HomeMy Public PortalAbout9071 LAS TUNAS DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, ora certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab C ) 76A364C ,
CE-818(REV 10/81) s
Policy No Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building tnspec- FOR APPLICANT TO FILL IN - - BUILDING �Q
tion department (J�/ I
(PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY C
NO- TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST -rZ&5 JUnQs
(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 ($100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this d
permit is issued, I shall not employ any person in any manner
so as to become subject to the Worker 'C t LOWS BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date �-"94Applica COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT If, er making this Certificate of VENTILATION SYSTEM FINAL Is_
Exemption, you should be ome subject to the Workers' v
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or-this permit shall be
deemed revoked ' FURNACE F GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU a
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT(commencingWALL
with Section 7000) of Division 3 of the Business �
and Professions Code,and my license is in full force and effect d,
388 y5 O
License Number Lic Class
�/c.ou �✓a �'o-'r T^•^Teti ijt� t CC
Contractor ate —�u L� 1 ' 5 Irl U
❑ `i ~
I am exempt under Sec � �
Plan check fee H
B 8.P C for this reason PERMIT ISSUING FEE $ Z
of to
TOTAL FEE
SianaturP
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031 5, Business and NAME Z@ 9 3 7,9 A
Professions Code) -
i
❑ I, as owner of the property, or my employees with ADDRESS #;o}o:0 0 0 8
wages as their sole compensation, will do the work and CITY TEL NO
the structure is not intended or offered for sale(Section T-!-'2 2 7 5
- OWNER 2 '��] 5
7044, Business and Professions Code)
' r , ,0 0 0 �
❑ j, as owner of the property, am exclusively contracting 2
with licensed contractors to construct the'project (Sec- IV
ADDRESSksh r 0 3. 0 2-8 4
tion 7044, Business and Professions Code) Cl
CONSTRUCTION LENDING AGENCY CITY l 055 t Sl NO _�f 8
I hereby affirm that there is a construction lending agency for.
the,performance of the work for which this permit is issued -CONTRACTORn S�' 110'(Sec 3097, Civ C ) _ I l d,a T 1
LI ADDRESS l�
Lender's Name Vl1e ' t S Df/
,
CITY C_ TEL NO
Lender's Address
217 7
STATE /i� LIC
.I i
certify that I have read this application and state that the LICENSE NO -i"( CLASS
above Information Is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize represe at'
of this County to enter
u oZt above-me oned p erty for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0108060007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
D BUILDING ADDRESS:
TR: 14467 LT: 75 5032 CAMELLIA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803853
ASSESSOR INFORMATION NUMBER- NEAREST CROSS STREET: LA ROSA
8589-017-022 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 .
30 AIR INLETS/OUTLETS 7.00 UNI 30.45 08/06/01 UT 02/02/02
TOTAL FEES 112.20
OWNER: TEL. NA TE F E:
SKINNER WILLIAM R;LILLIAN A (818) 286-6241- C O Q 1
5032 CAMELLIA AV l
TEMP 917803853 DESCRIPTION OF WORK�_� U61
NEW HVAC SYSTEM
SAME AS OWNER -
SPECIAL CONDITIONS:
F-L ®�
CONTRACTOR: 0: ®� �w�� APPROVALS DATE INSPECTOR SIGN
SAME AS OWNER -
LIC. NO FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT OR
LIC. NO(:// _ I -7,1111111 11 AC/COMPRESSOR
THERMOSTAT1
rI n�� t���l ��� I� �� ij FIRE DAMPER
)�I-.� i _J �1°I 'Qn LF1-1����C��JJ� SMOKE D T C
COMMERCIAL H00
IJ
61 c
REPORT ID: DPR264 ROUTE TO: BS0508
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