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Home My Public Portal About5036 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364C PW 9/69 �PUC „ TM Y hereby affirm that I have a Certificate of consent to self insure, �ERM�� or a certificate oT Worker's Compensation-Insurance, or a certifiedd HEATING -VENTILATING -ATR CONDITIONING"' copy thereof(Se .3800 b. C Policy No ❑ COUNTY OF LOS ANGELES DEPT OF PUPC WbRKS BUILDING AND SAFETY.DIV. Certified copy is'hereby furnished. / Certified copy is filed with the co y uil g inspection FOR APPLICANT TO FILL IN BUILDING DD E S d rtment. (PRINT OR TYPE ONLY) 1 LOCALITY, Date • '' Applicant N0. TYPE OF APPLIANCE OR EQUIPMENT FEE n CERTIFICATE OF EXEMPTION FROM WORKE$, ' NEAREST CROSS ST. COMPENSATION INSURANCE ,. ABSORPTION UNIT;BTU (This section need not be completed if the work involved by the ASSESSOR MAP BOOK PAGE' PARCEL permit is for one hundred dollars($1100)or less.) AIR HANDLING UNIT,'CFM DISTRICT NO. - - - PROCESSED BY I certify that in the performance of the work for which this permit is issued, 1 shall not employ.any,person"in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. py �Q� e ✓ --� v COMPRESSOR,BTU ... APPROVALS1.=h s DATE'. .. •,INSPECTOR'S SIGNATURE• ' Date Applicant VENTILATION SYSTEM1. NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Ezemption,'you should become subject to the Workers'Compensation EVAPORATIVE COOLER o provisions of the Labor Code, you must forthwith comply with'such FINAL 2! provisions or this permit%shall be deemed revoked. FURNACE:' FA A MY ' LICENSED CONTRACTORS DECLARATION' J FLOOR GT V•LID TION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPEN ED UNIT ,(commencing with'Section 7000) of Division 3 of the,Business and HEAT R: WA Professions Code,and my license is in full force and effect.j� p License Number 1!x'3 r �Lic.Class c::Z' �•4 Contractor Date 4.. D o ❑ I am exempt under;Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ Date: TOTAL FEE Wa Signature _:: OWNER-BUILDER`DECLARATION PLAN CHECK APPLICANT t� i Z_ I hereby affirm that I'am exempt from the Contractor's License Law NAME. fE for the following reason (Section 7031.5; Business and Professions D I_I o Code) ADDRESS ❑ .. .. .irk: •., I a's owner of the property, or my.employees with wages "' HEC s as their sole compensation, will do the work and the CITY TEL'NO. 'HANG, vI,{{-( 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 •`� with licensed contractors to construct the project (Sec- ADDREoq S ! t: tion 7044, Business and Professions Code). . a I�� rhotic% CONSTRUCTION LENDING AGENCY CITY TEL'. I hereby affirm that there is a construction lending agency for CONTRACTOR D the performance of the work for which this permit'Is issued (Sec.3097,Civ.C.). )0?7 ` 464 ADDRESS ]�f Lender's Name CITY TEL.N -- Lender's Address STATE LIG I certify that I have read this application and state that the above LICENSE NO. CLAS✓ information is correct. I agree to comply with all County ordinances and State law lating to building construction,and hereby,authorize representat' es f this County to enter upon the above-mentioned proper f r in a tion.purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE, SIGNATOR OF APPLICANT OR AG T DATE - - " p WORKERS'COMPENSATION DECLARATION 76A364C CE -818 (2-80) A P FI L�IC AT�ON F®If\C I!"nE R�/�g�%� T I here�y,afftrrr that I have a certificate of consent to pelf insure, or,ae,eltificate oRran kers'Com nsation lnsur of Fp(s ATINCs,.V[ENTILATING_AIR CONDITIONING a c S_r?P i s v thereof 800, La' . : t o ily' 7 CY Q Certified dopy is hereby :-atnished. � � COUNTY OF LOS ANGELES I BUILDING AND SAFETY Certified copy is filed with the _i unty building ins a tion BUI'LDING a Datet. FOR APPLICANT TO FILL IN ADDRESS �' Applicant (PRINT OR TYPE ONLY) - LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE / COMPENSATION INSURANCE.. NEAREST CROSS ST. } (This section need not.be completed if the work involved ABSORPTION UNIT, BTU— 0 O by the permit is for one hundred dollars-($100) or less.) DISTRICT NO. PRO SSE Y U I certify that in the performance'of the work for which this AIR HANDLING UNIT,%CfM Cr permit is issued., I shall not employ any person in any manner so as to become subject to the.Workers'.Compensation.Laws. BOILER, BTU O APPROVALS DATE INSPECTOR'S SI _ ATURE IU Date Applicant --- COMPRESSOR,BTU a •ROUGH Us NOTICE TO APPLICANT:•If, after making this Certificate of VENTILATION SYSTEMZ• Exemption, you should become subject to the•Workers' FINAL q — Compensation provisions of the Labor Code, you must forth- EVAPORATiVE,COOLER VALIDATION with comply with such provisions or this permit shall be ,,•c.� , deemed revoked. FURNACE: FAU GRAVITY 7 LICENSED CONTRACTORS DECLARATION FLOOR: . BTUC ?-%� / I hereby affirm that I am licensed u»der provisions of Chapter HEATER: SUSPENDED NIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL O` ness and Professions Code, and my license is,in full force and effect.' License Number Lic:Class Contractor Date QI am exempt from the licensing.requirements as I'am a licensed architect or'a registered professional engineer Plan cheek fee 25%Of above. acting in my professional capacity (Section 7051; Bus- iness and Professions Cod�e)).� PERMIT ISSUING FEE Lic,or Reg.No.� Date `"< cS TOTAL FEE. . HOME OWNER-BUILDER DECLARATION PLAN CHECK PPLicANT I hereby affirm that I am exempt from- the Contractor's NAME License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS Z 3 .) DI, as owner of the property, will do the work and the CITY 0, V/YI TEL. NO structure is not intended or-offered for sate Section 7044, Business and Professions Code). QOWNER I, as owner of the property, am exclusively contracting. with licensed contractors to construct the project = MAIL 36 4V (Section 70'44, Business and.Professions Code). ADDRESS c! 6 ( h v " 2'1 4,.2,A: CITY f TEL.NO. CONSTRUCTION LENDING.AGENCY' ��^ -_ #,o.olo o.(I I'hereby affirm that there is a construction lending agency - for theerformance of the work for which this ermit is CONTRACTOR ,- issued (Sec. 3097,Civ.C.). p2.0.0 7.0,0 Lender's Name ADDRESS t7,Q d v Lender's Address o 0 0 CITY /, "'_'_ TEL.NO.. I certify that-I have read this application and state that the- STATE "LL LIC. /-3=/— ordinances 9.1 15# above information is correct.I agree to comply with all County LICENSE NO. r � CLASS /- ' ordinances and State laws regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE County enter upon the a r mentioned property for ' inspec• or purposes. S lure of Permittee Date y COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT ., DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1103070028 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID ( BUILDING ADDRESS: 1 ITR: 14832 LT: 15 I I 5036 KAUFFMAN AV 1 I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ) TEMP CA 917803943 I (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1 18589-018-011 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, Cl 1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 (TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: 1 1 I TOTAL FEES 81.80 103/07/11 SR 1 I I I I (OWNER: TEL. NO: 1 IFINAL DATE FINAL BY: CODE: 1 IGARCIA EFREN (626) 533-5284- I I 15036 KAUFFMAN AV II ITEMP 917803943 .1 IDESCRSPTION OF WORK 1 I' IREPLACE 100,000 BTU FURNACE (4) TON 14 SEER A/C & COIL 1 I I ISAME EXISTING LOCATION 1 JAPPLICANT: TEL. NO: 1 I JARS OF CORONA, L.YENULONIS (951) 280-3113- I I 1 11225 GRAPHITE DR. 1 (SPECIAL CONDITIONS: 1 (CORONA, CA 92881 1 I I I I I I I. (CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE 1 JARS OF CORONA (951) 280-3113- I 1 I 11225 GRAPHITE DRIVE LIC. NO 1 IFAU/WALL FURNACE I I I (CORONA, CA 92881 645050 C20 1 I 1 I I I (COMBUSTION AIR OPENINGS 1 I I I I I I 1ARCHITECT OR ENGINEER: TEL. NO: 1 INDUCT WORK I I I I I I I I LIC. NO: I JAC/COMPRESSOR I I (THERMOSTAT I I I I I I I I IFIRE DAMPERS I I I I I I I I I I I ISMOKE DETECTION DEVICES I I I I I I I I I ICOMMERCIAL HOOD I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I EXPIREL) I I I I I ! I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I II I I I I I I I I I I I l I I I I I I I I (REPORT ID: DPR264 ROUTE TO: BS0508 I 1 1 I I I I I I