HomeMy Public PortalAbout9707 BLACKLEY ST_Mechanical__ 76 A364- CEO18- 5-73
APPLICA ON FOR PERMIT,
HEATING - VENTILATING - AIR. CONDITIONING
COUNTY'OF LOS ANGELES ADDRESS 70 IQC /c JQ
DEPARTMENT OF COUNTY ENGINEER
:BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST. rdxe
FOR APPLICANT TO-FILL IN OWNERL
(PRINT OR TYPE ONLY) 904 .1,
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MAI L
N0. TYPEOFAPPLIANCEOR EQUIPMENT ;FEE ADDRESS '7U GL L
CITY �� /�' TEL. NO. de
ABSORPTION UNIT, BTU l��
'CONTRACTOR Ott,'w
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY TEL. NO.
-COMPRESSOR, BTU STATE - LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. �GROUPbZONE CESSED BY
EVA PORATIVE.COOLER
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FURNACE: FAUGRAVITY INSPECTION RECORD
FLOOR BTU
/ HEATER: SUSPENDED UNIT_
WALL✓
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Plan check fee 255 of above. See reverse. z
PERiNUT ISSUING FEE 3 00
TOTAL FEE (�
PLAN CHECK APPLICANT
J�
NAME �0 �O Q'Q s
ADDRESS 0
CITY 4L6S goo TEL.NO.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALLORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OF
CHAPTER 9, DIVISI N OF TH USINESS AND PROF SSIONAL FINAL
CODE OF THE STATE 0 CA IFOR
SIGNATURE
OF PERMITTEE PERMIT- /VALIDA ION CK. M.O. C.SHJ) '
PLAN CHEC ALIDATION CK. M.O. CASH '
4 1 6 JUN '10 4 1 D 8.0 (),A98
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE - _
76A364C..
WORKERS'COMPENSATION DECLARATION CE:818 (2;80) Q p,p-,.q AST I Q N FOR PE R WT
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEA -TINGC®1�®ITI®1�1(r�Gi "
a certified copy thereof(Sec. 3800, Lab. C.) -•
Policy No. Company
Certified copy is hereby furnished. -
- COUNTY OF LOS•'ANGELES-""' .BU.ILDING.AND SAFETY _
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN- BUILDING
ADDRESS
department. �'7y aG
/ k�
Date Applicant (PRINT-OR TYPE ONLY) Q�J
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE . LOCALITY •�7 m n1� C' ,
COMPENSATION INSURANCE. NEAREST r '
CROSS ST. r ve_f A CL:,
(This section need not be completed if the work involved ABSORPTION UNIT,-,BTU _r Is
QiK `'I+ AV �._
by the permit is for 'one'hundred dollais ($100) or less.) DISTRICT NO. PROCESS'D BY (J
I certify that in the performance of the work-for which this AI,R-HANDLING.UNIT,.GFM
permit is issued, I shall not,employ any person in any manner ��L' Q
so as to become subject to dthe "lorke4rs' Compensation Laws. BOILER, BTUUAPPROVALS 'DAT'E -INSPECTOR'S•SIGNATURE- WDate _�0 8Applicant � COMPRESSOR, BTU ROUGH �' VNOTICE Cf APLICANT: r making this Certificate of VENTILATION SYSTEM �a
Exemption, you should become subject to the Workers' FINAL C=�
Compensation--provisions of the Labo,r Code, you must forth- IVE•COOLER .
with comply with such provisions or this EVAPORATIVE permit shall be VAI lDATION
deemed revoked. GI n�nCE.: .FAU _ GRAVITY
LICENSED CONTRACTORS DECLARATION �. 1-LOOR BTU�a.�l�c�d- (
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT'
9 (commencing with'Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code,and my license is in full force and
effect.
License Number Lic.Class -
Contractor Date
I am exempt from the licensing'requirements as. I'am-a 4 _
licensed architect or a registered-professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051,.Bus
iness and Professions Code). , PERMIT ISSUING FEE$
Lic.'or Reg.No. Date TOTAL' FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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
KIL, as owner of the property, Will do'•the work and the ( —/J5 2 2 A
-structure is:not intended or offered for sale Section .CITY. TEL. NO.
7044, Business and Professions Code). / o'o•0 0 0
n8
OWNER f _ _ #: ! ,
I, as owner of the property, am exclusively contracting• �.V) �O i UlF S l
with 'licensed contractors to construct the project MAIL G " L 2 ° °23;Q Q
(Section 7044, Business and.Professions Code)'. ADDRESS 1707 gJQG/C f 7
CITY �± TEL;NO ;0:0,6 2tl 0,0,v
CONSTRUCTION LENDING AGENCY `]-�pt'_��_c.i__ _ �^ O�
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. ;
I ceftify that I-have read this application`and state that the STATE CIC:
above information is correct.I agree to comply with all County LICENSE NO: CLASS _
ordinance's and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to, enter, upon
�the
�above-mentioned property for
LSisg—
p.0:�n pu• osel( `�•n .re of Permittee Date