HomeMy Public PortalAbout10022 DAINES DR_Mechanical__ 76P.364,-CCC&18 - 3-69 - APPLICATION FOR PERMIT
r HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS 0 iQe
BUILDING AND SAFETY DIVISION
JOHN A LAMBIE, COUNTY ENGINEER LOCALITY G
COLEMAN W. JENKINS,SUPERINTENDENT OF BUILDING NEAREST
CROSS ST
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY) OWNER c-
MAIL _
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS
ABSORPTION SYSTEM, BTU CITY TEL. NO
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AIR HANDLING UNIT, CFM CONTRACTOR
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BOILER, HORSEPOWER ADDRESS 0
CITY TEL. NO 1—
COMPRESSOR, HORSEPOWER ^� L5STATE LIC
LICENSE NO. Z CLA.SS G - 2
VENTILATION SYSTEM DISTRICT NO. GROUP /ZONE �PROCESSED Y
EVAPORATIVE COOLER
FURNACE• FAU GRAVITY
FLOOR BTU ���0� Cj J INSPECTION RECORD
HEATER* SUSPENDED UNIT a
WALL IAJ I/
CI-
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NEW—ADDITION— PERMIT $ 3 00
ALTER_REPAIR_ TOTAL FEE $
PLAN CHECK 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 ORDINANCES AND LAWS REGULATING HEATING,VENTI- APPROVALS DATE I CTOR'S SI ATURE
ATING, AIR CONDITIONING. ,
I i`VREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF ROUGH - '
CHAP,ER 9, DIVISION 3, OF THE USINESS AND PROFESSIONAL FINAL 7
CODE'OF THE STATE OF CALI ORNI .
SIGNATURE ) JACK R. ALLEN, EVI
RSING ECHANICAL ENG'R.
OF PERMITTEE '
PERMIT VALIDATI N cK. ! M.O. CASH
PLAN'CHECK VALIDATION
LAW a 1- 7 9,-' IlCS 11. 4 1 D 15-5 0,
=E BACK OF APPLICATION FOR COMPLETE FEE:SCHEDULE
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' 'WORKER'S COMPENSATION DECLARATION 76A364 DPW 9,69 APPLICATION FOR PERMIT LIME, KEEN
76A364C
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING'-AIR CONDITIONING i
copy thgeof°(Sec 3800 Lab C) ;
Policy NNo��D�'O o�3lCompanylA)9 /�s'1'len e-A COUNTY OF LOS ANGELES DEPT OF R`!BLIC WORKS BUILDING AND SAFETY DIV.
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certlfled copy Is hereby furnished •`
' FOR APPLICANT TO FILL IN ADDREBUILDISS D
Certified copy is filed`with the county building Inspection (PRINT OR TYPE ONLY) ADDRESS'•
de�partmen
Date, A hcant LOCALITY
pp NO TYPE OF APPLIANCE OR EQUIPMENT FEE ,
NEAREST
CERTIFICATE OF EXEMPTION FOOM WORKERS'.,, CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT',*BTU
This section need,not be com leted if the work involved b the ASSESSOR
( p Y MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY
A 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,BTUi.
become subject to.the Workers'Compensation Laws C� "
COMPRESSOR,BTU
APPROVALS - DATE + INSPECTOR'S SIGNATURE ;
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 - GRAVITY VALI ATION
�.. ,LICENSED_CONTRACTORS,DECLARATION FLOOR BTU
I hereby.affirm that I am licensed under provisions of Chapter 9 SUSPENDED " UNIT
(commencing wYaH Section 7000) of-Division 3 of the'Busmess and HEATER WALL
Professions Code,and my license is in full force and effect
/ a ,
License Number�!1112 f/ LIc Clas's
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Contracto e, [E ,iS_ .Tr 0
�' Plan check fee _
I am exempt under Sec ; r _ Q
y
7 5 t= =
B 8P C for this reason PERMIT'ISSUING FEE $ O
1—
Date TOTAL FEE: 1 GIF( E d" :z W
Signature o _HECK 71
- •a
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION {
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Z
iiNIUL
hereby affirm that I am exempt from the Contractor's License Law NAME i ( -
for the following reason (Section 7031 5, Business and Professions
Code), ADDRESS
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I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITYTEL,NO -ry ii r'e'•E,
structure is not intended or offered,for sale (Section 7044, L— )r 1
Business*and Professions Code) OWNER'
❑ I, as,ownen of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code)
r CONSTRUCTION LENDING AGENCY " CITY TEL'NO
I hereby affirm that there Is a construction lending agency for CONTRACTOR "
the performance of the work for which,this permit is Issued NER A r
(Sec 3097,Civ C)
ADDRESS r
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
information Is correct I agree to comply with all County ordinances
and State'laws relating to budding construction,and hereby authorize =r
,representatives of this County to enter upon the above-mentioned ,
Apro erty for,mspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNA R F AP I PLICANT OR AGENT DATE