HomeMy Public PortalAbout5572 WELLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I.hereby affirm that I have a certificate of consent to self
,insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.) 76A364C
__` CE-818(REV. 10/81)
Policy IN 3820 Company FVWJ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESSto-r-2_ v y\
•
Date Applicant LOCALITY kt I C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. S
(This section need not be completed if the work involved by ABSORPTION UNIT,BTU DISTRICT NO. (� PROCESSED Y
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM ) �/[
I certify that in the performance of the work for which this �J c (J
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS D E I EC R'S SIGNATURE
06
Date Applicant I COMPRESSOR,BTU 2Y4 v ROUGH
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NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VITY 1
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force d effect.
License NumberLM�5 Lic. Class V
Contractor ,
Date =8437A
I am exempt under Sec.
Plan check fee I o 03050
'n
B.&P.C. for this reason PERMIT ISSUING FEE$ z
Date: TOTAL FEE (� o e o J Q 5 0 v
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I 1.30-87
I hereby affirm that I am exempt from the Contractor's License ►
Law 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 CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS ` L
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY--,I
C4&4L. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordI
nances and fe laws relating to building construction,
nd hereby out or a representatives of this County fo enter
Pon the ove ntip_ne property ftor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
r,
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
•� DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS
ME 0508 1107270005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
TR: 43590 LT: 1 UN: 6 I 1 5572 WELLAND AV I
IFEE DESCRIPTION: QUANTITY: UOM: - AMOUNT:( TEMP CA 917802900 1
(ASSESSOR INFORMATION NUMBER: II NEAREST CROSS STREET:
18573-019-064 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: D3 LOCALITY: TEMPLE CITY, Cl
I 102 COMPRSR < 100 KBTU 1.00 COM 27.00 1 I
(TENANT: I TOTAL FEES 54.80 (ISSUED ON: PROCESSED BY: PLAN BY:
107/27/11 SR i
(OWNER: TEL. NO: I IFINAL DATE FINAL BY: CODE: 1
IJIANET, DING
5572 WELLAND AV • - 1
1I I I
(TEMP 917802900 I IDEStRIPTION OF WORK I
I I ICOND C/0 & COIL
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1APPLICANT: TEL. NO: I .� 1
IIWAI COOLING & HEATING (626) 932-1163-
�848 S. MYRTLE #2 1 (SPECIAL CONDITIONS:
MONROVIA, CA 91016 f
ICONTRACTOR: TEL. NO: I IAPPROV S DATE INSPEC R SIGNA I
IIWAI COOLING AND HEATING (626) 932-1163= 1 I
848 S. MYRTLE #2 LIC. NO IIFAU'/•WALL FURNACE 1
IMONROVIA, CA 91016 778839 C20�*1 I I I
I I _ ICOMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: - 1 (DUCT WORK I I I
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LIC. NO: 1 i 1AC/COMPRESSOR I I
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THERMOSTAT
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Ii* ADDITIONAL DATA ON FILE
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1REPORT ID: DPR264 ROUTE T0: B50508 I I 1 I
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