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HomeMy Public PortalAbout6013 GOLDEN WEST AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self i,isure, or a ertificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a-certified copy thereof (Sec. 380(', Lab. C. 76A36420-0046 DPW 9/88 Policy No. Company ❑ 'Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ElCertifiedcopy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /+ tion department. ADDRESS � -S (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE, CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. - C/!` (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCES BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM I certify that in the performance of the work for which this 5.1 permit is issued, I shall not employ any person in any manner so as to become subject to the War rs' Compe s Tion Laws. BOILER, BTU APPROVALS DATE NSPEC R'S SIGNATURE Date � � " Applican COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, afte .king this Certif cote of VENTILATION SYSTEM FINAL :— Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY t �� LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. � g— } O. License Number Lic. Class O U Contractor Date O 0 ❑ I am exempt under Seca Plan check fee W B.&P.C. for this reason. PERMIT ISSUING FEE $ H Date: Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): ; I, as owner of the property, or my employees with ADDRESS a^: a wages as their sole compensation, will do the work and ACC'T'g L, NO. -,3 _ ,�� the structure is not intended or offered for sale(Section CITY TEL. 37 �1ot(= ❑ 7044, Business and Professions Code). {OWNER d 1 e EMS I, as owner of the property, am exclusively contracting with licensed contractors to construct thero ect (Sec- MAIL tion 7044, Business and Professions Code). I ADDRESS TOTAL 1)AL 53� . 00 CONSTRUCTION LENDING AGENCY t, CITY TEL. NO. ��NEs:r. _y�e('I I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR , CYilyi3 .C_1f3 (Sec. 3097, Civ. C.). ADDRESS Lender's Name ' a c 'a .9 CITY TEL. NO. I�11;1�?y�-11E�I�1 i :tI 1t 0 Lender's Address ' I certifythat I have read this application and state that the STATE LIC. 01466 Ail 10 1 PP LICENSE NO. CLASS above information is correct. I agree to comply with all County ordinances and State ws relating to building construction, nd hLthori r presentatives of this County to enter u n te-me io ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Ap cant or Agent Date t� ©s COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0302250026 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: EGAL ID: FEES PAID BUILDING ADDRESS: TR: 6561 LT: 94 6013 GOLDEN WEST AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801719 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: WOODRUFF 5385-019-010 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A2 LOCAL-ITY:TEMPLE CITY 02 COMPRSR < 100 KBTU 1.00 COM 27.00 TENANT: 08 FURNACE/HEATER <100 1.00 UNI 27.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 30 AIR INLETS/OUTLETS 4.00 UNI 17.40 02/25/03 JK 08/24/03 41 VENTILATION FAN 1.00 FAN 15.75 OWNER: TEL. NO: TOTAL FEES 114.90 F104 45 E 6 SAPIA DANNY K;TERESA L (626) 287-1032- Ip� (.� 6013 GOLDEN WEST AV TEMP 917801719 DESCRIPTION OF WORK NEW HVAC, ADDITIONAL DUCTS FOR ADDITION PPLICANT: TEL. NO: SAME AS OWNER SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC. NO FAU/WALL FURNACE COMBUSTION AIR OPENINGS ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK / LIC. NO: AC/COMPRESSOR / THERMOSTAT FIRE DAMPERS SMOKE DETECTION DEVICES COMMERCIAL HOOD REPORT ID: DPR264 ROUTE TO: BS0508