HomeMy Public PortalAbout9014 HERMOSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
' insulebo affirm that havea certificate ofr kers ce'Ci Kpi RsotiD Insurancf cement to e
en
or a certified copy thereof (Sec. 3880, Lab. E.) _ 7640640 HEATING - VENTILATING - AIR CONDITIONING
.h0-0046 DPW 9/88
Policy No. Company
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
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE PL
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. S
ABSORPTION UNIT, BTU
(This section need not be completed if the work involved by DISTRIa PRocEssE
the permit is for one hundred dollars ($100) or lass.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Worker//s' Compensation Laws. BOILER, BTU APPROVALS DATE SPEQ 's SIGNATURE
Date(�Applicant 7`( /Ns4-Gft-S COMPRESSOR, BTU ROUGH
NOTI T A PLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 111-12-74) e
Exemption, you should become.subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be deem-
ed
eem ed revoked. FURNACE: FAUAVITY 0
LICENSED CONTRACTORS DECLARATION FLOOR B7
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT WALL
(commencing with Section 7000)of Division 3 of the Business '
and Professions Code,and my license is in full force and effect.
G Ts 0117eOD >
License Number y/,/� Lic. Class , d
Contracts /r/��IRJ Date a�
❑ • I am exempt under Sec.
Plan check fee
B.BP.C. for this reason. IL
Date:
PERMIT ISSUING FEE $
Signature TOTAL FEE 2
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): v
❑ I, as owner of the property, or my employees with ADDRESS y
t114T.
wages as their sole compensation, will do the work andr
NO. C1 i
the structure is not intended or offered for sale (Section• CITY TEL.
7044, Business and Professions Code). __
F-1 1, as owner of the property, am exclusively contracting OWNER ;�'U'7
S. 1 ITEMS
EMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL :e
s9 e (30
CONSTRUCTION LENDING AGENCY CITY 6/� L TEL. NO. _ !:ASH G.01J
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR— CHANGE .=11E
(Sec. 3097, Civ. C.). 4- --s l�
ADDRESS
Lender's Name '
CITY ' T./ y TEL. NO. `z_
:tea 001 ii_i-p001 4I13i91j
Lender's Address /�' 00`/i 1 AM Q:il.7
I certifythat I have read this application and state that the STATE
PP n LIC.
LICENSE NO. CLASS
' 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
upon the above-upon the above-m�fio�d property property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
igna,ure of Applicant orr nt --�y?� D to
�s
COUNSY OF LOS ANGELES TEMPLE CITY # 0508i^R4AvICAL PERMIT
DEPARTME.' IT OF PUBLIC WORKS 9701 LAS TUNAS ME 75^.fl 040°100010
BUILDING AND SAFETY I LAND DEVELOPMENT TEMPLE CITY CA 957;0
PHONE: (626; 2�'-0438 EXT:
LEGAL IC: FEES PAID BUILDING ADDRESS: _
TR: 5905 LT: 126 9014 HERMOSA DR
_ _ FEE DESCRIPTION: QUANTITY: UOM: A-i.^.UNT: TEMP CA 917801877
ASSESSOR INFORMATIONNUMBFR: _ NEAREST CROSS STREET:
5387-014-023 Oi PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: N3 LOCALITY: TEMPLE CITY, C
X41 VENTILATION ON FAN 1.00 FAN 15.75
TENANT: -- TOTAL FEES 4.50SSUED- ON—PROCESSEC BY: PLAN BY: EXP( SON:
08/10/04 JK 02/06/05
OWNER: --- TEL. N0: —� -INA DTE FINAL BY: CODE: -
iOWNER RAYMOND S (818) 286-7466- IL / //
9014 HE MOSA DR L
TEMP 917801837 D CRI ON OF WORK —
BATHROOM'VENTILAT iON F.N
APPLI CANT: TEL. N0:
MORAD (318) 519-7706-
112512 CHANDLER BL (SPECIAL CONDITIONS:
(NORTH HOLLYWOOD
CONTRACTOR: TEL. NO: - (APPROVALS SATE INSPECTOR SIGNATURP
ID & 8 CONSTRUCTION (800) 501-333
14411 HAMLIN STREETLIC. Np iFAU/WALL FURNACE
VAN NUYS, CA 91401 340 ie46
GM6USLi0N AIR OPENINGS
--- -I
(ARCH-ITECT GR ENG(NEEP,: � TEL_ F10:� I ;DUCT S.!ORK
LIC. NO: ,^••FRES^>G — ---�
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FIRE CAMPERS
SMOKE DETECTION DEVICES --
CO.'MERCIAL HOOD
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(REPORT ID: DPR264 ROUTE TO: BS0508 —_