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HomeMy Public PortalAbout9142 LA ROSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT a hareby„affirm that I have a certificate of consent to self Insure; or a certificate of Workers'.Compensation Insurance, " HEATING - VENTILATING - AIR CONDITIONING oV a certified copy thereof (Sec. 3800,'Lab. C.) 76A3641-y -• - 20-0046'DPW 9/88 'P,61iey'No. Company 1- ' ' n;Certified copy.Ls hereby furnished" , COUNTY OF LOS ANGELES - ' BUILDING•AND SAFETY. ❑' Cerrified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING d tion department. (PRINT(PRINT OR TYPE ONLY) ADDRESS Date ' Applicant LOCALITY _ NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF•EXEMPTION FROM-WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST pr!&p.J er ABSORPTION UNIT, BTU (This section need•not be completed if the Work Involved by DISTRICT NO (1 PROCESSED BY the permit is for one hundred dollar's ($100) or less.) I certify that in the performance of the work for which this I permit is Issued, I shall not employ ohy.person In any manner so as to become subject to the Workers' Compensation Laws. BOILER, BTU /� `APPROVALS DATE INSPECTOR'S SIGNATURE COMPRESSOR, BTU 60 B0 ROUGH-,• '.Date Applicant ' NOTICE TO.APPLICANT: If, of r making this Certificate•of VENTILATION SYSTEM FINAL Exemption, 'you should become sublect`'to the Workers' Compensation provisions''of the Labor Code, you must forth- �J EVAPORATIVE COOLER 4660 c p p p VALIDATION with comply with such pfoVnsions or this permit shall be deem- L -'ed revoked. ', 1 FURNACE- FAU GRAVITY LICENSED CONTRACTORS DECLARATION 1 FLOOR . BTU I hereby affirm-that)am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL O� and Professions Code,and my license Is In full force an effect. - a License Number U q/ {�-1Llc. Class O C S t 6 k 5 ,-16 B-O , Contractor Dae ❑ • LA 1 am exempt under Sec. O F- Plan check fee GD u HB 8P.`C. for this reason DO1e I PERMIT ISSUING FEE $ �3 Ov Z Signature TOTAL FEE 9 p d !, OWNER-BUILDER'DECLARATION PLAN CHECK APPLICANT a I,hereby affirm that I am exempt from,the Contractor's License �'t• Law for the following reason (Section 7031.5, Business and NAME Lp°j;jl Professions Code): ___ ❑ I, as owner of The'.property, or my employees with ADDRESS - 1 i I Elft:., wages as their sole compensation,will do the,'work and .' the structure is not intended or offered for sale(Section CITY TEL. NO TOTAL �`� a �� 7044, Business and Professions Code). . OWNER - CHECK�i1, `f O°I I! I, as owner of the property, am'exclusively controctirg' -� �� with licensed contractors,to construct the project Sec_ MAIL ,tion 7044, Business cind Professions Code): ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL NO I hereby affirm that there is a construction lending agency for F •y 1• Ic the performance of the work for,which this permit is Issued CONTRACTORs IlI�IJI�_t�'L031 1��`•=I'f (Sec:3097,'Civ C ) • � ,+M q i °57 ° ADDRESS 9 Y13 t Lender's Name t � ' CITY Q� TEL NOVID, 7� '�. _ Lender's Address I certifythat I have read this application and state that the STATE LIC pP LICENSE NO CLASS C 1 above information is correct I agree to comply.with all County ordinances and State laws relating to building construction,. and hereby authorize representatives of this County-to enter upon the above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date- ©s COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0602210016 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 ERT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 28317 LT: 5 9142 LA ROSA DR FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803016 ASSESSOR INFORMATION NUMBER: - NEAREST CROSS STREET: 5388-009-012 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY, C 44 SPRAY BOOTH 1.00 BOO 65.40 TENANT: TOTAL FEES 93.15 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: TOP WOOD SHUTTER 02/21/06 JK 08/20/06 OWNER: TEL. NO: FINAL DATE tAHjf!UY: CODE: TOP WOOD SHUTTER (626) 286-8817- 9145 LA ROSA DRIVE TEMPLE CITY CA 91780, DESCRIPTION OF WORK PRE-FAB SPRAY BOOTH APPLICANT: TEL. NO: M.B. TECHNICAL SERVICES (562) 426-3453- P.O. BOX 9130 SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE BAR Z INDUSTRIAL (909) 481-3450- 8356 BELLA VISTA LIC. NO FAU/WALL FURNACE ALTA LOMA, CA 91701 727856 B COMBUSTION AIR OPENINGS ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK LIC. NO: AC/COMPRESSOR THERMOSTAT FIRE DAMPERS SMOKE DETECTION DEVICES COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508