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HomeMy Public PortalAbout5634 BALDWIN AVE_Mechanical__ r � t VXORKERS' COMPENSATION DECLARATION NPPLICATION FOR PERMIT 1"P ,ey"affkim that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HE LTING - VENTILATING - AIR CONDITIONING CE-818 or a certified copy thereof (Sec. 3800, Lab. C.) CE 818(REV. 10/81) Policy No. Company Certified copy is hereby furnished. COUNTY OF 11.0,3)ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO Fr,LL IN BUILDING tion department. ADDRESS ` ? (PRINT OR TYPE ONLY) Date rF -�� A licant �cd �' LOCALITY pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROMWO, KERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU — DISTRICT NO. PROCESSED 8Y the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT,CFM (` 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. BOILER, BTU APPROVALS DATE INS FTC SIGNAT E 1 Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL —z �/L �/✓ Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED. UNIT— '(commencing NIT Ar A) '(commencing with Section 7000) of Division 3 of the Business WALL [V (j U' and Professions Code,and my license is in full force and effect. 2 0 License Number Lic. Class ® 61 Contractor Date ❑ I am exempt under Sec. Plan check fee 2 4 0 0.9'A cs. B.&P.C. for This reason (/ PERMIT ISSUING FEE $ / SGSa o o o Z Date: ' n ft a 8 TOTAL FEE �(� I a © Signature 2050 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License a a a 2 0 5 0 S Law for the following reason (Section 7031.5, Business and NAME Professions Code): 0 2 L1_8 6 I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). O WNER F; f ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY----- f j— TEL..NO.� I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY TEL. NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS above 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 upol' 7e above entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE IC A�n Signature of Appli nt or Agent b Date -- -- - - - - WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, ora certifilate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C - / 0 Policy No.l' '�'� Company S�y �L'�'r/vt' 2 -0046 DPW 9/88 - ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with thounty wilding inspec- FOR APPLICANT TO FILL IN BUILDING tion tion department' . ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST p 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,($100) or less.) AIR HANDLING UNIT, CFM ,.ry I certify that in the performance of the work for which this C v 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 INSPECTOR'S SIGNATURE f` Date Applicant COMPRESSOR, BTU 3� 0 496) 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 %1W16 _ 10 with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. CL �� ;� Lic. Class �0 ® O License Number SJ Contractor� � Date ❑ I am exempt under Seca Plan check fee w B.&P.C. for this reason. IL PERMIT ISSUING FEE $ Q s�} Z Date: TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I.hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME Professions Code): j I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ACC''- s the structure is not intended or offered for sale(Section. CITY TEL. NO. t 0 ■� 7044, Business and Professions Code). OWNER '� MCI 3 ❑ _I . I� I, as owner of The property, am exclusively,contracting ` , with licensed contractors to construct the project (Sec- MAIL �. y,0 1 I i E ADDRESS �' S tion 7044, Business and Professions Code). -r_--- 30. 50 . CONSTRUCTION LENDING AGENCY CITY,-FFVPLC-C ( TEL. NO. t f i I AL 30 4 5 I hereby affirm that there is a construction lending agency for , (; IC 30 7 l the performance of the work for which this permit is issued CONTRACTOR �L■.51 nT�c-c Sd'EC��c t CH �` .SIJ (Sec. 3097, Civ. C.). � � / �t��;�(_ ADDRESS �' ��r- /� � "t/'0q Lender's Name // CITY ^ C/r,Z�{, TEL. N Lender's Address ��'12 16 STATE - / l- LIC. C 2-4L:!1 ' I certify that I have read this application and state that the LICENSE NO. �} / CLASS t;174 1 AN • 93" above information is correct. I agree to comply with all County 'O .ordinances and State laws relating to building construction, and he e y author' a representatives of this County to enter upon th boveoned property fo Inspection purposes. f C^, SEE REVERSE FOR EXPLANATORY LANGUAGE ?c "Z- Signature of Applicant or Agent Date ©s i ~ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1210020025 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ILEGAL ID: I FEES PAID BUILDING ADDRESS: ITR: 16957 LT: 18 1 5634 BALDWIN AV I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917802628 (ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: 1 18586-021-005 101 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: B3 LOCALITY: TEMPLE CITY, Cl 1 102 COMPRSR < 100 KBTU 1.00 COM 27.00 1 TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 11SSUED ON: PROCESSED BY: PLAN BY: 154 NO PERMT $224.70 MIN 342.20 342.20 110/02/12 SR I TOTAL FEES 424.00 1 (OWNER: TEL. NO: I IFINAL DATE FINAL BY: �/V CODE: COOPER, SHARON (626) 445-5509- 15634 BALDWIN AVE 1 ] - (f yir`y P11 II 1 / 1 ITEMP 917800000 I IDESCRIPTION ON WORKS L-J 1 I 13 TON A/C CHANGE OUT AND FURNACE I (APPLICANT: TEL. NO: 1 I I ISCHNIERER, STEVEN (951) 241-6876- 1 125251 ALESSANDRO BL. I ISPECIAL CONDITIONS: IMORENO VALLEY 92553 I I ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I ISERVICE CHAMPIONS HEATING AND A, C (714) 777-7777- 1 I 1 122911 SAVI RANCH PARKWAY LIC. NO FAU/WALL FURNACE 1 1 1 IYORBA LINDA CA 92887 799170 C20 1 I 1 1 1 ICOMBUSTION AIR OPENINGS (ARCHITECT OR ENGINEER: TEL. NO: 1 IDUCT WORK I I I I LIC. NO: i JAC/COMPRESSOR ITHERMOSTAT I I I I 1 IFIRE DAMPERS I I I I I I 1 I ISMOKE DETECTION DEVICES I I I 1COM.MERCIAL HOOD I I I I I I I I I I I I I I I I I I I I I I I 1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I IREPORT ID: DPR264 ROUTE TO: BS0508 I I I I I I