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WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT -L ME GREE14
76A364C `
I hereby affirm that I have a certificate of consent to self Insure,
cop certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
- copy thereof(Sec 3800 Lab C) '" •• -
"Policy cdf
NoCompany COUNTY OF,LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
El ' Certified copy is hereby furnished
bepy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS /P
XR
; (PRINT OR TYPE ONLY) _
r�
Date Apphcarit' LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT;BTU
(This section need not be completed If the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) MAP BOOK PAGE ]PARCEL
AIR HANDLING UNIT,CFM DISTRICT NO• P CESSED BY
I certify-that in.the performance of the work.for which this permit _
Is.issued, I shall not employ any person In any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws '
COMPRESSOR,BTU
^ - APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If,,after making this Certificate of ROUGH"
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER p Y
provisions of the Labor Code, you must forthwith comply with such FINAL G
provisions or this permit shall be deemed revoked FURNACE FAU - GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU -� /Q VALIDATION'
1 hereby affi(m,that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and- HEATER WALL
Professions Code,'ar d my license Is full force and effect f
ACCT.g'
License Numbe Llc Class
„ , a 3303 53090 a
Contracto Dat 1 ITEMS .�, O
❑' , I am exempt'under Sec Plan Check fee TOTAL 53 90 �
B&P C for this reason PERMIT ISSUING FEE$ CHECK 53.90 O
Date TOTAL FEE _ 3, �1 CHAI`IGE a00 W
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT n n i, i [f (/)
I hereby affirm that I am exempt from the Contractors License Law NAME �0-0001 3/M11/96 Z
for the following reason (Section 7031 5, Business and Professions , 529 1 F,i ila�: }
Code) ADDRESS d 7
❑ I, as owner of the property, or my employees with wages n ;
a4s their sole compensation, will do the work and the C, TEL N
tructure Is not Intended or offered for sale (Section 7044,
�Business and Professions Code) OWNER
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRES
tion 7044,Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm th t there is-a construction lending agency for
the performance' f the work' for whlc his permit Is Issued CONTRAC R
(Sec 3097,Civ C
ADDRES n l
Lender's Na /
CITY TEL NO
Lender's'Address STATE LIC
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 _
and St a laws relating to building construction,and hereby authorize
repre ntatives of this County to enter upon the oye-m ntioned
pr ` rt for inspe io urposes SEE REV ERSEyFOR EXPLANATORY LANGUAGEX4' 41 VK i
SIG NATUR O IC AGENT DATE - - ,
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0904150006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
ILEGAL ID I FEES PAID I BUILDING ADDRESS-
ITR 12157 LT 5 I 1 9026 LAS TUNAS DR
I IFEE DESCRIPTION QUANTITY- UOM. AMOUNT I TEMP CA 917801834 I
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET. SULTANA
15387-029-004 101 PERMIT ISSUANCE FEE 27 75 I THOMAS PAGE- 596 GRID H3 LOCALITY TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1 00 COM 27 00 I 1
ITENANT 108 FURNACE/HEATER <100 1 00 UNI 27 00 (ISSUED ON. PROCESSED BY PLAN BY. EXPIRES ON 1
130 AIR INLETS/OUTLETS 10 00 UNI 43 50 104/15/09 SR 10/12/09 1
I 1 TOTAL FEES 125 25 1 1
(OWNER - TEL NO. 1 IFI DATE FI BY CODE 1
IROZAK FAMILY PROP (949) 474-4906- 1 I / 1
12192 MARTIN ST I 1 I
11
(IRVINE I 1DESCRIPTI N OF WORK I
I I 11NSTALL HVAC SYSTEM
I
(APPLICANT TEL NO 1 I I
IPOWER SOURCE CONSTRUCTION (626) 233-2861- I I I
18305 DUARTE ROAD I ISPECIAL CONDITIONS I
1SAN GABRIEL CA 91778
I I I I
CONTRACTOR TEL NO (APPROVALS DATE INSPECTOR SIGNATURE I
IPOWER SOURCE CONSTRUCTION (626) 233-2861- 1 1 1
IP 0 BOX 52 LIC. NO I FAU/WALL FURNACE
ISAN GABRIEL, CA 91778 833729 1
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1COMBUSTION AIR OPENINGS I I I
(ARCHITECT OR ENGINEER TEL. NO I IDUCT WORK I I I
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IREPORT ID- DPR264 ROUTE TO BS0508
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