HomeMy Public PortalAbout9827 DAINES DR_Mechanical__ 76 A364 - �E 818-1/75 .
APPLICAT N FOR PE:R IT
HEATING - VENTILATING - AIR CON01ITION'ING
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COUNTY OF LOS ANGELES ADDRcNS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY Tr_km m -e C' '
NEAREST
CROSS ST. U e
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION 7��, 'Q
CITY --1 L TEL. NO.
FORCE AIR FURNACE,. BTU-
CONTRACTOR
COMPRESSOR, BTU
ADDRESS
VENTILATION FAN
CITY TEL. NO
LIST ALL OTHERS BELOW STATE LIC
LICENSE NO. CLASS
rnytt'T"NO GROUP I ZONE I SSED BY
0 INSPECTION RECORD
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Plan check fee. See reverse.
10'1'41, 1�"E'1':
PLAN CHECK APPLICANT /,
NAME P/)/ GO_ II C,k
ADDRESS 2 Ilu � H�S r ,
CITY I� (jl� TEL NO'-
1,HEREBY ACKNOWLEDGE THAT I HAVE,READ THIS APPLICATION - -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL ORDINANCES AND LAWS REGULATING HEATING,.VENII- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING. AIR CONDITIONING _
CHAPTER
CERTIFY THAT I AM NOT ACTING IN VIOLATION f6-2
C
OF HAPTER 9, DIVISION OF THE BUSIN SS'AND PROFESSIONAL FINAL ROUGH Z�-
CODE OF THE STATE OF AL FOR NIA
SIGNATURE - PERMIT VALIDATION CK M O CASH
OF PERMITTEE
PLAN CHECK VALIDATION CK M O CASH
r v li t�tSb G�+ 4 i I) 1g.. .O O.A�-
WORKERS'COMPENSATION DECLARATION w CE p 8 8C(2-80) A P P U`>as AT B ON FOR P E R MT
I hereby affirm that I have a certificate,of consent to self
insure, or,a certificate-of Workers',Compensation'Insurance,or I-IEATINC•s-V ENT ILATING-AIF CONDITIONING
CC2r03e9008'532�1(See. 3800, Lab.C)
Policy No Compagy - Western 'Ins . - - ''
❑ Certified copy is hereby furnished i• COUNTY OF LOS ANGEL'ES /' BUILDING AND SAFETY _
❑'Certified copy is filed with the county building inspection 9 FOR APPLICAfVT TO FI LL III BUILDING
department. ADDRESS• 9827 DalrI66 Drive
Date Applicant - r(PRIN,TOFI,TYPE.ONLY) ;f, -
• LOCALITY '°•fiem 1`e Cit
CERTIFICATE OF EXEMPTION FROM WORKERS' NO TYPE OF APPLIANCE OR-EQUIPMENT FEE P Y
COMPENSATION INSURANCE
(This section need not, be completed if the work involved ABSORPTION UNIT, BTU CROSS STO' .
by the permit is for one-hundred dollars'($100) or'less.)'' `, " DISTRICT ND• PROLES cD BY O
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 mariner O
so as to become subject to the Workers' Compensatiod'Laws BOILER, BTU
t'1•' 48 OOO 15 .00 APPROVALS _ DATE IN PECTOR'SSIGNATURE w
Date Applicant— —` COMPRESSOR;BTU-' ROUGH d
cn
NOTICE TO APPLICANT: If, after making this Certificate ofl VENTILATION SYSTEM / Z� Z
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 revokedFURNACE ' :_F'AU a`V'"'
LICENSED CONTRACTORS DECLAR ATIOIN �- FLOOR BTU 12 O t OOO— 301 OO
I hereby'affirm that I am licensed under provisions of Chapter.' 'r HEATER. SUSPENDED UNIT
9 (commencing with Section 7000) of,Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full,forceand. „
effect.
License Number .�c.Class
Contractor' Date
k I am exempt from the licensing requirem'onts as'I am-a''
❑ licensed architect'or a registered professional engineer Plan check feeJ5%'of above. r
acting in my professional capacity (Section 7051, Bus-
mess and Professions Code).' PERMIT ISSUING FEE $ 8 50
Lie or Reg.No. Date TOTAL FEE_ 53 50
HOME OWNER-BUILDER DECLARATION PLAN CHECK APRLICAN_T 'i
I hereby affirm that d am 'ehem t from-'fhb"Coniractor's
License Law for the following,rea on (Secfion 7031-.5, Busi-
ness and Professions,Code) 3 ADDRESS 982 7_ Dairies` Drive
❑ I, as owner of the property, will do-the work and the ' 1
CITY TEL. N0.285-7796 °IO
11
structure is not intended.or offered for, sale ,(Section rj'emple' Cit o�o' � ,�v
7044, Business and Professions Code).
OWNER game as above 00`9,--8 2
El I,•'as owner of the property,•ami exclusively contracting - ,
with licensed contractors, to construct • the •project 'MAIL
(Section 7044, Business and Professions Code).. ADDRESS -
CONSTRUCTION LENDING AGENCY `CITY' ,��" - TEL.NO. r
°�,A
I hereby affirm that there is a construction lending agency
fdr the performance of the-work for which this permit is CONTRACTOR;ReSsaC', DBA• Rdfrig: . Sales
issued (Sec 3097,Civ:C)
Lender'$Name ADDRESS' 207 'E. LoS Feliz '& ,Service ;
Lender's Address CITY TELNO 24.0-7710 I L
Glendale
I certify,that.I have read.this application and state that the .STATE _ LIC• _
above information is correct.I agree tb comply with dll County LICENSE NO. '22�2 53M CLASS C-2 Or C
ordinances and a laws regulating to)g, Ventilating and
Air Conditu reby autho ze re a ntatives of this r ' SEE REVER'SE•FOR EX PLANATORY'LANGUAGE,
County er upon the ab e- e i property for -
inspe poses. ,
Sign ture of Permittee Date