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WORKER'S
haveCOMPENSATIONcertificate
DECLARATION 76A364 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN.
eA364C
hereby affirm That I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. PC 4 3 6 7 7 cPPTIFROM
emn�WNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby
® Certified copy is filed itild s tion FOR APPLICANT TO FILL IN - BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS 5644 N. He leo
Date 12/9/92 ApplLOCALITY Temple Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXWORKE S' NEAREST
CROSS ST.
COMPENSNCE ABSORPTION UNIT,BTU
(This section need not be co work nv ved by the ASSESSMAPBOOR PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM
.
I certify that in the performance of the work for which this permit DISTRICT NOPROCESSED BY
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. a A
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'6SIGNATURE
"
Dale 12 9/9 2pplicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 1'ZU,y3
Exemption,you should become subject to the Workers' Compensation - EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL — L
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
Licen Number"�- LiC.. lass C-20 , }
12/9/92 0
Contractor e V
❑ am empt untler Sec. Plan Che Be
B P.C.for this reason V PERMIT ISSUING FEE $ 2' . 75
e
Date: TOTAL FEE _ AT
Ud�4T
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ` 3307 48.UII Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , 1 ITEMS
for the following reason (Section 7031.5, Business and Professions TOTAL fir ' v 00Code): ADDRESS
❑ I, as owner of the property, or my employees with wages - - } CHECK
as their sole compensation, will do the work and the CITY TEL.NO. w��� ffrry�
structure is not intended or offered for sale (Section 7044, ' CHANGE
Business and Professions Code). OWNER
M
❑ I, as owner of the property, am exclusively contracting rs . Cathy Swanson
MAIL �'hll n
with licensed contractors to construct the project (Sec- ADDRESSrc) 000L0-00101 i?/10/72
tion 7044, Business and Professions Code). CITY TEL.NO. 6986 1 AN 10:41
CONSTRUCTION LENDING AGENCY Temple286-9183
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.).
Lender's Name
ADDRESS 1350 East Las Tunas Drive
CITY San Gabriel TEL NO 286-1141
Lender's Address STATE LIC.
1 certify that I have read this application and state that the above LICENSE N0.2 21 7 51 ,CUSS C-20
information is correct. I agree to comply with all County ordinances
an tate laws elating-t building construction,and hereby authorize "
re res ryt as of is ounty to enter upon the above-mentioned
pr
or
y ter s cry' urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
12/9/92
SIG A E A LIC Nr ORA N1 DATE
COUNTY OF LOS ANGELES - TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 9808240006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 25202 LT: 3 5644 HELEO AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802423
ASSES OR INFORMATION NUMBER: NEAREST CROSS STREET: LIVE OAK
8588-004-003 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT. 30 AIR INLETS/OUTLETS 1.00 UNI 4.35 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 59.10 08/24/98 UT 08/24/99
OWNER; TEL. NO: FINAL DATE FINAL -CODE:
SWANSON CATHLEEN (818) 286-9183-
5644 HELEO AV
TEMP 917802423 DESCRIPTION OF WORK
ADD AIR CONDITIONING TO EXISTING HEATING SYSTEM
APPLICANT: TEL. NO:
BRYANT HEATING AND AIR COND. (626) 286-1141-
1350 LAS TUNAS DR. SPECIAL CONDITIONS:
SAN GABRIEL, CA &eLES ®�
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
BRYANT HEATING AND AIR (626) 286-1141-
1350 E LAS TUNAS DR LIC. NO FAU/WALL FURNACE
SAN GABRIEL CA 91776 221751 C20
COMBUSTION AIR OPENINGSi
ARCHITECT OR ENGINEER: TEL. NO: - ® DUCT WORK
LIC. N0: -- AC/CCMPRESSOR V
THERMOSTAT
P U B U C W U R KS FIRE DAMPERS
--/� �( SMOKE DETECTION DEVICES
COMMERCIAL HOOD
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REPORT ID: DPR264 ROUTE TO: 850508