�i3�w►.9-�✓ '.S�` ...
department. (PRINT OR TYPE ONLY)
Date �-/ Applicant ,0AY0A 4 :C .` LOCALITY
v. NO ' TYPE OF'APPL'IANCE OR EQUIPMENT, FEE
NEAREST
CERTIFICATE OF EXEMP,.TION,FROM WORKERS'„ } CROSS ST
COMPENSATION INSURANCE .. ., = ABSORPTION UNIT;BTU "
ASSESSOR
(Thissection need not be completed If the-work involved by the MAP BOOK PAGE- PARCEL r
permit Is foi one hundred dollars($100)or less.) =t ,'AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY
I certify that in the performance of the'.work for which this permit ;
is issued, I shall-not employ any'person In an"manner so as to BOILER,BTU
become subject to the.Workers'Compensation Laws:
G• / COMPRESSOR,BTU
Date cant* r APPROVALS DATE INSPECTOR'S SIGNATURE
< "' VENTILATION'SYSTEM -�
NOTICE TO APPLICANT: 'If,,after.making'this'Certificate of ROUGH
Exemption,you should'beco. subject to the.Workers'-Compensation EVAPORATIVE COOLER, o- W
provisions of the Labor Code, you must forthwith comply with such �` FINAL•• Z
provisions or this permit shalt be deemed revoked. FURNACE:.- FAU RAV!11y
LICENSED CONTRACTORS DECLARATION ;/ FLOOR o t BTU b VALIDATION .
F hereby,affirm;fhat I am licensed under provisions of Chapter 9' , SUSPENDED UNIT
(commencing with Seclion'7000) of Division 3 of the Business and HEATER; WALL
Professions Code;and my license.is in'full force'and'effect
License Number 6 / 7 Lic:'Class
Contracto IPA Dat e • 8— / y , Q
❑ I am exempt under Sec, Pl6n,check feV
e ,;j.; -
+• .•
BAP C.'for•this reason, PERMIT ISSUING FEE$ �, r•r•r ,a O
Date: TOTAL FEE jJ.. �J' X07 166.65 W
Signature ��,3
PLAN'CHECK APPLICANT 1' ITEM- co
OWNER-BUILDER'DECLARATION " Z
I hereby affirm'that I am exempt from the Contractor's License Law NAME • - 1 f I t HL 1061® 6—�
for the following reason (Section 7031 5, Business and Professions 'ems 1 {t its
-'COde) Ec
- ..• 'ADDRESS tp .•C: . ,1:�,J e65
❑T', I, as owner of,the property, or,my employees with wagesry i �1f0
as their s6lefd6mpensation, will do the, work and:the, CITY• TEL.NO',
HAA
structure is not intended or offered for,sale (Section 7044,
Business;and'Professions,Code). ' ' = OWNER
❑ I, as owner of the property, am exclusively,contracting• C}t1CJ l"LIIJOI �Ir it`=•
MAIL
V licensed contractors to construct•ihe project (Sec- ADDRESS ri qt��,II t("•'1c '
tion 7044, Business and Professions Code). - =i��� FlIi1 fa;-�
CONSTRUCTION LENDING AGENCY CITY TEL NO. "
I herperformance
affirm that there is a construction'lending agency for ��//��ii�
the of the work for which thi''s permit Is issued IVIOQ• Cp/1/��rf'O/I�//✓ !Ne ;
(Sec.3097;Civ.C:) CONTRACTOR
ADDRESS
Lender's Name w �7
CITY f'/f��It//� TEL.NO r. •a ;
Lender's Address STATE LIC.
I'certrfy that I have read this application and state that the above LICENSE NO �j �� `j CLASS
Information is correct. I agree to comply with all County ordinances
and Statelaws 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 •, 1 -
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1403050013
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: 1 FEES PAID I BUILDING ADDRESS: I
ITR: 26026 LT: 5 I I 8628 HALDEMAN ST • 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( SGAB CA 917752637 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1
15386-007-056 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 596 GRID: G2 LOCALITY: TEMPLE CITY CAI
141 VENTILATION FAN 2.00 FAN 31.60 1 1
(TENANT: I - - TOTAL FEES 59:40 TISSUED ON: PROCESSED BY. PLAN BY:
I 103/05/14 SR 1
(OWNER: TEL. NO: I IFI DATE FINAL CODE:
(WAN, ANTHONY (323) 240-7707- 1
18628 HALDEMAN ST 1 _
ISGAB 917752637 DEJCRIPTIOlq OF WORK 1
I 1 ITWO VENTILATION FANS FOR TWO BATHROOMS REMODEL
(APPLICANT: TEL. NO: I 1 I
IDE LA ROSA, GERARDO (213) 305-5535- I I I
1460 S LA VERNE AVE ISPECIAL CONDITIONS: 1
ILOS ANGELES CA 90022 1 I
1
1
(CONTRACTOR: TEL NO. (APPROVALS DATE INSPECTOR SIGNATURE
IDE LA ROSA CONSTRUCTION (213) 305-5535- 1 1
1460 S LA VERNE AVE LIC. NO IFAU/WALL FURNACE I I 1
ILOS ANGELES CA 90022 855010 1 1 I I 1
I 1 (COMBUSTION AIR OPENINGS 1 1 1
(ARCHITECT OR ENGINEER: TEL. NO: (DUCT WORK I I I
I LIC. NO- IAC/COMPRESSOR I 1 1
I ITHERMOSTAT I I 1
(FIRE DAMPERS
I I (SMOKE DETECTION DEVICES 1 1
1 (COMMERCIAL HOOD
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1 IREPORT ID: DPR264 ROUTE TO: _BSO508 1 1 I
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