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HomeMy Public PortalAbout9559 WOODRUFF AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that t have p certificate of consent to self insure, ora certificate Workers'Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING or p certified copy thereof(Sec. 3800! Lab. C.) CE-BIB(REV. 10/81) Policy No Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS —"- {PRINT OR TYPE ONLY} Date �7 Applicont � IOCAUTY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed If the work involved by ABSORPTION UNIT,BTU DISTRICT NO PROCESSED BY the permit is for one hundred dollars($1100)or less.) 4 - I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER,BTU APPROVALS DATE INSPECT SIGNATURE Date Applicant FrOMPRESSOR,BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU &0.VIT1L LICENSED CONTRACTORS DECLARATION FLOOR BTU Oo ©(� I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. License Number �� I ic. Class 0O Contractor 4ate I9 O ❑ � tom exempt under Sec. B.&P.C. for this reason Plan check fee CL Date: PERMIT ISSUING FEE$ ID Signature TOTAL FEE ©Ct 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): ❑ I, as owner of the property, or my employees with ADDRESS 7 7 wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. r o 0 0 0 0 8 7044, Business and Professions Code). OWNER F17r, l 0 030.00 ❑ I, as owner of the property,am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESSC( , o a o 3 Q C Q u CONSTRUCTION LENDING AGENCY CITY '4�, TEL. NO. } I hereby affirm that there is a construction lending agency for o7,0sb 7 the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). � 'f✓ ADDRESS S n Lender's Name Lender's Address CITY { TEL. NO _-2 v STATE LIC. I certify that i have read This application and state that the LICENSE NO. 3,6 CLASS above information is correct. I agree to comply with all County ordinances and State lows relating to building construction, and hereby authorize representatives of this County to enter U he a-�entioned property for in o purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i�s+� S.gnature of Applicant or Agen Date A" COUNTY OF LOS ANGELES TEMPLE CITY # 0508 M FC WKICKU TERRI DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508 4701 50003 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA PHONE: (818) 285-0488 EXT: LE ID: F S PAID 9 TR: 6561 LT: 257 9554 WOODRUFF M FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: T.F.IOIs-Elt- 962043 ASSESSORIN 0 M 0 NEAREST CROSS STREET: 5385-013-011 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 COM 27.00 TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: P EXPIRES ON: 30 AIR INLETS/OUTLETS 8.00 UNI 34.80 01/15/97 TC 01/ 98 TOTAL FEES 116.55 OWNER: TEL. NO: FINAL DATI-zs FINAL BY: CODE: WONG, JESSE (213) 222-8929-9559 WOODRUFF AV d TEMP 917802043 DESCR P 0 OF OR MECHANICAL FOR INTERIOR REMODEL A D ADDITION APPLICANT: TEL. NO: AMERICAN TECH CONSTRUCTION (213) 222-8929- ` SPECIAL CONDITIONS: ` 4 CONTRACTOR: TEL. NO: l;j'j \ APPROVALS DATE INSPECTOR SIG A. RE AMERICAN TECH CONSTRUCTION (213) 222-8929- ��� TARE/ A 130 E. AVE 32 LIC. NO // � "i�'% \\` S FURNACE i 0 t . LOS ANGELES, CA 90031 013107 * 1C `�-=-� COMBUSTION AIR OPENINGS ARCHITECT OR ENGINEER: 0- �-� (�L. 0: - � 'OnCl��I CT y I LIC. NO: ' �� I '^ _ 1 AC/COMPRESSOR THERMOSTAT ^FFIRE DAMPERS :SMOKE DETEC IO DEV CES COM ERCIAL HOOD 6 STI * ADDITIONAL DATA ON FILE REPORT ID: DPR264 ROUTE TO: BS0508