HomeMy Public PortalAbout5226 MCCLINTOCK AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of corisenLj;�_ ��.�t
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
I or a certified copy thereof(Sec. 3800,.Lab:C.) : 76A364C
CE-818(REV. 10/81)
policy No. Company
Certified copy is hereby furnished. I COUNTY OF LOS AN /� BUILDING AND SAFETY
Certified copy is filed with the county building.inspec- FOR APPLICANT TO FILL IN BUILDING �• /r
tion department. (PRINT OR TYPE ONLY). ADDRESS V b N L 't
j Date Applicant I LOCALITY �(� LT ••
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST: 1W,44.64, Lw.�nrTe
(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 Y O(� 02 ,�-
permit is issued, I shall not employ any person in any manner BOILER,BTU
'SO as to become subject to the Workers'Compensation Laws.• APPROVALS DATE INSPECTOR'S SIGNATURE
,� COMPRESSOR, BTU RI a �✓ ROUGH
,� <
Date �� D
pplicant di+f W" a"��- N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL L ZI
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI 3AATION
with comply with such'provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY r. y
LICENSED CONTRACTORS DECLARATION FLOOR BTU r too
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 effecti
License Number;Z'16 Lic. Class 6" 2"oUrL L N�e 7> j ► -
t 7 l
Contractor-D.s J [�✓1L s Datell-'3Q F-? O
❑ ._
I am exempt under Sec. �
Plan check fee v-
v,
B.BP.C. for this reason' � �
PERMIT ISSUING FEE- p
Date: 72 U P
TOTAL FEE
Signature 2 a 0 1,q,7
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 04P AL L LO A.40 -/4-X
I hereby affirm that I am exempt from the Contractor's License , a " IL n r,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑. I, as owner of the property, or my employees with ADDRESS 6. bL� T
wages as their-sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section l •i O
7044, Business and Professions Code). OWNER /5 '
El '
I, as owner of the property,am exclusively contracting IL � C'6-J-1-�4e�' _ L
with licensed contractors to construct"the project (Sec- WA-IL --
-tion '
.tion 7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY CITY ✓YL TEL. NO.
I hereby affirm that there is a construction lending agency for _
the performance of the work for which this permit is issued CONTRACTOR ,
(Sec. 3097, Civ:C) B� & :�'w
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. oZq-@ ( 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 r \
n the above-mentioned property for inspection purposes. j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature 0
f A icant or Agent Date
+� + COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
• DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
M8 0508 1209240002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 13384 IT: 14 I ] 5226 MCCLINTOCK AV 1
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:] TEMP CA 917803558
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: FREER I
18574-005-021 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY, Cl
I 102 COMPRSR < 100 KBTU 1.00 COM 27.00 I
TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 81.80 109/24/12 SR
(OWNER: TEL NO: I iFINAL DATE FINAL BY: CODE:
IACOSTA ROBERT W;CATHY M _ I
15226 MCCLINTOCK AV( I �TEMP 917803558 I I� -
ION OF WORK I
IREPLACE 4 TON PACKAGE A/C AND HEATING UNIT ON ROOF I
(APPLICANT: TEL. NO: I
I
IPETTIBONE, MICHAEL A (818) 749-6045- I I
] ISPECIAL CONDITIONS: I
NIP 0�ner YT-�k s. Cc1-1 J526 f R ]
ICONTRACTOR: TEL. NO: I (APPROVALSDATE INSPECTOR SIGNATfJRE
ICALIFORNIA COOLING (818) 749-6045- I I
110965 GLENOAKS BLVD. LIC. NO I JFAU/WALL FURNACE
IPACOIMA, CA 91331 778817 C20 If o Y
ICOMBUSTION AIR OPENINGS I I
(ARCHITECT OR ENGINEER: TEL. NO: I (DUCT WORK ] I
I - I
LIC. NO: i IAC/COMPRESSOR I
ITHERMOSTAT I I
IFIRE DAMPERS ]
ISMOKE DETECTION DEVICES I ] I
(COMMERCIAL HOOD I I I
I ] I I
1 I I I I I
I I I I I I
I I ] I ]
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I IREPORT ID: DPR264 ROUTE TO: BS0508 I— I
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