HomeMy Public PortalAbout5229 GOLDEN WEST AVE_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CEA 818 C(2.80) A P P UCAT 0 O `YI FOR PER YOU T
I here8'y affirm that I have a certificate Iof consent to self
insure, or a certificate of Workers'Compensation In ante,or HEATING-VENT ILATING-Al R CONDITIONING
a certified copy thereof(Sec 3800,Lab.C.) ./� `
Policy No 64-89-3,lw°n'pan3,S-tate—C.Omp-.—Ins-.Eund
COUNTY OF LOS ANGELES BUIL ING ARID SAFETY
Certified copy is hereby furnished ,-
Certified copy is filed with the county building inspection BUILDING
EJ department FOR APPLICANT TO FILL IN - ADDRESS22 Goldent_est_A-V-e
DatclO/30/80 ApplicantAtom Heating Co (PRINT OR TYPE ONLY) 5 9
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Te-mple_C-it_y
COMPENSATION INSURANCE NEAREST }d
(This section,need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST Olive 0
by the permtt,•is for one hundred dollars ($100) or less.) DISTRICT,NO P CESSED B' 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM / O
permit is issued, I shall not employ any person in any manner ' - v
so as to become subject-to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNIC E IU
Date Applicant COMPRESSOR,BTU�3&,-000 10 00 ROUGH N
NOTICE TO APPLICANT 1f, after making this Certificate ofVENTILATION SYSTEM -�-� Z -
Exemption, you should become- subject to the Workers' FINAL —
Compensation provisions'of the Labor Code, you must forth- ' EVAPORATIVE 60OLER VALIDATION
with comply- with sdch provisions or this permit shall be
deemed revoked. _ r n
FURNACE' FAUT-67-8-5-1-
R TY o -
LICENSED CONTRACTORS DECLARATION l FLOOR. BTU_H-O_,_�-�_O 0 00 ya,
I hereby affirm that I am licensed under provisions of Chapter F EATER SUSPENDED UNIT QQ��
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and O
effect. ' - C-2 O'C-10
License Number.195214 Lia Class__C_=�4-4
ContractoA,t-Qm_Heatmng_Coate 0/30/80 "
I am exempt from the licensing requirements as 1 am a
licensed architect or a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).'' PERMIT ISSUING FEE $ 7 99
Lit or Reg No. Date TOTAL FEE ' 06
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT'
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code), .ADDRESS
❑ I, as owner of the.property, will'do the work and theTEL NO.
structure is not intended or offered for sale (Section CITY '
7044, Business and Professions Code). _
ndBo
I; as owner of the property, am exclusively contracting OWNER Sam Y • ,
with licensed contractors to construct the project MAIL
(Sectron,7044, Business and Professions Code).- ADDRESS 5229_G_o1den_West_Ave ;029,9.3A
CITYTem le Cit Ca TEL.N0287-1973 #,a ore o 4. 1
CONSTRUCTION LENDING AGENCY P City
' Ca
hereby affirm that there Is a construction lending agency
for the performance of the work for which this permit Is CONTRACTOR
m_.eati_ 2.
issued (Sec:3097,Civ At C). - - C-o -,0,27.0 0•
Lender's Name ADDRESS . '
458-7—B>^az-i-l9-t-.-, ,c 0,6 2 7. 0 0
'Lender's Address CITY
TEL NO '-
I certify that I have read this application and state that the Los_Ange-les 90039 242:2fAA-9— t �,0,7 ,8 0
STATE LIC.
above information.is correct.I agree to comply with all County LICENSE Nj 1 -5214 CLASSC-2
ordinances and State laws regulating Heating, Ventilating and C-44
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the ientioned property for
inspection purp ,
.Signature of Permittee Date _ -,
COUNTY OF LOS ANGELES TEMPLE _'IIY 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0406160019
BUILDING AND SAFETY / LAND DEVELOPI:EKi TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGA D: FEES PAID BUiLD1NG ADDRESS:
TR: 15683 LT: 1 5229 GOLDEN WEST AV
FEE DESCRIPTION: QUANTITY: U%l: AMOUNT: TEMP'C4 917803247-
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: BLACKLEY
8589-010-001 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, C
30 AIR INLETS/OUTLETS 2.00 UNI 8.70
TENANT: 47 ALTER EXIST DUCT SYS 1.00 SYS 27.00 ISSUED ON; PROCESSED B EXPIRES ON:
TOTAL FEES 63.45 06/16/04 JK 12/13/04
OWNER: TE'_. hZI: FINA FINAL BY: CODE:
MOLINAR, JAMES/ANNA (626) 286-8003-
5229 GOLDEN WEST AV _•
TEMP 917803247 D IIUh OK WO
E EN DUCT TO ADDITION WITH 2 OUTLETS
APPLICANT: TEI. 110:
COOLMAN (626) 285-0835-
P. 0. BOX 90336 SPECIAL CONDIf10NS:
PASADENA, CA 91109 I
I
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CONTRACTOR: N0: - APPROVA_S DATE INSPECTOR SIGNATURE I
SULLIVAN, FRANK (818) 307-0603-
1625 N. AVON STREET LIC. NO FAU/WALL FURNACE
BURBANK,
RN CF-
BURBANK, CA 91505 3492983
• COMBUSTIO`: AIR OPENINGS
ARCHITECT OR ENGIHECR: IEL. Ido; DUCT 6'O, K
CAL CIVIC ENGINEERING (6%6) 1`98-2828- 10i
2160 PARNELL WAY LIC. NO: AC/COMPRESSOR
ALTADENA, CA 91001 N0"E _
THERMOSTAT
FIRE DAMPERS
SMOKE DETECTION DEVICES
COMMERCIAL HOOD
I
I
REPORT ID: DPR264 ROUTE TO: BS0508
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