HomeMy Public PortalAbout5638 MCCULLOCH AVE_Mechanical__ WORKERS'CC;` "NSA'TIONDECLAR•�TIOI1t-ti' _ °'4 APPLICATION FOR PERMIT
I rre y-•Etfirm tlirtl�I rave a certificate of consent to self i
In are, or a certificate oftWorkers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
a certified copy thereof(Sec. 3800, Lab: C.) 76A364C
CE-818(REV. 10/81)
`f 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 p
tion department.., (PRINT OR TYPE ONLY) ADDRESS C�
Date ,Applicant 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 BV
the permit is for one hundred dollars(;100)or less.)
AIR HANDLING UNIT,CFM VU
I certify that in,the performance of the work for which this
permit Is issued, I shall not employ'any person in any manner
So as to become subject to the Workers'Compensation LOWS. IBOILER,BTU APPROVALS DATE INS R'S SIG��N��TTUrURE
D —�� 1, COMPRESSOR, BTU e���0 l ROUGH _ J i 'r/ GC�v.
� PP tc9.,� _
IVOTICE,TO APPLICANT.' If, after making this Certificate of VENTILATION SYSTEM FINAL �
Exemption, you should become subject to the Workers'
Compehsation'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
withcomply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU 9YITYf�
�1 LICENSED CONTRACTORS DECLARATION FLOOR BT C/
1 I hereby affirm that I'am,licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
1(commencing',with Section 7d00)of Division 3 of the Business WALL
and Professlon"s!Code,anifmy license is in full force and effect.
r
License Num ; 1 I Lic. Class ,
y ritr Date ^ 99 17 0
I am exempt and . Sec. W
I Plan check fee o.
B.&P.C. for this reason' \1 I �
1' + �'\ I • PERMIT ISSUING FEE$
ti Date:
• Si nature 1 A TOTAL FEE
1 g
�,- :,,OWNER-BUILDER D�C RATION PLAN CHECK APPLICANT.
+l hereb�y affirm that I am exempt fept .the Contractor's License 0-03050
1 `Law`fo'Tthe following reason (Section 7031.5, Business and NAME
Prgfessions Code): , �� "� ' , 3Q5030:
as�'wner of the:property, o`rr my employees with ADDRESS
`% \
wages a's their sole copensation,L�illldo'the work and 7
9,87
N the structure is not intended or offered for sale Section CITY TEL. NO. 0
V ti 7.044; Business and,Professions Code).
I °(' ( •; 111 OWNER
' I,"s owner of the-prbperty,am exclusively contracting
wi s"licensed contractors to construct the project (Sec- MAIL
tio�''7044, Business and Professions Code). •, ADDRESS
I,1 t / CONSTRUCTION\LENDING AGENCY: '}� CITY TEL. NO.
�II her4i, affirm that,there'is a construction lending agency for ,
e performance oft re work f&,which this permit is issued CONTRACTO
ec:3097 Civ. C.).,
' ( ADDRES
Lender's Named �®
Lender's C TY TEL_e 91
Address
17
STATE L1
I certify that I have read this application and state that the LICENSE N C5
49S _ 2.�
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 th a ave-m ntioneerty for inspecgtioh purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7—/ � �/
t
Signature of Applicant or Agent Date
A 1
� a
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1009140021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
[LEGAL ID: I FEES PAID BUILDING ADDRESS: I
ITR: 44413 LT: 1 UN: 6 5638 MCCULLOCH AV [
[FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802960
(ASSESSOR INFORMATION NUMBER: [ I
NEAREST CROSS STREET:
[8573-013-056 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, Cl
I[ 102 COMPRSR < 100 KBTU 1.00 COM 27.00 TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 81.80 109/14/10 SR
IDWNER: TSL. N0: I [FINAL DATE F BY: CODE: [
IHSU, DAN (626)1617-7113- [5638 MCCULLOCH AV I ,
TEMP 917802960 I
JIMSCRIPTIO14 OF WORK
(REPLACE EXISTING FURNACE, COIL & CONDENSER NO NEW DUCTS
[APPLICANT: TEL. NO: it
[MARTINEZ, FELICIA (626) 286-3157- [ [
14931 N. ENCINTA AVE. i [SPECIAL CONDITIONS: [
ITEMPLE CITY CA 91780 I
[ I
[CONTRACTOR: TEL. NO: [ [APPROVALS DATE INSPECTOR SIGNATURE
ICONNOR AIR CONDITIONING (626) 286-3157- 1I
14931 ENCINITA AVE LIC. NOI IFAU/WALL FURNACE r{
ITEMPLE CITY, CA 91780 403735 C2O �I1
( xvy
COMBUSTION AIR OPENINGS
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(ARCHITECT OR ENGINEER: TEL. NO: I DUCT WORK I [ I
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LIC. NO: I IAC/COMPRESSOR I I
I (THERMOSTAT I I
I I (FIRE DAMPERS [ I
ISMOKE DETECTION DEVICES I I I
(COMMERCIAL HOOD I I I
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[REPORT ID: DPR264 ROUTE T0: BS0508
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