HomeMy Public PortalAbout9216 WEDGEWOOD ST_Mechanical__ WORKERS'COMPENSATION DECLARATION I APPLICATION PERMIT
I hereby affirg that I have a,ceitlficate ofIconsSnt to self
insurg, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
4 CE-818(REV. 10/81) Re lacement. Unit
�I�PTo. 7 9 7 0 2 Company Frpmon P '
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- i FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY)
ADDRESS
Date 04-1 6- l Applicant AAA rind -AirI LOCALITY Te
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS;ST. Encenita
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. n PRO ED BY]]�
the permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM ( ' -F-{�
I certify that in the performance of the work for which this v �I ++
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE I R5 SIGNATU E
Date Applicant l COMPRESSOR, BTU 48 , 000 0( no ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should `become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA 1 A
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUXX_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTUWN 010
_7M
hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
`(commencing
USPENDED UNIT`(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. i IL
O
License Number 293599 Lic. Class C 2 n ® V
t�
Contractor AAA Cond A i r Date n 10-9n O
❑ I am exempt under Sec. I I a
Plan check fee I-
BAP.C. for this reason,
IL
PERMIT ISSUING FEE$
Date: '
Signature I TOTAL FEE Q
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and NAME
Professions Code): }
❑ Cos owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and A"' l `F
the structure is not intended or offered for sale(Section CITY TEL. NO. _ l=�;
30
7044, Business and Professions Code). ��:1€� __ On
OWNER
Eli ITENS,
I, as owner of the property, am exclusively contracting 1 ENS,
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL 00
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHIEC; 37.OF0
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ® -CPA GE .130(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name I t 01 .1r,
CITY TEL. NO. Llf l;�s]—U,Is}LI�,i �1/h!?ru]�`�ilt
Lender's Address STATE LIC. 147 .t AM 7�if
I certify that I have read this application and state that the LICENSE NOI CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby�e- entl
resentatives of this County to enter I I'
upon the abb9. roperty for inspection purposes. SEE REVERSEFOR EXPLANATORY LANGUAGE
DaviG-c/�'
Signature of Applicant or Agent Date
76iA364•-CE 818 - 9-71 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES FNEAREST
SS 9216 E. Wed ewood
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ITY Temple CityST. -
FOR APPLICANT TO FILL IN OWNER David Ceja
(PRINT OR TYPE ONLY) '
MAI L
NO. TYPEOFAPPLIANCEOR EQUIPMENT FEE
ADDRESS 9216 E. Wedgewood
CITY Temple City TEL. NO.
1 ABSORPTION UNIT, BTU,=-te=,_ 5 00
CONTRACTORgr ant Heating and Air Cond. I
AIR HANDLING UNIT, CFM ADDRESS 1350 E. Las Tunas Drive
BOILER, BTU CITY San Gabriel TEL. NO. 286-1141
COMPRESSOR, BTU STATE LIC.
LICENSE NO. 221751 CLASS C20
VENTILATION SYSTEM DISTRICT NO. GROUPZONE SED BY
EVAPORATIVE COOLER / g:
�-off 2 �- a
1 FURNACE: FAU X GRAlV�IZY _ v'
FLOOR BTU INSP 10 RECORD
HEATER: SUSPENDED UNIT_ C)
WALL v
W
CL
N
• Z
Plan check fee 25%of,alioye. See reverse. t;'�•r %. .�'d'� cel✓ ,I �!-�•y'�'-('lr
PERMIT ISSUING FEE S s oo
TOTAL FEE 15 50 �(t 3
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL,NO. (!�
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT,AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS'•RE1 LATING•HEATING, VENTI- APPROVALS DATE CTOR'S SIGNATURE
LATING, AIR CONDITIONING. .r'+'
I '�" ROUGH71
I HEREBY CER IFY T''I OT ACTIN�6,?IN,"VIOLATION
OF CHAPTER 9, DI IS10 SINESS AND,PROFESS IONAL FINAL -
CODE OF THE STAT 0
SIGNATURE "• 5 PERMIT VALIDA ON CK. M.O. CASH
OF PERMITTE // - '
PLAN CHE ALIDA• ON CK: M.O. CASH
I
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE