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HomeMy Public PortalAbout4817 HALLOWELL AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT Jr iereL.4 affirm that I have a certificate of consent to self insure, or a certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec.-3800, Lab. C.) 76A364C k /1 )-/iq�y, 20=0046 DPW 9/88 Policy.No. Company Vf". COUNTY OF LOS ANGELES BUILDING AND SAFETY F-1 Certified copy is hereby furnished. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING f Tion department. 6 (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY .e �J,1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM W KERS' NEAREST COMPENSATION INSURANC CROSS ST. �,,1,46J Zi( (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.) I certify that in the performance of the work for.which this AIR HANDLING UNIT, CFM D Q permit is issued, I shall not employ any person in any manner o so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DAIE SPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU �t 2—# ROUGH V NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 1z 1,3,�J� y� Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY /2 i LICENSED CONTRACTORS DECLARATION FLOOR BTU / Thereby 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. U r License Number f e Lic. Class -Z6 , 0 Contractor Date 1122- ❑ I am r exempt un ec. O Plan check fee u W B.&P.C. for this reason. tZ Date: PERMIT ISSUING FEE $ �- Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT J I hereby affirm that I am exempt from the Contractor's License , 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 i-lN I s the structure is not intended or offered for sale (Section CITY TEL. NO. .�_,;:- 7044, Business and Professions Code). OWNER +"r.!lr _'r oill_1 ❑ I, as owner of the property, am exclusively contracting y -Tri with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS T I{A{ 57 = 00 7 = 00 CONSTRUCTION LENDING AGENCY CITY TEL. NO: 11 L I hereby affirm that there is a construction lending agency for 19 CHECK 5%s10..1 the performance of the work for which this permit is issued CONTRACTORr�3. (Sec. 3097, Civ. C.). , CHANGE n�Rr1 ADDRESS 4j Lender's Name t- s CITY y-�q,S• TEL. NO. �� L ii iCF.;1gtr'7(i Lender's Address vl ( 0 #I 0 F STATE LIC. I certify that I have read this application and state that the LICENSE NO. S CLASS — '299 1 AN :5i 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 u n the ab ve-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 7 'Signature of Ap ant or Agent Date ©s • COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0807090007 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ITR: 15098 LT: 6 4817 HALLOWELL AV IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803457 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I 18585-016-014 101 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C5 LOCALITY: TEMPLE CITY, Cl 1 141 VENTILATION FAN 2.00 FAN 31.50 1 (TENANT: I TOTAL FEES 59.25 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1 1 107/09/08 SR 01/05/09 I I I I 1OWNER: TEL. NO: I IFINAL DATE FIN Y: CODE: ICHAN, DEBRA (626) 442-0556- I 1 I 14817 HALLOWELL AV I I /22 u ITEMP 917803457 I IDE CRIPTION OF WORK 14I 1 1 12 VENTILATION FANS I I I I I 1APPLICANT: TEL. NO: I I (UNIVERSAL REMODELING (888) 343-9111- I 1 1 19135-A RESEDA BLVD. I (SPECIAL CONDITIONS: I INORTHRIDGE CA 91324 1 1 I I I I i (CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I (UNIVERSAL REMODELING, INC. (818) 285-6939- 1 1 1 19135-A RESEDA BLVD., SUITE 195 LIC. NO I 1FAU/WALL FURNACE I I 1 INORTHRIDGE, CA 91324 617830B I I I I I 1 I ICOMBUSTION AIR OPENINGS I 1 I I I I I I (ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK I I I I - 1 11 1 LIC. NO: I IAC/COMPRESSOR I I I I I I I I I I ITHERMOSTAT I I 1 I 1 1 11 I IFIRE DAMPERS I I I I I I I I I ISMOKE DETECTION DEVICES I I I I I I 1COMMERCIAL HOOD 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 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 I I I I I I I I I I I I I I I I I I I I I IREPORT ID: DPR264 ROUTE TO: BS0508 1 I I I I I I I I I