HomeMy Public PortalAbout5520 PERSIMMON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
}'?'iereby'tffirm that I have a certificate of consent to self
insure,—or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy Ngo. ompany
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 .� c
tion department. ADDRESS �,� Q 4L�d�� (J
/ (PRINT OR TYPE ONLY) ,
Date/a_ APPlicant J,- u-� 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. PR SE BY
the permit is for one hundred dollars(;100)or less.) JC Cy
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ` CJ
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. /y} APPROVALS DATE INSPECTOR'S SIGNATU3E
Date Applicant COMPRESSOR,BTU 0 tl v ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 3
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID TI dN
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY /�/�
LICENSED CONTRACTORS DECLARATION FLOOR BTU (J6
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number 7 SM& Lic. ClassU
poll
Contractor Date,
pe
❑ I am exempt under Sec.
Plan check fee
BAP.C. for this reason fA
PERMIT ISSUING FEE $ 0 ��
Date:
Signature TOTAL FEE Q< d
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
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER (?14m /;v o ;2 1 27.5 A
El1, as owner of the property, am exclusively contracting MAIL
tion 7044, Business and Professions Code). (� d ` f o 0 0 0 0 8
with licensed contractors to construct the project (Sec- ADDRESS zf lJ !4-In J/(1l�! UG
Iaa3Q50
CONSTRUCTION LENDING AGENCY CITYTEL. N / / L/ ��� o 0 0 3 0,5 0 v
1 hereby affirm that there is a construction lending agency for 111--9 6V,11
the performance of the work for which this permit is issued CONTRACTOR-7'- —�`-L yf� �����
(Sec. 3097, Civ. C.). 1 2-07-8 8
Lender's Name ADDRESS
CITY �! C!r TEL. NO�
Lender's AddressSTATE nn
I certify that I have. read this application and state that the LICENSE NO. 14- ��d'� CLASS oma-O
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize re resentatives of this County to enter
upon the above-m nti ed�property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/—)- ct4ioO I
Signature of Applicant or Agent Date �V/
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1007140010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
ITR: 13613 IT: 133 1 [ 5520 PERSIMMON AV I
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917802805 I
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET-
18573-009-013 101 PERMIT ISSUANCE FEE 27.80 J THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 1 1
TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 JISSUED ON: PROCESSED BY: PLAN BY:
I 1 TOTAL FEES 81.80 107/14/10 SR 1
DOWNER: TEL. NO: 1 IFI DrATE FI AL BY: CODE: 1
IYIM, DAVID (626) 941-6222- 1 I '`� I
15520 PERSIMMON AV
TEMP 917802805 [DESCRIPTION OF WORK 1
1 I IREPLACE 80,000 BTU FURNACE & (4) TON A/C, SAME EXISTING
I I [LOCATION 1
[APPLICANT: TEL. NO: I I
IYENULONIS, LAURA (951) 280-3113- 1 I
11225 GRAPHINE DR. I SPECIAL CONDITIONS: J
ICORONA, CA 92881 1 1
I 1 I I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE J
JARS OF CORONA (951) 280-3113- 1 I
11225 GRAPHITE DRIVE LIC. NO [ 1FAU/WALL FURNACE I I
(CORONA, CA 92881 645050 C20 I I I
1 I ICOMBUSTION AIR OPENINGS I I 1
JARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I I
1 LIC. NO: 1 JAC/COMPRESSORI
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1 I IFIRE DAMPERS 1 J 1
1 1 [SMOKE DETECTION DEVICES 1 1 I
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J [REPORT ID: DPR264 ROUTE TO: ES0508 1 1 1 1