HomeMy Public PortalAbout9969 BROADWAY_Mechanical__ 76 A364 - CF 819-1/75
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING ` . p At^
DEPARTMENT OF COUNTY ENGINEER ADDRESS ¢ �-C
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER J�
(PRINT OR TYPE ONLY)
NO. TYPE&SIZE OF EQUIPMENT FEE ADDMAIL �� A
ADDRESS U3�'
SEE BACK OF APPLICATION
FORCE AIR FURNACE, BTU CIT\'ter Vjr /� ATV TEL. NO. ., c,�1(`! (�1? 1
��� CONTRACTOR c� CI
1` ` �-O {1.
COMPRESSOR, BTU p=_ L� Uv
ADDRESS fv�
VENTILATION FAN
CITY TEL. NO.
LIST ALL OTHERS BELOW STATE LIC.
LICENSE NO. CLASS
DISTRICT NO. GROUP ZONE PROCESS EO BY
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INSPECTION RECORD
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Plan check fee. See reverse. z
P P:RII I'f LSSI-IAC flS h: & 3 00
PLAN CHEC 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 ORDINANCESAND LAWS REGULATING HEATING, VENT[- APPROVALS DATE INSPECTOR'S SIGNATURE
LATINS, AIR CONDITIONING.
ROUGH 19
HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION 9
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL FINIAL L "
CODE OF THE STAT O IFOR NI P. (�
SIGNATUPE PERMIT VALIDATION cK M.D. CASH
OF PERMITTE
PLAN CHECK VALIDATION CK. M.D. CASH
5 9 3i`JUN 5 4 1 U 1 3. A;b
rn)Ith WORKER'S COMPENSATION PENSATION DECLARATION 76004fi DPW 9/89 APPLICATION FOR PERMIT `IME GREEN
I hBYeby yf?irm that I have a certificate of consent to self insure, 76A36aC
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING �I
copy thereof(Sec. 3800 Lab. C.) u
Policy 140,7w-750Company dX!rA ' PAIL-30 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
IN
Certified copy is filed with NFOR APPLICANT TO FILL IN A11Re county building inspection ADDRESSG
depa�N nt. (PRINT OR TYPE ONLY) '
LOCALITY
v NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
Date Applicant
AREST C-
NEq1
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. U�WI
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed It the work involved by the ASSESSOR /�i �v/
PAGE
permit is for one hundred dollars($100)or less.) MAP BOOK PARCE
AIR HANDLING UNIT,CFM olsrncr No. PROCESSED By
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws. s� n ,Q
��
COMPRESSOR,BTU G TO�•f K
APPPOVALe HATE INS CTOR's 51GNANPE
Date Applicant VENTILATION SYSTEM -
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ,
provisions or this permit shall be deemed revoked. FURNACE: FAU_GRAVITV
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Business and.
HEATER: WALL—
Professions
ALL Professions Code,and my license is in full farce and effect.
I �(.q '
License Number 4� Lic.Class .05 �• ,•
► nV_ I .a .
Contractor r Date HOI-cl� Ts.41r O
❑ Plan check fee ? 1
am exempt s rI cit U
under Sec. TOT
I AL 9� 9
a 0t R
8.&P.C.for this reason PERMIT ISSUING FEE$ T _ O
[:t-IE�;� "I H
Date: TOTAL FEE L)
Signature CHhPsuE •'I LU
1 a-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (n
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I hereby affirm that I am exempt from the Contractor's License Law NAME �'i j 1 r1�ryr_i
for the fallowing reason (Section 7031.5, Business and Professions , I1013 11,0 . :.
Cade):
F-1ADDRESS 1`r�n
I, as owner of the property, or my employees with wages 6472 1 HhS1•�_
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER I
F-1 1. as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Cade).
CONSTRUCTION LENDING AGENCY CITY <T c , TEL.NO.
hereby affirm that there is a construction lending agency for CONTRACTOR:' Pr�� ,
the performance of the work for which this permit is issuedpq
(Sec.3097,Civ.C.).
ADDRESS !'-V.n A l eye
Lender's Name r✓I`.
CITY TEL.NO.- O
Lender's Address STATE LIC. C•
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
prop inspection pu oses. SEE REVERSE FOR EXPLANATORY'LANGUAGE
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SIG TUBE FAPPIL IT OR AGENT ATE