HomeMy Public PortalAbout9235 KENNERLY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.X3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
BUIL❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN /--ADDESS '
department. (PRINT OR TYPE ONLY)
bate
LOCALITY
Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L'
NEAREST or,/
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SSOR
(This section need not be completed if the work involved by the MAPBOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit .
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU �Q•" �
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER FINAL
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV TY
LICENSED CONTRACTORS DECLARATION FLOOR _BTU!
2 o n C C.PSLf 1� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number Lia Class f D
Contractor Date
ElI am exempt under Sec. Plan Check fee Q
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE a d
Signature PLAN CHECK APPLICANT -...... C/)
OWNER-BUILDER DECLARATION _. - -
I hereby affirm that I am exempt from the Contractor's License Law NAME , t- I °s
for the following reason (Section 7031.5, Business and Professions ) ; °-_c
'
Code ADDRESS J-1 a.4
_ a.4
1
I, as owner of the property, or my employees with wages F(C!Ci.�S
as their sole compensation, will do the work and the CITY TEL.NO. ----•• -
AL
structure is not intended or offered for sale (Section 7044, F I-I) 122 - 25
Business and Professions Code). OWNER /' r C 4or1 CHECK o 1`222.25.
I, as owner of the property, am exclusively contracting MAIL Q
with licensed contractors to construct the project (Sec- ADDRESS i leNb� (
tion 7044, Business and Professions Code). -
CI 1/ TEL.NO.
CONSTRUCTION LENDING AGENCY —
I hereby affirm that there is a construction lending agency for aILas�U-rltl) � rear
I
performance of the work for which this permit Is issued CONTRACTOR i t i s.�
(Sec.3097,Civ.C.). v V ., .. -I-71S,1i� i AN '=u 7
ADDRESS ... .. .. .. ...._.. ..,._..__._
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances c
and State laws re"i to building construction,and hereby authorize
representatives f t s Cou ty to enter upon the above-mentioned a
property for in pec io SEE REVERSE FOR EXPLANATORY LANGUAGE
�-is-•�.� -
`� SI AT E OFV PLI ANT OR AGENT DATE
COUNTY OF LOS ANGELES , TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1009290026
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID 1 FEES PAID BUILDING ADDRESS:
ITR: 16475 LT: 116 1 9235 KENNERLY ST
I IFEE DESCRIPTION: QUANTITY- UOM AMOUNT- 1 TEMP CA 917803728
(ASSESSOR INFORMATION NUMBER: I - - • _ I NEAREST CROSS STREET: 1
18590-010-016 _ 101 PERMIT ISSUANCE FEE- -• -."27.80, 1 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY, Cl
1 1102 COMPRSR < 100 KBTU 1.00 COM :27.00 1 1
(TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 11SSUED ON: PROCESSED BY: PLAN BY: 1
1 - TOTAL FEES 81.80 109/29/10 SR 1
10WNER: TEL. NO: 1 (FINAL DATE FIN BY: CODE:
IQUAN, NELSON' (626) 703-4251- _ 1 1
19235 KENNERLY ST
ITEMP 917803728 1 1 WSCRIPTION OF WORK 1
1 1 _ REPLACE FURNACE 90,000 BT9 80% AFUE & A/C 4 TON 16 SEER
1APPLICANT: TEL. NO:
1ERIC TACOMBY (818) 735-7876-
15858 DOVETAIL DR. 1 ISPECIAL CONDITIONS: 1
1AGOURA HILLS 91301
1CONTRACTOR:• TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE 1
ISERVICE CHAMPIONS HEATING AND A, C_ (714) 777-7777- iI 1 1
122911 SAVI RANCHY PKWY LIC. NO 1 - •IFAU/WALL FURNACE 1 1
IYORBA LINDA, CA 92887 799170 C20 .1 I D1 1
I 1 (COMBUSTION AIR OPENINGS 1 I
1ARCHITECT OR ENGINEER: TEL. NO: 1DUCT WORK 1 1
LIC NO: 1AC/COMPRESSOR 1
1 I (THERMOSTAT 1
I I I FIRE DAMPERS,
(SMOKE DETECTION DEVICES I I
1 - _ ICOMMERCIAL HOOD I 1
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1 (REPORT ID: DPR264 ROUTE TO: BS0508 1 1 1 1
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