HomeMy Public PortalAbout4940 ARDSLEY DR_Mechanical__ 76 A364- CE 818- 5-73
APPLidATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES AU L'EIN C Al. A SCS U
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY C f'
NEAREST'EAREST.
CROSS ST: C/ 131 VO. -tk0WCK AZl�
FOR APPLICANT TO FILL IN OWNER -
(PRINT OR TYPE ONLY) I C"en V foAl
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS p ' •. A 0SL6 VR
CITY `/ TEL. NO. Zd
ABSORPTION UNIT, BTU
CONTRACT0
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY TEL. NO.
COMPRESSOR, BTU STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE �71ESSED BY
EVAPORATIVE COOLER ( Q f
FURNACE: FAUGRAVITY
FLOOR BTU INSPECTION RECORD
HEATER: SUSPENDED UNIT_ yy
/'. WALL �J ?-
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Plan check fee 255 of above. See reverse.
PERMIT ISSUING FEE S 3 .00
'TOTAL FEE 0
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY- ..- TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
'AND STATE.THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH /
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION _ � __j
OF CHAPTER 9, DIVISION 3,.OF THE BUSINESS AND PROFESSIONAL FINAL �-
CODE'OF THE STATE OF CA FOR NI A.•,
SIGNATURE o PERMIT VALIDATION CK. M.o. cA.sr+
OF PERMITTEE
PLAN CHECK VALIDATION CK: M.0. CASH
9 3'.7 r4'2''FE8 24.4.1 D 8.0 (D A
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE .
WORKER'S COMPENSATION DECLARATION - 720-0046 6A364C PW,9/69. QP P UCATION FOR PERMT
Ctiierebyaffirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or:a•certified HEATING -VENTILATING-AIR CONDITIONING u lir uuuu �J u�«t���LLL���LLLIII UUU
copy thereof(Sec.3800 Lab. C.) f J
Policy No. r ?ompany COUNTY.OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING•AND SAFETY'DIV.
El . Certified copy is hereby furnished.
❑ Certified copy'is filed with the county'building inspection" FOR APPLICANT TO FILL IN BUILDING
department. ,r 1t�i0» G-A ,B ♦ (PRINT OR TYPE ONLY) ADDRESS
Date S. G—�— Applicant N J-!q #a LI u .. j LOCALITY
., NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE
NEAREST �A
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST (-f G10-- .
COMPENSATION INSURANCEABSORPTION UNIT,BTU
(This section need not be.completed if the work involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is,for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DIsrRlcr No. PRoeesseD av
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. cP1 !J
COMPRESSOR,BTU 0 .-
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICP',Tb APPLICANT:. If, after making this .Certificate of ROUGH.
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER q
provisions,of the Labor Code; you must forthwith'comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU—GF3AVTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU D C1 VALIDATION
I hereby-affirm that I am licensed under provisions of Chapter 9SUSPENDED' UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL
Professions Code,andmy license is in full force and effect.
License Number 11/3 7 T Lic.Class ``KJ ( l� a.
Q j
_
Contractor iSkVIMA LL IIA. Date V
I am;exept under Seca Plan Check fee �
m
B.&P.C.for this reason PERM IT,ISSUING,FEE$ O
Date: TOTAL FEE D O a
Signature
PLAN'CHECK APPLICANT '�.
OWNER-BUILDER DECLARATION 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 fvK hA C�
/
/ / !"/n��U`� .D
Code) - ADDRESS 3. /���„�f ',! ' V
❑ I as owner of the property, or my,employees with'wages V,�' 'C I °
as their sole compensation,.will:do the work.'and the CITY /'' TEL.NO. i ? ,
structure is not intended or offered-for sale(Section 7044, t�1
Business and Professions Code). OWNER T G
❑ c
.l, as owner of the property, am exclusively contractingMAIL IF -v -
with licensed contractors to`construcf the project (Sec- ADDRESS s a I(sL _3 i'm 3J+ a
tion 7044, Business and Profession's Code). ?
CONSTRUCTION LENDING AGENCY CITY ! TEC NO.
tt
I hereby affirm that there is a construction lending agency for'. ti�E it31= I;;
the performance of the work for which this permit Is issued CONTRACTOR
(Sec. 3097,Civ:C.). D
ADDRESS G&
Lenders Name
CITY NO. r . -
Lender's Address �. /1 �I�7s1 i A E�'CIL
STATE LIC'.• •; fsr.i.• .; _
I certify that I have read this application and state that the above LICENSE NO. CLASS C.�S
information is correct. I agree to comply with all County ordinances _
and State laws rela'
to building construction,and hereby authorize
representatives is Co y t(r enter upon the above-mentioned
property for i ection poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APP CANT OR AG NT DATE -