HomeMy Public PortalAbout5802 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATIOW DECLARATION 20.0046 DPW 9/89 '
} 76A364C. ' • APPLICATI'ON 'FOR'.PERMIT
I'herela`+•affi,4*.t I have a'6ertrticate of consent to self insure,' LI-MEGREEN
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or a'certificate of Workers Compensation Insurance, or a certified,", ' HEATING'--VENTILATINGR'CONDITIQNING
copy thereof(Sec.3800 Lab. C.)
Poljicy N �vCompany COUNTY OF LOS ANGELES • DEPT-OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ IJ
Certified copy is hereby furnished
BUILDING '
Certified copy is filed with the coun wilding insp n FOR APPLICANT TO FILL IN ADDRESS
departm nt: (PRINT OR TYPE ONLY)
LOCALITY
Date 2 Applicant
NO' TYPE OF APPLIANCE OR EQUIPMENT FEE ,
CERTIFICATE OF EXEMPT N FRO RKERa NEAREST
COMPENSATIO INSURANCE CROSS ST.
• " ABSORPTION UNIT,BTU " ' ASSESSOR
(This section need not be completed If the�work irivolved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($1i00)_oi less.) 'AIR HANDLING UNIT,',CFM'- µ
DISTRICT NO PROCESSED BY
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. ' ; - "J-��
' 'COMPRESSOR,BTU ^' tY ,
Date Applicant APPROVALS DATE INSPECTOR'S SIGNATURE•
PP 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 GRAVII /
LICENSED CONTRACTORS DECLARATION FLOOR BTU v'O (p D VALIDATION
I hereby affirm'•that I am licensed under'provisions of Chapter 9 HEATER: SUSPENDED'—UNIT—
(commencing
NIT(commencing with Section 7000) of Division 3 of the Business and WALL 'y
Professions Code;and my hcerise'is'in full•'force and'effect ;
FS'22� ��2(7
' License Number Lia Class �• '
Contractor Date
❑ I a "exe oder s Plan check fee _ _ ACCT•g O
B.BP.C.for this reason' PERMITS ISSUING,FEE $ a 3JQ.� 91.70 0
bate:- TOTAL FEE 1 _ITEMS U
Signature TOTAL ,.,�1'-.701,a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANTco
ClEC:N� ' 91.70 ,'z
I hereby affirm that fain exempt from the Contractor's License Law NAME. _ \ �•tt��wt'�-c
for the following reason (Section 7031.5, Business and Professions �-/ , CHANGE
Code): ADDR
Y
❑- I, as owner of the property, or my employees with wages .•. n [ o
as their'sole compensation, will do the work and the CITY '; TEL.NO D000'0001 1/2i5�9
structure is not intended or offered for sale (Section 704 L[ ieI rf
Business and Professions Code). OWNER 4481 1 Ahli1:17
❑' I, as owner of the property,-am,exclusively contra ting MAIL,
with licensed contractors to.'construct ithe'project Sec- ADDRESS' V\�M
tion 7044, Business,and;Professions Code)
CONSTRUCTION LENDING AGENCY CITY `""'.C�, TEL NO by-2,•
hereby affirm that there Is a-construction lending a''gency b• v
the:performance of the work'for which this permit Is Issued TRACTOR
(Sec 3097,Civ.C).
RESS -C .".'
Lender's Name
T L NOx,'
Lender's AddresLIC
s'
certify that I have'read,this application and state,that the above �ICENSE'NO. '"Q`Z� CLASS . C
Information is correct. I agree-to comply with all County ordmances' 'r
and State laws relating to building construction,and'hereby authorize
representatiyAs of this.Cou oto enter upon theabove-mentioned
propert r n e longloses. .SEE REVERSE'FOR EXPLANATORY LANGUAGE'S
SIGNAT E OF APPLI R AGE/ DATE
i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1005240009 .
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS: I
ITR: 6561 LT: 499 I 5802 KAUFFMAN AV I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917802205 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I
18587-024-028 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I 102 COMPRSR < 100 KBTU- 1.00 COM 27.00
(TENANT: '108 FURNACE/HEATER <100 1.00 UNI 27.00 11SSUED ON: PROCESSED BY: PLAN BY: 1
1 I TOTAL FEES 81.75 105/24/10 SR 1
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1OWNER: TEL. NO: 1 1FQ ATE FIN BY: CODE:IHJERTSTEDT, LORENE (626) 286-2779-15802 KAUFFMAN AV I 1ll l� T 1
ITEMP 917802205 1 ID CR TION OF WORK 1
I IREPLACE 4-TON 90,000 BTU HEATING & A/C SYSTEM W/NEW DUCTWORKI
I 11N EXISTING LOCATION 1
(APPLICANT: TEL. NO: I 1 1
1GUZMAN, JERREN (626) 557-5311- 1 I 1
11630 S. MRYTLE AVE ISPECIAL CONDITIONS: - 1
IMONROVIA, CA 91016 1
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1CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
(AIR TRO INC. (626) 357-5311- 1 1
11630 S. MYRTLE LIC. NO 1 - 1FAU/WALL FURNACE I'
IMONROVIA, CA 91016 258228 C10 *I I
ICOMBUSTION AIR OPENINGS I
(ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK I I
1 LIC. NO: 1 1AC/COMPRESSOR 1 1
1 1 (THERMOSTAT 1
IFIRE DAMPERS I I 1
I- ISMOKF DETECTION DEVICES I I I
I (COMMERCIAL HOOD I I 1
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1* ADDITIONAL DATA ON FILE I I
IREPORT ID: DPR264 ROUTE TO: BS0508 1
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