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Home My Public Portal About9121 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION certificate of consent to 7GA348DPW9/89 APPLICATION FOR PERMIT LIME GREEN I hereby�affirm Ihat i have a certificate of consent to self insure, 76A364C or @ c6rtlfidatA of Worker':£Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Pollak No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN BUILDING 9 ^ y t,�6 Certified copy is filed with the county building inspection PRINT OR TYPE ONLY) ADDRESS 1 .G !�Y'+ department. ( � T Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST YYV PL� G J 11 CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS SST. m COMPENSATION INSURANCE ABSORPTION UNIT,BTU _ ASSESSO (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 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 become subject to the Workers'Compensation Laws. � COMPRESSOR,BTU APPROVALS DATE INSP R'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL �L provisions or this permit shall be deemed revoked. FURNACE: FAU RTY 1 LICENSED CONTRACTORS DECLARATION FLOOR BTU �— J VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED--- UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. 100, License Number Lic.Class a , > JL8 Contractor Date ACC °a C ❑ I am exempt under Sec. Plan Check fee 3307 109.55 p( B.&P.C.for this reason PERMIT ISSUING FEEt Ll 76— 1 ITEM k Date: TOTAL FEE ��— TOTAL. 109 .55 ia 1 Signature PLAN CHECK APPLICANT CHECK 109.55 Cr OWNER-BUILDER DECLARATION A 1 hereby affirm that 1 am exempt from the Contractor's License Law NAME 1 1 ' CHANGE ' I[l for the following reason(Section,7031.5, Business and Professions i t Code): ADDRESS lJ� I?, :�,� � , I, as owner of the property, or my employees with wages RR 10/29/x2 as their sole compensation, will do the work and the CITY TEL.NO. a �r structure is not intended or offered for sale (Section 7044, 1_� 1 Ct 6247 Aft 9t 1.01 Business and Professions Code). OWNER L/L L J ❑ 1, as owner of the property, am exclusively contracting ,\ with licensed contractors to construct the project (Sec- ADDRESS tion 7044,CONSTRUCTION LENDING AGENCY CITY JJ' \� TEL.NO. 1� I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permitAs issued (Sec.is ADDRESS Ctv.C.). � Lender's Name CITY TEL.NO. Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. CLASS 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 roperty for ins o r se . SEE REVERSE FOR EXPLANATORY LANGUAGE i a�-��. SIGNATURE APPLICA R AGENT DATE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 9702180017 f BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE: (818) 285-0488 EXT: -LEGALID: FEES-PAID L G ADDRESS: TR: 11218 LT: 14 BL: B 9121 RANCHO REAL RD FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803033 ASSESSOR 0 T 0 UMBER: NEAREST CROSS STREET: LOMA 5388-002-014 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 COM 27.00 TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: P RES ON: 30 AIR INLETS/OUTLETS 6.00 UNI 26.10 02/18/97 TC 02/18/98 TOTAL FEES 107.85 OWNER: TEL. N0: FINAL DA FINAL BY: C ZULESKI MARK A;MARGARET R (818) 286-6126- 9121 RANCHO REAL RD 1 TEMP 917803033 SCR P 0 0 0 SECONDARY HEATING AND AIR SYSTEM EW ADDITION APPLICANT: E O: SAME AS OWNER �� ' ®,y SPECIAL CONDITIONS: 101 4 CONTRACTOR: EL. N0: d��f l' , r�� \� APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER j , ; a LIC. NO y n / ��+% !FAU/WALL FURNACE COMBUSTION AIW OPENINGS ARCHITECT-OR ENGINEER: TEL. NO: �_j IDUCT WORK LIC. NO: �' ;I AC/COMPRESSOR 171 THERMOSTAT FrIRE DAMPERS Nyh; - ✓• �✓ �.� SW 0 METION DEVICES COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508