HomeMy Public PortalAbout8704 HERMOSA DR_Mechanical__ WORKER'S
haveCOMPENSATIONcertificate
DECLARATION 76A3fi4C PW 9,99 APPLICATION FOR PERMIT
I hereby af(jrm that I have a certificate of consent to self insure, '
or 3 certificate of worker's compensation Insurance, or a certified HEATING VENTILATING -AIR CONDITIONING
copy thereof( ea 3800 Lab. C.),
vTbTrdyN�(o�- C33o�lmPOIO- 6,hz,4,4 1 46401
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV „
CertRetl copy is hereby furnished.
Cer ified copy is filed with the county building inspection FOR APPLICANT TO FILL IN AOI RENS
department. (PRINT OR TYPE ONLY).
Date Applicant - _-_. LOCALITY
NO. TYPE OF APPLIANCE OR EpUIPMENT FEE'. I'
CER IFICATE OF EXEMPTION FROM WORK S' - -
NEAREST
P_
COMPENSATION INSURANCE CROSS ST. SCJ
ABSORPTION UNIT,BTU - ASSESSOR' / p
(This section need not be completed if the work involved by the MAP BOO PAG Q b PARCE63
permit is for one hu mired dollars($100)or less.) AIR HANDLING UNIT,CFM
BISrRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU O Q
become subject to the Workers'Compensation Laws. - C/
COMPRESSOR,BTU
APPROVALa GATE INSPECTOR'B eIGNpTURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT:' If, after making this Certificate of - ROUGH '
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code',you must forthwith comply with such FINAL _
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITY
LICENSED,CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions at Chapter 9 SUSPENDED UNIT_ - - -
(commencing with Section 7000) of Division 3 of the Business and HEATER:- WALL oho
Professions Code, andmylicense is in full force and effect. _.
License Number LSO ,7� / Lic.Class -
,CG�nI for Date , 0
E'J I am exempt under Sea Plan check fee - - - '-- - - - 0
B.$P.C.for this reason - PERMIT ISSUING FEE$- 0
Date: TOTAL-FEE ! - tJ
W
Signature - - - d
OWN BUILDER DECLARATION PLAN CHECK APPLICANT
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for.the following reason (Section 7031.5, Business and Professions -
Code): ADDRESS t n,_
1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended Or offered for sale (Section 7044, - -
-Business and Professions Code). OWNER
1; as owner of the property, am exclusively contracting MAIL �L�rRif_y i$ _x FF ® 00
with licensed contractors to construct the project (Sec- ADDRESS a -- -
tion 7044, Business and Professions Code). CHEN,ff?j �-t•='i'
CONSTRUCTION LENDING AGENCY CITY TEL , .; _
.1:17
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.). _-
ADDRESS 1 _ E' _
Lender's Name -_
CITY TEL.NO. ._ .- _.
Lender's Address STATE ` �61C.
I certify that I havereadthis application and state that the above LICENSE NO. ( CLASS —
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 upon the above-mentioned -
property for inspection put uses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN p LICANT ORAGEMT 6
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1206120010
EUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL I0: FEES PAID BUILDING ADDRESS:
IBE: 40 PG: 39 PC: 1 1 1 6704 HERMOSA DR E
IEEE DESCRIPTION: QUANTITY: DOM: AMOUNT: I SGAH CA 917753009
I ASSESSOR INFORMP.TION NUMBER I I NEAREST CROSS STREET:
15387-006-036 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: G3 LOCALITY: TEMPLE CITY, Cl
1 108 FURNACE/HEATER 1100 1.00 UNI 27.00 1 1
(TENANT: I TOTAL FEES 54.80 ISSUED ON: PROCESSED BY: PLAN BY: I
106/12/12 SR I
I I I
(OWNER: TEL. NO: I IFINAL DATE FINAL BY: CODE: I
IFADANELLT, MARCELA (626) 292-7329- 1 1 1
18704 HERMOSA DR I I I
SGAB 9177,53009 (DESCRIPTION OF WORK
(WALL HEATER C/O I
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(APPLICANT: TEL. NO: I I
IGAUTHIER, CHERYL (626) 777-1142- 1 1
(SPECIAL CONDITIONS: 1
I
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CONTRACTOR: TEL. NO: I JAPPROVALS DATE INSPECTOR SIGNATURE I
INTER CITY ENERGY SYSTEMS (562) 777-1142- 1 1 1
112252 MCCANN DR LIC. NO I IFAU/WALL FURNACE I I I
(SANTA FE SPRINGS CA 90670 587709 C20 I I I I I
I I COMBUSTION AIR OPENINGS I I I
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IARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK I I I
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I LIC. N0: I IAC/COMPRESSOR
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I THERMOSTAT
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COMMERCIAL HOOD
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(REPORT ID: DPR269 ROUTE TO: 850508
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