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Home My Public Portal About9243 LA ROSA DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION. FOR PERMIT I hereby dffrcm that I have a certificate of consent to self I � ' nsure,•of'a certificate of Workers' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING 4[e p CEJ copy thereof•(Sept 3800, Lab. C ) CE-81 C , (I c //o�� y CE-81 g(REV 10/81) Po is r� Com an �� Ar,, ❑ Certified copy is hereby furnish d COUNTY OF LOS ANGELES- BUILDING AND SAFETY Certified copy is filed with the county building lips p FOR APPLICANT TO FILL IN BUILDING �� tion department. (PRINT OR TYPE ONLY) ADDRESS Date Applicant N ` LOCALITY O TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be completed If the work involved by, ABSORPTION UNIT, BTU DISTRICT NO PROCESSED BY the permit is for one hundred dollars (5100)or less.) AIR HANDLING UNITCFM I certify that in the performance of the work for which this , J (J o permit is issued, I shall not employ any person in any mariner BOILER, BTU so as to become subject to.the.Workers'Compensation Laws /l APPROVALS DATE SP CTOR'S SIGNATVIRE COMPRESSOR,-BTU 'Ll 2 t 000 O(/ ROUGH 7 Date- Applicant 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 COOLER VALIDATI with comply with such provisions or, this permit shall-be . deemed revoked. FURNACE F.AU TY ,e '1 LICENSED CONTRACTORS DECLARATION FLOOR BTU U [J I hereby affirm that Lam licensed under provisions of Chapter 9 HEATER- SUSPENDED—UNIT— (commencing USPENDEDUNIT(commencing with Section-7000) of Division.3 of the Business WALL and Professions Code,and my license Is in full force and effect.:-- d (� c 3 1 O License Number 4/0327" Lic. Class ��` ► U �N/Uo�2 6— -4V - Contractor Date - H ❑ I am exempt under Sec U W Plan,check fee a 8.8P C. for this reasonH PERMIT ISSUING FEE $- U S� ;27266A Z Date- Signature TOTAL FEE #,e a-� •,e 8. OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I o;0 3 k.0 0 I hereby affirm that I am exempt from"the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME o 0 3 O O v Professions Code): o; ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,,wlll do the work and 1 7-87 the structure is not Intended or offered for sale(Section CITY TEL NO 7044, Business and Professions Code) nA� � OWNER (�/4 ❑, j, as owner of.the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL •tiori 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY'.". 'TEL NO —3 lur 7 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 ( IAf GL�itI Lender's.Name CITY' _ TEL NO LIC . 2161 , ✓lJ`/ Lender's Address STATE7 I certify thoi'I have read this application and state that the ICENSE"NO C•0 J CLASS C-13 SC a above Information Is correct I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize%rep resentatives of this County to enter up the a ove-mention perty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ ✓ `-/7 7*.- Signature of Applicant or Agent Date Y COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1110170041 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: FEES PAID BUILDING ADDRESS: ITR: 16475 LT: 102 I 9243 LA ROSA DR IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803732 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: RIO HONDO 18590-010-002 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY, Cl 1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 (TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 11SSUED ON: PROCESSED BY: PLAN BY: TOTAL FEES 81.80 110/18/11 SR I I I TOWNER: TEL. N0: I (FINAL DATE FINA BY: CODE: IWEIS STEVE;SHELLY (626) 285-3836- I 1 �/�j/j� I 19243 LA ROSA DR 1 1 `�' `' ITEMP 917803732 I IDMCR OF WORK 1 1 (INSTALL A/C AND HEATING SYSTEM I I I I 1APPLICANT: TEL. NO: 10-LEAKY, TOM (626) 287-0927- 1 - 15823 AGNES AVENUE I ISPECIAL CONDITIONS: I (TEMPLE CITY CA 91780 I o 2 1CONTRACTOR: TEL. NO: IAP ROYALS DATE INSPECTOR SIGNATURE 1 1502 O CONSTRUCTION (626) 287-0927- I I 1 15823 AGNESGNES AVENUE LIC. NO I (FAU/WALL FURNACE ITEMPLE CITY, CA 91780 489354 I 1 I 1 1 1 ICOMBUSTION AIR OPENINGS I I (ARCHITECT OR ENGINEER: TEL. NO: I IDUCT WORK I 1 1 LIC. NO: I AC/COMPRESSOR I I I 1 ITHERMOSTAT 1 I 1 I I I 1 1 IFIRE DAMPERS —1-1 1 I I I 1 I ISMOKE DETECTION DEVICES 1 I (COMMERCIAL HOOD 1 1 I I I I I I l I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I 'ADD7&-j&0NAL DATA ON FILE do r ', „REPORT ID DPR fig R0UT8 ;, TO: • COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1103280005 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID FEES PAID BUILDING ADDRESS: 1 ITR: 16475 LT 102 9243 LA ROSA DR 1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917803732 ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET: RIO HONDO 18590-010-002 101 PERMIT ISSUANCE FEE 27 80 I THOMAS PAGE 596 GRID: JS LOCALITY: TEMPLE CITY, Cl I 130 AIR INLETS/OUTLETS 2.00 UNI 8.70 1 1 (TENANT: 147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 (ISSUED ON: PROCESSED BY: PLAN BY: I 1 1 TOTAL FEES 63.50 103/28/11 SR (OWNER. TEL. NO: 1 1F AL FINAL BY: CODE: IWEIS STEVE;SHELLY (626) 285-3836- 19243 LA ROSA DR TEMP 917803732 DESCRIPTION OF WORK 1 1ANTERATION OF EXIST DUCT SYSTEM, 2 AIR INLETS FOR NEW ADDIT11 1APPLICANT: TEL. NO: 1 I I IO'LEARY, TOM (626) 287-0927- 15823 AGNES AVENUE 1 1SPECIAL CONDITIONS: 1 ITEMPLE CITY CA 91780 1 1 . ICONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE ITOM O'LEARY CONSTRUCTION (626) 287-0927- 1 15823 AGNES AVENUE LIC. NO 1 IFAU/WALL FURNACE I I 1 ITEMPLE CITY, CA 91780 489354 B-1 1 " 1 jCOMBUSTION AIR OPENINGS I 1 I I I I 1ARCHITECT OR ENGINEER TEL NO: i DUCT WORK 1 LIC. NO: 1 IAC/COMPRESSOR 1 1 1 ITHERMOSTAT I 1 I I I 1 1 IFIRE DAMPERS 1 I 1 1 1 ISMOKE DETECTION DEVICES I 1 I COMMERCIAL HOOD 1 I I I I I I 1 I I I I I I I I I I 1 I I I I I I 1 I I I I I I I I I I 1 I I I I I I I I I I I 1 1 I I I I 1 1REPORT ID: DPR264 ROUTE TO: BS0508 I I I I I I I