HomeMy Public PortalAbout4929 BALDWIN AVE_Mechanical__ ION
DEC
WORKER'S I have
a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING-AIR CONDITIONING
copy thereof4See. 380b Lab. C.)
Policy NO. G961113001Company Cal Comp COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
® Certified copy is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUILDING
department. y p (PRINT OR TYPE ONLY) ADDRESS 4929 Baldwin Ave.
Date 5/3/96 Applicant LOCALITY Temple Cit
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. Lower Azusa
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PROCESSED BY
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 BOILER,BTU
become subject to the Workers' Compensation Laws.
1 COMPRESSOR,BTU 16,000 26 60
APPROVALS DATE INSPECTOR'S SIGNATURE
Date 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 GITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU ��•OU1— 26 60 VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
8 inlet outlet @ $4.20 33 60
License Number 221751 Lic.Class C-20
CL}
contractor Date 5/3/96l`l-//Zl1t , O
F] I am exempt under Sec. Plan Check fee �
B.&P.C.for this reason PERMIT ISSUING FEE$ 27 30 1
U
Date: TOTAL FEE
114 10 AC:C:T•T a
Signature PLAN CHECK APPLICANT 3303 114.10 Z
OWNER-BUILDER DECLARATION kI _
I hereby affirm that I am exempt from the Contractor's License Law NAME ' 1 ITEMS
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS TOTAL 114 - t10
El 1, as owner of the property, or my employees with wages CHECK 114.10
as their sole compensation, will do the work and the CITY TEL.NO. !� t�
structure is not intended or offered for sale (Section 7044, CHANGE .00
Business and Professions Code). OWNER Mann Del Rosario
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 4949 Baldwin Ave. 0000-0001 5/ 3/96
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Temple City TEL.No. 579_7392 r?05 1 AM10„58
1 hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued Bryant Heating & A/C
(Sec.3097,Civ. C.).
ADDRESS 1350 E. Las Tunas Drive
Lender's Name
CITY Temple City TEL.NO. 286-1141
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 221751 CLASS C-20
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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
I
SIGNATURE OF APPLICANT OR AGENT DATE
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