HomeMy Public PortalAbout9630 VAL ST_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
J hereby affirm thol I have a certificate of consent to self
insure or 8 certificate of Workers' Compensation Insurance 7en36K HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec 3BO0 Lab C ) CE BIB(REV tOABt)
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county budding inspec FOR APPLICANT TO FILL IN BUILDING 3
tion d/gyp,a�rtment (PRINT OR TYPE ONLY) ADDRESS 0 4�-5/
Date(t//�/siC Applicant LOCALITY
7"�Y"�"� NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST /J/
COMPENSATION INSURANCE CROSS Si 1 C` 77w'
(This stolon need not be completed If the cork Imrolwd by ABSORPTION UNIT BTU DISTRICT NO RROCLSSED er
the porrtsH Is for one hundred dollen ({100)or Ins)
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM ✓s a
permit is issued I shall not employ any person in any manner
so as to become sublect to the Workers'Compensation Laws BOILER BTU AVPROVALS OA I CTO4 s TuK
Date i plica COMPRESSOR BTU ROUGH
NOTICE T AP ICANT If aftfir making A&teirtificafeftf VENTILATION SYSTEM FINAL —Z
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI
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 SUSPE D UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license Is In full force and affect d
License Number LIc Class , 2 2 9 A U
# • •
Contractor Date ,I • • C
• • • 8 0
❑ I am exempt under Sec 2 Q 5 0 U
B 8P C for this reason Plan check fee w
Date PERMIT ISSUING FEE $ 1 JCJ JY 2 Q 5 0 5 Z
Signature TOTAL FEE 6 1 .85
OWNER BUILDER DECLARATION PAN CHECK APPLICANT TOTAL
1 hereby affirm that I am exempt from the Contractor s License P11110Law 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 CITr TEL NO
the structure Is not intended or offered for sale(Section
7044 Business and Professions Code)
E] OWNER
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL
tion 704 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency fa ►
the performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097, Civ C ) _ _ -
ADDRESS
Lender s Name
CITY TEL NO
Lenders Address
STATE LIC
I certify that I have read this application and state that the I LICENSE NO CLASS
above information Is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter '
�uu av on the abmenti ed property for insp ctio purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
�L
S,gnotare pLcant a Ag I Date
COUNTY OF LOS ANGELES TEMPLE CITY A 0508 MECHANICAL PERMIT
• DEPARTMENT OF PUBLIC (KIRKS 9701 LAS TUNAS ME 0508 0207250004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE. (626) 285-0488 EXT-
LEGAL ID' FEES PAID BUILDING
ON FILE 9630 VAL ST ADDRESS:
FEE DESCRIPTION OLLUTITY LION AMOUNT TEMP G 917800000
ASSESSOR INFORMATION NUMBER. NEAREST CROSS STREET: TEMPLE CITY BLVD.
5383-014-006 01 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE. GRID- LOCALITY: TEMPLE CITY, C
30 AIR INLETS/OUTLETS 4.00 UNI 17.40
TOTAL FEES 45.15 ISSUED ON PROCESSED BY PLAN BT EMLKE5 UK
07/26/02 JK A01/22/03
OWNER: TEL NO: FINAL DATE FINAL BY CODE
GULIN (626) 353-1685-
9630VALSTJ) ,/ 3 a y
TEMPLE CITY 91780 6nTQ1Frr6W 6
MECHANICAL FOR ADDITION
APPLICANT TEL NO.
SAME AS OWNERSPECIAL CONDITIONS
-
SAME AS OWNER -
LIC NO FAU/WALL FURNACE
EffiffogrrowwrVarmnvar
ARCHITECT OR ENGINEER.- TEL NO DUCT WORK
LIC N0:
THERMOSTAT
FIRE DAMPERS
COMMERCIAL HOOD
REPORT ID DPR264 ROUTE TO BS0508