HomeMy Public PortalAbout5717 RIO HONDO AVE_Mechanical__ ' WORKERS' COMPENSATION DECLARATION .APPUCATI®N FOR PERMIT
I•hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING . VENTILATING . AIR CONDITIONING
irr a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
V q0-0046 DPW 9/88
Policy!lo.—Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑- Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY L-6 ��
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -FeM
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST I �1��
COMPENSATION INSURANCE CROSS ST. (✓lam 0 F--
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT N PR ED By
the permit Is for one hundred dollars($100) or less.) f/
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM o
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�q APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU �o"°1� ROUGH "
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED 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 Lic. Class ® O
U
Contractor Date tY
❑ I am exempt under Sec. V
Plan check fee u,
B.BP.C. for this reason CL
PERMIT ISSUING FEE $ /n
/ H
Date: TOTAL FEE z
Signature
ED
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 VP
Professions Code): AC
I, as owner of the property, or my employees with ADDRESS AtlCCL
wages as their sole compensation,will do the work and CITY 1
TEL. NO. 3307 y.1 5ij
the structure is not intended or offered for sale(Section i "'
7044, Business and Professions Code). OWNER ITEM
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL TOI FAL 41 !To
tion 7044, Business and Professions Code). ADDRESS _ r
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 4'1.50
1 hereby affirm that there is a construction lending agency for ® Chlr^NVE o f
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS COM-0001 1C0i23-lH
CITY TEL. NO. -a
Lender's Address'°rW 44
I certify that I have read this application and state that the S ATE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and here -ut ize representatives of this County to enter
upon the entioned property for inspeption p rposes.
10/2-13SEE REVERSE FOR EXPLANATORY LANGUAGE
/91
Signat a of Appl ant or Agent Date
COUNTY OF IAS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1212110010
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS:
ITR: 6561 LT: 1 BL: .001 II 5717 RIO HONDO AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802433
]ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-003-019 101 PERMIT ISSUANCE FEE 27.80 ] THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY Cl
I 108 FURNACE/HEATER <100 1.00 UNI 27.00 [ I
ITENANT: 130 AIR INLETS/OUTLETS 2.00 UNI 8.80 (ISSUED ON: PROCESSED BY: PLAN BY: ]
I 141 VENTILATION FAN 1.00 FAN 15.80 12/11/12 SR
I TOTAL FEES 79.40
(OWNER: TEL. NO: I [FINAL DATE FIrJAL BY: CODE: I
]AYE AYE MAW _
15717 RIO HONDO AVE I 1 1
ITEMPLE CITY 91780 ' 1 I SCD SCn-SON OF WORK
ADD ONE HEATER, 2 AIR INLETS AND 1 VENTILATION FAN
(APPLICANT: TEL. NO: [ I
ISAME AS OWNER -
I i SPECIAL CONDITIONS:
I 1
ICONTRACTOR:
TEL. N0: [ ]APPROVALS DATE INSPECTOR SIGNATURE ]
ISAME AS OWNER _ I I
LIC. NO i IFAU/WALL FURNACE
I I I
1COMBUSTION AIR OPENINGS I ]
ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK [ I ]
I -
LIC. NO: i JAC/COMPRESSOR ] ]
(THERMOSTAT
IFIRE DAMPERS ] I
ISMOKE DETECTION DEVICES
ICOMMERCTAL HOOD I I I
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IREPORT ID: DPR264 ROUTE TO: BS0508 I I I I
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