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Home My Public Portal About5428 CAMBURY AVE_Mechanical__ 'GASISLEICE-BIBA)'9/77 APPLICATION FOR PERMIT. HEATIN ENTILATING - AIR ND IONING ' COUN LOS ANGELES DEPARTMENT OF COUNTY ENGIN R , BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN BUILDING (PRINT ORTYPE ONLY) ADDRESS _ LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE - - NEARESTCHO NEARE ABSORPTION UNIT. BTU - OWNER / i �' � .ALJ AIR HANDLING UNIT.CFM MAIL - /�• ,/�/��J - BOILER.BTU CITY/ /Z- TEL.NO. �7fJC� L ! COMPRESSOR,BTU CONTRACTOR// f eAj +�d NJ VENTILATION SYSTEM ADDRESS EVAPORATIVE COOLER - QTY Qi� TEL.NO pr&-Y� FURNACE: FAU GRAVITY STATE �Q S�l� CLASS FLOOR TU S� LICENSE NO. L ` (J HEATER: SUSPENDED U IT— D: TRIC N ORauP ZONE PRDc BEDBY WALL �-- -I ' 5. -3 ,P INSPECTION RECORD • OC Plan check fee 25% of above.. PERMIT ISSUING FEE$• 45-0 Z TOTAL FEE PLAN CHECK APPLICANT NAME ADDRESS - CITY TEL.NO. IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND, STATE THAT THE ABOVE 15 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 APPROVAL5 DATE INSPECTOR'S SIGNATURE CHAPTER 9. DIVISION 3. OFTHEJ.41NESS AND PROFESSIONAL CODE ROUGH �a OF THE STATE OF CALIF SIGNATURE FINAL -, OFPERMITTE PLAN CHEC ALIDATION CK, - m.o. cnsH PERMIT VALIDATION cx. M.o. CASH - gL-f'>>S COMPENSATION '-POLICY HOLDER: _ ,�-� 867nFEB 284.1 �" `�" "" �"� 1) POLICY NUMBER: 3 �7I/2 5_1- 7� � WORKERS'COMPENSATION DECLARATION { CE SIC APPLICATIONF-OR PERMIT I hereby affirm that I have a certificate of consent to self I CE -81APPLICATION insure, or a certificate of Workers'Compensation Insurance,or r• HEATING-V ENTILATING-AIR- CONDITIONING - acertified//rop^�elIhJ/erFFof(Sed.3800, L�+F�:�rrl/gyp �J//J - Policy No.F+ 7hW Company— ^"�—t= \— —r ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES / �• BUILDING.AND SAFETY �� Certifiedy copy is filed with .o,l�nldmyction FOR APPLICANTTO FILL IN BUILDINGazI� t _ Applicant— CERTIFICATE ADDRESSDate9- Applicant_ (PRINT OR TYPE ONLY) LOCALITY I n CE RTI FICATEOF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE COMPENSATION INSURANCE - 'NEAREST (This sebtion need not be completed if the Work involved ABSORPTION UNIT, BTU CROSS ST. by the permit- is for one hundred dollars (SI00) or less.) OISTRICTNO. PROCESSE ev O I certify that in the performance of the work for which this `` AIR HANDLING UNIT,CFM— [Ch O/ Cr permit is1ssued, I shall not employ any person in any manner v l7 6 O so as to become subject to the Workers' Compensation Laws. BOILER, BTU - . I ��•t APPROVALS DATE INSPECTOR'S SIGNP.TURE U Date_ Applicant COMPRESSOR, BTU AV p� ROUGH • d NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM Exemption, you should become subject to the. Workers' FINAL rZ Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shell be deemed revoked. FURNACE: FAU— GRAVITY—:- LICENSED RAVITY_LICENSED CONTRACTORS DECLARATION FLOOR: BTU ' 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, andmy license is in full force and - LicenseNumber Y=��/(��3f5W�(7/�j0 Lie.Clens ,, Con[racto[_fd%2 ,= .Date ❑ 1 am exempt from the licensing requirements as 1 am a - - licensed architect or a registered professional engineer Plan Check fee 25%of above. - acting in 'my professionalcapacity (Section 7051, Bus- iness; us- - PERMIT ISSUING FEE $ ��• O - - inessand Professions Code). Lie.or Reg,No. Date TOTAL FEE A.X a- - HOMEOWNER-BUILDER DECLARATION PLAN.CHECK APPLICANT - 1 hereby affirm that 1 ani`exempt from-.the Contractor's NAME - -;',41'r7,18 A License Law for the following reason (Section 7031.5, Busi- - t #N ness and Professions Code): ADDRESS Is,• e`• 8 ❑ 1, as owner of the broperty, will do thework and the 2'-,'-.2.212 5structure is not intended or offered for sale (Section CITY TEL NO. q 7044, Business and Professions Code). - • • • 22 2 J`c=a ❑ OWNER 1, as owner of the property, um exclusively contracting O 4 2�+-8 4 with licensed contractors to construct the protect 'MAIL (Section 7044 Business and Professions Code) ADDRESS CITYTEL. NO. CONSTRUCTION LENDING AGENCY - I hereby perform that there rs a k for phis p agency for the affirm that there the work for wlrrefi this eager is issued (Sec. 3097,Civ.C.). / - - Lender's Name ADDRESS %`/ (A,', �. /JCC/JZ (J•Q . Lender's Address CITY •A`-I/T/-�'�N�• ;, TEu.'NO. WY-612—Y'7 I certify that: I have read this application and state that the STATE �L LIC. 1 above information is correct.I agree to comply with all County LICENSE NO. ` T '70 CLASS (1 - - - anand $[ate laws regulating Fteating. Ventilating.andAirondnSEE REVERSE FOR EXPLANATORY LANGUAGE Coonto,�vdm5 I. 'Ignature of Permittee Date - • ,- - _ DEC TION s WORKERS t I have a certificate cafe of corse APPLICATION FOR PERMIT h6 e y affirm that I have a certificate of consent to self I or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) 76A364c HEATING - VENTILATING - AIR CONDITIONING / - - CE-818(REV. 10,81) �Policy No. Compony Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department ADDRESS (PRINT OR TYPE ONLY) Date - Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DiSTRiR NO. vROCESSED BY the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you -should become subject To the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAL % GRAVITY LICENSED CONTRACTORS DECLARATION / FLOOR - BTU hereby affirm that i am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ Y ommencing with Section 7000) of Division 3 of the Business WALL a d Professions Code, and my license is in full force and effect. O U ense Number Lic. Class ' m LL nlractor Date am exempt under Sec. at Plan check fee B.BP.C. for this reason 'r 0 O Date: PERMIT ISSUING FEE $ Z. Signature TOTAL FEE e w a w OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT reby affirm?hat I am exempt from the Contractors License , for the following reason (Section 7031.5, Business and NAME essions Code): • < a G I, as owner of the property, or my employees with ADDRESS - wages as their sole compensation, will do the work and CITY TEL NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY TEL NO. reby affirm that there is a construction lending agency for , erformance of the work for which this permit is issued CONTRACTOR 3097, Civ, C). ADDRESS is Name CITY TPI NO is Address STATE LIC ify that I have read this application and state that the LICENSE NO. CLASS information is correct. I agree to comply with all County onces and State laws relating to building construction, ereby authorize representatives of this County to enter the-above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE e of Applicant cT Agent Date