HomeMy Public PortalAbout10564,10600 DAINES DR_Mechanical__ 76 A 364- C E 8 1 8 - 5-73
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING '1
DEPARTMENT OF COUNTY ENGINEER ADDRESS 1O 64 INES -f.
BUILDING AND SAFETY DIVISION LOCALITY TEMPLE CITY
NEAREST r / k _/f9a
CROSS ST. l• l
FOR. APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) O E E
MAIL TTom�
NO. TYPEOF APPLIANCE OR EQUIPMENT FEE ADDRESS 10564 DA
CITYTEMPLE CITY TEL. N0. 443-7193
ABSORPTION UNIT, BTU
AIR HANDLING UNIT, CFM CONTRACTOR AQUATIC
ADDRESS 101 E. HMINGTON DRIVE
BOILER, BTU j9, moo ARCADIA 446-4661
� CITY TEL. NO.
COMPRESSOR, BTU STA E LIC.
LICENSE NO. 315620 CLASS C-53
VENTILATION SYSTEM DISTRICT NO. GROUP /n�ZONE PROc SED BY
EVAPORATIVE COOLER ,jf, O e �"
FURNACE: FAUGRAVITY
FLOOR BTU INSPECTION RECO
HEATER: SUSPENDED—UNIT—
/g L 0/J772 'T4
WALL
r
/6'07761--Y our 11-C�.7e7Z ✓(5f7V1_ g
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Plan check fee 25" of above. See reverse.
Z
PERMIT ISSUING FEE S / I
'I'OTAI, FEE 7.5 ' 1
PLAN CHECK APPLICANT I I
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCESANO LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING. i
ROUGH
HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLA ON
OF CHAPTER 9, OIVISI 3, 0 E BU NMA NOt/R�FE 10 AL FINAL ✓77
CODE OF THE STAT F C L �/
SIGNATURE
OF PERMITTEE PERMIT VALIDAT ON cK. M.D. CASH
PLAN CHECKVALIDATION CK. M.O. CASH
6 1 9't EB 11 4 1 0 1 5.7 5 Aye
(51 Y-O>
WORKERS'COMPENSATION DECLARATION 7GA364C APPLICATION
1p l� p y p�' p 1p l�op(1
I herebl, affirm that I have a certificate of consent to self CE-818 (2-80) `f— Y— LICA 1 I O 1 tl FOR . PERMIT
If—E R IVY IT
linsure, or a certificate of Workers'Com isation Insurance,or HEATING-VENTILATING=AIR CONDITIONING
a certified copy thereof(Sec.3800, La .)
Policy No. Company_ I
❑ Certified copy is hereby furnishedr COUNTY OF LOS ANGELES I LDI JD SAFEToY
Certified copy is filed with the. . only hjilding inspection
department. - FOR APPLICANT TO FILL IN BUILDING
y ADDRESS (�
Date 1 Applicant (PRINT OR TYPE ONLY) LOSE --
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATEOF EXEM PTIOI FROM WORKERS' —
COMPENSATIONINSURANCE NEAREST ?
(This Section need not be Completed if the work involved ABSORPTION UNIT, BTU CROSS ST. CL
by the permit is for one hundred dollars (SI00) or less.) DISTRICT No. PROCESSED BY U
1 certify that in the performance of the work for which. this AIR HANDLING UNIT,CFM �D cr
permit is issued, I shall net employ any person in any manner - • YL O
so as to become subject to the Workers' Compensation Laws. BOILER, BTU H
APPROVALS DATE I INSPECTOR'S SIGNATURE W
Date - Applicant COMPRESSOR,BTU ROUGH g y
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM g?
Exemption, you should become subject to the Workers' FINAL
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATIO
deemed revoked. FURNACE: FAU_ GRAVITY__
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
1 hereby affirm that I am licensed under provisions of Chapter' HEATER. SUSPENDED UNIT �y IYl
9 (commencing with Section 7000) of Division 3 of the Busi- / WALL
ness and Professions.Cole, and my license is in full force and !I
effect.
License Nu/mhhh i/ Lie.ClasslZ
ContractoY r� ate_J aI am exe, t rOa uta licensing requirements as I am alicensed 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 $ �U
Lie,or Reg.No. - Date TOTAL FEE �.i
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ?S
I hereby' affirm that I am exempt from the Contractor's NAME 2�^ ^•2,Q 5,�
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS dee e z Q 5 Q v
❑ 1, as owner of the property, will do the work and the CITY TEL. NO.
structure is not intended or offered for sale (Section .,,1 2,1 5—83
7044, Business and Professions Code). - r/J
13 1,
/<
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS /JQ...)[l�
CONSTRUCTION LENDING AGENCY CIT jyL,r (�G7 �//
TEL. N6
I hereby affirm that there is a construction lending agency " s
for the performance of the work for which this permit is CON TR AC.�OR �/•
issued (;Sec. 3097,Civ.C.). '
Lender s Name ADDRESSJ��y�<rf
Lender's Address CITY a - „/J` V TEL. NO.9 q 1. 7d 7 0 '
I certify that I have read this application and state that the STATE —r��(/}�/�— LIC.
above information is correct.1 agree n>comply with all County LICENSE NO. CLASS Pte/
ordinances 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- •n[ioned property, for "
inspection w ur ses. '
Signature of Permittee Date - '