HomeMy Public PortalAbout6214 LOMA AVE_Mechanical__ WORKER;'COMPENSATION DECLARATION APPUCAMN FOR PERNT
I hereby affirm that I have a certificate of consent to'self
Insure, or a certificate of Workers' Compensation Insurance, ' HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800 6 C ) 76A364C
CE-818(REV 10/81)
Policy Certified copy is herebympany urnlshed COUNTY OF LOS AP�IGELES / BUILDING AND SAFETY
J� Certified copy Is filed with the county building Inspec- FOR-APPLICANT TO FILL IN- BUILDING
�"► tion department (PRINT OR TYPE ONLY) ADDRESS (Y!�' (�l1`(�►
Date Applicant LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST '
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NOPROCESSED Y
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 V 0�
permit is Issued, I shall not employ any person in any manner BOILER, BTU d
so as to become subject to the Workers'Compensation Laws APPROVALS DATE INSPECTOR'S SIGNATURE
A �
COMPRESSOR, BTU v a ROUGH
Date Applicant
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 A
with' comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY %G r
LICENSED CONTRACTORS DECLARATION FLOOR BTU < 113(,
/ ? /
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER 'SUSPENDED—UNIT—
(commencing
SUSPENDED UNIT J l0 7�
(commencing with Section 7000) of Division,21 of the Business WALL
and Professions Code,and my license is in full force/and effect d
License Number Y Lic Class V
Contracto Date �
❑ I am exempt under Sec
. Plan check fee �
- N
B&P C for this rea Z
PERMIT ISSUING FEE $ 111, p sO
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 9,3 0 5 1 A
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031 5, Business and NAME # 0 0 0`o
0 t
Professions Code) y
• ❑ ADDRESS ;2 o,- 3 0.50
I, as owner of the property, or my employees with o'eo =
wages as their sole compensation,will do the work and CITY TEL NO 3 0, O U
the structure is not Intended or offered for sale(Section
073 0-84
7044, Business and Professions Code)
OWNERTIl ��
❑ I, as owner of the property, am exclusively contracting MAtL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code) _
CONSTRUCTION LENDING AGENCY CIT TEL NO
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTO �� D
(Sec 3097, Civ C )
ADDRESS, lav �t� ,
Lender's Name
CITY �ii�' • . TEL
Lender's Address STATE /Y�[��' /'/�'� /• _IT
I certify that I have read this application and state that the LICENSE NO✓ �!f bb 72__— CLASS
above In on is corre ag a to comply with all County
ordinan s State la s at g to building construction,
and eby a t r e r e atives of this County to enter
I
upo he ab v roperty for Inspec on p/Drposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Da$
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1108100019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT '
ILEGAL ID FEES PAID BUILDING ADDRESS
ITR 5904 LT 267 1 1 6214 LOMA AV 1
IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917801634 I
(ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET
15384-012-013 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID- H2 LOCALITY TEMPLE CITY, Cl
1 130 AIR INLETS/OUTLETS 1 00 UNI 4 40
ITENANT 141 VENTILATION FAN 1 00 FAN 15.80 (ISSUED ON PROCESSED BY PLAN BY
147 ALTER EXIST DUCT SYS 1 00 SYS 27 00 108/10/11 SR
I 101 PERMIT ISSUANCE FEE 27 80 1 1
1OWNER TEL NO 130 AIR INLETS/OUTLETS 1 00 UNI 4 40 IFINAL DATE FINAL BY CODE 1
IWONG, ALAN - 141 VENTILATION FAN 1 00 FAN 15 80 1 r J,
16214 LOMA AV 147 ALTER EXIST DUCT SYS 1.00 SYS 27 00 1
ITEMP 917801634 I TOTAL FEES 150 00 IDESCRIPTION OF WORK 1
(EXTEND DUCT TO BEDROOM WITH 1 OUTLET AND INSTALL 1 BATH
FAN
1APPLICANT TEL NO
1KWOK, TERENCE (323) 697-2120-
1760 E GARVEY AVE 1 ISPECIAL CONDITIONS 1
IMONTEREY PARK 91755 1 1 I
ICONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE I -
IBEN KWOK CONSTRUCTION CO (626) 922-6181- 1 1 I
1720 HILL PLACE #3 LIC NO 1FAU/WALL FURNACE I '
ILOS ANGELES, CA 90012 591589 B I
I ICOMBUSTION AIR OPENINGS
1ARCHITECT OR ENGINEER TEL NO IDUCT WORK I '
IKWOK, TERENCE (323) 697-2120- 1 1 1
1260 E GARVEY AVE LIC NO 1AC/COMPRESSOR I
IMONTEREY PARK, CA 91755 C24796 1 I I I I
- ITHERMOSTAT I I
IFIRE DAMPERS
I + 1 ISMOKE DETECTION DEVICES 1 1
ICOMMERCIAL HOOD 1
I I I I I I
I I I I I I
I I I I I I
1 I I I I I
I 111 I I I I
I - III I I I I
I I I I I I
IREPORT ID DPR264 ROUTE TO BS0508 I
I I I