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Home My Public Portal About9669 BROADWAY_Mechanical_7/6/2015_COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1507060039 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: ON FILE ASSESSOR INFORMATION NUMBER: 8588-010-018 OWNER: TEL. NO: MOK, ERIC (626) 673-5072- 9669 BROADWAY TEMPLE CITY CA 91780 APPLICANT: TEL. NO: RAMIREZ, CONSUELO (626) 815-1632- 1017 W. FOOTHILL BL. AZUSA CA 91702 CONTRACTOR: TEL. NO: COMFORT CLIMATE CONTROL INC. (626) 815-1632- 1017 W FOOTHILL BLVD LIC. NO AZUSA CA 91702 641060 OR ENGINEER: TEL. N0: EMPIR-En LIC. NO: PERMIT EXPIRES 180 DAYS IF 1) WORK DOES NOT COMMENCE, OR 2) WORK IS SUSPENDED OR ABANDONED, OR 3) FAILS TO OBTAIN CODE REQUIRED INSPECTION FEES PAID FEE DESCRIPTION: QUANTITY: DOM: 01 PERMIT ISSUANCE FEE 02 COMPRSR 1 100 KBTU 08 FURNACE/HEATER 1100 REPORT ID: DPR264 1.00 COM 1.00 UNI TOTAL FEES ROUTE T0: BS0508 BUILDING ADDRESS: 9669 BROADWAY AMOUNT: TEMP CA 917803211 NEAREST CROSS STREET: 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY 27.00 27.00 IlSSUED ON: PROCESSED BY: PLAN BY: 81.80 107/06/15 SR FINAL DATE FINAL BY: CODE: DESCRIPTION OF WORK REPLACE HEAT MOVE TO ATTIC ADD A/C / BACK YARD E"oSPECIAL CONDITIONS: (APPROVALS DATE INSPECTOR SIGNATURE FURNACE N AIR OPENINGS WORK FIRE DAMPERS SMOKE DETECTION DEVICES COIMIERCIAL HOOD OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I. JOB ADDRESS ' I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the reason(s) indicated below by the checkmark(s) I have placed next to the applicable item(s) (Section 7031.5, Business and Professions Code): Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U I, as owner of the property, or my employees with wages as their sole compensation, will do (✓) all of or (_) portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale.). L) I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contrbr for pursuant .to the Contractors' State License Law). (_) I am exemdt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior) to completion of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: httD://w .leoinfo.ca.00v/calaw.html. Date: Signature of Property Owner or Authorized Agent I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full fort %anted effect. License las "" License No. Dat Contractor Signature WORKERS' COMPENSATION DECLARAT N WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. poi ey No. / I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My orkers' mpensation in ura ce aria policy nu bar e� 'Tie r _ JJ /( Policy Number UExp' o to 0 Name o Agent(, V ]rL n Phone Number I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation visions of Section 3700 of the Labor Code, I II forthwith c p with those provisions i, �i ` SS''grfa ure of App ican Dat6 / LOBBYIST ORDINANCE CERTIFICATION Complete this section for.permlts in Unincorporated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 at seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continue to comply therewith through the application process. Applicant (Print Name) Applicant Signature Company Name Date LOCALITY HAZARDOUS MATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ N o ❑ Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ No ❑ I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements under the Los Angeles County Code Title 2, Chapter 220' Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notification of asbestos removal is not applicable to addressed project. DECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender's Address By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property. owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building Construction. I authorize representatives of this county to enter the above -id tified prope for in ectlonpwe poses. Signa r of Property er uthonzed Ag t Date l