HomeMy Public PortalAbout5826 BURTON AVE_Mechanical__ WQRKER'haveCOMPENSATION DECLARATION 7BA346 DPW 9/89 APPLICATION FOR PERMIT UME GREEN
0A 16
' I harebyy,affirm 11 that I have a certificate of consent to self insure,
0'r-a ceTtific$te'of Worker'sCompansa(ion Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thelwyot(Sec.3800 Lab.C.) '
Policy No. Company • COUNTY OF LOS ANGELES•, • - .DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑. Certified copy is hereby furnished.
,❑ Certified copy is filed with the county'building inspection FOR APPLICANT TO FILL IN AooRESS
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY /
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE SAm
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTtf
CROSS ST. -
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars(5700)or leas.) 4 AIR HANDLING UNIT.CFM
DI$TPILT NO. P110CE$$ED 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
mI�O
becoe subject to the Workers' Compensation Laws.
COMPRESSOR,BTU OO .
APPROVALS DATE IN$PECTOP'S$IGNATVflE
Dale 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 � v L.
provisions or this permit shall be deemed revoked, f ' FURNACE: FA �Q
-,1 LICENSED CONTRACTORS DECLARATION FLOOR BTU /;;LVALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED --J 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.
License Number Lic.Class
a.
Contractor Date - DD D O
❑ 1 am exempt under Sac. Plan check fee O
I
BAP.C.for this reason - PERMIT ISSUING FEE $ -� - O O
Date: TOTAL FEE Q W
Signature IL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U)- - - "z
I hereby affirm that I am exempt from the Contractor's License Law NAME -
for the following reason (Section 7031.5, Business and Professions D -
Coe): ADDRESS
sl t _3
I. as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. .i3D7 51,�IiI
structure is not intended or offered for sale (Section ]044, - T
"Business and Professions Code). '' OWNERl(i ITEME .
\� I, as owner of the property, am exclusive) contracting MAIL � ' C
p p y y g R TOTAL -_E 1 _ 00
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and.Professions Code). r.-r CHECK
_CONSTRUCTION LENDING AGENCY - CITU S9 4 6o ho 'TEL.NO. a8 t_ - - -
hereby affirm that there is a construction lending agency for UUU t-NHNI1GE
t ._I!I
he.performance of the work for which this permit Is issued CONTRALTO
(Sec. 3097,.Civ.C.). D _ ^ '. 11
1, //
ADDRESS I�))IJO_tjiilll '
. Lender's Name ( ( i
CITY TEL.NO. bUbS., _ 1 till vaj
Lender's Address STATE LIC. - " - •• -
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is Correct. I agree to comply with all County.ordinances
and Stale laws relating to building construction,and hereby authorize
represtrilefives of this County to enter upon the above-mentioned
pro ly r inspec'on PAPoseall SEE REVERSE FOR EXPLANATORY LANGUAGE
$IDN TURF FAPPLI1i OaA ENT DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0209180021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL S PAID BUILDINGADDRESS:
TR: 3623 LT: 118 BL: .001 5826 BURTON AV N
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: SGAB CA 917753075
ASSESSOR INFORMATIONER: NEAREST CROSS STREET: HERMOSA
5387-006-027 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: G3 LOCALITY: TEMPLE CITY
32 APPL VENT (OTHER) 1.00 UNI 12.90
TENANT: 41 VENTILATION FAN 1.00 FAN 15.75 ISSUED ON: PROCESSED BY: PLAN Y: EXPIRES .
TOTAL FEES 56.40 09/18/02 JK 03/17/03
OWNER: TEL. NO: FINAL DATA, FINAL BY: CODE:
BAS CLE STEVEN L;LINDA A (626) 286-5096-
5826 BURTON AV C/
SGAB 917753075ETION RK
MECHANICAL FOR
CONVERSION
APPLICANT: L. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO AU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT OR
LIC. NO: AC/COMPRESSOR
THERMOSTAT
FIRE DAMPERS
SMOKE EC N V C
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: BS0508