HomeMy Public PortalAbout8807 HERMOSA DR_Mechanical__ WORKEit'SCOMPENSATION DECLARATION 20-0048DPW 9/89 APPLICATION FOR PERMIT `IME GREEN
I hereby Arm 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(Sea 3800 Lab. C.) - -
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADORES$
department. (PRINT OR TYPE ONLY) C / le-.
Date Applicant LOCALITY 7Z,1 �
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need net ed completed($1 0 the work involved by the MAP BOOK PAGE PARCEL
permit Is for one a performance
dollars f the or leas.) AIR HANDLING UNIT,CFM DISmCT No. PROCESSED By
Icertity that in the performance of the work for which this permit
is issued, 1 shall not employ any person in any manner so as to BOILER,BTU D�
become subject to the Workers'Compensation Laws.
_ COMPRESSOR,BTU
94 /1 OF f APPROVALS GATE INSPEL 'S SIGNATURE
Data Applicant— C VENTILATION SYSTEM
NOTICE O PPLI ;ANT: If, after making this Certificate of ROUGH j
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER v
provisions of the Labor Code, you must forthwith comply with such FINAL r
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY / 261 P
VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU - C/
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section ]000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full farce and effect.
r
/yTL �
License Number[' L/ � Lic.Class ;T i
a
Ckwt .4/v-ioAbrY&�wT 3303 109.900
CaMract1 1 ITEMS 0
❑ Plan check fee
I .& exempt under Sec. - TOTAL 1jDq„ 9(3O
B.&p.C.for this reason PERMIT ISSUING FEE$ p CHECK 109.90
Date: TOTAL FEE �� CHANGE OOa
Signature 0-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT cc Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , 0000—M�01 5/ 2/96
for the following reason (Section 7031.5, Business and Professions t
Code): ADDRESS 018E 1 PM 5:04
I, 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
❑ I, as owner of the properly, am exclusively contracting MAIL PA 122
Pn
with licensed contractors to construct the project (Sec- ADDRESS V 6 r_.7 _ 1
tion 7044, Business and Professions Code).
CITU ;
CONSTRUCTION LENDING AGENCY flcTEL.NO. — 1
I hereby affirm that there is a construction lending agency far CONTRACTOR n '
the performance of the work for which this permit Is issued - r - 'A
(Sec. 3097,Civ. C.).
ADDRESS
Lender's Name _
CITY TEL.NO654
.
Lender's Address STATE -
' r4
I certify that I have read this application and state that the above LICENSE NO. CLASS L
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 purposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
5IGNATU�FAPPLICANT OR AGENT ATE -
COUNTY OF LOS ANGELES TEMPLE CITY N 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1307180026
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91980
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS: 1
ITR: 5904 LT: 111 UN: .002 1 8807 HERMOSA DR 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917801816 1
(ASSESSOR INFORMATION NUMBER I INEAREST CROSS STREET:
15386-011-051 101 PERMIT ISSUANCE FEE 27.00 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY CAI
102 COMPRSR 1 100 FRIG 1.00 COM 29.00
(TENANT: 154 NO PERMT $224.70 MIN 344.00 344.00 JISSJRD ON: PROCESSED BY: PLAN BY:
TOTAL FEES 398.80 107/18/13 SR
OWNER: TEL. NO: EJ.WjJ, DATE FINAL PTN CODE:
ILEIU, FRANK (562) 345-4294-
16807 HERMOSA DR
ITEMP 917801616 DkSCrZIP1ONOF WORK 1
I (CHANGE OUT AND REPLACE EXISTING 3.5 TON CONDENSER
APPLICANT: TEL. NO:
ROORIGUE Z, GEORGE (626) 858-9000-
11534 B INDUSTRIAL PK 1 (SPECIAL CONDITIONS: 1
COVINA CA 91722
I
I I I 1
(CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
(AIR ON TIME CO. (626) 437-1998-
11534-B INDUSTRIAL PARK ST LIC. NO FAU/WALL FURNACE
WEST COVINA, CA 91766 867863 C20
COM.SGSTION AIR OPENINGS
(ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
LIC. N0: AC/COMPRESSOR 2
I 1THEr,MOBTAT
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i
(FIRE DAMPERS -
ISMOKE DETECTION DEVICES 111
jCOMX-cRCIAL HOOD
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(REPORT ID: DPR264 ROUTE T0: 850508 I I I