HomeMy Public PortalAbout9527 BLACKLEY ST_Mechanical__ 76 3644IC0818A)-9/77 APPLICATION FOR PERMIT
r' HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND,SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING G' /
(PRINT OR TYPE ONLY) - ADDRESS ��- - �`' r.
LOCALITY 1 -
N6 TYPE OF APPLIANCE OR EQUIPMENT FEE _ "
NEAREST
CROSS ST
ABSORPTION UNIT,BTU -
OWNER
•AIR HANDLING UNIT,CFM MAIL r- `
- ADDRESS
BOILER,BTU CITY TEL NO
COMPRESSOR,BTU` (� '
CONTRACTOR -�-
VENTILATION SYSTEM ADDRESS
EVAPORATIVE COOLER CITY, �G` �.STATE [ TEL NVl
FURNACE FAU_G yITY -0 LICENSE NO yr Q :?AyelO � CLASS
LIC
FLOOR BTU �!
HEATER SUSPENDED-' UNIT DISTRICT NO G,R/,O11 ZONES 4OCESSED_BY,/
WALL41r" /• L��✓
INSPECTION RECORD 0
' 0
Plan check fee 25% of above. 3d !L f Xl� G
PERMIT ISSUING FEE$ 0
TOTAL FEE-'
PLAN CHECK APPLICANT '
NAME ��J7• .�... ���• ,
ADDRESS
CITY �� J 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, VENTILATING, AIR
-CONDITIONING
I HEREBY CERTIFY THAT I AM NOT ACTING IN,VIOLATION OF APPROVALS DATE 1 SPECTPR S SIGNATURE,
CHAPTER 9, DIVISION 3, OF THE SIN S AND PROFESSIONAL CODE
OF THE STATE OFC IFQNIA ROUGH 7
SIGNATURE _ FINAL
OF PERM 17TEA �`•-
PLAN CHECK VALIDATION `CK M O CASH PERMIT VALIDATIO CK M O CASH
76 1N EB c1 4.1 p ,c<
19.50 ®� t,
WORKERS'COWDECLARATION 76A364C ,yy�� ,pp p� �[�
I hereby affirm that J have a'yertificate of consent to self CE -818 (2-80) l=1 ��l�l U ®1 CI ®� tlx/U ��
i ure, or(a�artif�cateGf Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
Es ce t' opy there f(Sec. 3800, I mob.C.)
t J/ �! 1
PolicyN f L'✓_Company �� 2 COUNTY OF LOS ANGELES
D Certified copy is hereby furnished. v BUILDING AND SAFETY
.Certified copy Is filed with the coun y buildi ..sr c'tion FOR�APPLICANT TO FILL IN BUILDING
Date,_,_- _YOAppIicant_� (PRINT OR.TVPE ONLY) ADDRESS
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION'INSURANCE NEAREST .}
(This section need not 'be completed if the work involved ABSORPTION UNIT, BTU CROSS ST, O
by the permit is for one'hundred, dollars ($100),or less.) DISTRICT NOPROCESS BY 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFML ti
permit is issued, I shall not employ any person in any manner O-
so as to become subject to.the Workers' Compensation Laws BOI LE R, BTU F-
APPROVALS DATE INS P Tf i'S SIGN URE LUU
Date Applicant ( COMPRESSOR,BTU �� I dd0
ROUGH Ibi IN'
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 VALID ION
With-comply with such provisions or this permit shall be w
deemed revoked ✓
LICENSED CONTRACTORS DECLARATIONFURNACE: FAU C R�fVIQT�Y
E FLOOR' BTU_3_S
I hereby affirm that I am licensed under provisions of Chapter° HEATER, SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust- WALL
ness and Professions Code,'and my license is m•full force and
effect.- j S'Cd 61
License Number� 23Ud Lie Class �-•�
Contractor_ d/V/V d Ot Dale_,;L-=A.> Y8 ;2 9 0&6•A
ElI am exempt from the licensing requirements as I am a%
licensed architect or a registered professional engineer -Plan check fee 25%of above.' # 8
acting in my professional capacity (Section 7051,•Bus- -
iness and Professions Code). PERMIT ISSUING FEE $1 3 0.5,O•
Lie.or Reg.No. Date TOTAL FEE .a'o'e 3,Q 5-0 v
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT F
02. 26;%88'
I hereby affirm that I am exempt from- the ContraCtor's. NAME
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code)- ADDRESS
OI, as owner of the property, will-do the work and the
structure is not intended or offered for.sale (Section, CITY ' TEL NO. P ;
7044, Business and Professions'Code).
OWNER
I, as owner of the property, am exclusively contracting
with- licensed contractors to construct theproject' MAIL' Q/� J�n7
/ 111`6141, 4X7
��Jj��'l
(Section 7044, Business and Professions Code). ADDRESS //J / !C T
CITY ' /� TEL:NO. v �J
CONSTRUCTION LENDING AGENCY Ie ” C."r -y �O !�0 Z l
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACT R
issued (Sec 3097,Civ C),, -4'�r/�
Lender's Name ADDRESS
Lender's Address CITYe_' TEL. NOf ?��7
I certify that I have read this application and'state that the STATE �•' LIC f�eJ n
above information is correct.I agree to comply with all County LICENSE NO. 3J CLASS,��lJt e�b
ordinances and State laws regulating Heating, Ventilating and ,
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon�,e
theabove-mentioned propertyy for
^gnat
n purpo
e of Permittee Date w