HomeMy Public PortalAbout9247 KEY WEST ST_Mechanical__ i WORKER'S COMPENSATION DECLARATION �r 20-0046 DPW 9189 APPLICATION FO'R `I ` 1- IIT 1
76A364C ` LIME ;GREE-"
I'heretvy affirm'that I have a certificate of consent to self insure,
or a certificate,of WorkerTs Compensation Insurance, or a cerfified x r` HEATING,-VENTILATING,AIR CONDITIONING,
copy thereof(Sec 3800 Lab C)
Polley No ` ` ' Company COUNTY OF LOS ANGELES`' DEPT OF PUBLIC WORKS BUILDING AND SAFETY1DIV.,
❑• Certified copy Is hereby furnished
F Certified co Is'filed with the county building inspection _ FOR APPLICANT TO,FILL IN , BUILDING
copy g p PRINT OR TYPE ONLY), ADDRESS W'Ar ST _
_ 117
department � ( _ w ,•_ - _ - `
., t - F
Date Applicant ` { _ LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
.CERTIFICATE OF EXEMPTION,FROM WORKERS', CROSS ST
-,COMPENSATION INSURANCE ABSORPTION UNIT,BTU's ASSESSOR
(This section need not be completed if the work involved by the 1. MAP,BOOK PAGE,•• PARCEL"
permit for one hundred dollars($100)or less) i AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED By
I certify that In the performance of the'work for which this-permit
"` . v
Is Issued; I shall not employ any person in any manner so as to BOILER,BTU^
become subject to the Workers' Comp Insl, Law o
/ " COMPRESSOR,BTU 3(V
Date b A plicant APPROVALS DATE NSP,ECTOR S'SIGNATURE
P VENTILATION SYSTEM
NOTICE TO APPLICANT If, after make g this Certificate of ROUGH+
Exemption,you should become subject-to the Workers' Compensation EVAPORATIVE COOLER v 1
provisions of the Labor Code-, you must forthwith comply with such FINAL z
provisions or,this permit"shall be deemed revoked _' v FURNACE FAU G AVITY "
LICENSED CONTRACTORS DECLARATION ' FLOOR BTU VALIDATION �'''
11 hereby affirm that I am hcensed,under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
-_Professi,ns Code,and,my-license is In full-force'and.effect
. ' � yCd wit' - '�p.. e=0• - .. -�^
License NumberLlc Class• �- ,' _ -
Contractor Date ti 4 O
I am exempt under Sec Plan check-fee
B&P C for thisireason PERMIT ISSUING,FEE$
DateTOTAL FEE .' p-p W
s
SI naturePLAN CHECK APPLICANT t
OWNER-BUILDER DECLARATION a " 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) . 1, ADDRESS1 11II 1r n it
I, as owner of the property, or my employees with wages"
as their sole compensation, will do the work an-d the CITY TEL NO
,structure is not'Intended or offered for'sale (Section 7044,
Busmess,and Professions Code) OWNER , �f � a o 00'
I,-as owner'of,,the property, am exclusively contracting ' MAIL H
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code) CITY TEL NO
CONSTRUCTION LENDING AGENCY
I hereby affirm th'atrthere Is a construction lending a9ericy for CONTRACTOR'
the performance of the work',for which this permit is-issued
(Sec 3097,Civ C) s
k w ADDRESS
Lender's Name
CITY i/L �. TEL NO" a3'tic/ -
Lender;s Address
" Y LIC
STATE O CLASS thathaeread this'apphcation and state that the above LICENSE NO OInform'ation
y
Is correct I'agree to comply with,all County ordinances ,
and State laws relating to bullding'construction,and hereby,authonze-
representatives f this ounty to enter upon the above-mentioned ;^ r
props y for In ectron urposes s �, SEE REVERSE FOR EXPLANATORYLANGUAGE
'I
SIG RE A LICANT OR AGENT DATE , ` _' "# f •�_ - , ~ ' c
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0309080003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 16475 LT: 88 9247 KEY WEST ST
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803730
ASSESSORNEAREST CROSS STREET: RIO HONDO
8590-027-014 01 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J5 LOCALITY: TEMPLE CITY
02 COMPRSR < 100 KBTU 1.00 COM 27.00
08 FURNACE/HEATER <100 1.00 UNI 27.00 ON:
47 ALTER EXIST DUCT SYS 1.00 SYS 27.00 09/08/03 JK 03/06/04
TOTAL FEES 108.75
OWNER: TEL. NO: FINA DA CODE:
MAIDENS RANDY L (626) 287-4804-
9247 KEY WEST ST
TEMP 917803730 15,ff9LrRvr - .-RED
C/O FURNACE & A/C; ALTER DUCT SYSTEM
APPLICANT: .
SAME AS OWNER
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS D INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NOFAU/WALL FURNACE
COMBUSTION AIR OPENINGS
ARCHITECT OR R: --TEL. NO_- DUCT WORK
LIC. N0: C COMPR SSOR
THER MOSTATi
IRE DAMPERS
SMOKE CT DEVICES
COMMERCIAL HOOD
REPORT ID: DPR264 ROUTE TO: SS0508
' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 0704300008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
(LEGAL ID I FEES PAID BUILDING ADDRESS 1
ITR 16475 LT 88 I I 9247 KEY WEST ST 1
I IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917803730 I
(ASSESSOR INFORMATION NUMBER I 1 NEAREST CROSS STREET 1
18590-027-014 101 PERMIT ISSUANCE FEE 27 75 I THOMAS PAGE 596 GRID J5 LOCALITY TEMPLE CITY 1
1 102 COMPRSR < 100 KBTU 1 00 COM 27 00 I
(TENANT 108 FURNACE/HEATER <100 1 00 UNI 27 00 (ISSUED ON PROCESSED BY PLAN BY EXPIRES ON 1
I 147 ALTER EXIST DUCT SYS 1 00 SYS 27 00 104/30/07 JK 10/27/07 1
I 1 TOTAL FEES 108 75 1 I
1OWNER TEL NO I Fl.UAL DATE FI CODE 1
(MAIDENS RANDY L,PATRICIA C,LODWICK (626) 287-4804- 1 1
19247 KEY WEST ST
(TEMP 917803730 IDE CRIPTION F WORK 1
I C/O FURNACE & A/C ALTER DUCT SYSTEM
I I
(APPLICANT TEL NO I I
ISAME AS OWNER - I
I 1 (SPECIAL CONDITIONS 1
I I I I
(CONTRACTOR TEL NO 1 1APPROVALS DATE INSPECTOR SIGNATURE 1
ISA4E AS OWNER - 1 I I
I LIC- NO I - _ 1FAU/WALL FURNACE I 1 1
1 1 (COMBUSTION AIR OPENINGS I 1
I I I I I I
(ARCHITECT OR ENGINEER TEL NO (DUCT WORK I I I
I LIC NO 1 1AC/COMPRESSOR I
I 1 (THERMOSTAT 1
I I (FIRE DAMPERS 1 I 1
I I I I I I
I I (SMOKE DETECTION DEVICES I I 1
I I I I I I
I I (COMMERCIAL HOOD 1 I 1
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I I I I I I
I (REPORT ID DPR264 ROUTE TO BS0508 1 I