HomeMy Public PortalAbout4802 RIO HONDO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION /Ant to self PPLICATION FOR PERMIT
•.�•insutLr,�r afcgrtif cairm rte of Workers'CompensatioI have a certificate of n eInsurane,
76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified cop thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81)
Policy No.oCompany �/ Fu"�
COUNTY OF LOS ANGELES BUILDING AND SAFETY
El Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9%D
❑ N�a
ti'n7 department. (PRINT OR TYPE ONLY) ADDRESS
Date �6-� Applicant 4;e ^��� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
NEAREST / O� V
COMPENSATION INSURANCE CROSS ST.
ICOL
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO ,r'� PROCESSED
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM ` /V
I certify that in the performance of the work for which this J
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE IN CTOR'S SIGN TURE
Date Applicant COMPRESSOR,BTU 6 0 On ROUGH li -�
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
F',cemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID ION
44th comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAURAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU do
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,
and mylicenseis in full force and effect.
License Number G J ��c O Lic. Class ` V-7 �� � � �� O
® �975,4A Im
Contractor&' TOZO Date �! # o 0 0 0 o f O
❑ I am exempt under Sec. 1 ° ° 4 a C C ba
Plan check fee
B.&P.C. for this reason 0 0 0 4 8 " 0
PERMIT ISSUING FEE$
Date: n 6(J'2--
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PAN 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):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). / O ,D
OWNER In
❑ I, as owner of the property, am exclusively contracting MAIL /�
with licensed contractors to construct the project (Sec- ADDRESS Z j 0 6
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY /,,�7 ' TEL. NO.
I hereby affirm that there is a construction lending agency for
M—176
the performance of the work for which thi; permit is issued CONTRACTOR 2 — 20
(Sec. 3097, Civ. C.).
ADDRESS 1630 sz IF
Lender's Name � ^ TEL. NO. �j S 5--3
r
CITY /"W N�dV�
Lender's Address TATE +-� A
I certify that I have read this application and state that the LICENSE NO.'-Z � �•$ C ASS L L/
D ?P0
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and he by auth 'ze rep` entatives of this County to enter
upo a ab ve entione property foyins�ection poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
5 gnature;/Applicant or Agent r//�//ZDate 0 95j
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1007140001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEfiS PAID I BUILDING ADDRESS:
ITR: 16475 LT: 51 I [ 4802 RIO HONDO AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT.1 TEMP CA 917803738
(ASSESSOR INFORMATION NUMBER: IINEAREST CROSS STREET: LOWER AZUSA
18590-025-017 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: JS LOCALITY: TEMPLE CITY, Cl
1 141 VENTILATION FAN 2.00 FAN 31.60 1 1
ITENANT: TOTAL FEES 59.40 ISSUED ON: PROCESSED BY: PLAN BY: [
107/14/10 SR
[OWNER: TEL NO: [ iF DATE FINAL BY: CODE: [
ICHIU, RINGO H (626) 286-6014- I [
14802 RIO HONDO AV IT J�
ITEMP 917803738 1 (DESCRIPTION OF WORK 101
I [ ITWO VENTILATIONS FANS FOR BATHROOMS REMODEL
[APPLICANT: TEL. NO: 1 I [
[SAME AS OWNER
1 (SPECIAL CONDITIONS:
I
I
(CONTRACTOR: TEL. NO: 1 1APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER - I I I
I LIC. NO [ IFAU/WALL FURNACE I I 1
I 1 ]COMBUSTION AIR OPENINGS I I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I [
[\ LIC. NO: I IAC/COMPRESSOR [ I I
1THERMOSTAT 1 [
(FIRE DAMPERS
1 ISMOKE DETECTION DEVICES 1 I
1 1 [COMMERCIAL HOOD 1 1
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1 (REPORT ID: DPR264 ROUTE TO: BS0508 I [ I ]
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