HomeMy Public PortalAbout5807 KAUFFMAN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
orc t led copy thereof (Sec 3800, Lab C.) 76A364C f I
4 CE-818(REV-10/81)
Poll y /JAa Company 2,0 2 ;
❑ Certified copy is hereby furnished. -COUNTY-OF LOS ANGELES' BUILDING AND SAFETY
Certified'copy )s filed with the county building ins ec- FOR'APPLICANT TO FILL IN BUILDING r h
tion department. (PRINT OR TYPE ONLY) ADDRESS
— U LOCALITY �+
Date 'Applicant <�
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need•not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT-NO PROCESSED BY
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT, CFM -
I certify that in the performance of the work for which this _
permit is issued, I'sholl not employ any person many manner
so as to become subject to'the•Workers'Compensation Laws BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT- If, after making 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 VALIDATION
AJith comply with such provisions,or this permit shall be R
deemed revoked. ' FURNACE: FAU�RAVITYY a
LICENSED CONTRACTORS DECLARATION FLOOR BTU -2JJr Q-� �•�•-,
I hereby affirm that I am licensed under provisions of Chapter 9HEATER SUSPENDED• UNIT may-
,..{..l w� ' •_I..!
(commencing with Section 7000) of Division 3 of the Business WALL w1.• >,
and Professions Code, and my license is in full force and effect." - I,
License Number Li'. Class 20
Datri' O
r Contractor eOAIIVV 4Fe . V�
F-
❑ I am exempt under Sec �,`_ V
Plan check fee "' _�! d
A
B.&P.C. for this reason Z
PERMIT ISSUING FEES
Date: -
Signature TOTAL FEE I (', F •`i! LTi _r
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT. L' '`1.
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'):
❑ Cas owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and" CITY TEL NO >
the structure is not mfended or offered for sale(Section
7044, Business and Professions Code). .
El 1,
A/C Co 4 / -
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 ff4,
-CONSTRUCTION LENDING AGENCY• CITY P r• TEL NO 20 7
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR D �� �pN�
(Sec 3097, Civ. C )
ADDRESS �' /l/C//✓i �.� _
Lender's Name phi / /�' 7 �7
CITY. !C - C ( TEL NO
Lender's Address [/ -7 y '
STATE
I certify that I have read this application and state that the LICENSE NO 1 d J7, . •• CLASS- •fC V -
above information is correct. I agree to comply with all County
ordinances and'State jaws relating to building construction,
and hereby authorize represen es of this County to enter
upon a abo -mentione roper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE... .
Signature of Applicant or Agent. '3 Date
COUNTY, OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0803120003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 513 5807 KAUFFMAN AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802206
(ASSESSOR INFORMATION NUMBER: i I NEAREST CROSS STREET: 1
18587-021-003 �01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I J02 COMPRSR < 100 KBTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 JISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1
130 AIR INLETS/OUTLETS 4.00 UNI 17.40 03/12/08 SR 09/08/08
' 141 VENTILATION FAN 1.00 FAN 15.75
1OWNER: TEL. NO: I TOTAL FEES 114.90 JFI5AL DATE FINAL BY: CODE:
ILAM, QUANG (626) 215-7412- 1 11-4
15807 KAUFFMAN AVENUE 1 ,_�Y V
ITEMPLE CITY CA 91780 1 1 DfS(fRIPTIi7N OF WORK 41
11NSTALL HVAC SYSTEM FOR 2ND: UNIT
APPLICANT: TEL. NO:
ILAI (626) 288-2651-
18748 VALLEY BLVD. #K ISPECIAL CONDITIONS:
IROSEMEAD, CA 91770
CONTRACTOR: TEL. NO: JAPPROVALS DATE INSPECTOR SIGNATURE
IQUANG T LAM (626) 215-7412-
JXIA0 YING MAI LIC. NO FAU/WALL FURNACE
9303 RALPH STREET NONE
IROSEMEAD, CA 91770 ICOMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
LEE, PETER (626) 0J
1LIC. N
18748 VALLEY BLVD. #L LIC. NO:: JAC/COMPRESSOR
JROSEMEAD CA 91770 NONE
THERMOSTAT 1
11 /v why-,���`(q,`•' IRE DAMPERS
w�L6Ya (�'D SMOKE DETECTION DEVICES
COMMERCIAL HOOD
* ADDITIONAL DATA ON FILE
IREPORT ID: DPR264 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0811030010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
ITR: 6561 LT: 513 I 1 5807 KAUFFMAN AV
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917802206
(ASSESSOR INFORMATION NUMBER: I INEAREST CROSS STREET:
18587-021-003 101 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I 130 AIR INLETS/OUTLETS 3.00 UNI 13.05 I 1
1TENANT: 141 VENTILATION FAN 1.00 FAN 15.75 11SSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 111/03/08 SR 05/02/09 1
1 TOTAL FEES 83.55 1 1
(OWNER: TEL. NO: I IFINAL DATE FINAL BY: CODE: 1
(LAM, TU QUANG (626) 215-7412- 1
15807 KAUFFMAN AVE. I I1
1TEMPLE CITY CA 91780 1 IIJESCRIPTIONPOF WORK I1
I I 1ALTERATION OF EXIST DUCT SYSTEM, 3 AIR INLETS AND 1
I I 1VENTILATION FAN
1APPLICANT: TEL. NO: 1 I I
ILAI (626) 288-2651- I I
18748 VALLEY BLVD. #K 1SPECIAL CONDITIONS: 1
1ROSEMEAD, CA 91770 I I
I I
I I I I
1CONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
1QUANG T LAM (626) 215-7412- 1 1 I
1XIAO YING MAI LIC. NO IFAU/WALL FURNACE I I i
19303 RALPH STREET NONE
IROSEMEAD, CA 91770 1 ICOMBUSTION AIR OPENINGS I I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I
LIC. NO: 1AC/COMPRESSOR I I I
1THERMOSTAT I I I
I I I
1 I 1FIRE DAMPERS I 1 I
I I I
I I ISMOKE DETECTION DEVICES 1 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 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
1 IREPORT ID: DPR264 ROUTE TO: BS0508
I I I I I I