HomeMy Public PortalAbout5543 1/2 SANTA ANITA AVE_Mechanical__ / •% WORKERS'COMPENSATION DECLARATION �—3-31- APPLICATION FOR, PERMIT
I hereb'y.affiim that.l haveta certifh,ate of consent to self
insure,'bar a certificate of Workers'Compensation Insurance, ., 76A3�C y ., H-EATJNG - VENTILATING - AIR CONDITIONING
or g certified copy thereof(Sec. 3800 L b. .) '
CE-818(REV. 10/81)
Pokicy No. +' Compan UA<
COUNTY OF LOS ANGELES BUILDING AND SAFETY
0 Certified copy is hereby furgished,
Certified copy is filed with'the county buil n inspec- FOR APPLICANT TO FILL IN BUILDING G / a ��
'
tion department. ADDRESS %��
/ (PRINT OR TYPE ONLY)
Date/6 b Applicant LOCALITY
�'�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ,
CERTIFICATE OF EXEMPTION FROM O ERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCES BY
the,perniit is for one hundred dollars($100)•or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM n
permit is issued, I shall not employ any person in any manner V
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSP TOR'S SI URE
Date Applicant COMPRESSOR,BTU 96 ROUGH -�
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER d VAL' DATION
with comply with such provisions or this permit shall be e
deemed revoked. FURNACE: FAU GRAVITY
u LICENSED CONTRACTORS DECLARATION ' FLOOR BT
I hereby affirm that I am licensed under provisions of Chapter 9 , HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 9 of the Business - WALL
and.Professions Code,and my license is in full force and effect.
o O
License Number .S�17 Lic. Class
Contractor — -s Date �� 0
❑ 1 am exempt under Sec. Lu
!� Plan check fee H
BAP.C. for this reason' rn
Signatur z
PERMIT ISSUING FEE$ J"
Date:
TL FEE
OWNER-BUIL CLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ►
Law �or 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 C' � z5658A
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS #;0 0 0 0 0 8
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO. I ,0 0 4 4.5 O
1 hereby affirm that there is a construction lending agency for 2
the performance of the work for which this permit is issued CONTRACTOR f �. gJ �n4 ► 0 0 0 41j.5 0(Sec. 3097, Civ. C.). . , A/ Q 5-8 6
ADDRESS G /l! b
Lender's Name q
CITY f a TEL. NO.
Lender's Address STATE JLIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby outh i resentatives of this County,to enter
u n abov io d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature oficv or Agent Date.
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1407100028
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 44319 IT: 1 UN: 13 15543 1/2 SANTA ANITA AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917802912
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
8573-020-054 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY CAI
102 COMPRSR < 100 KBTU 1.00 COM 27.00 1
ITENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY, I
130 AIR INLETS/OUTLETS 10.00 UNI 44.00 107/10/14 SR I
I I TOTAL FEES 125.80 I I
(OWNER: TEL. NO: I I NAL DATE F BY: CODE: I
ICHEN TERESA P (626) 288-8000- I 1 F I
15543.1/2 SANTA ANITA 1
ITEMP 917802912 1 1 DWtlnl?TtOlt OF WORK I
I I (HVAC C/O SAME LOCATION A/C TON, FAD 701C BTU DUCT REPLACEMEI
I I INT (10) I
(APPLICANT: TEL. NO: 1 1 I
IGORMAN, ROBERT (714) 453-1243- 1 I I
122911 SAVI RANCH PKW ISPECIAL CONDITIONS: I
1YORBA LINDA I 1 I
ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
ISERVICE CHAMPIONS HEATING AND AIR (714) 637-0407- 1 1
122911 SAVI RANCH PKW LIC. NO 1 IFAU/WALL FURNACE I I
IYORBA LINDA CA 92887 799170 I ,1 I I
ICOMBUSTION AIR OPENINGS I I I
[ARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I I
1 LIC. NO: I IAC/COMPRESSOR I I I
[ I 1THERMOSTAT 1
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IFIRE DAMPERS
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IREPORT ID: DPR264 ROUTE TO: BS0508 [ I I
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