HomeMy Public PortalAbout9405 BLACKLEY ST_Mechanical__ 6 -
C EMB:► - 9-7 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
FBUILDINGu /� /'COUNTY OF LOS ANGELES '/O J�{,(� ��DEPARTMENT OF COUNTY ENGINEERBUILDING AND SAFETY DIVISION /P SS r "o
FOR APPLICANT TO FILL IN OWNER ''J('`
(PRINT OR TYPE ONLY) v� e
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MAIL
NO TYPE OFAPPLIANCEOR EQUIPMENT FEE ADDRESS SC7 121
CITY TEL NO";�
ABSORPTION UNIT, BTU
CONTRACTOR
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY TEL NO \`
COMPRESSOR, BTU STATE LIC \
LICENSE NOV CLASS
VENTILATION SYSTEM DlsrRlcT No GROUP ZONE CESS ED By
EVAPORATIVE COOLER
FURNACE FAUGRAVITY
FLOOR BTU INSPECTION RECORD c�
HEATER SUSPENDED UNIT_ O
WALL U U
W
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Plan check fee 257. of above See reverse
PERb9IT ISSUING FEE 8 3 Oo
I OTAL FEF U
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 SPECTOR' SI ATURE
LATING, AIR CONDITIONING `
ROUGH
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL FINAL
CODE OF THE ST TE OF CALIFORNIA
SIGNATURE PERMIT VALIDAkjbh
OF PERMITTEE CK M 0 CASH
PLAN CHECK VALIDATION CK M 0 CASH
L A Cc, 07Z w ,` t-A j 2. a.
EE
EE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
WORKERS'COMPENSATION DECLARATION C6A3$$C(2 80) AP
"pIL IC AT B O "tl FOR P E R Il�lf T "
I h,,+reay�af`Irm that I have a certificate of consent to self
insure -or,a c';rtificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR AT.ING-AIR CONDITIONING _
a certified copy thereof(Sec 3800, Lab C)
Policy No Company s
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished - "
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department
Date Applicant (PRLNT OR TYPE ONLY) ADDRESS �S
aNO TYPE OF APPLIANCEOR EQUIPMENT FEE LOCALITYoe
r "b'
' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT, BTU - CROSS ST 7 . d ,
by°the permit is for one hundred dollars ($100) or less) DISTRICT NO PROCES,ED BY UO
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, 1 shall not employ any person in any manner 0
so as to become subject to the WoN ers' C�op�m,safn BOILER, BTUO
CL
� it 1 COMPRESSOR, BTU— °PPROVALS DA INSP ORSSIGNAT W
Applicant _ ROUGH LLI `
'NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM rn
Exemption, you should become subject to the Workers' FINAL Z
Compensation provisioris of the Labor Code, you must forth-
with comply with sudh provisions -or this permit shall`be p EVAPORATIVE COOLER VALIDATION L
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU
I hereb affirm that I am licensed under provisions of Chapter Y p p HEATER SUSPENDED— UNIT" 1
9 (commencing with Section 7000) of Division•3 of the Bust WALL
ss and Professions Code, and`my license is in full fotce and /
ect [.�
rise Number �� ��Lic Class (
actorb�' Date �/`� -0 / ► f,
m exempt from the licensing requirements as I am a <:
nsed architect or a registered professional engineer_ Plan Check,fee 25%Of above -
g in my professional-capacity (Section 7051, Bus- � "
iii.._ and Professions Code) PERMIT-ISSUING FEE $
Lic or Re No Date ni .�
_ s _ ., - TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT y _ r
I hereby affirm That I am exempt from-the Contractor's NAME � '�
License Law for the following reason (Section 7031'5, Bust- n^ ,- ��{� 4
ness and Pr4essions Code) ADDRESS, 11 .�C V3� A � � `, 49.7-1
1, as o+vner of the property, 'will do the work(nd the CITY, /(/Y// "�"��'���"///```"'''" TEL NO 06V3 HANG
structwe is not intended or offered for sale (Section"
t, w
7044, Business and Professions Code) + i
OWNER Y =2 •, _
I, as owner of the property, am exclusively contracting s, t Tr` r
with licensed contractors to construct • the project MAIL tll[ "�11�� ��3uf+�
(Section 7044, Buqiness and Professions Code) ADDRESS_=� � ��� t epi �•��
i CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending agency
for' the performance of the work for which this permit is CONTRACTOR
issued(Sec 3097,Civ C)
Lender's Name ADDRESS _
Lender's Address CITY - •TEL NO - e -
I certify that I have read this application and state that theSTATE LIC
&
above information is correct I agree to comply with all County LICENSE NO CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE-
Co,•nty to enter upe- the above-mentioned properly for
ieco n iu,io
Signature of Yerniatee Date