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APPLICATION FOR PERMIT
HEATING- VENTILATING - AIR CONDITIONING
COUNTY-OF LOS ANGELES BUILDING" ® 07,
DEPARTMENT OF COUNTY ENGINEER ADDRESS /
BUILDING AND SAFETY DIVISION LOCALITY�� at't4
NEAREST ,
CROSS ST. ��-
FOR APPLICANT TO FLLL IN OWNER
(PRINT OR TYPE ONLY) lVhj
MAIL
NO TYPE&SIZE OF EQUIPMENT ` _ FEE ADDRE
SEE BACK OF APPLICATION C -
CITTEL. NO
FORCE A!R FURNACE, BTU ��
CONTRAC OR 'r
COMPRESSOR, BTU
ADDRESS
.VENTILATION FAN CITY � TEL. NO.
.LIST-ALL OTHERS BELOW STATE LIC. /
LICENSES CLAS -ao
DI TRICT NO: GROUP NE OCESSEOBY
a�-N-�
INSPECTION RECORD
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Plan'check.fee. See reverse.`
F'f:;RNAT ISS
U11(.; F'f;I`: S U
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL:NO, s- •e; a,:d
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
W.ITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS' I0AT-E'- 'IJINSPECTOR'S�SIGNATURE .
LATING, Al CONDITI ONIN
ROUGH
I rRE: CERTIFY THAT •I M -NOT ACTING IN VIOLATION OC
F. CH ,+D I V I SION•3, OF T E USINESSPROFESSIONALFINALCODETATE OF IFOI SIGN PERMIT VALIDAT`I+ON •"C .. �'.d: � '! 'CASH •
Or P MIT
., - Ci Y - c.- •7 ..-.. � Tim
PLAN ,.-
CHECK 'AL ON cK. M.O. CASH
6.6-5-SEP T 1 0:: fi 2 3.�"5 A=33
rl5,e -
_ I .
`'WORKERS'COMPENSATION DLCLARATION .n 76,613640'
C 818 (2.80) IL I� LLQ�C AT�BUJ�V OO I11t1f'"Lam" . R U�%{)7
I hereby affirm` that. I'have a certificate of'.consent=to,self : )
insure,-or,aecertificar`e of Workers'Compensation Insurance,or } HEA-TIRIC !!'ENTILATINCv,'AIR-.�.®.N(DIP'Id�Nl4�G
a certified copy there6f(Sec. 3800,,L 15,C.)
C.)
w r
1
Policy No Company ; l
C
Certified.copy is hereby furnished, r
s COUIUTV OF LOS ANGELES ` ' BUILDING AND SAFETY
.;_Certif,ied copy is-filed wi;h-the county building inspection. BUI LDI(VG
P i• ADDRESS
FOR'APPLICl�NT TO FILL'lIV
Date ant" x
(P*RJ OR-TYRE ONLY),
PMEN FEE
CERTIFICATE OFX
EEMPTION-FROM WORKERS' TYPE'OF APPLIANCE OR,EOUI Tr''
. //`
COMPENSkTION INSURANCE
LOCALITY
(This section need not'be'completed tf`the,work involved; 4BSO,RPTION UNIT, BTU OSS 5T 7 - -.CL ;.
CR�
b .'the' ermit .is`for, one hundred dollars ($100) or less. ? :- oIsTAICTNo. PRocessEo U
Y P ) ,.
I`certify,that,in the performance of the work for which this AIR HANDLING UNIT,CFM
perrntt ts,issued, Lshall not employ any,person many°manner`: _ j' ,� 6 J O
so as to-became subject.to'the Workers Cornpensation•Laws: BOILER, BTU U
+_ � � t OAT
- ECTOR`S SIGNATURE
APPROVALS» E INc v
x W
V Date Rpphcant ' `"" COMPRESSOR,BTU
_ UGH '[
NOTICE TOsAPPLICANT:'If, after making this Certificate of
VENTILATION SYSTEM d
RO
Exemption you should .become" subject.'to the Workers', {
Compensation provisions of the'Labor Code",you must forth :u `
FINAL
EVAPORATIVE COOLER
_ sz v;
VALIDATION . �
with comply with uch provisions or this permit"shall..be � °
deemed'revoked- -
= FLOORC� UBTU
s FA GRAVITY
.LICENSED CONTRACTORS-DECLARATION'
I1hereby-affirm that I am"licensed under-provWons.of Chapter HEATER:;.; SUSPENDED. -UNIT
9 (commencing with Section 7000) of Division 3 of•the'Busip '' ;,`._WALL'
ness-and Professions,Code,,and my;license is in full force and
effect., , : .»<.
License Number 38 - ' 3 'Lic.Class—/�i
Contractor ,Date ( . n
t am exempt,from the-licensing requirements as I am,a
I icensed -architect `or.a'registered professional engineer, Pla6-check fee 25%Of abbve.
acting`in my•professional capacity .(Section.7051 -Bus
mess and Professwns Code). PERMIT ISSUING.FEE
Lie or Reg;.No Dafe TOTAL FE ` L�w
-.
"HOME OWNER-BUILDER DECLARATION P K APPLICANT'
LAN CHECK
'I hereby,affirm that l_an :,exempt from-;the Contractor's ; NAME a •'.• -
License Law for the`following reason (Section 7031.5 Susi-
ness and'1?rofessio
ns,,Code): - AD:DR�ESS.
'I, as .owner of.the-property,.will do the work and'the' r
�° TELo 5'3 9,A`'�A
structure"4is not intended or for sale ;(Section' 'CITY, _� -_
'7644, Business and Prgfessions Code).' �._+ � # o o:E o 0 o'
OWNER t
I, as owner of the property,-am exclusively'contractin -`
P p
i
with. licensed contractors to eonstrucf'«,the.'- project.. ADDRESS 2royo'� [( �'Q
.,. '(Section 7044;.Business and Professions Code):'
,, ®`�
CITY TEL.NQ..., t cJ 0
CONSTRUCTION LENDING AGENCY
-1 hereby affirm that there -is a construction lending'agency ��I t 3 .,}
for the performance of the work for which this, permit is CONT RACTOR 'G
issued (Sec. 3097,Civ.C.).
0'8'0, .4 82
rol
Lender's Name - y .ADDRESS,'Lender's Address CITY �f r(�, TE ' tO. ,,1c3(� �,
V �LNL�I certify that I have read this application and.state that the STATE C.
SS 7�
above information is correct.I agree to comply with all County LICENSE NO. $
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this 'SEE REVERSE TOR,EXPLANATORY LANGUAGE
County to enter urun he above-mentioned property for
'inspection purposes.
Signature of Permittee Date