HomeMy Public PortalAbout6023 GOLDEN WEST AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR ' PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of.Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy.thereof (Sec 38000, Lab C ) 76A364C
—0O— 0 rjl J 1 •,1�,r ` CE-818(REV 10/81)' r_
Policy No Company
'Certified'copy is hereby furnished t COUNTY OF LOS ANGELES ` BUILDING AND'SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN- n- -- - BUILDING
tion department ADDRESS
" _ (PRINT OR TYPE ONLY) ,
Date Applicant LOCALITY �. L
NO TYPE`OF APPLIANCE OR EQUIPMENT FEE c..�
CERTIFICATE OF EXEMPTIOeRA
RKERS' _ NEAREST'
COMPENSATION CROSS ST -
(This,section need 'not be compleork Involved by ABSORPTION UNIT, BTUDISTRICT NO PROCESSED BY 'the permit is for one hundred door less.)
I cgrtify,that In.the performance,of the work for which this AIR HANDLING UNIT, CFM J 116
permit is issued, I shall not employ any person in any manner S V
so as,to become subject to the Workers'"Com pe nsati on Laws BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH ./S•
NOTICETO APPLICANT If, after making this Certificate of VENTIIATION•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
deemed revoked FURNACE FAU GRAVITY' -
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPEND UNIT
(commencing with Section 7000) of Division 3 of the•Busmess WALL /
and Professions Code,and my-license is in full force and effect d
License Number I?", v&'liLIc Class G� - V'
OC
Contractor Date 19 O
ED - _ F—
I a e empt under Sec'
Plan check fee h
B 8 UJ
for this reason Z
PERMIT.ISSUING FEE $ p
Date
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 s 8 1,7 A.
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO
7044, Business a-nd Professions Code)"
OWNER /`/ ;o'O
❑ j, as owner of the property, am exclusively contracting L 2 O.5 O
with licensed contractors'to construct the project (Sec- MAIL - - _
tion 7044, Business and Professions Code) ADDRESS G T o 0,0 Z 0,,5 O 5
CONSTRUCTION LENDING AGENCY e r
CITY �` ` ` ' � TEL NO '1012.&8-84
I hereby affirm that there is a construction lending agency for
the performance of the work fog which",this permit is issued CONTRACTOR - . •
(Sec 3097, Civ C ) r �� _ ,`
_
ADDRESSJ
Lender's Name cQ 4
CITY ill TEL NO
Lender's Address !1f 7
STATELIC '
I certifyr that I have read this application and state that the LICENSE NO 5 CLASS, - - -
above Information is correct I agree to comply with all County
ordinances,and State jaws relating to building construction, ;
and hereby authorize representatives of this County to enter
upon he bove: n Heel property for inspection purposes SEE REVERSE FOR EXPLANATO RY.LANGUAGE
' - '^ CLQ� l i" - - ' •' - - �- . .. - - - -
Sig e of Applicant or Agerit Date - _
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0209050009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BU WFS—S:
TR: 6561 LT: 93 6023DGOLDEN WEST.AV '
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801719 r
INFORMATIONASSESSOR NEAREST CROSS"STREET: LAS TUNAS '-
5385-019-008 01 PERMIT ISSUANCE FEE 27.75 THOMAS--PAGE' 597 GRID: A2 LOCALITY: .TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
30 AIR INLETS/OUTLETS 8.00 UNI 34.80 ISSUED ON: PROCESSED-BY: PLAN BY: EXPIRES
TOTAL FEES 89.55 09/05/02 -JK 03/04/03
OWNER: TEL. N %'; p. sr v'r=;',' "' J •`' _', FINAL DATE FINAL BY: CODE:
ROAN LEE H;PEACE A (626). 286-4987—
6023 GOLDEN WEST AV
TEMP 917801719 ) DESCRIPTION
ADD CENTRAL AIR
A L.
CONNOR A/C & HTG (626) 286-3157-
4931 ENCINITA AVE SPECIAL CONDITIONS:
TEMPLE CITY 91780
CONTRACTOR: TEL. N0: - "���� \� APPROVALS DATE INSPECTOR SIGNATURE
CONNOR A C (626) 286-3157-
4931 N ENCINITA LIC. NO FAU/WALL FURNACE
TEMPLE CITY CA 91780 403735 C38 p
COMBUSTION AIR 0 ENINGS
ARCHITECT OR ENGINEER: TEL. NO: DUCT WORK
LIC. NO•� ' I i i ��1111�1I ��,� AC/COMPRESSOR
THERMOSTAT
L1i� �� \ j,;' � � ��, i �� '� FIRE DAMPERS
_ , ,
COMMERCIAL HOOD
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* ADDITIONAL DATA ON FILE
REPORT ID: DPR264 ROUTE TO: BS0508