HomeMy Public PortalAbout5738 GOLDEN WEST AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0046 DPW 9/89 APPLICATION FOR PERMIT
7 6A364 LIM" E• GREEN
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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 thereof(Sec 3800 Lab C) '
Policy No C� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND'SAFETY.DIV.
❑., .Certified copy is hereby furnished
FOR APPLICANT TO FILL IN BUILDING
Certified copy Is fled with the county budding InspectlorL
department �/ (PRINT OR TYPE ONLY) ADDRESS,
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Dater^ Appll0 A• NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST g7 C V
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SSOR
(This section need not be completed If,the.work Involved by the
MAPBOOKPAGE PARCEL
permit is,for one hundred dollars($100),or less.) AIR HANDLING UNIT CFM
DISTRICT NO PROCESSED BY
certify that,in the performance of the work for which this permit , , '
Is Issued, I shall not employ any person In any,manner so as to BOILER,BTU
become subject to,the Workers'Compensation Laws {
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' - - APPROVALS DATE INSPECTOR'S SIGNATURE J
Date' Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the.Workers'Compensation EVAPORATIVE COOLER
• ,provisions of e Labor Code, you must forthwith comply with such FINAL
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provisions or this permit shali be deemed revoked FURNACE FAU_GBA ITY s7
LICENSED CONTRACTORS DECLARATION / FLOOR BTU / O�p GS VALIDATION
I hereby affirm that,l am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license Is in full force and effect
32, 'q-O47X 27
License Numb - Lic Class i
-� 'Dat O'
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Plan check fee
1 am exempt under Sec Q
B&P C for this reason PERMIT ISSUING FEE$ 04�q 40 t, ., 0
Date TOTAL FEE
Signature ,' a
PLAN CHECK APPLICANT
OWNER-BUILDER'DECLARATION 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
Code) ADDRESS ;• ,-.r.„e E'..
❑ 1,,as owner of the property, or my employees with wages ,
as their sole`compensation, will do the work and the CITY TEL NO _Li _' ''„ til •i
-structure is not intended or offered for sale (Section 7044,
Business and Professions Code) OWNER ,`lLI t
❑ l,'as owner of the property,-am exclusively contracting MAIL il_)1 L':. "� 10 1�
with licensed contractors to'construct the project (Sec- ADDRESS� _
'tion 7044, Business and Professions Code) CITY TEL N r £'��;E`,.-• AFI,�. j.
v CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is,a construction lending agency for
I performance of.the work for, which this permit Is issued CONTRACTOR m
(Sec 3097,Civ C)
ADDRESS ” '
Lender's Name :�`
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' CITY TEL NQ:� G�� '•��{i t -
Ail is
Lender's Address STATE
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='1 certify,that I have read this application and state that the above LICENSE NO �f 9
G ASS C Z d a4~5
information is correct I agree to comply with all County ordinances
and State laws relating to budding construction,and hereby authorize
representatives of this County to enter upon the ve-mentioned ;
proper or ins ction rpose SEE REVERSE FOR EXPLANATORY LANGUAGE
OFA L ANT OR AGENT D E 1 _
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0003100002
-BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 11131 LT: 18 BL: .001 5638 GOLDEN WEST AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802520
ASSESSOR INFORMAT NUMBER: NEAREST CROSS STREET: LIVE OAK
8588-012-029 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED PRO BY: PLAN BY: EXPIRES ON:
30 AIR INLETS/OUTLETS 11.00 UNI 47.85 03/10/00 UT 09/06/00
TOTAL FEES 129.60
OWNER: TEL. NO: FINAL DATE FINAL BY ODE:
KU;
5638 GOLDEN WEST AV
TEMP 917802520 DESCRIPTION OF WORK
NEW HEATING AND COOLING SYSTEM FOR RESIDENCE
APPLICANT: TEL. NO:
KWOK (323) 728-7833-
109 E. FLORAL DRIVE SPECIAL CONDITIONS:
MONTEREY PARK, CA
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CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
INTERNATIONAL CONTROL (626) 917-1125-
16026 DOUBLE GROVE ST LIC. NO FAU/WAL
VALINDA, CA 91744 5904850-36
eCOMBUSTION AIR OPENINGS
ARCHITECT OR ENGINEER: DUCT WORK I vu
LIC. N0: 1111111 AC/COMPRESSOR
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* ADDITIONAL DATA ON FILE
REPORT ID: DPR264 ROUTE TO: BS0508