HomeMy Public PortalAbout9011 HERMOSA DR_Mechanical__ WORKER'S h ve a ce SATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT LANE GREEN;
6A364C
Ihereby 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 Polither (Sec.3800 Lab.C.)/�. - -
cy No."•'t 7 JbS�Ceifipany �. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certif d copy is filed with the cou ,y ulitling inspection FOR APPLICANT TO FILL IN BUILDING c
p ment. _ ding i spec �j tPRINT OR TYPE ONLY) - ADDRESS
Dme Applicant ���'rrr' �/ LOCALITY �^ ILI�
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSS ST.
ABSORPTION UNIT,BTU 'ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
olsmlcT Na. PaocEsseo BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. - �jlO p L _ _
i
COMPRESSOR,BTU
APPROVALS GATE INSPECTOe's SIGN E
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL _
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTu .VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 -) SUSPENDE _ UNIT_,
(commencing with Section 7000) of Division 3 of the Business and ( HEATER: WALL D�
Professions Code,and/my license is in full force and effect.
License Number I� ` Lic.Class
� o
Contractor /.LA4Lu-� �! Date ?42 � - EL
❑ I am exempt under Sea Plan check fee
Q
B.&P.C.for this reason PERMIT ISSUING FEE$ /o /fes O
Date: - TOTAL FEEa QsJ W
Signature - PLAN CHECK APPLICANT - fn
OWNER-BUILDER DECLARATION
Z
I hereby affirm that I exempt from the Contractor's License Law NAME pop. -
for the following reason on (Section 7031.5, Business and Professionss
Code): ADDRESS
❑ 1, as owner of the property, or,my employees with wages cn c
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, i TTEt�R I_
Business and Professions Code). OWNER /L/ for _
I, as owner of the property, am exclusively contracting MAIL a AL - 05
with licensed contractors to construct the project (Sec- ADDRESS C&1 d A— i--tf,�rrvir c>•: c
tion 7044, Business and Professions Code). �'7 �C�"I' -1—`C I`r
CONSTRUCTION LENDING AGENCY CITY / /A /1•� TEL.NO. ��^ [
hereby affirm that there is a construction lending agency sissued'
for D, _ r
the
hereby'
affirm
of the work for which this permit Is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name - CITU (� TEL.NO. ! J ^� G - "' �._.r1 AM 1:20
Lender's Address STATE C LIC.
I certify that I have read this application and state that the above LICENSE NO. �j CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
re resentatives of this County to enter upon the above-mentioned
r or inspection purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE '
;GP -
51 UFE PPLICANT OF AGJI GATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9471 LAS JUNAS ,. , ME 0508 9705050006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5904 LT: 169 9011 HERMOSA DR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801836
ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET:
5384-016-019 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
18 BOILER 101 500 KBTU 1.00 BOI 52.35 r
TENANT: TOTAL FEES 80.10 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
05/15/97 TC 05/15/98'
OWNER: TEL. NO: FINAL DATE FINAL BY: E:
REYNA JOSEPHINE M -
9011 HERMOSA DR
TEMP 917801836 ESCRIP1f0 0a O C
BOILER FOR PRE-FAB SPA
APPLICANT: TEL.. O: r ��•� -�
QUALITY 4 LESS (909) 595-7283- ��� �`—'"==�,
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: \ ��J �, APPROVALS DATE INSPECTOR SIGNATU E
QUALITY 4 LESS (909) 595-7283-
20537 STARSHINE RD. LIC. NO '�' �. F U/WALL FURNACE
WALNUT, CA 91789 695475 B
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. N0: DUCT WORK
LIC. NO: ;�L J r- AC/COMPRESSOR
1 .THERMOSTAT
r,
EIRE DAMPERS
SMOK DETECTION ICES
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508