HomeMy Public PortalAbout6038 AGNES AVE_Mechanical__ 70A36#E ICS 818A) 9/77 '
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
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COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST
ABSORPTION UNIT BTU
OWNER
AIR HANDLING UNIT CFM MAIL
ADDRESS ac
BOILER BTU
CITY � � TEL NO�
COMPRESSOR BTU CONTRACTOR
Ah44 5L
VENTILATION SYSTEM ADDRESS O Ll)L d
EVAPORATIVE COOLER CITY-/ TEL NOFURNA
FLOORCE FAU BTU LICENSE
STATE LIC
LICENSE NO o2
'L7 W CLASS
/+ HEATER SUSPEN ED UNIT- /S DISTRICT NO GROUP ZONE PROCESSED BY
/ WALL (J
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INSPECTION RECORD d
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Plan check fee 25% of above 9
PERMIT ISSUING FEE$ ut
Z
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL NO
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THEeABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL
ORDINANCES AND LAWS REGULATING HEATING VENTILA G AIR
CONDITIONING
I HEREBY C FY TH T I AM N T ACTING IN ATION OF APPROVALS DATE SPECTOR S SIGNATURE
CHAPTER 9 DIVIS O 3 OF E BU SS AND PRO SS f NAL C E ROUGH
OF THE STATE OF FORN
SIGNATURE
FINAL /�^,
OF PERMITTEE
PLAN CH VALIDATION CK MO CASH PERMIT VALIDATION CK Mo CASH
i y
POLICY HOLDER.L 3 U� 14 r� �. 1 '7 0 0 ® �
,POLICY NUMBER. We C;2/6 S��-S-
k� - 76A364C - `t �'fr�G���C�,�'B,®N FOR PI�(�f�ilB`� -
eWC3)ZI��RS COMPENSATION DECLARATION`
h e�y aff►-nm that I have a � CE 818 (2 80)
a<
ertcficatb of consent to self
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) " r HE:ATIN,G VENTILATING-AIR -CONDITIONING
Policy No Company.
❑ Certified copy is hereby furnished' p COUNTY OF,,LOS ANGELES _x, BUILDING AND SAFETYa
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ' BUILDING
department it , ADDRESS , Iv ES
Date Applicant `� (PRINT OR TYPE ONLY), _
`
LOCALITY
- 'CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE "
Ne NEAREST -, a
`(This section Beed not be completed if the Work tnvOlved d i k ABSORPTION UNIT BTU } CROSS ST' /.ISS -T4N ar`'t f ox y O
by the permit is for one hundred dollars ($100) or less) r _ ,q DISTRICT NO PROCE� v U
T certify that in the performance of the work for which this AIR HANDLING UNIT CFM ' cr
permit is Issued I shall not employ any person in any manner O
` so as to become subject to the Workers Compensation Laws I" BOILER BTU a +
APPROVALS DATE INSIEC10 S Sl TURF W
Date�a�2��1plicant� �� COMPRESSOR BTU t1
ROUGH t 1 i tq
NOTICE TO APPLICANT If after making this Certificate,of * VENTI LATION SYSTEM .> "Z
.Exemption you should become subject to the Workers r� ¢ FINAL _ —
y--Compensation-pfbvisionsiof the�'Labor Codd-i ou'mustiforth` ° - �" r°� °' J' " L Ii� ``
with comply swith such provisions or this permit shall be EVAPORATIVE COOLER wa ALIDATION
deemed revoked � I . FURNACE FAU" GRAVITY—
LICENSED
O BTU r
LICENSED CONTRACTORS DLGLAR ATLON FLOOR 7
{ I hereby affirmtthat I,am,licensed under provisions of Chapter HEATER SUS NDED UNIT s r
9 (commencing with Section 7000)of Division 3 of the Busi ALL ' ` 00
ness and Professions Code and my license is in full force and
effect
�08b5A
s � ; }
ti
License Number Lie Class
y d
s y # o o s s 08
Contractor Date r
❑ I am exempt from the licensing regbi ents as'I am,a '� s - two ° 20.50
"
licensed architect or a registered professional engineer Plan check fee 25%of above M
acting in my professional capacity (Section 7051 Bus w o o e 2 Q 5 0
s mess and Professions Code) s 5 PERMIT ISSUING FEE $ �Q �'� a A $4y
F - 20 O v l�
Lie or Reg No Date 4 r -TOTAL FEE "
HOME OWNER BUILDER DECLARATION � ; ' ° PLAN CHECK APPLICANT
I hereby affirm that I am exempt from 'the iContractor s NAME-, J a
License Law for the following reason (Section 7031 5 Busi £ f
ness>and Professions Code) ADDRESS
y N
i❑ 1 A
I as'owner.of the property ;will do the work and the` ti CITY s �`� r ,'w a TEL tN0^
structure is not intended or offered-for sale (Section `
+�
b7044 Business and Professions Code)
t
..i ' ;s OWNER
Joftih �� a• s ,� S 4g* `� b t <> #.�� r
❑ �I as owner e'property am exclusively contracting r a 1
A with licensed contractors to construct the project MAIL � ,� ,� r P
(Section 7044 Business and Professions Code) r ADDRESS (o,6 3 � (�teQnr.a�., r y
A
CONSTRQUCTION LENDING AGENCY« CITY �� �i ITEL NO .�3°
I herebyaffirm that there is a construction lending agency m , a a - .Mq a v sF- wa + r 4
for the performances of the work for which,this permit',is �CON,TRACTOR ` �,
issued(Sec 3097 Civ, C) 1, � I n y �t , ti - NNS 8
s e - ADDRESS F 'r > +, B R ..
Lender s Name g Z 11� s
r Lender s Address " e�+ - , q
I A - CITY SP %NA , s STEL NO, g i'r 73
i - _
I certify,that I have�'read this application'and state that the j' STATE u" "LIC s+ a =
' above information is correct I agree to comply with all County LICENSE NO _ tf CLASS 3 r q t
i brdinances'rand State laws regulating Heating Ventilating and
Air Conditioning and,.hereby authorize representatives of this n SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above mentioned property for , z a a a w t f y
u"Spec
ion,purposes1_6 x
l l L 3 2 y ,a,1 ✓ d �� y `4� ti
a Signature of I ermittee Date
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