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WORKERS'COMPENSATION DECLARATION CEA 818 (2-80) Yi1 1f- P Its C lr T� O N FOR R If-E R IIVp T
I hereby affirm that I have a certificate of consent to self
inspre, of a certificate of Workers'Compensation.Insurance,or H EATI"NG-V ENTILAyl��y.�ll�y' COQ®1'�IOfI�OGt1G
a certified copy thereof(Sec. 3800,Lab C.)
Policy No.01677321=9`pany—P.ac-i f i-c--Emp-l-oye- `s
Certified copy is hereby furnished,
COUNTY OP LOS ANGELES BUILDING-ARID SAFETY
Ins.. Co.
Certified.copy is filed with the county building inspection FOR APPLICAIUT-TO FILL IN BUI LDING
department. ADDRESS . 62,24,No. Hart Ave;
Date_2=2.7=8.1_ ApplicantAnkhOny P001 s (PRINT OR TYPE ONLY)
LOCALITY Temple Cit
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.' TYPE OF APPLIANCE OREQUIPMENTFEE p y '
COMPENSATION INSURANCE NEAREST
(This section need" not be completed. if the work involved ABSORPTION'UNIT,-BTU CROSS ST. % a}
by the permit is 'fOY one hundred dollars ($IO,O) or less.)' DISTRICT NO. PROCESSEC Y p., O
I certify'that in the performance of the.work for which this AIR HANDLING UNIT,CFM O U'
permit is issued,'I shall not employ any person in any manner cc
so as to become subject to the Workers' Compensation Laws. BOILER, BTU. O
' - - - APPROVALS DATE INSPECTOR'SSIGNATURE V
Date Applicant. COMPRESSOR,BTU ROUGH-_* a
NOTICE TO APPLICANT: If, after making.this Certificate o£ VENTILATION SYSTEM FINAL Z
.-
Exemption, you should become subject to the, Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or, this''permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARAT..ION FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT-
9
NIT9 (commencing with,Section 7000) of•D`ivision 3 of the Busi- WALL
ness and Professions Code , and my license is in full force and
effect. 190179 C-53 '�l// 'L�O�� 1�E= L ��"
License Number Lic.Class s�
Contractoi_An 606y POOISate 2-27781 43�iGbo
Lam exempt"from'the licensing requirements as I am a
licensed architect or a registered professional engineer Plan Check fee 25%"of above.
acting in my professional capacity (Section_765-1, Bus:
mess and Professions Code). PERMIT"ISSUING FEE
Lic:or Reg.No. Date TOTAL FEE a
HOME OWNER-BUILDF•R DECLARATION PLAN CHECK APPLICANT
I hereby affirm that.1, am exempt from- the Contractor's NAME Anthony Pools
-License Law for the following reason,(Section 7031.5, Busi-
ness and.Professions Code): ADDRESS 5871 Firestone- Blvd.
I, as-owner of the property,'will do the work and the
structure is not intended or offered for sale'(Section CITY S0. GateTEL.NO. x,4;4 7J,9 A
7044, Business and Professions Code). 92-8'-33'81 . . 1.❑ OWNER �'# o. oi 0 0 4 1..
I, as owner of the,property,am exclusively contracting
With licensed- contractors to construct the project MAIL LOU1-Se-C-ll-g nett 210.02700
(Section 7044, Business and-Professiorws Code). ADDRESS 6.224 Na._H.ar_t_Ave..'
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0.22'7 0 0'c=�
�o,o*
I hereby affirm that there is a construction lending agency Temp-l-e-Ca-ty _285-102-9
for the'performance of the work for which this permit is CONTRACTOR Anthony Pools 0318'-81
issued(Sec.3097,Civ.C.).
Lender's Name C.as.h ADDRESS
.5.8.7-1_F_i-r_e.ston.e_B_l_v d-,
Lender's Address CITY TEL.NO.
I certifythat I have read this application and state that the SO-.—Gate �2-8=3381
pP STATE tIC.
above information is correct:I agree to comply with all County LICENSE NO. 1 90_1.79 CLASS C=53
ordinances and State laws regulating Heating, Ventilating and
Air CoP:'.ior'ig,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Count neer ,.Z� to above-mentioned property for
�tior �/
/Anthony Pools .2-27-81
Sight/r re of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0406090025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5904 LT: 233 6224 HART AV
FEE DESCRIPTION: QUANTITY: IJOM: AMOUNT: TEMP CA 917801630
ASSESSOR INFORMATION NUMBER: NEAREST, CROSS.STREET: GARIBALDI
5384-009-004 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY- TEMPLE CITY, C
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 30 AIR INLETS/OUTLETS 5.00 UNI 21.75 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
35 AHU < 2000 CFM 1.00 AHU 12.90 06/09/04 - VG 12/06/04
-TOTAL�EEES , 89.40
OWNER: TEL. NO: FINAL DATE FINA BY: CODE:
BLUM CARL L,JEANETTE M TRS BLUM TRIJ (626) 287-4745- (/� a
6224 HART AV ( _l _
TEMP 917801630 DESCRIPTION OF WORK
INSTALL 4 TON HEAT PUMP SYSTEM ON 2ND FLOOR
APPLICANT: TEL. NO:
AIR TRO (626) 357-5311-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
AIR TRO (626) 357-5311-
1630 MYRTLE AVE LIC. NO FAU/WALL FURNACE
MONROVIA CA 91016 258228C10
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
LIC. NO: AC/COMPRESSOR
THERMOSTAT
—'� FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
* ADDITIONAL DATA ON FILE
REPORT ID: DPR264 ROUTE TO: BS0508