HomeMy Public PortalAbout9958 LIVE OAK AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION j APPUCQYMN FOR PERMPT
I hereby affirm that I have a certificate of con�en7(o elf- , : _
Insure, or a certificate of Workers'Compensation Insurance, HEATING -VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab'C ) 76A364C
CE-818(REV 10/81)
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL INrILDING' /�SO L/ULA /SfU
tion department DDRESS 7 O ,�
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY O Cir
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF'EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST A4 L /,d/
(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.)
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM
permit is Issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws APPROVAts DA INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH —1�.
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 FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER 1-1d_ENDEDUNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is In full force and effect �'
CL
0
License Number Lic Class - D V
mC
Contractor Date -
❑ M 1
I am exempt under SecLU
Plan check fee
B&P C for this reason PERMIT ISSUING FEE $ Z
Date
Signature TOTAL FEE -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ! D
Law for the following reason (Section 7031 5, Business and NAME
Professions Code)
❑ j, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO
7044, Business and Professions Code) OWNER re /C/ooAw o L9 0 11 3 2 A
� / �,_. )
❑ I, as owner of the property, am exclusively contracting T/Y r/v � 0}0 0
with licensed contractors to construct the project (Sec- MAIL # 0 8
tion 7044, Business and Professions-Code)' ADDRESS (� 210'0 2,'0.'5'0
CONSTRUCTION LENDING AGENCY CITY TEL'NO��S ?Z4Z\ f
I hereby affirm that there is a construction lending agency for "0 010 2 0:5 0 50
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097, Civ C ) D� 3.01 :-8 3
ADDRESS
Lender's Name
CITY TEL NO
Lender's Address
STATE LIC
I certify that I have read this application and state that the LICENSE NO- CLASS - -•
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
u e above-mentioned property for inspection purposes SEE REVERSE FOR,EXPLAMATORY LANGUAGE
Sig ture of Applicant or Agent- Date "
• - COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0508050014
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT.
LEGAL ID - FEES PAID BUILDING ADDRESS •
TR- 17200 LT: 21 _ 9958 LIVE OAK AV
FEE DESCRIPTION: QUANTITY UOM. AMOUNT TEMP CA 917802613
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET
8588-013-027 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE 597 GRID: A3 LOCALITY TEMPLE CITY, C
41 VENTILATION FAN 1 00 FAN 15 75
TENANT TOTAL FEES 43 50 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON:
08/16/05 JK 02/12/06
OWNER TEL. NO F AL DATE FINAL BY: CODE
HANK, LIN -
9958 LIVE OAK AV _ (�
TEMP 917802613 D'E'SCRIPTION OF WORK
INSTALL ATTIC VENT FAN
APPLICANT TEL NO
LIGHTEN UP SKYLIGHT (562) 500-4532-
5407 FOXTAIL LOOP SPECIAL CONDITIONS:
CARLSBAD, CA 92009
CONTRACTOR- TEL NO APPROVALS DATE INSPECTOR SIGNATURE
LIGHTEN UP SKYLIGHT (562) 500-4532- _
5407 FOXTAIL LOOP LIC NO - - _ FAU WALL FURNACE -- /
CARLSBAD, CA 92009 384768B
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