HomeMy Public PortalAbout10733 LA ROSA DR_Mechanical__ WORkYRS'CDMPEsISATiON DECLARATION 76A364C
! herby affirn that I have acertificate of consent to self
GE .818 (2.80) APPLICATION FOR PERMIT
insure;or a'c::rt1i Cate of Workers'Compensation Insurance,of HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab.C.)
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES - BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING )O 7 /,d
department. ADDRESS /' Jr..»
Date Applicant - (PRINT OR TYPE ONLY) n `
TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO.
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU- CROSS SL O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROC.MFEISY (�
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM-
permit
o,?-
�
permit is issued, I shall not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DAT IN9PEC R's. NATURE W
Date Applicant COMPRESSOR BTU ��, fL
ROUGH L/)
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM ✓ , Z
Exemption, you shouldbecome subject to he Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI ION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: STU
1 hereby affirm that I am licensed under provisions of Chapter I HEATER: 't"eRGN DED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and
effect.
License Number Lic.Class
Contractor Date
❑ 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. 2 4 7 4 7 A
iness and Professions Code). PERMIT ISSUING FEE
Lic.or Reg.No. Date TOTAL FEE �
HOME OWNER-BUILDER DECLARATIONPLAN CHECK APPLICANT A•- � 2 O S O
1 hereby affirm that I am exempt from- the Contractor's NAME 0,6,0
20505
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS ,0 b.O 2 e 8 6
❑ 1, as owner of the property,'will do the work and the
structure is not intended or offered for sale (Section
CITY TEL. NO.
7044, Business and Professions Code).
❑ OWNER LL.r •,rr __ !7 ,IM �.
1, as owner of the property, am exclusively contracting 17[/Jlj7�r'J/7J JZ_
with licensed contractors to construct the project MAIL / �t �ps?
(Section 7044, Business and Professions Code): ADDRESS IO7 uT
CONSTRUCTION LENDING AGENCY CITY 1fr� .a.A/.� D. .�. TEL.NO./j<[['I_[.{f�
I hereby affirm that there is a construction lending agency Y�L0)'t//�f�u�' / -(J r/e
for the performance of the work for which this permit is CONTRACTOR yVim_
issued (Sec. 3097,Civ.C.). /
Lender's Name ADDRESS_q.
Lender's Address CITY l •/� 1v7 �/ TEL. NO.7JJ S-C/G,-U , ' . .
1 certify that 1 have read this application and state that the STATE
above information is correct. I agree to comply with all County JLUCENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, ' r :reby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to cat p n e above-mentioned property for
iuspectiun pur' .�
Signature , Pe mi tee Dale .
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9101 LAS TUNAS ME 0508 1305020006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 17867 LT: 48 10733 LA ROSA DR
I IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT: 1 TEMP CA 917803410
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET: PERSIMMON
IB574-002-024 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE; 597 GRID: C4 LOCALITY: TEMPLE CITY CAI
102 COMPEER 1 100 KHTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER 1100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY- PLAN BY:
130 AIR INLETS/OUTLETS 7.00 UNI 30.80 105/02/13 SR
141 VENTILATION FAN 2.00 FAN 31.60 1
IOWNER: TEL. N0: TOTAL FEES 144.20 ����F FINAL By CODE:
LIAW, KATHERINE (909) 331-1155-
110733 LA ROSA DR
1TEMP 917803410 1 ID SCRIPTION OF WORK
(INSTALL A/C, HEATING SYSTEM, 7 AIR INLETS AND 2 VENTILATION
FANS
1APPLICANT: TEL. N0: I I 1
IGRANADINO, HUGE (626) 618-2288- 1
12022 SANTA ANITA AVE ISPECIAL CONDITIONS:
IS EL MONTE CA 91733 1 1 1
1CONTRACTOR: TEL. NO: I1APPROVAI.S DATE INSPECTOR SIGNATURE I
1TOUCHSTONE CONSTRUCTION DEVELOPMENT (626) 618-2280- 1 1
12022 SANTA ANITA AVE LIC NO FAU/WALL FURNACE 1 1 1
1SOUTH EL MONTE CA 91733 938016 1 1 1
COMBUSTION AIR OPENINGS
I I
ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK
I LIC. NO: 11 IAC/COMPRESSOR �3 11
. (THERMOSTAT
1 11
(FIRE DAMPERS
1 1 (SMOKE DETECTION DEVICES 1 I 1
I
COMMERCIAL IAL HOOD
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` ADDITIONAL DATA ON FILE
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IRE PORT ID: DPR264 ROUTE T0: B80508
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