HomeMy Public PortalAbout9937 OLIVE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9789 APPLICATION I=01 PERMIT
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I hakaby affirm that I have a certificate of consent to self Insure, M ("REEN
or a certificatdwf Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR UCONDITIONING
9cgpy- preof(Sec.3800 Lab. .) G L
Policy No! o�Z�� Omp L COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. opr
Certified co is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING
PY Y 9 P ADDRESS
epartmen 'Sd�/��/ � " (PRINT OR TYPE ONLY)
D to `� Applicar4 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER.BTU r
become subject to the Workers'Compensation Laws. / } �a n J• e./ �s�6 L•ct..� ,/
COMPRESSOR,BTU J
. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM �/
NOTICE TO APPLICANT: if, after making this Certificate of ROUGH t�`Z� J
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
/ IUD
License Numb VS17W z LIC.Class G :d
� ACCT.Ja
cdVr � 3� � i�bo71'
❑ I am exempt under Sec. Plan Check fee 1 ITEMS C
B.BP.C.for this reason PERMIT ISSUING FEE$ G1 TOTAL � +, e
Date: TOTAL FEE CHECK 126.74
Signature CHANGE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0�
O
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions J��
Code): ADDRESS VV
❑ I, as owner of the property, or my employees with wages 5754 1 AN 7:57
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CI TEL.NO.
I hereby affirm that there is a construction lending agency for LADDA
the performance of the work for which this permit is issued �s
(Sec.3097,Civ.C.).
Lender's Name TEL.N22130-5J,0 /
Lender's Address STA TELIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS 0
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
prop for speq ia�pur oses. /7—/✓f-"r!Pk SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1301100015
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: FEES PAID I BUILDING ADDRESS: I
ON FILE I 1 9937 OLIVE CT I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917803239
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: BALDWIN
18588-019-014 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY CAI
1 141 VENTILATION FAN 1.00 FAN 15.80 I 1
ITENANT: I TOTAL FEES 43.60 ISSUED ON: PROCESSED BY: PLAN BY:
1 I 101/10/13 SR
(OWNER: TEL. NO: IFINAL PATE FI BY: CODE:
IPAN, SHU (626) 280-9317- I 1 1
19937 OLIVE COURT I I 1
ITEMPLE CITY CA 91780 I ID SCRIPTION OF WORK I
I I (REPLACE ONE VENTILATION FAN
(APPLICANT: TEL. NO: 1 I I
ISAME AS OWNER
I � I (SPECIAL CONDITIONS:
ICONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE I
ISAME AS OWNER - I 1
LIC. NO i IFAU/WALL FURNACE I I I
I I ICOMBUSTION AIR OPENINGS 1
(ARCHITECT OR ENGINEER: TEL. NO: I ]DUCT WORK I I
LIC. NO: i JAC/COMPRESSOR I I I
I I iTHERMOSTAT I 1 I
1 (FIRE DAMPERS
1 I ISMOKE DETECTION DEVICES 1 I I
ICOMMERCIAL HOOD I I I
I I I I I
I I I I 1 I
REPORT ID: DPR264 ROUTE TO: BS0508
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