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Home My Public Portal About5801-5803-5805 TEMPLE CITY BLVD_Mechanical__ q, p c � � N1 ORKLRS'COMPF NSATION DECLARATION CEA 8518(2-80) �L�� `� ®II rl ®� R �& I hereby affirm that I have a certificate of consent to self PE insure, or a certificate of Workers'Compensation Insurance'or HEATING-VENTILATING-AIR ENTIL.ATING-AIR CONDITIONINC-) a certified copy thereof'(Sec.3800, ab.C.) B Policy No//' q15�C°ompan, �� . N�f t°iy tT COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is hereby furnished. Certified copy Is filed with the county build inspection BUILDING d artme PP � FOR APPLICANT TO r-1 LL IN R i Date S-� Applicant V•p��/��MILLf✓ (PRINT OR TYPE ONLY) ADDRESS � �C_ MVCt FEF LOCALITY -`cp ' 'f- _C� CrRTIFICATL OP EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT F�F COMPENSATION INSURANCE -- NEAREST } (This section need not be completed if the work involved ABSORPTION UNIT, BTU cRoss ST. 1[N .s a0 by the permit is for one hundred dollars ($100) or less.) - ---- DISTRICT NO PROCESSED Y V I certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM— _ /f� permit i% issued, I shall not employ any person in any manner i lJ 0 so as to become subject to the Workers' Compensation Laws. BOILER, BTU-_ _-- _ - -- � APPROVALS DATE INSP TOR' GN UHE tL Date Applicant COMPRESSOR,BTU 3b OUCU ROUGH i N NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z Exemption, you should become subject to the Workers' _ FINAL Compensation provision% of the Labor Code, you must forth- EVAPORATIVE COOLER IiA, nA� ON with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU V Ty I LICENSED CONTRACTORS DECLARATION i I FLOOR BTU_ o� / I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT 9 (commencing with Section 7000)of Division 3 of the Busi- WALL ;21 8 0 3 A ness and Professions Code, and my license is in full force and effect. �7 # 0 0 0 0 0 8 LicenseNumber C/d 31 y Lic.ClassL/ �rJ?v ( 0 o 3 Q 5 0 C� Contr6ctor d yNd 2 Date 7-J-)O'JO ❑ I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Plan Check fee 25%of above. o 0 o30,505 acting in my professional capacity (Section 7051. Bus- F - iness and Professions Code). PERMIT ISSUING FEE$ 0 k 0 4-8 5 Lic.or Reg.No. Date — TOTAL FEE U HOME OWNER-BLIILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that 1 am exempt from- the Contractor's NAME , License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): ADDRESS 5A 03 C Q to-C ❑ I, as owner of the property, will do the work and the CITY 1,, rn TEL. NO. structure is not intended or offered for sale (Section -te , Cf vim— -SS 7044, Business and Professions Code). ` ❑ OWNER SLIM ST Y�'� I, as owner of the property, am exclusively contracting �, with licensed contractors to construct the project MAIL (Section 7044,Business and Professions Code). ADDRESS CITY l TEL.NO. r `' CONSTRUCTION LENDING AG[NC'Y - TeWII„C�_ -C, L� �� I hereby affirm that there is a construction lending agency CONTRACTOR tl /y -1. for the performance of the work for which this permit is �o til x0612 2�(2i 5 1 d L issued Sec.3097,Civ.C.). -- �7l Lender s Name ADDRESS q`13f N I`IytiN• fiA _ Lender's Address CITY ?�nl, i� C.'-� TE L.NO.-1(l{ _�`(3g 1 certify that I have read this application and state that the STATE! !y - LIC. 1 above information is correct.I agree to comply with all County LICENSE NO t7 J 7 J S CLASS C. 3_ ordinances and State laws regulating Heating. Veritilating and Air Conditioning, and hereby authorize representatives of this SRR REVERSE I'UR EXPLANATORY LANCA'AGF. County to enter upon the above-mentioned property for iiZctio p p ose, es r- yS Signature of Permittee Date p ,tea , t10RJ.i.RS'C0MPI'NSAT10N DECLARATION CE-818C(2-80) ��L�O`>�� I®tl�l ®� �L��11�7U0� I nerehs atlirrn that 1 have � certificate of consent to self iat.u,r, ur a� ..Irifiedtc of\\'Ori:ers'Compensation Insura>!Ice,or H EATING-VENTI ATING-AIR CONDITIONING d Certifi,d�Or))ththLGrja�ooff(Sce.3fio0.t,�h.._C/.)/ y II Policy N�/:LA_' `fix lCompany,� Id �L NCIP/y1/V.� Co-rtiried copy is hereby furnished. COUNTY OF LOS ANGELES; BUILDING AND SAFETY -91 Certified copy is filed with the counts building' diction BUILDING UIL ier•artment. FOR APPLICANT TO FILL IN DING �{ j� Date 9��3d`-��Applicant_�� i/ (PRINT OR TYPE ONLY) j ADDRESS 4 131ree CI.Ri!J•1C'AfE Or LXEMPTION FROM WORKERSI, NO. TYPE OF APPLIANCE OR EQUIPMENT FEf1 LOCALITY e!'� COMPENSATION INSURANCE NEAREST } CROSS ST. CL (This section need not be completed if the work involved ABSORPTION UNIT, BTU O by the permit is for one hundrEd dollars ($100) orless.) DISTRICT NO. � PROCESUDAY V I certify thLt in the performance of the work for which this AIR HANDLING UNIT,C'FM )r permit is issued. 1 shall not employ any person in any manner �t so as to become subject to the Workers' Compensation Laws. BOILER,BTU APPROVALS DATE INS CT SSIGNATURE W Date Applicant 1 COMPRESSOR,BTU CL ROUGH PN NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the Workers' FINAL AT I Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALID ISN kith comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUR VI LiC ENSFD CONTRACTORS DECLARATION FLOOR: BTU I harebt affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT r 9 (commencing with Section 7000) of Division 3 of the Busi- WALL J rtes~ and Professions Code, and my license is in full force and V etlel't. 7Q r I L1CenSe Number_ 1037103713� Lic.Class ✓ o 2 5 7 p v ��2 Date�_=30AS. Contractor_ _ ./IJ i I am exempt from the licensing requirements as I am a I # 0 0 0 0 0 8 licensed architect or a registered professional engineer Plan check fee 25%of above. •ecting in tiny professional capacity (Section 7051, Bus- o o 3(1 5 0 incss and Professions Code). 'PERMIT ISSUING FEE$ S� o 0 L.ic.ur Regeg No. 0 Date I TOTAL FEE 3 Q 5 O5 PLAN CHECK APPLICANT HOMF OWNER-BUILDER DECLARATION 0730-85 1 hereby affirm that I am exempt from- the Contractor's NAME License Las, our the following reason (Section 7031.5, Busi- ness and Professions Cod_): ADDRESS UI, as owner of the property, will do the work and the CITY TEL.NO. structure Is not intended or offered for sale (Section 7044, Busines;and Professions Code). ❑ OWNER. AIOAM S e2 I, as Owner of the property, am exclusively contracting with licensed contractors to construct the project MAIL 93 . rJ�� (Section 7044. Business and Professions Code). ADDRESS rIN J CONST RUCTION LENDING AGENCY CITY telt /Ile ()I! 6 TEL.NO.2 C rs-5 I I,rr.h; affirm that there is u construction lending agency CONTRACTOR CV,0VWOeL AC 1^NC fu: the peI[ormanCe of the work for which this permit is issued (Sec. 3097,Civ.C'.). Lenders Name ADDRESS N ' 44 Lender's Adoireas CITY �V �L TEL.NO.L,(ls (� I ter!ify that I have read this application and state that the STATE elo LIC. C3 above information is correct. I agree to comply with all County LICENSE NO. Tv�7 CLASS O ordinances and State lms regulating Heating, Ventilating and Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE. Cour. to enter upon the above-mentioned property for Ination purposes. Signatur.o} I'ermitwe Date