HomeMy Public PortalAbout9667 WOODRUFF AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION50.0046DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 10S6A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspection
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY o
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST Z K
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSE Y
I certify that in the performance of the work for which this permit Q
is issued, I shall not employ any person in any manner so as to BOILER,BTU SJ D
become subject to the Workers'Compensation Laws. r ,1 !f
r • COMPRESSOR,BTU ', JV / 0,0pppROVALS GATE INSPECTOR'S SIGNATURE
Date (42—( �� Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY gv VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. t.
License Number fV&Q0 Lic.Class �~ O
C
Contractor_ y� " Date
❑ I am exempt under sec. Plan check fee p
B.&P.C.for this reason PERMIT ISSUING FEE$ 15 1-
Date: TOTAL FEE ® Ll
0
Signature (�
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
e
I hereby affirm that 1 am exempt from the Contractor's License Law NAME ® _
for the following reason (Section 7031.5, Business and Professions _
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages — -as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 'T'-t':
Business and Professions Code). OWNER ,
F1 1, as owner of the property, am exclusively contracting MAIL ,0 ifL 5.l�_ e -00
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit is issued f
(Sec.3097,Civ.C.). _
ADDRESS _111 'D/IJ r7
Lender's Nam
CITY ` r TEL.NO ,"�1=: = rfl l :iR
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. /0) CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for I spection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGXrURE OF APPLICANT OR AGENT DA
i
a
COUNTY OF L S ANGELES TEMPLE CITY # 0508 --MEGHANtCAr-PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS ME 0508-974-0070003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
- LEGAL ID: -4 FEES PAID B I D .GD_ SS:
`9
TR: 6561 LT: 117 67`/~WOODRUFF AV `
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: -TEMP -CA 917802017
ASSESSOR IOR I BER: NEAREST CROSS STREET:
5385-018-013 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY
30 AIR INLETS/OUTLETS 3.00 UNI 13.05
TENANT: TOTAL FEES 40.80 ISSUED ON: -PROCESSED LAN BY: EXPIRES
10/07/97 UT 10/07/98
OWNER: TEL. NO: FINAL DATE FINAL BY: E:
KOO WEI Z;JENNY X
9667 WOODRUFF AV
TEMP 917802017 D SCR PT ON OF WORK
ADD THREE DUCTS FOR ADDITION
1
APPLICANT: T L.
AMERICAN TECH CONSTRUCTION (213) 222-8929-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: �� APPROVALS DATE INS ECTOR SIG ATURE
AMERICAN TECH CONSTRUCTION (213) 222-8929-1
130 E. AVE 32 LIC. NO �" �� �`4yFURNACE
LOS ANGELES CA 90031 013107
• � COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: T . NO: DUCT WORK `
LIC.-NO: i "� f' jr � AC/COMPRESSOR /
PIS � ---L' THERMOSTAT
J! IN f� I,a N 7-virs�V-� FIRE DAMPERS
, 1,�5'�__ __-IL`ems•" .1
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j `k� ,�',psi /`i �y,� COMMERCIAL HOOD
* ADDITIONAL DATA ON FILE
REPORT ID: DPR264 ROUTE TO: BS0508