HomeMy Public PortalAbout5717 LOMA AVE_Mechanical__ WORKERS'COMPENSATION DE-CLARATION
+ 1 hereby affirm that I have a certificafE df consent to self A'PPLICATI®N - F®R PERMIT
insure, or a certificate of Workers' Compensation Insurance, j6A36 .r
4c �`� "'� HEATING - VENTILATING` - AIR CONDITIONING
or a certified copy thereof (Sec. 3800; Lab. C.)
WCP3341C41 Allianz InsurACW(REv. 10 sT)
Policy No. ompany .
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 IN BUILDING
ti on department." (PRINT OR,TYPE.ONLY) ADDRESS 5.717 -Loma Avenue
Date t-Z(L Applicant L. LOCALITY Temple City
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROWORKERS' NEAREST
COMPENSATION INSURA E CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. /'1 PRO SED BY
'(This section need not be completed if the'work involved 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 l'
so as to becomeBOILER, BTU
subject to the Workers'Compensation LOWS. APPROVALS DATE NSP CTOR'S SIGNATURE y
l
COMPRESSOR, BTU' 6 O: btUh ROUGH
Date Applicant ..
NOTICE TO APPLICANT: -if,'after making'this Certificate of VENTILATION SYSTEM,
FINAL t
Exemption, you should become subject to the Workers'. 1
Compensation'provisions of the-Labor Code, you must forth- EVAPORATIVE COOLER VALInATIO114
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU X C,gF�V;TK - -
LICENSED CONTRACTORS DECLARATION -` FLOOR BTU YS ll ll/)lUi UU dj
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED' UNIT
(commencing with Section 7000)'of Division 3 of the Business -WALL '-
and Professions Code,and my license is in full force and effect. �.
License Number 419923Lic. Class C2 V
Y n Date 5-,15-8 9 ®
Contractor KIts
oo 1 e Eng _ o
I am exempt under Sec. U
Plan check fee CL
B.&P.C. for this reason
- PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
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
Professions Code):
❑ I, as owner of the p ro ert or m employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. _
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). .
OWNERneth NI Park. S
❑ I, as Ken
owner of the property, am exclusively contracting fY� `
with licensed contractors to construct.the project (Sec- ADDRESS 5MAIL .717 Loam' Avenue C IT AL 30 = 50
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITYTemCit TEL-NO. CHECK 30.5,11l
City
I hereby affirm that there is a construction lending ple agency for t
the performance of the work for which this permit is issued CONTRACTOR Kobler Engineerinq, Inc . ® CHANGE .00
(Sec. 3097, Civ. C.).
none ADDRESS 56.0.1 :Downey "Road
Lender's Name _ i-000 I) �} /89
CITY Vernon TEL. NO.2 13"5 8 2—7 0 0. _
Lender's Address ti '� - { 1- 3
STATE, LIC. ' 6.O 7 e !! .i
I certify that.I have read this application and state that the LICENSE NO` C
4x9923 CLASS "
above information is correct.1 agree to comply with all County
ordinances and State laws relating to building construction,:
and hereby authorize representatives of this County to enter
upo the above-mention d property for.inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5--15-89
Signature ofplicant or,Agent Date
COUNTY OF LOS ANGELES - TEMPLE CITY # 0508 MECHANICAL'PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0612270007
BUILDING AND SAFETY /LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL. ID: FEES PAID - BUILDING ADDRESS:
TR: 12977 LT: 5 BL: .001 5717 LOMA AV ,
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802453
ASSESSOR INFORMATION NUMBER:, - NEAREST CROSS STREET LAS TUNAS
5387-022-006 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, C
30 AIR INLETS/OUTLETS 3.00 UNI 13.05
TENANT: - 47 ALTER EXIST DUCT SYS 1.00 SYS 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES - 67.80 12/27/06 VG 06/25/07
OWNER: TEL. NO: F NAL DATE FIN B CODE:
TSAI, WEN CHI (62.6) 576-7123- �Q1
5717 LOMA AV vv '-
TEMP 917802453 SCP.I PTION OF WORK
EXTEND DUCT TO ADDITION A 3 OUTLETS
APPLICANT: TEL.-NO: ,
FAN (626) 454-0816-
355 PEACH ST #A SPECIAL CONDITIONS:
MONTEREY PARK 91754 - -
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
WU WU CONSTRUCTION (626) 487-2884-
4518 HORNBROOK.AVE LIC. NO FAU/WALL FURNACE
BALDWIN PARK 91706 864088
"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