HomeMy Public PortalAbout9229 HECLA AVE_Mechanical__ ? WORKERS'COMPENSATION DECLARATION n n(�(( IC jA T DO N FOR (�2 n n 57
I� eii bffirm that 'I have a certificate of"consent to self G�11f Il—L� /� I1V FOR I!"LSI1�11V11
insure, or a'ce,rtificate cif-Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C. 76A364C -
���7fge s5747� �v�! / CE.-818(REV. 10/81)
Policy No. Company f3
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, rj
tion department. (PRINT OR TYPE ONLY) ADDRESS /o� o� /f,l e G A9 S.7-
Date f_ _9 8 Applicant "e ""I91T'aFi `fit LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST i
>pe;rfo
TION INSURA E o CROSS ST. Ne N .`
ABSORPTION UNIT, BTU DISTRICT No. WPROC�ESSBY
(This section neomplet the work involved bythe permifis forredars ($100)or less.)I certify.that in nce of the work for which thisAIR HANDLING UNIT, CFM
permit is issued, em oy any person in any mannerBOILER, BTUsous to becomethe kers'Compensation Laws. APPROVALS DATE INSPEC OR'S SI TURE
COMPRESSOR, BTU '! TON �/�OOO ROUGH
Date Applicant r
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should'become' subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
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 9SUSPENDED ✓ UNIT /,
OU
'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions.Code,and my license is in full force and effect.
License Number tic:Class G V
'44/
y/ h'-<r1
Contractor °�Goct.Cl � Date O
❑_ I am exempt under SecaW
S,
Plan check fee 2.1 2Z,:8:A
8.&P.C. for this reason #.0 0 0 0`0 8 Z
Dai� -PERMIT ISSUING FEE $ .
j _
Signature TOTAL FEE (�, 11 0 0.3
OWNER-BUILDER DECLARATIO -� PLAN CHECK APPLICANT 0.50
' 5 O
I hereby affirm at I am exempt from the Contractor' icense D o 0 o'3 5'0,6
Law for the foll <,''h
eason (Section 7031.5, iness and NAME
Professions Code _
❑ I, as ownere property, or y employees with ADDRESS 2 Q 2i 8 8
wages as the.compens '' n,will do the work and'
the structuref intend or offered for sale(Section CITY TEL. NO.
7044, Busined Pr essions Code). // /
OWNER /1Ci7 AoL y� C�iPq �QO/¢�k
❑ I, as owner r0perty, am exclusively'contracting
with licensetra tors to construct the project (Sec- MAIL
tion 7044, s a Professions Code). ADDRESS o� 9 /7�G/i4 sT
NSTION' NDING AGENCY CITY Te�P1 P C�`7� TEL. NO.j O
I hereby off'-m thae is a co truction lending agency for
the performance owork for ch this permit is issued CONTRACTOR Nf( ff-e ' // �y ��0�/��'6 D
(Sec. 3097, Civ. C. .. /S` l`1Pf?7 �'
ADDRESS
Lender's NameIG�/�/T
CITY... c�S�/L/�;oi TEL. NO. D (O—1,1133
Lender's Address
/ p� '
I certify that I have read this application and state that the STATE LICENSE NO. s�// �� LIC.CLASS G dto
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�thhee-, ioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant o ent - Date - _
COUNTY OF LOS ANGELES TEMPLE CITY # -0508 MECHANICAL PERMIT '
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0610250004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS: -
'
TR: 17387 LT: 5 - ,9229 HECLA AV '
FEE DESCRIPTION: - - QUANTITY: UOM: AMOUNT: TEMP CA 917803121 '
ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: 107f
L 0�
8588-031-005 - 01 PERMIT ISSUANCE FEE - 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY:- TEMPLE CITY, C
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:
47 ALTER EXIST DUCT SYS 1.00 SYS . 27.00 10/25/06 JK 04/23/07
TOTAL FEES 108.75
OWNER: TEL. NO: FINA7kd'��ATE FINAL BY: CODE:
ROACH MICHAEL B;CHERYL (626) 309-0203- ! %
9229 HECLA AV rb
TEMP 917803121 ES RIP ON OF WORK
RijLACE HTG & A/C EQUIPMENT
APPLICANT: TEL. NO: -
AMERICAN HTG & A/C (626) 285-8206-
5308 NOEL DRIVE SPECIAL CONDITIONS: -
TEMPLE CITY CA 91780
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
AMERICAN HEATING AND A, C (626) 285-8206- '
5308 NOEL DR. LIC. NO FAU/WALL-FURNACE
TEMPLE CITY, CA 91780 664929020
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: - DUCT WORK
LIC. NO:
AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
1
COMMERCIAL HOOD .
REPORT ID: DPR264 ROUTE TO: BS0508