HomeMy Public PortalAbout9213 LEMON AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046'DPW 9/89
', 76A364C APPLICATION 'FOR PERMIT
I refiy,aljiirm'that I have a certificate of consent to self insure, IME.- GREEW .,
of a
certificate of Worker's Compensation insu�ence, or a certified a .HEATING,.;,VENT,IL'ATING,,AIR CONDITIONING:.'
copy there f(Sec. 3800 Lab.C.), ,.c
r' l��,� Q
Policy No.i Company'— 'U,�/L�(i COUNTY OF'LOS ANGELES ' "DEPT OF PUBLIC WORKS' BUILDING•AND.SAFETY DIV.�t�' °
❑ Certified copy is hereby furnished
Y� Certifled'copy is idea with the county building Inspection FOR APPLICANT TO.FILL IN -> BUILDING
department (PRINT OR TYPE ONLY) ADDRESS.•QZ�3 �, ,ham. -17.
bate ' Applicant �a/YU',`i C(/ •I�U LOCALITY ��1.
NO. TYPE OF'APP_LIA_NCE OR EOUIPMENT , FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' '. :CROSS ST ""
COMPENSATION INSURANCE'
ABSORPTION UNIT;BTU—
(This
TU(Tfiia section need not be completed if the work InASSESSORvolved by the `• a '
;+ MAP BOOK' PAGE i - - •, PARCEL'
permit Is for one hundred dollars.($100),,oraess.) AIR HANDLING UNIT CFM _
="� DISTRICT NO PROCESSED Y,:-
I certify that In ttie performance of¢he work for'whlch this permlY P.. - ;
Is issued, I's'hall not em to ori Bison in an manner so as to -
P Y Y'P Y BOILER,BTU !`
become subject to the Workers:Compensation Laws'. U°Yj. 7.
COMPRESSOR;BTU •�[J•—
rr v , 7 APPROVALS' DATE _ + INSPECTOR'S,SIGNATURE
Date Applicant " VENTILATION SYSTEM
NOTICE SO'APPL'ICANT•+If,'affer making this Certificate,of ROUGH
Exemptioh,`you should tiecome subject,to the Workers'Compensation EVAPORATIVE COOLER
provisions of,the Labor Code, you must forthwith comply with such ` " FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU' GRAVITY
A
LICENSED CONTRACTORS.''* LARATION+ si FLOOR BTU 127'ai>ID Zj X05 VALIDATION"
I here-by'afflrm that-I am'licensed under provisions'of Chapter-9 SUSPENDED UNIT-`
,(commencing with Section 7000) of Drvislon 3 of tfie Business and HEATER WALL
Professions Code,and•my"license'is In full;force,and effect.'
Llcense,Numbei 2 Jb Z2 .• Lia Class
CL
Contractor � Date'
' 12 -� r t O
❑ -.Plan check fee*I am exempt undersec. U
BAP C for this reason PERMIT ISSUING FEE$--2„(p•�(7' 4 if t 0'
Date: TOTAL',` FEE . - 0.2 W
Signature :�. d
PLAN CHECK;APPLICANT _
OWNER-BUILDER DECLARATION " Z
I,hereby affirm that I am exempt from the Contractor's License Law
NAME-.'
for the fallowing-reason (Section 7031.5, Busiriess and Professions
Code). _ ADDRESS
❑ ," I, as owner of,th r °t Q�' i r •.
e•p operty, or my employees with.wages t It''`
as their sole compensation, will do the work and the CITY TEL.NO'
Structure Isnot intendeii or offered for sale•(Section 704,4,
Business'and Professions'Code). ' ' OWNER.'; �, 'j:�,
❑`'
I_as owner of the property, am,exclusively.contracting .US - : Ja`
MAIL ,.� a _ L.y 3t*.�}..;.; x. 'tiy`'f i EE
with licensed contractors to construct the project (Sec- ADDRESS Z �' L�%l9GyLf `J.y` �' I ;tLi�. '
tion 7044, Business and Professions Code). /!m ,
CITY � � � :
CONSTRUCTION LENDING AGENCY �• ;.
1.hereby affirm'that there is a construction lending agency for +-. - i i
the performance of the work for which this permit Is Issued. CONTRACTOR O ��,G
(Secy 3097-, Civ.C.).
'Lender's Name ,. - ,:. ami';, • 't'�a �'t
ADDRESS `�cJ� �I�TC L� / Y Srrc.;
CS M _. .. _ [!1 I[i
CITY TEL.NO
1 H
TIL= , -71
ei��7'4:." ..
///O��OIIL r ! CL7iw m I lI s'e -;,
Lender's Address STATELIC:
I 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 State laws relating to building construction,and hereby authorize
repr atives of this ounty to enter upon the above-mentioned
pro rty r insp'ction urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
` SIGNATURE OF APPLICANT OR AGENT DTE• - 'q -
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0209050005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGALADDRESS:
ON FILE 9213 LEMON AV ,
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801327
ASSESSOR INF NEAREST CROSS STREET: OAK
5382-015-029 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE:-596 GRID: J1 "LOCALITY: TEMPLE-CITY
30 AIR INLETS/OUTLETS 4.00 UNI 17.40
TENANT: TOTAL FEES 45.15 S ROLE B EXPIRES .
09/05/02 JK 03/04/03
OWNER: EL. 0: FINAL DATE FINAL BY: CODE:
WONG
3749 COGSWELL RD _ -
EL MONTE 91732 MT7MIUN OF WORK
MECHANICAL FOR ADDITION
APPLICANT:
SUNG-LAM CHAN (626) 926-9840-
120 W CAMINO REAL AV SPECIAL CONDITIONS:
ARCADIA 91007
0 C TEL. N ���i����\ APPROVALS DATE N ECTOR SIGNATURE
INF BUILDERS (626) 574-0138-
120 W CAMINO REAL LIC. NO /V �Ly\ FAU/WALL FURNACE
ARCADIA CA 91007 490547BHICCOMBUSTION AIR OPENINGS
C G NEE . 0: �/ I - -J /' \\ DUCT WORK
LIC. N0�1� ! ii j --� �\��I AC/COMPRESSOR
THERMOSTATii ._-___---,- - --- ---- - -- - - ---- ---- R DAMPERS
SMOKE f= �ti i 1 i �l �,
DETECTIONCE
OMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508