HomeMy Public PortalAbout6022 CLOVERLY AVE_Mechanical_7/8/2011_TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
IFEE DESCRIPTION: QUANTITY: UOM:
I
101 PERMIT ISSUANCE FEE
102 COMPRSR < 100 KBTU 1.00 COM
108 FURNACE/HEATER <100 1.00 UNI
TOTAL FEES
ZEPORT ID: DPR264 ROUTE TO: BS0508
MECHANICAL PERMIT
ME 0508 1107080010
BUILDING ADDRESS:
6022 CLOVERLY AV
AMOUNT:( TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
27.80 THOMAS PAGE: 596 GRID: S3 LOCALITY: TEMPLE CITY CA
27.00
27.00 JISSUED ON: PROCESSED BY: PLAN BY:
81.80 107/08/11 SR
F��11A��--L DATE FINAL BY: CODE:
�DESCR4AN OF WORK /�' /`yn•U
(INSTALL NEW A/C
I
I
(SPECIAL CONDITIONS:
�Yi LGi-t Zvy�sc�
IAPPR V S (7 DA E SPECTOR SI ATURE
FAU/WALL FURNACE
ICOMBUSTION AIR OPENINGS
IDUCT WORK
JAC/COliPRESSOR %y'I
THERMOSTAT J�I(i� l
I
FIRE DAMPERS
(SMOKE DETECTION DEVICES
COMMERCIAL HOOD
�. ^OUNTY OF LOS ANGELES
DEPARTMENT OF
PUBLIC WORKS
` BUTLDING AND SAFETY
/ LAND DEVELOPMENT
LEGAL ID:
ITA: 6561 LT: 304
UN: .003
ASSESSOR INFORMATION NUMBER:
15385-007-017
1
ITENANT:
I
(OWNER:
TEL. NO:
(WOMACK ANN
(626) 221-0876-
16022 CLOVERLY AV
ITEMP 917802025
APPLI CANT:
TEL. N0:
ILE CHIEU
(626) 234-5453-
111902 KILLIAN ST
IEL MONTE CA 91732
I
(CONTRACTOR:
TEL. NO:
ILE CHIEU
(626) 234-5453-
111902 KILIAN ST
LIC. NO
IEL MONTE CA 91732
I
714507
ARCHITECT OR ENGINEER:
I
TEL. NO:
I
LIC. NO:
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
IFEE DESCRIPTION: QUANTITY: UOM:
I
101 PERMIT ISSUANCE FEE
102 COMPRSR < 100 KBTU 1.00 COM
108 FURNACE/HEATER <100 1.00 UNI
TOTAL FEES
ZEPORT ID: DPR264 ROUTE TO: BS0508
MECHANICAL PERMIT
ME 0508 1107080010
BUILDING ADDRESS:
6022 CLOVERLY AV
AMOUNT:( TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
27.80 THOMAS PAGE: 596 GRID: S3 LOCALITY: TEMPLE CITY CA
27.00
27.00 JISSUED ON: PROCESSED BY: PLAN BY:
81.80 107/08/11 SR
F��11A��--L DATE FINAL BY: CODE:
�DESCR4AN OF WORK /�' /`yn•U
(INSTALL NEW A/C
I
I
(SPECIAL CONDITIONS:
�Yi LGi-t Zvy�sc�
IAPPR V S (7 DA E SPECTOR SI ATURE
FAU/WALL FURNACE
ICOMBUSTION AIR OPENINGS
IDUCT WORK
JAC/COliPRESSOR %y'I
THERMOSTAT J�I(i� l
I
FIRE DAMPERS
(SMOKE DETECTION DEVICES
COMMERCIAL HOOD
OWNER -BUILDER DECLARATION
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).):
UI, 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.).
U 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 properly who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant to the Contractors' State License
Law.).
(_) I am exempt 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 entirely 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: lfttp.BhawwJgim6a.ca.eromecala�nr.blml.
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penally 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 force and effect.
zzzLicense Class License No. � �Q� � �
-�uate6— /1 Contractor Signaure (/fifL Iq_,-
WORKERS' COMPENSATION DECLARATION
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.
Policy 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
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent 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 provisions of Section 3700 of the Labor
Code, IM forth hco l y rol tho
lse provision
\Jsignature of Applicant Date
JOB ADDRESS <
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 ❑ No ❑
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 SCAQMD 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.
LOBBYIST ORDINANCE CERTIFICATION
have read this application and the information I have
Complete this section for permits in
provided Is Correct.
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
I agree to comply with all applicable city and coullty
requirements of Los Angeles County Code Chapter 2.160 at seq.,
ordinances and state laws relating to building
(relating to the Los Angeles County Lobbyist Ordinance) and that
construction.
all persons acting on behalf of myself complied and will continue
I authorize representatives of this county to enter the
to comply therewith through the application process.
above -identified property for inspection purposes.
\ /Applicant (Print Name) Applicant Signature
Signature of Property Owneor Authorized Agent
/_
(/R ddYY
Company Name Date r
J'
^v
Date --,2—
2EPORT ID: DPR264 ROUTE TO: BS0508
MECHANICAL PERMIT
ME 0508 1107080010
DUPLICATE
BUILDING ADDRESS:
6022 CLOVERLY AV
TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
ISSUED ON: PROCESSED BY: PLAN BY:
07/28/11 SR
FIjIlL1 FINALLY: CODE:
DBE CRI PTIONOP WORK
INSTALL NEW A/C AND FAU SYSTEM
SPECIAL CONDITIONS:
DATE INSPECTOR SIGNATURE
FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
DUCT WORK
AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
TEMPLE CITY
#
COUNTY OF LOS ANGELES
DEPARTMENT OF
PUBLIC WORKS
BUILDING AND SAFETY
/ LAND DEVELOPMENT
LEGAL ID:
TEMPLE CITY CA
91780
ITR: 6561 LT: 304
UN: .003
1
ASSESSOR INFORMATION NUMBER:
EXT:
5385-007-017
1
TENANT:
(OWNER:
TEL.
NO:
�WONACK ANN
(626) 221-0876-
I6022 CLOVERLY AV
27.80
TEMP 917802025
COMPRSR c 100 KBTU
1.00 COM
APPLICANT:
TEL.
08
N0:
ILE CHIEU
(626) 234-5453-
111902 KILLIAN ST
AIR INLETS/OUTLETS
8.00 UNI
JEL MONTE CA 91732
CONTRACTOR:
TEL.
NO:
ILE CHIEU
(626)
234-5453-
111902 KILIAN ST
LIC. NO
IEL MONTE CA 91732
714507
ARCHITECT OR ENGINEER:
TEL.
N0:
1
LIC. NO:
2EPORT ID: DPR264 ROUTE TO: BS0508
MECHANICAL PERMIT
ME 0508 1107080010
DUPLICATE
BUILDING ADDRESS:
6022 CLOVERLY AV
TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
ISSUED ON: PROCESSED BY: PLAN BY:
07/28/11 SR
FIjIlL1 FINALLY: CODE:
DBE CRI PTIONOP WORK
INSTALL NEW A/C AND FAU SYSTEM
SPECIAL CONDITIONS:
DATE INSPECTOR SIGNATURE
FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
DUCT WORK
AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
TEMPLE CITY
#
0508
9701 LAS TUNAS
TEMPLE CITY CA
91780
PHONE: (626) 285-0488
EXT:
FEES PAID
FEE DESCRIPTION:
QUANTITY: DOM:
AMOUNT:
01
PERMIT ISSUANCE FEE
27.80
02
COMPRSR c 100 KBTU
1.00 COM
27.00
08
FURNACE/HEATER <100
1.00 UNI
27.00
30
AIR INLETS/OUTLETS
8.00 UNI
34.80
TOTAL FEES
116.60
2EPORT ID: DPR264 ROUTE TO: BS0508
MECHANICAL PERMIT
ME 0508 1107080010
DUPLICATE
BUILDING ADDRESS:
6022 CLOVERLY AV
TEMP CA 917802025
NEAREST CROSS STREET: WOODRUFF
THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CA
ISSUED ON: PROCESSED BY: PLAN BY:
07/28/11 SR
FIjIlL1 FINALLY: CODE:
DBE CRI PTIONOP WORK
INSTALL NEW A/C AND FAU SYSTEM
SPECIAL CONDITIONS:
DATE INSPECTOR SIGNATURE
FAU/WALL FURNACE
COMBUSTION AIR OPENINGS
DUCT WORK
AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
OWNER -BUILDER DECLARATION
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).):
UI, 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.).
U 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 properly who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant to the Contractors' State License
Law.).
(_) I am exempt 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: P�tllp:/Fmww. inia.ca.uamAealaw.hlmP-
Date:
Signature of Property Owner or Authorized Agent
LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS
I hereby affirm under penalty of perjury that I am licensed under LOCALITY
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, and my
license is in full force and effect. HAZARDOUS MATERIAL DECLARATION
�-[O_ ^7 Will the applicant or future building occupant handle a hazardous
License Class G License No. �71 Lp K��1)-7 - �� ,gmraaterial or a mixture containing a hazardous material equal to or
DaContCCSignature /'I/(/�/�r./i%l/Lf yiractor
v . ater than the amount specified on the hazardous materials
information guide?
WORKERS' COMPENSATION DECLARATION
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.
Policy 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
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent 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' compensattiionn°pprrPoJvisions o ectkm 3700 of the Labor
Co I all rt ! '(.Clv i use proyrsjon ,, i�
Signatureo pp scant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits 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 et 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
Yes ❑ No ❑
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 ❑ N o ❑
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 SCAQMD or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penally 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 -identified property for inspection purposes.
Signature �Off roppeerty O rner or Au�t�hro_rized Agent
Date--) -21X '��%