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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0206210022
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5904 LT: 182 6167 SULTANA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801552
ASSESSOR NFORMATION UMBER: NEAREST CROSS STREET: LONGDEN
5384-006-019 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TEWA-N-f 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED 0PROCESSED BY: PLAN B : EXPIRES ON:
TOTAL FEES 81.75 06/21/02 JK 12/18/02
OWNER: TEL. NO: FINAL TE FI L BY: CODE:
ONG•GINA AND ALICIA ARRIZON (626) 286-1379- �U Z
60 SULTANA AV
TEMP 917801552 --1-10 OF WORK
C/O HVAC
APPLICANT: TEL. NO:
CONNOR A/C (626) 286-3157-
4931 ENCINITA AVENUE SPECIAL CONDITIONS:
TEMPLE CITY 91780
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
CONNOR AIR CONDITIONING (626) 286-3157-
4931 ENCINITA AVE LIC. NO FAU7WALL FURNACE
TEMPLE CITY, CA 91780 403735 C20
COMBUSTION AIR OPENINGS
ARCHITECTOR ENGINEER: TEL. NO: DUCT WORK
LIC. NO: AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETEEMOY-D-971-C-E-S
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508
I,d' .VV(�RKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
1'her�by'affkeh chat I have a certificate of consent to self
�I-nsurp-orig cam► icate.of Workers'Compensation Insurance, 76A3baC HEATING - VENTILATING - AIR CONDITIONING
or a corfif�ted co y Ilie�eof(Sec. 3800 Lab. C.) �+ CE-818(REV. 10/81)
Policy.'N�Compan .__ 1 �17
F-1Certified,.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. ADDRESS '
(PRINT OR TYPE ONLY)
Date +A licant�� maJA. • LOCALITY
pp F-T - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. ,
ABSORPTION UNIT, BTU , PR CE BY
(This section need not be completed if the work involved by DISTRICT NO;I I
the permit is for one hundred dollars(;100)or less.)- L
AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this I �Q
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU J 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 VALIDATION
with comply with 'such provisions or this permit shall be
deemed revoked. FURNACE: FAU -SOP-GRAVITY `U
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. `
License Number AM-541Z Lic. Class ad V
IM
Contractojsl�'dNi�G�� ��ate 9-1(. $Co O
❑ b
I am exempt under Sec. LU
Plan check fee IL
B.&P.C. for this reason' upup
PERMIT ISSUING FEE$ 10,50
te:
Sign r TOTAL FEE86
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm:that I am exempt from the Contractor's License
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). OWNER ;15 4 4.6 A
❑ I, as owner of the property, am exclusively contracting i
with licensed contractors to construct the project (Sec-. MAIL MAILADDRESS Q A• # a o 0.0 0 8
tion 7044, Business and Professions Code). I'
CONSTRUCTION LENDING AGENCY CITY (�•
TEL.NO.� ej 1 - 3650
I hereby affirm that there is a construction lending agency for .I
the performance of the work for which this permit is issued I CONTRACTCO � I o - 36500'
(Sec. 3097, Civ. C.).
ADDRESSZ.O+' .�• �� A 0 9 16-4-86
Lender's Name
TEL. NO.
Lender's Address
S 4 TATE I CLASS
LIC
I certify that I have read this application and state that the LICENSE NO. Z
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby outh ize representatives of this County to enter
upon above i proper y for inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE
q -A
Signature of Applicant or gent Date