HomeMy Public PortalAbout6349 TEMPLE CITY BLVD_Mechanical__ WORKERS COMPLNSATION DECLARATION 7BA364C APPLICATION FOR PERMIT
1 hereby affirm That I have a certificate of consent to self CE 818 (2 80)
insure, Or a certificate of Workers Compensation Insurance or HEATING-VENTILATING-AIR CONDITIONING
ace 0G��pd''c)�op) th re�Sec 3800 Lab C)
PW.i 14�6'�1 nmpany'fi�ON2ALL1 I4• COUNTY OF LOS ANGELES 7
CeBUILDING AND SAF T •�gN
❑
Certified copy is hereby furnished
Certified enp) Is filed with the county budding inspection FOR APPLICANT TO FILL IN
ADDRESS BUILDING
dpar
mi. r 4 9 gip_ 1.1 PL
Date Applicant ��p 1. A 6 (PRINT OR TYPE ONLY)
LOCALITY
CERTII KATE OF FXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE / i
COMPENSATION INSURANCE NEAREST
(This section deed not be completed if the work involved ABSORPTION UNIT BTU----F—
TU CROSS ST d
by the Permit is for One hundred dollars (SI00) Or IM) DISTRICT NO PROCESSEf 3y
1 certifythat in the AIR HANDLING UNIT CFM—
permit
pc rformance Of the cork for whish this
permit Is Issued I shall not emplo) any person in any manner O
so as to become subject to the Workers Compensation Laws BOILER BTU
-�`-1 1l'v APPROVALS DATE INSPECTOR SSIGN PTURF
Dale Applicant COMPRESSOR BTU_Z?.= Alf sX,/ W
ROUGH ��,-,3/' (r•CG-s,M+'rJ
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation prosisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall he
deemed revoked FURNACE FAU x GRAVITY_ _
LICb NSED CONTRACTORS DECLARATION FLOOR BTU_160/00L�— �O
I hereby affirm that I am licensed under Provisions of Chapter HEATER SUSPENDED UNIT �yJL ir, �•L(r/•
9 (commencing with Section 7000) of Division 3 of the Bust WALL
n"S and Professions Code and my hcense is In full force and �1 p�
effect gg�/��sveeap / A
License Number.3—z4o21_ Lic Class.
ContvactorbUA JAt-.A_ Date-i-GI -81
❑ 1 am exempt from the licensing requiremenu as 1 am a
licensed architect or a registered professional engineer Plan check fee 25% Of above
acting in my professional capacity (Section 7051 Bus
iness and Professions Code) PERMIT ISSUING FEE $
Lic or Reg No Date I TOTAL FEE GO
HOME OWNLR BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractors NAME �.3 7 Q 7 R
license Law for the following reason (Section 7031 5 Bust
nets and Professions Code) ADDRESS i. . . 41
❑ 1 as owner of the property will do the work and the i
gructure is not Intended or offered for sale (Section CITY TEL NO 2 — 2700
7044 Business and Professions Code)
❑ OWNER 11\ ytiE�flC��, Co• . . . 27006
1 as o [mg
wner of the property ora exclusively co ntrac
with licensed contractors to construct the project MAIL .��`` �A�� ���typ pp��
(Section 7044 Busmess and Professions Code) ADDRESS W-6. 51^k_171Ljev\{,Z oLrr Q '2-8 1
CONSTRUCTION LLNDING AGENCY CITY ..1_ ��L TEL NO .'(SX -9:02'
1 hereby affirm that there is a construction lending agency KV 1 �+ r 1,/
for the performance of the work for which this permit is CONTRACTORoxZIA NRS- 1t
issued (Sec 3097 Civ C) '-i-eS
Lender s Name ADDRESS
ZO23 (2pJTVAL
Lender s Address ,rte
CITY ty MON•r TEL NO 44:6-4,q'1 _
I cunt) that I have read this application and state that the STATE 3 '^ L'
abose irmation it c rect I agree to comply with nil Count) I ENSE NO Z�J CLASS Lv
ordm nc t and Star iws regulating Heating Ventilating and
Air i ni mg ai hueb) authonre representulnes of this SEE REVERSE I OR LXPLANATORY LANGUAGE
Col r y t nter on the above mentioned property for
ct on
Signature of Permute Date
COUNTY OF IAS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC PARKS 9701 LAS TUNAS ME 0508 0908100015
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
I
LEGAL ID FEES PAID BUILDING ADDRESS
ITR 35584 ON 2 6349 TEMPLE CITY BL
FEE DESCRIPTION QUANTITY UGM AMOUNT TEMP CA 917801455
1AS5ES50R INFORMATION NUMBER I NEAREST CROSS STREET
15382-022-072 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 596 GRID 72 LOCALITY TEMPLE CITY Cl
102 COMPRSR < 100 KBTU 1 00 COM 27 00
(TENANT 100 FURNACE/HEATER <100 1 00 UNI 27 00 ISSUED ON PROCESSED BY PLAN BY EXPIRES ON
I TOTAL FEES 81 75 08/10/09 SR 08/10/10
OWNER
TEL NO i �DATE FZ�BY CODE
GRAMS, SUGIMTO
6349 TEMPLE CITY BL
TEMP 917801455 DESCRIPTI N OF WORE
REPLACE FURNACE AND A/C
APPLICANT TEL NO 1
JMARKLEY (714) 744-1243- l
114770 FIRESTONE BLVD 11 SPECIAL CONDITIONS 1
LA MIRADA CA 90638 1
CONTRACTOR TEL NO 1 APPROVALS GATE INSPECTOR SIGNATURE
MECHANIC REFRIGERATION (714) 522-7986- I
14770 FIRESTONE BLVD #214 LIC NO �I FAU�WALL FURNACE 1
LA MIRADA CA 90638 697664 C38 -
ICOMBUSTION ASA OPENINGS
ARCHITECT OR ENGINEER TEL NO
DUCT WORK
LIC NO AC/COMPRESSOR �i /7I
I —I
THERMOSTAT
e FIRE DAMPERS
SMOKE DETECPION DEVICES
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lCOMFERCT n*. HOOD
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y
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REPORT ID DPR264 ROUTE TO BS0508
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