HomeMy Public PortalAbout5508 SARA MAR LN_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 trereby ayfxm that I have a certificate of consent to self
insure or o copy the of Workers Compensation Insurance 7yA364C HEATING - VENTILATING - AIR CONDITIONING
or aper� ad copy thereof (Sac 3800 Lob C ) CE 818(REV 10/8I) -
Company
Certified copy is hereby furnish d COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
Certified copy is filed with the county building ms FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS oL
S (PRIM OR TYPE ONLY)
Date_Applicant LOCALITY p '
CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST ��
COMPENSATION INSURANCE CROSS ST
(This section need not be completed If the work nwolved by ABSORPTION UNIT BTU DISTRICT NO T PROCESSED By
the permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM / 1
I certify that in the performance of the work for which this JJJ s VV
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVMs DATE INS-1b&s SIGNAT RE
I
Date Applicant COMPRESSOR BTU D 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 'VALIDATJFN
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby off Into 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 Cade,and my license is in full force and effect >
f 1 ? 6
License Number ���1 Lic Classss J C t�(7 - - ;29222A 11.0
�
Contractor 6&AJo2 Date �_2z �6 - , # s s s s s 8 0
El1 am exempt under Sec e -21250 Will
d
Plan check fee
B 8P C for this reason =
Date PERMIT ISSUING FEE $ . . . 2 0 5 05
Signature I TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT 0 322-88
I hereby affirm that I am exempt from the Contractor s License loop
for the following reason (Section 7031 5 Business and NAME '
Professions Code)
❑ I as owner of the property w my employees with ADDRESS
wages as their sale compensation will do the work and CITY TEL NO
the structure Is not Intended or offered for sale(Section
7044 Business and Professions Code)
OWNER 2c
ElI as owner of the property am exclusively contracting v
with licensed contractors to construct the project (Sec MAIL
tion 70" Business and Professions Code) ADDRESS Ne
` CONSTRUCTION LENDING AGENCY Cltt Q O� - TEL NO _ O�
hereby affirm that there Is a construction lending agency for i
the performance of the work for which this permit is issued CONTRACTOR
(sec 3097 Cry C ) d Z •� VN�
Lander s Name ADDRESS 9 £NG/" `
Lender s Address CITY Plkifile •� TEL NO 2$6-,.315
STATE LIC Np c
1 certify that I have read this application and state that the LICENSE NO 0 CLASS CQ 3
above Information is correct I agree to comply with all Count' '
ordinances and State lows relating to budding construction
and hereby authorize representatives of this County to enter "
u�the ave menlldFse rty for Inspection put SEE SEE REVERSE FOR EXPLANATORY LANGUAGE
—A2—y0
519nature of Appl¢oni or Agent Date
•
76 A564 CEO 16- -73
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS 5508 Sara Mar Lane
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY Temple Cit
NEAREST
cROss ST Broadway
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) Mr. and
Mrs. 0. Travis
MAIL
NO TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS 5508 Sara Mar'Lane
CITY Temple City TEL NO jenue
ABSORPTION UNIT, BTU
CONTRACTOR E p
AIR HANDLING UNIT, CFM
AYNE COMPANY
ADDRESS 1661w. Live Oak Av
BOILER, BTU
CITY Arcadia TEL NO 4
COMPRESSOR, BTU STATE LIC
LICENSE NO 120228 CLVENTILATION SYSTEM DISTRICT NO GROup ZONE
EVAPORATIVE COOLER
FURNACE FA V� a� 10 00
l FLOOR BTU U INSPECTION RECORD
HEATER SUSPENDED—
UNIT-WALL y
a-
O
U
O
1--
U
W
L
N
Plan check fee 25- of abo%c See rc%,r, z
PERNIII ISSIIINC FEF S ]e OD
IOIAI FCL' 17 00
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL NO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ;?8 0 2 4 A
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING VENTI- APPROVALS DATEF•Tgl'%Sp T RE
LATING AIR CONDITIONING
ROUGH
HEREBY CERTIFY T T E NOT A TING IN VIOLATION
OF CXOF TER 9 OI VI610N OF THE EU91 NE AND PROFESSIONAL FINAL f1-.30
CODE OF THE STATE IFOR NIA
SIGNATURE PERMIT VALIDATION CK D
OF PERMIT EE
11,2'9- 79
PLAN CHECK VA TI N DK M 0 CASH
BEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE