HomeMy Public PortalAbout5025 RYLAND AVE_Mechanical__ WORKERS' I have a cerci DECLARATION APPLICATION 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
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
�C'-> CE-818(REV. 10/81)
Po'cy No. �`�� Company S�[. i c+N'_ ly,12tdQ/�f
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
tion department. a
��1, (PRINT OR TYPE ONLY) ADDRESS
Date 17-4 Applicant `CGL+.' LOCALITY /Y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST 4�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work Involved by ABSORPTION UNIT,BTU DISTRICT NO PROCE ED
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM )Jr
permit is issued, I shall not employ any person in any manner ✓ v
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPE R'S SIGNATURE
Date Applicant
COMPRESSOR,BTU 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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G V TY
LICENSED CONTRACTORS DECLARATION r FLOOR BTU
1 hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT WALL
(commencing with Section 7000) of Division 3 of the Business �
and Professions Code,and my license is in full force and effect.
License Number /103
2J5 Lic. Class 40
Contractor 1601tll"2 Date 2`J�—�7
-215529A
❑ I am exempt under Sec.
Plan check fee # a a a o a 8
B.&P.C. for this reason PERMIT ISSUING FEE 6 �
Date: 1 a o20,50
Signature g TOTAL FEE a - 20503u:
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ® 0 2 18—&7
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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). J
OWNER
❑ I, as owner of the property,am exclusively contracting /G
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITYTEL. NO. _173
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ONA/DOZ /
(Sec. 3097, Civ. C.). U/v� /vNiN
Lender's Name ADDRESS
CITY —� TEL NO.
Lender's Address
I certifythat I have read this application and state that the STATE 7 LIC.
pp LICENSE NO. O � �J S CLASS
above 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
Z
the above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
���fI�LGY�
Signature of Applicant or Agent Date
P COUNTY OF LOS ANGELES TEMPLE CITY # 0508
MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
M8 0508 1206140019
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID BUILDING ADDRESS:
JTR: 10821 LT: 6 BL: .0015025 RYLAND AV
(FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917804039
ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
8585-008-042 101 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 JISSUED ON: PROCESSED BY: PLAN BY:
130 AIR INLETS/OUTLETS 13.00 UNI 57.20 06/14/12 SR
TOTAL FEES 139.00
OWNER: TEL. NO: IFINAL DATE� FINAL BY: CODE:
5025 RRT YLYLAND�AVB� A (626) 444-1763- i i P�/ - 1 Z
TEMP 917804039 ID SCRIPTION OF WORK V�/
C/0 OF A/C HEAT
APPLICANT: TEL. NO:
lCONTRERAS, CARRA (626) 286-3156-
14831 N. ENCINITA AVE ISPEOIAL CONDITIONS:
(TEMPLE CITY CA 91780
CONTRACTOR: TEL. NO: I I RO ALS TE INSPECTOR SIGNATURE
ICONNOR AIR CONDITIONING AND REFRIG. (626) 286-3157-
14931 NORTH ENCINITA AVENUE LIC. NO FAU/WALL FURNACE
TEMPLE CITY, CA 91780 403735-C20
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: - i JDUCT WORK
LIC. NO: i JAC/COMPRESSOR
(THERMOSTAT
(FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
i• ADDITIONAL DATA ON FILE
REPORT ID: DPR264 ROUTE TO: BS0508