HomeMy Public PortalAbout8603 GARIBALDI AVE_Mechanical__ WORKERS' CONIPQJSATION DECLARATION
eI hereby affirm that I have a certificate of consent to self APPLICATION FOR PERM
IT
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING al
or-a certifled copy thereof (Sec 3800, Lab. C.) 76A.364C
20-0046 DPW 9/38
Policy No Company
r_1 Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the county building Impar- FOR APPLICANT TO FILL IN 11t.1ILDING
tlon department. INT OR TYPE ONLY) ADI)RESS
Date Applicant LOC
NO. TYPE OF APPLIANCE OR C{,?IIIPMEM FEE
CERTIFICATE OF DCEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. ,r
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DCSTRICT NO. Ay
the permit Is for one hundred dollars (;100) or baa.)
I certify that In the performance of the work for which this AIR HANDUNG UNIT, CFM
permit Is issued, I shall not employ any n In Aaannar
so as to become subject to the Workers. mpe BOILER, BTU APPROVALS DATE IMSPfL7C)R'S SX TLJRE
DateT�D Applicant r BTU �7 ROUGH
NOTICE 'TO APPLICANT: If, after making this Certfflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers
Compensation provlsioru of the Labor Code, you must forth- EVAPORATM COOLER VALIDATION
with comp)y with such provisions or this permit shall be deem-
ed revoked. FURNP.CE: FAU GRA
LICENSED CONTRACTORS DECLARATION FLOOR BTL
I hereby affirm that I am licensed under provlslons of Chapter 9 FLEATER: SUSPEND® UNIT—
(commencing wath Section 7000)of Division 3 of the Business WALL
and Profeesions Code,and my 11 nse is in full force and effect. v
CL
License Number I I c_ Ck= , 0
Contract Date -
_ O
El - I am exempt under Sec. Plan check fee G
B.&P.0 CL for this reason PERMIT ISSUING FEE $ t
Date: —
Signature TOTAL FEE
OWNER-BUILDER DECLARAnQN RAN C HEC]C APPLICANT /jOt—
I hereby affirm that I am exempt from the Contractors License ii 7 7' 2 A
Law for the following reason (Section 7031.5, Business and NAME
# 0 0 0 0 0 8
Professions Code):
❑ I, as owner of the property, or my employees with
ADDRESS I 4 n - 39. 00
wages as their sole compensation,will do the work and -
the structure Is not Intended or offered for sale(Section CITY TEL �' 0 0 0 3 9, O O H
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting R ow O a O cJ 9 O
with licensed contractors to construct the project (Sec- _
tion 7044, Business and Professions Code ADDRESS
CONSTRUCTION LENDING A= a; g/7? ,$. NO K-0-1QQq
I,hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3047, Civ. C.}
Lenders Name � U r
CITY TEL.. NO.
Lenders Address
I certify that I have read this application and state that the STATE LICENSE NO uL
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and h eby authorize epresentailves of this County to enter
u n e abovo-mei prorty for I Ion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
_2
Slgnature of Applicant or Agent Date �s
COONTY OF IAS ANGELES T3fPT.R CITY 0508 MECHANICAL PER=
DEPARTMENT OF PUBLIC WORKS 9701 LAS T4HA.9 ME 0508 0910200009
BUILDING AND SAFETY / LAND DEVSIDPME TP TE4?LE CITY CA 91780
PHONE: (626) 285-0488 EMT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5903 LT: 14 8603 GARIBALDI AV
FEE DESCRIPTION: QUANTITY: DOM: AMOUNT: SGAB CA 917752615
ASSESSOR INFORMATION NUMBER: NEAREST CROSS 9T9EET:
5386-007-032 Ol PMUffT ISSUANCE FEE 27.75 TTriNAa PAGE; 596 GRID: G2 LOCALITY: TEMPLE C=, C
02 COMPR.4R < 100 KBTO 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCE99ED BY: PLAN BY: EMPIRES ON:
TOTAL FEES 81.75 10/20/09 SR 10/20/10
OWNER: TEL. NO: F DATrSj FINAL BY- CODE:
ROUSE WILLIAM 2JULRJOR113 J (626) 286-3889-
8603 GARIBA DI AV
SCAB 917752615 D39CP±PpnCgt OF IkORX
A/C-HEAT SSSTEM CHANGE OUT
APPLICANT: TEL. NO:
CARRA OONTRERAS (626) 286-3157-
4931 N. E2CII9TTA AVE SPECIAL COfmITIONS:
TEMPLE CITY CA 91780
CONTRACTOR: TEL. NO: APPROVAIS DATE IM PECTOR SIGNATURE
CONNOR AIR CONDITIONING (626) 286-3157-
4931 ENCSNI'TA AVE LIC. NO FAD KkLL FURNACE
TEMPLE CITY, CA 91760 403735 C2O
COMBUSTION AIR OPENINGS
ARCHITECT OR EMTWR72: TEL. NO: DUCT WORK
LIC. NO: AC COKPRESSOR
THERMOS TAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
OOMMERCIAL HOOD
1
REPORT ID: DPR264 RO= TO: BS0508