HomeMy Public PortalAbout10435 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C L IC PY 1 I O 1 tl FOR Y'C Ir IG I�ItlY I 1
I herebv affirm that I have a' certificate of Consent to self CE -818 (2-80)
insure, or a certificate of Workers'Compensation Insurance,of HEATING-V ENT ILATING-AIR CONDITIONING
a certified copy thereof(Sec.38000 Lab
•:O.)
Policy No..Wsl]' •ompan;J—✓a/—� /uu
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county buil di Ig, nspection FOR APPLICANT TO FILL IN BUILDING
d�eemn-trneev,^� ADDRESS 10,93,5'
Date./�(QJ_ Applicant _ _ _ _ (PRINT OR TYPE ONLY) 7'e
ggqq�/q...iii��
/ LOCALITY / 1
CERTIFICATE OF EXEMPTION.FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE e� y� e yL —�•1
COMPENSATION INSURANCE NEARESTCROSS ST. �r�e�! C
(phis section need not be completed if the work involved ABSORPTION UNIT, BTU O
by the permit is for one hundred dollars ($100) or .less.) DISTRICTNO, < PROCESSED BY U
01
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ` ,n O
permit is issued, I shall not employ any person in any manner ✓7 C,G//
_
so as to become subject to the Workers' Compensation Laws. BOILER, BTU f—
�� aO4 APPROVALS DATE INSPECTOR'S SIGNATORE W
Uate Applicant ,/ COMPRESSOR,BTU_ / ROUGH y
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.COOLFR - VALIDATION
with comply with such provisions or this permit shall be
deemed revoked.
FURNACE: FAUS.v— GRAVITY
LICENSED CONTRACTORS DECLARATION. / FLOOR:— BTU—/0 .
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number.� J�� Lia Class�+ O -
Contractor jr-(S �/� Date_/
/4-8
❑ 1 am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEES _-�
Lic.or Reg.No. Date TOTAL FEE .
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor's .NAME
License Law for the following reason (Section 7031.5, Busi.
ness and Professions Code): ADDRESS 4'4 t,2 A
❑ I, as owner of the property, will do the work and the '
structure is not intended or offered for sale (Section CITY TEL. NO. e e o 0 0 8
7044, Business and Professions Code). (�— I
❑ OWNER ��1_✓I►.�U21cI p�iJ O.—�O • �e
I, as owner of the property, am exclusively contracting
2 • 3 0.•5 0
with licensed contractors to construct the project MAIL ,
(Section 7044, Business and Professions Code). ADDRESS ,o•o • 3 0 5,0 chi
I .
CONSTRUCTION LENDING AGENCY CITY TEL.NO, 0 8,..1 0_8 3_
I hereby affirm that there is a construction lending agency �r {•S.
for the performance Of the work for which this permit is CONTRACTOR
issued (Sec. 3097,Civ.C.). --— "
Lender's Name ADDRESS
Lender's Address CITY ����� NO��
I certify that 1 have read this application and•state that the STATE �j�r�—•7 LIC.
above information is correct. I agree to comply with all County LICENSE vo s�W Jay CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and hereby authorize representatives of this - SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter -tpr t above-mentioned property for
ins ecr'on purpose!
Signature of
r&tie
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0106220001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL D: FEES PAID BUILDING-ADDRESS:
TR: 37580 LT: 11 10435 LA ROSA DR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803481
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ARDEN
8585-018-052 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 2.00 UNI 8.70 06/22/01 JK 12/19/01
TOTAL FEES 90.45
OWNER: TEL. N0: FINAL DATE FINAL BY: CODE:
WONG; SALLY (626) 229-2993- a..,0�_y�
10435 LA ROSA DR
TEMP �' -
917803481 ESCRIPTION OF WORK
DUCTWORK FOR ADDITION, REPLACE HVAC SYSTEM
APPLICANT: TEL. N0:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: -
SAME AS OWNER APPROVALS DATE INSPECTOR SIGNATURE
-
LIC. NO - FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
LIC. NO: I. AC/COMPRESSOR
T145RMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD yri
REPORT ID: DPR264 ROUTE TO: BS0508