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Home My Public Portal About5114 PERSIMMON AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self Insure, 78A364C or a certificate of Worker's Compensation Insurance, or a certified copy tof( c3800 LabC.) HEATING-VENTILATING-AIR CONDITIONING . Policy . COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. UILDING XP Certified copy is filed with the coun uil ' inspection FOR APPLICANT TO FILL IN PDDR SS S7/`7r depar�IFICATE (PRINT OR TYPE ONLY) LOCALITY DateApplicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CEF EXEMPTION FROM WORKERS' CROSS ST. 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PRocEseED BY I certify that in the performance of the work for which this permit , is issued, I shall not employ any person in any manner so as to BOILERBTi U d, /y become subject to the Workers'Compensation Laws. , a COMPRESSOR,BT APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH r Q Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply with such EVAPORATIVE COOLER FINAL —ZZ provisions or this permit shall be deemed revoked. FURNACE: FAU G I LICENSED CONTRACTORS DECLARATION AL FLOOR VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and : WALL Professions Code,and m�/y license isIn full force and effect. License Number : r &'2;S o v Lic.Class >0 Contractor Date ® C ❑ I am exempt under sec. Plan check fee C: a B.&P.C.for this reason PERMIT ISSUING FEE$ 13 C Date: TOTAL FEE B-0 C U. Signature PLAN CHECK APPLICANT U. OWNER-BUILDER DECLARATION 6 1 hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason (Section 7031.5, Business and Professions Code): ADDRESS " ❑ 1, as owner of the property, or my employees with wages Hv41c as their sole compensation, will do the work and the CITY TEL.NO. ir _ structure is not intended or offered for sale (Section 7044, :4;_1 , .6-1 Business and Professions Code). OWNER El1,I, as owner of the property, am exclusively contracting L SlLrl-' with licensed contractors to construct the project (Sec- ADDRESSTI.,"�L tion 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued CONTR R (Sec.3097,Civ.C.). ADDRESS (1 I Lender's Name �V _ - CITY TEL. _j"j (LI— j-[-,.L Lender's Address STATE LIC f iC 4, z a L I certify that I have read this application and state that the above LICENSE NO. CLAS information is cor . I agree to comply with all County ordinances and State laws latin to building construction,and hereby authorize representativ of th' County to enter upon the above-mentioned property for' ape n urposes. 1 SEE REVERSE FOR EXPLANATORY LANGUAGE S d's SIGNATURE OF PP T OR AGENT DA COUNTY OF LOS ANGELES TEMPLE CITY N 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0612270004 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE. (626) 285-0488 ERT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 5114 PERSIMMON AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803416 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: FREER 8574-004-050 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, C 02 COMPRSR < 100 KBTU 1.00 COM 27.00 TRUANT: 08 FURNACE/HEATER 4100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN SY: BKPIRES ON: 30 AIR INLETS/OUTLETS 15.00 UNI 65.25 12/27/06 VG 06/25/07 TOTAL FEES 147.00 OWNER: TEL. NO: FI AL DATE FIN CODE: BEDA, BASIS (626) 448-4126- 5114 PERSIMMON AV TEMP 917803416 D CRIPTZO OF WORK INSTALL NEW HVAC APPLICANT: TEL. NO: NGUYEN (626) 674-3014- 1139 GLENVIEW ROAD SPECIAL CONDITIONS: W. COVINA, CA 91791 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE BEDA, BASIS (626) 448-4126- 5114 PERSIMMON AVE. LIC. NO FAU WALL FURNACE TEMPLE CITY, CA 91780 NONE COMBUSTION AIR OPENINGS ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK TAGUDAR, FRED (626) 674-3014- 1139 GLENVIEW RD. LIC. NO: AC/COMPRESSOR WEST COVINA, CA 91790 C33612 THERMOSTAT FIRE DAMPERS SMOKE DETECTION DEVICES COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508