HomeMy Public PortalAbout5524 HILTON AVE_Mechanical__ '.✓\ L'ORKERS'COMPENSATION DECLARATION
r lThere'by�cifirm that It have a certificate of consent to self APPLICATION FOR PERMIT -
Insure, or a.certificcte of Worckws',iCompensation Insurance, ]aA3a4C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3000, Lab. C.) CE-818(REV. 10/81)
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 t✓ L
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not he completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) y
AIR HANDLING UNIT, CFM �sa
I certify that in the performance of the work for which this ✓c (/�
permit is issued, 1 shall not employ any person in any manner '
so as to become subject to the Workers BOILER, BTU
Compensation Laws. APPROVALS DATE INS C R'S SIGVAIDRE
per- `
Date�2— —TT ApplicanW � COMPRESSOR, BTU 612 pod ROUGH -'
NOTICE TO APPLICANT: If, after mioking this Certificate of VENTILATION SYSTEM FINAL _
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID 4fION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPE DED UNIT_
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
6
License Number— bT I Class U
:93633A °C
Contractor Date O
N
❑ 1 am exempt under Sec. # e e o e a 8 w
Plan check fee d
B.BP.C. for this reason NPERMIT ISSUING FEE $ los-0 ° ° `3 050 Z
Date: Q
Signature TOTAL FEE ,aj(� e o e 3 Q 5 055
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - 1210785.� O 8 5
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME 7
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sole(Section 'CITY TEL. NO.
7044, Business and Professions Code). '
OWNER
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR y
(Sec. 3097, Civ. C.).
2*I
Lender's Name ADDRESS 7-z
?-*7
��[ t ` TEL. NO.
Lender's Address
$TA2.6 il
TE LIC. S C'- Z J
certify that have read this application and state That the LICENSE NO. - Lc.
-
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
A2bove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/Z/iL
Signature of Applicont or Agent Date
• COUNTY OF LOS ANGELES TEMPLE CITY k 0508 MECHANICAL PERMIT
DEPARTMENT OF'PUBLIC WORKS 9701 LAS TUNAS ME 0508 0502080034
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 12410 LT: 15 5524 HILTON AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802405
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BROADWAY
8588-002-015 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY, C
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER c100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 5.00 UNI 21.75 05/31/05 JK 11/27/05
40 EVAPORATION COOLERS 1.00 UNI 21.90
OWNER: TEL. NO: 41 VENTILATION FAN 1.00 FAN 15.75 FINAL DATE FINAL BY: CODE:
HAYNES CHARLES E;ELIZABETH A (626) 205-4381- 47 ALTER EXIST DUCT SYS 1.00 SYS 27.00
5524 HILTON AV TOTAL FEES 168.15
TIME 917802405 DESCRIPTION OF WORK
REPLACE AIR CONDITIONING AND HEATING SYSTEM 6 ALTERATION
OF EXIST DUCT SYSTEM TO THE ADDITION
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
CAL CIVIC ENGINEERING (626) 798-2828-
2160 PARNELL WAY LIC. NO: AC/COMPRESSOR
ALTADENA, CA 91001 NONE
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508