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76A364*CEBt B-R-BB - APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER '
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS J
COLEMAN W. JENKINS, SUPERINTENDENT OF BUI LOIN LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
(Print or type only)
OWNER
NO. TYPE,OF APPLIANCE OR EQUIPMENT FEE
MAI
ADD SS
ABSORPTION SYSTEM, BTU CITY TEL. NO."L�'` ZJ
AIR HANDLING UNIT, CFM CONTRACTOA
BOILER, HORSEPOWER ADDRESS
COMPRESSOR, HORSEPOWER CITY TEL. NO.W`�i',
STATEq IC.
VENTILATION SYSTEM LICENSE NO.� ZO �6foCLASS
DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE CO R c
FURNACE: FAU_GRAVITY Q ii
FLOOR—STU�y'� INSPECTION ECORD
HEATER: SUSPENDED—UNIT—
WALL
U
Ao—
W
d
NEW—ADDITION PERMIT S 3 00
ALTER EPAIR_ TOTAL FEE $ GD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
HEATING, VENTILATING, AIR CONDITIONING.
1 HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISIO 3, OF THE BUSINESS AND PROFESSIONAL
CODE OF THE STATE 0 ALIFORNIA. APPROVALS DATE INS P CTON'S SI NA RE
SIGNATURE gzw G - ROUGH S/t
OF PERMITTE [[[[�����AA.i���������
FINAL /L
DATION JACK R. ALLEN
CK. .O. CASH SUPERVISING MECHANICAL ENG'R.
599s;3 14AY1041 0 13.00- Z'
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
y`
WORKER'S COMPENSATION DECLARATION 76"UDPw 9/09 APPLICATION- 04PERMIT L�HE GREEN
BA3 4C
I hereby affirfn that I Rave a certificate of consent ro sell insure, (,J
or a certificate of Workers Compensation Insurance, or a certified - ,,,HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab.,C.) A, LI
Po�f� I I 9 Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Ceni/ied copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN gDDLRESS
daqment. t (PRINT OR TYPE ONLY)
Date Applicant
Applicant LOCALITY 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS SL
COMPENSATION INSURANCE
'ABSORPTION UNIT,BTU ASSESSOR
(This t Is for need not ed completed($1 0 the work Involved by the MAP BOOK PAGE PARCEL
permit Is for i onehundred
pe fetl dollars f the or lase.) AIR HANDLING UNIT,CFM DISTRICT NO. - PROCESSED ar
I certify that in.the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as t0 BOILER,BTU •fO�
become subject to toe Wgprkers'Compensation Laws.
COMPRESSOR,BTU Z QQ
Date—Applicant APPIRWALs DRV INSPECTOR'S SIGNATURE
pP VENTILATION SYSTEM -
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' CompensationEVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
previsions Or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATIONFLOOR BTU 70 Q- VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9, SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000) of Division 3 of the,Business and HEATER: WALL ,
Professions Code,and my license is in full forceffect.
- •.
U ,r o ' �" T _
License Number Lic.Class CCT.:
- .
aD :..�.: 90 0
Contractorhl�w ��( :7 .� 130.
Dat _ U
❑ I am exem t under Sec. Plan Check iBB _
0
B.BP.C.for this reason PERMIT ISSUING FEE$ 1 iT ®��� U
IL
Data: - - T07AL FEE �. .. - - 130.90 W
Signature /{���y� (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .NW'117E - .00 Z
1 hereby affirm that I am exempt from.the Contractor's License Law NAME 0000—yL101 8/24/95
for the following reason (Section 7031.5, Business and Professions _
Cade): ADDRESS 5A� D �!_J 1989 ' 1 AM10:27
❑ 1, as owner of the property, or my employees with wages V
as their sole compensation, will do the work and the CITY - TEL.No.
structure is not intended or offered for sale (Section 7044, 10157,14-M
Business and Professions Code). OWNER k/f AA
❑ I, as owner of the property, am exclusively contracting MAIL W� _
with licensed contractors to construct the project (Sec- ADDRESS L
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. -
1 hereby affirm that there is a construction lending agency.for CONTRACTOR -
.the performance of the work for which this permit Is issued - - - -
( AAh
Sec.3097,Civ.C.). r OA��l
ADDRESS Li a 1 - }f
v
Lender's Name _
CITY TEL.NO.
Lender's Address STATE -LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS (ter
information is correct. I agree to comply with all County ordinances
and State w latingto building construction,and hereby authorize 1 -
re resen is County to enter upon the above-mentioned
pro f ' spa pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT OAT