HomeMy Public PortalAbout5823 KAUFFMAN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION- FOR PERMIT
I hereby affirm that I have a certificpte of consent to self
insure, or a certificate of Workers' Compensation Insurance, ,eA3eac HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, 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 inspect FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date ApplicantLOCALITY
• NO TYPE OF APPLIANCE OR EQUIPMENT FEE '-•��✓
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS S7
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DSTRICT NO PROCESSED BY
the permit Is for one hundred dollurs'($100)or less.)
d
I certify that'm the pAIR HANDLING UNIT, CFM
performance of the work for which this
permit is issued, I shall-not employ anyperson to any manner
50 a5 t0 beco esu BOILER, BTU
jec'to the-Workers'Compensation LOWS .-. APPROVALS - DATE INSPE O 'S SIGNATURE '
Date pplicarit COMPRESSOR, BTU ROUGH
-NOTICE TO WPLICANT 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
with comply with such pro'vi'sions 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 SUSPENDED WALL UNIT
(commencing with Section 7000) of Division 3 of the Business -
and Professions Code,and my license is in full force and effect -
License Number1 c Class ► V
Contracto Date 0 0
❑ I am exempt under Sec. _ UA
Plan check fee H
B.BP.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE 091.31A
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT '#'e'o•o,• 0 8
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME I ► tl ,o °2 Q5
Professions Code):
❑ j, as-owner of the property, or my employees with' ADDRESS o e o 2 Q 5 d U
--wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO ;I Q (�' 8 a
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 704 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 ,
(Sec 3097, Civ C )
ADDRESS
Lender's Name
CITY // TEL N
Lender's Address v L/
STATE' LIC -
I.certify that I have read this application and state that the LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State laws relating to building 'construction,
and hereb authorize resentatives of this County to enter
up the ove- ed prop ertyfor inspec n poses SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of A li nt or Ageri Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS - ME 0508 1205100025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
• - PHONE: (626) 285-0488 EXT:
LEGAL ID- FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 516 5823 KAUFFMAN AV 1
I IFEE DESCRIPTION. QUANTITY: UOM• AMOUNT: ' TEMP CA 917802206
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LAS TUNAS
18587-021-006 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, CI
1 108 FURNACE/HEATER <100 1.00 UNI 27.00
(TENANT- I TOTAL FEES 54.80 (ISSUED ON: PROCESSED BY: PLAN BY: 1
1 105/10/12 SR
I
(OWNER: TEL. NO: ' IFINAL DATE •FINAL BY: CODE:
IMA WALLACE Z;JEANIE -
15823 KAUFFMAN AV -
ITEMP 917802206 1
(DESCRIPTION OF WORK
I
'REPLACE WALL HEATER
I
'APPLICANT: TEL. NO: '
ICASTILLO, EDDIE (909) 829-5673- 1
1627 E. BONNIE BEACH ISPECIAL CONDITIONS:
ONTARIO, CA 91730 -
4 1
I
(CONTRACTOR: TEL. NO:
APPROVALS DATE INSPECTOR SIGNATURE
ISYNERGY MECHANICAL, INC. (909) 829-5673- 1
19375 ARCHIBALD AVE. #403 LIC. NO FAU/WALL FURNACE 1
IRANCHO CUCAMONGA, CA 91730 NONE I I- 1
I I ICOMBUSTION AIR OPENINGS 1 I
'ARCHITECT OR ENGINEER: TEL. NO IDUCT WORK
11 LIC. NO: ' IAC/COMPRESSOR 1 1 I
I I 'THERMOSTAT
-5- IFIRE DAMPERS RSEXP"'IREr'
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o-,3- 3
I ISMOKE DETECTION DEVICES 1 1 1
I 1 'COMMERCIAL HOOD 1 1 1
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' IREPORT ID: DPR264 ROUTE TO: BS0508 I I I