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Home My Public Portal About10212 NADINE ST_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT � I hereby affirm that I have a cgrtificatebf consent to self Insure or a certificate of Workers Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof(Sec 3800 Lab�lC) CE 81 C Policy No 7l 7��•E�ompany TNl�-d �PS� � 818(REV 10/81) 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 �^ tion department ADDRESS Q c� � (PRINT OR TYPE ONLY) � /1/ Dare �O— �T 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 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 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 / Date Applicant COMPRESSOR BTU 3 h ��' ROUGH NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL .3�� Exemption you should become subject to the Workers 71 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_ZAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU o I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code and my license Is in full f rce and effect d S�032 S Lic c sus g�c�01� v License Number , 009 Contractor Date ' id am exempt under Sec J W Plan check fee B 8P C for this reason d Date PERMIT ISSUING FEE; Z 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 property or my employees with ADDRESS ;_92855A wages as their sole compensation will do the work and the structure is not Intended or offered for sale(Section CITY TEL NO 4,0 • • s s $ 7044 Business and Professions Code) OWNER `p rl e c lee te 2 -;- 3050 Elas owner of the property am exclusively contracting with licensed contractors to construct the project (Sec MAIL 1,0.21d- y - °�,°7 2 3 0 5 0 czt tion 7044 Business and Professions Code) ADDRESS q'7 —8(( CONSTRUCTION LENDING AGENCY CITY 7e �'� �F 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 d /Zr (Sec 3097 Civ C) Lender s Name ADDRESS Z19 3 /� ��C N! , � Lender s Address CITY TA /r 671 TEL NO �ysa y _ 4C 3 It I certifythat I have read this application and state that the STATE LIC pp LICENSE NO 0�� CLASS.S'c sC- '11V I above Information is correct I agree to comply with all County ordinances and State jaws relating to building construction and hereby authorize representatives of this County to enter up the above mens oned properiv for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE S,gnatur of Applicant or Agent Date t COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0309230001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285 0488 EXT LEGAL 10 FEES PAID BUILDING ADDRESS TR 15862 LT 25 10212 NADINE ST FEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802727 Irsomem I FORMATION NUMBER NEAREST CROSS STREET ARDEN 8586 026 014 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID B3 LOCALITY TEMPLE CITY 30 AIR INLETS/OUTLETS 4 00 UNI 17 40 TENANT TOTAL FEES 45 15 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON 09/23/03 JK 03/21/04 OWNER TEL NO LLUAL DATE FINAL BY CODE GUGAJEW ROBERT & PAULINE (626) 447 1288 �j•-(� C. 10212 NADINE ST TEMPLE CITY 91780 bESCRIPTMWZ ADD 4 REGISTERS APPLICANT TEL NO SAME AS OWNER SPECIAL CONDITIONS CONrRACTOR TEL Nr- APPROVALS DATE INSP 5 P�GELES CQ SAME AS OWNER LIC NO FAU/WALL FURNACE XCOMBUSTION AIWIMMUNW ARCIITECT OR ENGINEER TEL NO DUCT WORK LIC N !� J/Ji THERMOSTAT lllliil �PUBUC WORK KSFIRE DAMPERS O D 0 o u 46��c oc 8e-rvice TMk� REPORT ID DPR264 ROUTE TO SS0508