HomeMy Public PortalAbout9651 LAS TUNAS DR_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
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r•.I lTereby 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, 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 IN BUILDING on--�� � C
tion department. ADDRESS i t7 �-
^ (PRINT OR TYPE ONLY)
Date Applicant,T;^�'r' �lyr'� LOCALITY "~� \
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(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
1 certify that in the performance of the work for which this lll//J VVV
permit is issued, I shall not employ any person in any manner BTU
so as to become subject to the Workers'Compensation Laws. BOILER, APPROVALS DATE I J E OR'S SIGNATURE
Date Applicants COMPRESSOR,BTU ��'2 0 19 74 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 4
Exemption, you should become 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: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 At WALL
and Professions Code,and my license is in full force and effect. a.
License Number `� Lic. Class 1 t'
Contractor I ape... ry Date
,_� ► 0
❑ I am exempt under Sec. w
Plan check fee a.
44
B.BP.C. for this reason' �
Date: PERMIT ISSUING FEE$ to 10
Signature' TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 2 a b 6 C A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ® + 0 0 0 0 0 8
Professions Code):
El1, as 'owner of the property, or my employees with ADDRESS I I ° ° 3- 1.06
wages as their sole compensation,will do the work and x
g p CITY TEL. NO. ° ° ° 31,U Q
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). I OWNER �,� 12.21 4—8 7
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to-construct the project (Sec- MAIL
ADDRESSV��_
r ��Lv�•- )
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.`f '
I hereby affirm that there is a cons.truction lending agency for 51
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name n�
CITY LY/�C TEL. NO.tyLl�e�-
Lender's Address
STATE �•7r LIC.
I certify that I have read this application and state that the LICENSE NO. CO's 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
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 rM CIANI.CAL .PERM3.1..'�f
• DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS i _N�0�8' 9801.090. 0
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
L I : E - Q
TR: 6561 LT: 138 1:9651: LAS'.TUNAS 183 -�
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP-�1F-1 "02'f03
ASSESSOR OR NUMBER: NEAREST CROSS STREET:
8587-020-021 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 2.00 UNI 8.70 01/12/98 UT 01/12/99
TOTAL FEES 90.45
OWNER: TEL. NO: FINAL DATE FINAL BY CODE:
SCURTO, PETE N. (818) 289-6543- � l /
-41
TEMP 917800012 }A@ AMNO AIR C!b OND W LON LN 9NL. IP�@Q E1[
APPLICANT: EL. .
SAME AS OWNER -
-� --! SPECIAL CONDIT ONS:
CONTRACTOR: TEL. N0: r' :i� �?� �r�°:` .':. APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER - '•.t
LIC. NO d�/' e { \` FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARC C R NGINE R: E 0: - +' 'I r ; (! ��__--r' DUCT,WORK
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J THERMOSTAT
I' FIRE DAMPERS
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SMOK9 DETECTION DEVICES
COMMERCIAL HOOD
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REPORT ID: DPR264 ROUTE TO: SS0508