The URL can be used to link to this page

Home My Public Portal About5928-5934 TEMPLE CITY BLVD_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364C PW 9/89 APPLICATION FOR PERMIT LIME GREEN I hereby affirm that 1 have a certificate of consent to self insure, or a certifivate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING Athereof(Sec.3800 Lab.C.) Poll�cy No.0<1d-Z-Z_- Company � If�� b g ❑ NTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. /Certified copy is hereby furnished. / 2_ Certified copy is filed with the count building inspection FOR APPLICANT TO FILL IN ADDRESS �q �/ UILDING department. (� (PRINT OR TYPE ONLY) 7 , „M e Date !"/ r Applicant N e J GZ le A LOCALITY M ff, NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU OR (This section need not be completed If the work Involved by the MAP OOK PAGE PARCEL permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PR OC ED BY I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to BOILER.BTU become subject to the Workers'Compensation Laws. 121 l�rlCl- COMPRESSOR,BTU COry tO° l APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU G VITY !, LICENSED CONTRACTORS DECLARATION ® FLOOR BTU 2� f*1 ✓ �J VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and my lice se is in full force and eff t. 1 c1�'b L%-Sc 0 a a�f32ry x le f� l<1C.'&e�� License Number / � 7-- G 0 Lic.Class O /S�f• �� r� J , A Z` .-U 2 1" `r0 C, chi ont a or � `� Date � �a" /� C F1 Plan check fee I am exempt under Sec. � B.&P.C.for this reason PERMIT ISSUING FEE$ 7n C Date: TOTAL FEE Signature U OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law NAME 11110. - for the following reason(Section 7031.5, Business and Professions .. • r Code): ADDRESS El 1, as owner of the property, or my employees with wages :-1:" 11L�X11 as their sole compensation, will do the work and the CITY TEL.NO. _ structure is not intended or offered for sale (Section 7044, _ , ; _, Business and Professions Code). OWNER _ 1, as owner of the property, am exclusively contracting MAIL - with licensed contractors to construct the project (Sec- ADDRESS Z� 1 tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY 0,0 44 TEL.NO. R-1- �L �'• I hereby affirm that there Is a construction lending agency for ONTRACTOR t , the performance of the work for which this permit Is issued N L �NG (Sec.3097,Civ.C.). 3'r_ ADDRESS Z4g) lzoCep 'elo T Lender's Name �� 7 ` CITY P&A�O�o N�- 7 TEL.NO. /`-� Lender's Address STATE /� LIC. I certify that I have read this application and state that the above LICENSE NO. , CLASS C Zp information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatives of this 9punty to enter upon the above-mentioned property for inspectio ur-poses. SEE REVERSE FOR EXPLANATORY LANGUAGE SIG QS wNATUREFA ONT OR AGENT DATE + COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0208120017 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 6561 LT: 192 BL: .001 5928 TEMPLE CITY BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802010 ASSESSORR R: NEAREST CROSS STREET: LAS TUNAS 8587-019-026 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 CON 27.00 TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED 0 PROCESSED B P EXPIRES LOCK, STOCK & BARREL 30 AIR INLETS/OUTLETS 10.00 UNI 43.50 08/12/02 JK 02/08/03 . TOTAL FEES 125.25 OWNER: TEL. NO: FINAL DATE FINAL CODE: MAHAFEY HERBERT L;JOANNE K TRUSTEES2- 2120 LOUISE AVE -- ARCADIA 91006 DESCRIPTI9N OF WORK NEW STON PACKAGE HEAT PUMP P G L KAPLAN CONSTRUCTION CO (626) 443-2662- 1702 CHICO AVENUE _ SPECIAL CONDITIONS: SOUTH EL MONTE 91733 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE G L KAPLAN CONSTRUCTION CO. (626) 443-2662- t:/ .�a-'�' a'•' 1702 CHICO AVE. LIC. NO ,°;;•� :� Ff�''s / ALL FURNACE SO. EL MONTE, CA. 91733 272360 B :• j ' ` COMBUSTION AIR OPENINGS ARCHITECT OR O: C R LIC. N0 - AC/COMPRESSOR THERMOSTAT FIRE DAMPERS a - — - ---- - r COMMERCIAL HOOD REPORT ID: OPR264 ROUTE TO: SS0508