HomeMy Public PortalAbout5723 ROWLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA38 8 ((2-80) AZ Irk P��,fi i� `moi"�O II FOR
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I hereby affirm that I have a certificate of consent to self /=�Ir l=a II i�I II� IIS Ir LS Ifs 0711
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONINGS
T (Sec.3d_fTVcudY 28y00Li0c bF WAUSAU
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Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
® Certified copy is filed ith/th4unty building inspe FOR APPLICANT TO FILL IN BUILDING 5723 ROWLAND AVE.
Date�epartFpen$OApplicant (PRINT-OR TYPE ONLY) ADDRESS
CERTIFICATE OF EX 'MPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY TEMPLE CITYoe
COMPENSATION INSURANCE NEAREST �t!-'e� }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, PROCESSED Y L)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �.� y cc
permit is issued,.I shall not employ any person in any manner • O O
so as to become subject to the Workers'Compensation Laws. I BOILER,BTUt
' APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,BTU in nn CL
ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Z
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be r
deemed revoked. FURNACE: FAUN_f6bVI bTf
LICENSED CONTRACTORS DECLARATION Z FLOOR: BTUlll1— ZO 00
I hereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number 265094 C�20
Lic.Class ,
ContractorTRANE HCC Date 10-9"80
FT I am exempt from tl)e licensing requirements as I akn a
licensed architect or)a tegistered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ 7 00
Lic.or Reg.No. Date I TOTAL FEE 27 100
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
''
I hereby affirm that 1 am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Coda): ADDRESS �9 2 5 a,5 A
I, as owner of the property, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section # 0 0 a o 4 1
7044,Business and Professions Code).a OWNER : R"
I, as owner of the property, am exclusively contracting 2 ° - 27.00
with licensed contractors to construct the project MAIL SAM
(Section 7044,Business and Professions Code). ADDRESS o a a 2 7 0 0 U
CONSTRUCTION LENDING AGENCY CITY TEMPLE 'CITY TEL.No.286-3278 0 0 9_8 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR TRANE HCC
issued(Sec.3097,Civ.C.).
Lender's Name ADDRESS 2034 N. PECK RD.
Lender's Address CITY TEL.N
I certify that I have read this application and state that the
above information is correct.I agree to comply with all County l LICENSE No.. 265094 CLASS C-20
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby author' representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County enter upon the ab ention�roper for
e ion ur oses.
ignature of Permittee Date
.76 A364 - CE 818 - 9-71 APPLICATION FOR P RMIT
- HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING C�� o
DEPARTMENT OF COUNTY ENGINEER ADDRESS V
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST ,
CROSS ST.
FOR APPLICANT TO FILL.IN OWNER
(PRINT OR TYPE ONLY) d
- MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS
CITY ' l TEL. NO.
ABSORPTION UNIT, BTU
CONTRACTOR
AIR HANDLING UNIT, CFM '
ADDRESS
BOILER,•BTU "�
CITY TEL:,NOa:
COMPRESSOR, BTU STATE J - LIC.
LICENSE NO. / CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP E PRO SSED BY
EVAPORATIVE COOLER � 0 X
FURNACE: FAU_GRAVITY )NSP TION RECO" CD
FLOOR BTU
HEATER: SUSPENDED UNI C)
WALL . � S d u
CL
w
Z
Plan check fee 25% of above. See.reverse.
PERMIT ISSUING FEE S s 00
TOTAL FEE S O
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENT1- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING,AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY T AT I AM NOT ACTING IN VIOLATION `
OF CHAPTER 9, DIVISION OF THE BUSINPSS AND PROFESSIONAL FINAL /
CODE OF THE STATE OF ALIFORNIA.
SIGNATURE
PERMIT VALIDAT •N 'CK. M.O. CASH
isd
PLAN CHECK VALIDATION CK. M.O. CASH
3' 7 ;S: AUG.' 4 1 -D. 8 40.0~
SEE BACK OF APPLICATION FOR COMPLETE FEE SCMEOULF