HomeMy Public PortalAbout10330 KEY WEST ST_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' Compens6tion Insurance, HEATING - VENTILATING - AIR CONDITIONING
or'a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
a } _{ /�_ CE-818(REV. 10/81)
Policy No.(O 6137- Company l l4 l� l llU
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDI G AND SAFETY
�- Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING IT
tion department. 1 /) (PRINT OR TYPE ONLY) ADDRESS i
Date Applicant EJ-S /9 t Q CnAJJ1�toA�� LOCALITY C� �l
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST. 1 GlX'
COMPENSATION INSURANCE
ABSORPTION UNIT, BTU DISTRICT NO. PROCESS v
(This section need not be completed if the wo involved by � fi
the permit is for one hundred dollars ($10 or less.) �o(
I certify that in the performance of the ork for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ a person in any manner
so as to become subject to the W ers'Compensation Laws. BOILER, BTU APPROVALS DATE INSP TOR'S SIGNATURE
COMPRESSOR, BTU '4%opo ROUGH
Date icant
NOTICE TO /ushou
T: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, ld become subject to the Workers' ,
Compensati0sions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or This permit shall be 61
deemed revoked. t FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU��.�0
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number 30 53 1�Lic. Class C 0-0 V
I s yrs l�S
Contractor`� evCeY Date 10 2S/ 5
a2 q_e.'t.xrn1 d L C_+5 '—d O
❑ 1 am exempt under Sec. LU
U
Plan check fee
B.BP.C. for this reason 9LPERMIT ISSUING FEE $ 3 2 7.2;A Z
Date:
TOTAL FEE # o.o 0 0 0 8
Signature
OWNER-BUILDER DECLARATI N PLAN CHECK APPLICANT I,'° ° 4 4,5 0.
I hereby affirm that I am exempt from th ontractor's License ,
Law for the following reason (Sectio 7031.5, Business and NAME ° ° ° 4 4 5 O.;c=Y
Professions Code):
❑ I, as owner of the prop ty, or my employees with ADDRESS I Q 2 4`'85
wages as their sole co ensation,will do the work and
the structure is not in nded or offered for sale(Section CITY TEL. NO.
7044, Business and rofessions Code).
❑ OWNER 11.E s
I, as owner of e property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL J 0 „
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
theerformance of the work for which this permit is issued
P CONTRACTOR ��S
(Sec.. 3097,.Civ. C.).
ADDRESS GL
Lender's Name v G /J.
Lender's Address
CITY /1"'t z_tsi TEL. NO. h
STATELIC.
I certify that I have read this application and state that the LICENSE NO. -305 3 l 'i CLASS —;/
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-menti one property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
10.A f g"-51
Signature of Applicant or Agent D to
l
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1011240005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID I BUILDING ADDRESS: I
ITR: 36735 LT: 10 1 10330 KEY WEST ST I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803476
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: HALIFAX
18585-018-074 101 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl
141 VENTILATION FAN 2.00 FAN 31.60 I
(TENANT: I TOTAL FEES 59.40 JISSUED ON: PROCESSED BY: PLAN BY: I
I I 111/24/10 SR
I I I 1
1OWNER: TEL. N0: 1 IF AL DATE FIF BY: CODE:
ITRAN, WILLIAM (626) 862-1778- 1 1 --
110330 KEY WEST ST I 1
(TEMP 917803476 I (DESCRIPTION 6F WORK
I I ITWO VENTILATION FANS FOR BATHROOMS REMODEL
1
(APPLICANT: TEL. NO: I I
IWENDT, RON (626) 497-6320- ( I
I ISPECIAL CONDITIONS:
I
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(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
IWENDT AND SONS CONSTRUCTION (626) 497-6320- 1 1 I
16149 LOMA AVENUE LIC. NO I 1FAU/WALL FURNACE
(TEMPLE CITY, CA 91780 432646 I 1 I 1 I
I (COMBUSTION AIR OPENINGS I 1 1
(ARCHITECT OR ENGINEER: TEL. NO: IDUCT WORK
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1 LIC. NO: 1 1AC/COMPRESSOR I I I
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I (REPORT ID: DPR264 ROUTE TO: BS0508
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