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Home My Public Portal About4836 RYLAND AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION ;6A364C a9 APPLICATION FOR PERMIT LIME GREEN I herebmit y afflrhat I have a certifibate of consent to self insure, or certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Date ApplicantLOCALITY ' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS ST. (This section need not be completed If the wABSORPTION UNIT,BTU ASSESSORork Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I sfiall not employ'any person in any••manner so as to BOILER,BTU / D become subject to the Workers'Compensation Laws COMPRESSOR,BTU �'J L7 APPROVALS DATE INSPECTOR'S SIGNATURE Date — .pllcan VENTILATION SYSTEM NO CE TO APPLICANT: If, ter r&kinWJAs fortificate of ROUGH Exemption,you should become JIubject to th orkers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU V GRAVITY Q LICENSED CONTRACTORS DECLARATION I FLOOR BTU V 4• VALIDATION I hereby affirm that I em licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and j HEATER: WALL Professions Code,and my license is in full force and effect. License NumberLid.Class Q �� Contra ctor� l� Data 3 ❑ I am exempt under Sec.Plan check fee Ix D B.&P.C.for this reason PERMIT ISSUING FEE$ d C Date: TOTAL FEE > Signature ' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT V� 1 hereby affirm that I am exempt from the Contractor's License Law SAME gaAW Je_ --J—,0 rf-C— , for the following reason(Section 7031.5, Business and Professions Code) ,ADDRESSACCT a AT .❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the 6TYC C, TEL.NO. yeA> 3303 108.90 structure Is not Iritended or offered for sale(Section 7044, 1 ITEMS Business and Professions Code). OWNER TOTAL 1� m � ❑ I, as owner of.the property, am exclusively contracting ,MAIL CHECK 100090 with licensed contractors to construct the project (Sec- ADDRESS CHECK tion 7044,CONSTRUCTION LENDING AGENCY CHA �E ;CITY TEL.NO. 000 I hereby affirm that there is a construction lending a�ency for CONTRACTOR the performance of the work for which this permit s Issued �VtNC A rt nArti (Sec.3097,Civ.C.). `�� i�/a 0000-0001. 10/25/95 ADDRESS / p Lender's Name I a 297 1 pl 7057 CITY ,/�f/ ��(j TEL.NO.��,� � Lender's Address ESTATE i LIC. _ I certify that I have.read this application and state that the above LICENSE NO. CLASS information is correct. I agree to cowith all County ordinances and State laws relating to building rction,and hereby authorize representatives o Co the above-mentioned proper t r i e es. SEE REVERSE FOR EXPLANATORY LANGUAGE , NAT OF AN OR AGENT DATE I COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0108160011 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 17107 LT: 7 4841 RYLAND AV FEE DESCRIPTION: QUANTITY: LION: AMOUNT: TEMP CA 917804034 ASSESSORR: NEAREST CROSS STREET: LOWER AZUSA 8585-010-003 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: B5 LOCALITY: TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 COM 27.00 08 FURNACE/HEATER <100 1.00 UNI 27.00SS . PROCESSED Y: P Y: EXPIRES ON: 30 AIR INLETS/OUTLETS 3.00 UNI 13.05 08/16/01UT 02/12/02 TOTAL FEES 94.80 OWNER: TE 0: FIyAL DAT FINAL Y: CODE: UYEDA NAOMI 4841 RYLAND AV y��Czl TEMP 917804034 DESCRIPTION ADD ROOM OFF OF KITCHEN APPLICANT: TEL. 0: M T C CONSTRUCTION (323) 293-6284- 5318 S. CRENSHAW SPECIAL CONDITIONS: LOS ANGELES, CA � .C \ CONTRACT-OR: TEL. 0: s` �j•-� 1�f \ APPROVALS DATE INSPECTOR SIGNATURE MTC CONSTRUCTION (323) 293-6284- \ 5318 S. CRENSHAW LIC. NO , ', F R LOS ANGELES, CA 91143 7365166 L f' f � �`a COMBUSTION AIR OPENINNACE GS ARCHITECT ORENGINEER: 0: / ' ii �I ,- -�.�� =�� UC WORK LIC. N0:' i /— ---�- I I i - •: AC COMPRESSOR 2 Jj I'.-, j �' �- 1 i! .i fl '�I _:)�� l� FIRE DAMPERS \% �_? k SMOKE DETECTIOWWE S -— -- = --—. COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508 WORKER'S COMPENSATION DECLARATION 2aooasDPW gf89 APPLICATION FOR PERMIT LIME GREEN I hereby,.ff?rm°that I have a certificate of consent to self Insure, 76A36aC or a certificate•of worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.Git Policy No. q Company r" � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. A /l a' Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) Date J Applicant qXJ- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPT FROM WORK NEAREST CROSS 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER.BTU become subject to the Workers'Compensation Laws. F COMPRESSOR,BTU ae�I Date Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE NOTICE TO APPLICANT: If, after king thisCe icate of ROUGH Exemption,you should become subject the Workers'O pensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith com y with such FINAL provisions or this permit shall be deemed revoked. FURNACE. / F U GRAVITY- LICENSED RAVITY VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTU dr I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my license is In full force and effect. G License Number /' Llc.Class if �' ) a Contractor AMA� Dat® � - o ❑ I am exempt under Sec. Plan check fee B.&P.C.for this reason PERMIT ISSUING FEE$ O Date TOTAL FEE 1.70 k/0 W Signature PLAN CHECK APPLICANT U, O BUILDER DEC TION I hereby affirm that I exempt from th ontractor's License Law NAME for the following reason(Section 7031.5, Business and Professions - Code): '-`- ADDRESS F1 I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. ,.N__ structure is not intended or offered for sale(Section 7044, lir Business and Professions Code). OWNER• LT) � f L 0L }i7;int ',94110 . 40 F1 1, as owner of the property, am exclusively contracting MAIL I _ with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). L' i1 CONSTRUCTION LENDING AGENCY CITY TEL.NO. I .dir(i_L. I herebypperformance affirm that there is a construction s permitding is issued for CONTRACTOR the erformance of the work for which this permit Is issued (Sec.3097,Civ.C.). r.•_. .,_, ,. _, ADDRESSJD r13 0 _I�I_i-I• I_�L .'f:: ;+,. Lender's Name CITY �o �� L.NO. Lender's Address STATE IC. I certify that I have read this application and state that the above LICENSE NO. ,?j?.Zb 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 property for i pact on pur ossa. SEE REVERSE FOR EXPLANATORY LANGUAGE I SIGNATURE DrYLICANT OR AGENT DATE