HomeMy Public PortalAbout5946 SULTANA AVE_Mechanical__ WO*E§S'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that•i have,at'certifitate 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
CE-818(REV. 10/81)
Policy No.- Company
Certified copy is hereby furnished. . COUNTY OF LOS ANGELES BUILDING AND SAFETY
F1Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /� �/
tion department. (PRINT OR TYPE ONLY) ADDRESS�7 /. • �let f
Date Applicant LOCALITY r� �f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. L/JI//t-. .S—
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) � /f
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM /
permit is issued,I-shall not employ any on in any nner BOILER,BTU
so as to become subject to the Vyor(cers' nsat' L w APPROVALS DATE INSP,*OR'S SI NATURE
COMPRESSOR,BTU ROUGH y
Dat `�f PP
NOTICE TO APPLICANT: If., after making this Certificate of VENTILATION SYSTEM FINAL v
Exemption, you should become subject to the Workers' Lo
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY }�
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
O
License Number Lic. Class , 1I.7
.0�
Contractor Date
❑ 1 am exempt under Sec. ILU
Plan check fee a.
B.BP.C. for this reason'
Dote:
PERMIT ISSUING FEE$
" � o •
Signature TOTAL FEE
OWNER=BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , z 9 6 3,2 A.
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): # 0 0.0 0 0
❑ l,'as owner of the-property, or my employees with
ADDRESS
wages as their tole compensation,will do the work and CITY TEL. NO. 'O ° 2 Q Jr
the structure is not intended or offered for sale(Section +�
7044, Business and Professions Code). OWNER icy 0 - 20.5020:
❑ I, as owner of the property, am exclusively contractingMAIL r 0 S 1 9 r-8 8
with licensed contractors to construct the project (Sec- ADDRESS `J J .
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY"� �— TEL. NO.
I herebyaffirm that there is a construction.lending agency for
the performance of the work for which this permit is issued CONTRACTOR' ,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name G�
TEL. NO.. �
Lender's Address STATEr LIC.
�
I certify that I have read this application and state that the LICENSE NO. "Y-7, 7V CLASS.
abov tion is correct. I agree t ¢0mply with all County
o nances nd State w relatin building construction,
and her thoriz re,rese ti 4-S of this County to enter
u a 'v me ti f ed p r for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
10
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0709210013
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: i
(LEGAL ID: I FEES PAID I ' BUILDING ADDRESS:
ITR: 5904 UN: .003 I I 5946 SULTANA AV 1
I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917801547 I
(ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET: I
15384-015-003 01 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 I 1
TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 11SSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
I TOTAL FEES 81.75 109/21/07 SR 03/19/08 I
(OWNER: TEL. NO: I IFINAL rrDAT FI Y: CODE: I
ICHUNUDI, TARN (626) 309-0215- I I ��`/^r I
15946 SULTANA AV �/
TEMP 917801547 I ID SCR PTION OF WORK
IC/O FURNACE & A/C UNIT
I
(APPLICANT: TEL. NO:
IARGO (626) 332-8200-
1662 SHOPPER IN #A I ISPECIAL CONDITIONS: I
ICOVINA, CA 91723 1 1 1
I
(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
IARGO CONSTRUCTION SERV. (626) 332-8200- 1 I
1662 SHOPPERS LANE #A LIC. NO IFAU/WALL FURNACE � I
ICOVINA, CA 91723 632879 I 1 �OI
1 I (COMBUSTION AIR OPENINGS I I
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(ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK I I I
LIC. NO: I IAC/COMPRESSOR I b 6 1 I
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I iIREPORT ID: DPR264 ROUTE TO: BS0508 I I I I
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