HomeMy Public PortalAbout5742 GOLDEN WEST AVE_Mechanical__ VyORKER'S COMPENSATION DECLARATION. '20.0046 DPW 9/89 'LIME..,„GRft
76A364C APPLICATION• FOR PERMIT N'
I hereby,affirm that I have a certificate,of consent to self Insure,
or a certihcate'of'Worker's Compen'sat�on Insu�anc'e,or a certified. ur �`” HEATING,'VENTILATING 'AIR�CONDITIONING-
copy thereof(Sec 3800 Lab C) " - a `
Policy No' Company �`. >' COUNTY OF.LOS'ANGEL'ES, '- "'DEPT OF.PUBLIC WORKS,',; ',BUILDING AND SAFETY'DIV:
Certified copy is hereby furnished
❑' - " , e '' 'k-,1'' � - FOR'APPLICANT TO FILL'IN BUILDING G' `
Certrfled copy is fdeil with th county tiullding-inspection-, „ ADDRESS:J Ail,
department (PRINT OR'TYPE ONLY).; e s t^
Date Applicant l LOCALITY
• `+ ;.f NO TYPE OF APPLIANCE"OR EQUIPMENT _FEE '' r
a -�CERTIFICATE,OF EXEMPTION'FROM WORKERS'- r CROSS NEARESST'
COM OENSATION'INSURANCE "
ABSORPTION UNIT;BTU - ASSESSOR
(This„section need.not,be coin leted.if the work`mvolved,b 'the ” + ,t. '
n P ,.Y -� MAP_.BOOK' PAGE PARCEL•' ,
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM'
- DISTRICT NO PROCESSED BY , % ,
'1 certify,that Iii the performance of the work,for.whlch this permit
" is Issued, I shall not employ any•person in.any manner so as to BOILER,BTU
become subject to ihe'Workers'Compensation Laws _
r .� O' ,r /f A ,st �/�' �l COMPRESSOR.BTU — O
` '•,APPROVALS DATE INSPECT 'S SIGNATURE 4
Date ppli, z VENTILATION SYSTEM- r..r - j
NOTICE TO-APPLICANT If, after making this Certificate of „ ROUGH r
Exemption•,'you should,become subject to the Workers' Compensation k EVAPORATIVE COOLER " 1-7 provisions of the'Labor,CoBe, you must forthwith comply with such FINAL ,Z•
prov`isioris or-this permit shall be deemed"revoked ,' FURNACE 'FAU- ' tMVM
LICENSED'CONTRACTORS DECLARATION -FLOOR BTU/ ` d VALIDATION
I`h`ereby affirm*that I am fllcensed under provisions of Chapter 9 SUSPENDED, UNIT-
0
(cmmencing with Section 7000),of Division 3 of the.Business and HEATER WALL
Professions Code;and'timy license Is In full force and effect p3 y
License Nurr> ��i��h., Llc`Class G'.
Contract
ate- "-'er, 0
❑~ I am exempt under ec Plan check fee
.� B,&P C for this reason �° PERMIT,ISSUING FEE$. 7 y
9 Date TOTAL FEE !Y pg<, W,
s•y ;:, �
o I" -,Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT r - '_� co
- a. Z,
I hereby affirm that I am exempt from,the'Contractor,'s License Law NAME
:forrthe,following reason(Section 7031-,6 Business and Professions "' ` "'`°'• �_ '
Coe)- ," :" p o ADDRESS q r.:.•:•; 'g
„as owner of the property,or'MY employees with wages
'as their'^sole'com ensaiion,' w)II`do the work'and the
P - CITY -•t TEL NO'S
'structure Is not'Intended;oEoffered for sale (Section 7044, - 3{
<• Business and Professions Code) ' OWNER Jr "k 1v .np D
f1l!' -1,,as owner of the property;,am exclusively contracting
MAIL ''- �♦ - `" -r f-` _3.: iC.. "B't_
with,licensed.contractors to construct the project (Sec ADDRESS' !if/✓ad�� t�Y — -�
• ` tion 7044, Busmess'arid_Professions Code)
w CONSTRUCTION LENDING AGENCY CffY TEL NO' a;y• o-
he'reby'affirm that there.is a construction lending a ency'for• ?` -•f friiti' �,I�(;
the 8 CONTRACTOR' rA
performance of the work4for which this permit is Issued ,3
(Sec 3097,Civ C) x, `
-. w, •`�.� ...,6 - ADDRESS ,'• - `.I'..` 7i�` �Et� f;`' 4 r_�•'I"
L`endei's,Name
CITY TEL
-Lender's Address - a
('certify,that I have read this application and state that the above- LICENSE NO 3z`fj CLASS C Z
information is correct I agree'to comply with,all,County ordinances_ ,
and State laws relating to building construction,and hereby'authonze L
representatives of this County to•enter upon the-above-mentioned
Pro ert for:Inspection proses
SEE REVERSE FOR EXPLANATORY LANGUAGE .'�•i; ': •: - ^*•� �.?.
SIO_NATURE OF APPLICANT OR AGENT - DATE - . 'i ,
' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1212050007 -
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
ITR 6561 LT 455 UN 002 5742 GOLDEN WEST AV - -
IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917802503
ASSESSOR INFORMATION NUMBER I - _ NEAREST CROSS STREET. LIVE OAK
8587-028-016 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 597 GRID A3' LOCALITY TEMPLE CITY CAI
141 VENTILATION FAN 3 00 FAN 47 40
TENANT I TOTAL FEES 75 20 JISSUED ON PROCESSED BY PLAN BY.
12/05/12 SR
OWNER - TEL. NO IFINAL IIATE FINAL,,BY CODE
IPIERCE PAUL R (626) 209-0634-
15742 GOLDEN WEST AV
TEMP 917802503 - 1DE�(�RIPTION OF WORK
- IREPLACE 3 VENTILATION FANS
APPLICANT TEL NO
(SAME AS OWNER -
I _ ISPECIAL CONDITIONS
w
ICONTRACTOR TEL NO JAPPROVALS _ DATE INSPECTOR SIGNATURE
ISAME AS OWNER - _
I LIC. NO IFAU/WALL FURNACE
I ICOMBUSTION AIR OPENINGS
(ARCHITECT OR ENGINEER TEL NO I IDUCT WORK
1 LIC NO 1AC/COMPRESSOR 1
ITHERMOSTAT
IFIRE DAMPERS
ISMOKE DETECTION DEVICES
_ ICOMMERCIAL HOOD
REPORT ID DPR264 ROUTE TO BS0508 -
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0712100014
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
ILEGAL IDI FEES PAID BUILDING ADDRESS
ITR 6561 LT 455 UN 002 I 5742 GOLDEN WEST AV
I IFEE DESCRIPTION QUANTITY UOM AMOUNT 1 TEMP CA 917802503 1
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET 1
18587-028-016 101 PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID. A3 LOCALITY TEMPLE CITY, Cl
1 102 COMPRSR < 100 KBTU 1 00 COM 27 00 I_, I
ITENANT ' 108 FURNACE/HEATER <100 1 00 UNI 27 00 11SSUED ON PROCESSED BY- PLAN BY EXPIRES ON
I 154 NO PERMT $224 70 MIN 257 00 257 00 112/10/07 SR 06/07/08 1
1 TOTAL FEES 338 75 1
OWNER TEL NO IIFINAL F 'E FIN FJ{L�BY- CODE
IPIERCE PAUL R (626) 285-1083-
15742 GOLDEN WEST AV I I A
ITEMP 917802503 ' 1 IDESCRIPTION OF WORK 1
1 ri HVAC CHANGE OUT HIGH EFF FURN 95 & 15 SEER A/C
1APPLICANT TEL NO• I
IJORDANAIR (626) 963-3313- I I
1129 S HACIENDA AVE 11 ISPECIAL CONDITIONS 1
IGLENDORA, CA 91741
i
I
(CONTRACTOR TEL NO I ` _ _ - (APPROVALS DATE INSPECTOR SIGNATURE 1
IJORDANAIR INC (626) 963-3313-
1129 S HACIENDA AVE LIC NO IFAU/WALL FURNACE
IGLENDORA, CA 91741 560429C20B1
I ` 1 ICOMBUSTION AIR OPENINGS �-1 1
1ARCHITECT OR ENGINEER TEL NO j1 1DUCT WORK I I I
1 LIC NO 1 1AC/COMPRESSOR .71 -� I
7 I
I 1THERMOSTAT 1 I
'I IFIRE DAMPERS 1 1 1
I 11 ISMOKE DETECTION DEVICES I I
I �I I_ I I
I L'I ICONME.RCIAL HOOD 1 1
I I I
i I I I
1
I 1* ADDITIONAL DATA ON FILE
I 1REPORT ID DPR264 ROUTE TO BS0508 1 I I
I I I I I I