HomeMy Public PortalAbout8863 ELM AVE_Mechanical__ 76 A364 — CE 818 - 9-71 APPLIC TION FOR PEIT
HEATING - VENTILATINd -.AIR CONDITIONING
COUNTY OF.LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS O J
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER/
(PRINT OR TYPE ONLY)
MAIL
No. TYPEOFAPPLIANCE OR EQUIPMENT FEE ADDRESS ® E7
CITY TEL. NO.
ABSORPTION UNIT, BTU
r
CONTRACTO
AIR HANDLING UNIT, CFM ^
ADDRESS!*.) '
BOILER, BTU CITYNO.-�
COMPRESSOR, BTU STATELIC.
LICENSE NO. Q 0 CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE ESSED BY
EVAPORATIVE COOLER �� t7, ` o�
FURNACE: FAUGRAVITY INSPECTION RECORD V
FLOOR BTU
HEATER: SUSPENDED UNIT_
WALL l oW
r, z
Plan check fee 25% of above. See reverse.
PERMIT ISSUING FEE S 3 00
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, VENT1- N _ APPROVALS DA EI CTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AN P SS IONAL FINAL
CODE OF THE STATE OF CALIFORNIA.
SIGNATURE `� �� PERMIT VALIDATION cK. M.O. CASH
OF PERMITTEE
PLAN CHECK VALIDA ON CK. M.O. CASH
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE ,�
'WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 ��.�������®� ® ,������
I - *c . . 76A364C 0 0 P ME
GREEN
I hereby affirm that I have a certific te•of'consent to self insure, ��or aibertificate of Wosker'sComperls tion Insurance, Dr a,certified HEATING -VENTILATING-AIR CONDITIONINGLa�
Copy thereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS.ANGELES DEPT OF PUBLIC WORKS BUILDING ANb SAFETY DIV: A
Certified copy is'hereby furnished.
❑ Certified copy is filed with,the county building,inspection FOR APPLICANT TO FILL IN ADDRESSADDRESS, 3
department. (PRINT OR TYPE ONLY) C,
Date Applicant NO. TYPE OF APPLIANCE OR•EQUIPMENT•.; FEE LOCALITY' " t� C
CERTIFICATE OF EXEMPTION FROM WORKERS';. NEAREST
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT.;BTU ASSESSOR:
(This section need not be completed if the work involved by the MAP BOOK' PAGE PARCEL-
permit
ARCEL-permit is for one-hundred llar
dos($100)or less.) 'AIR HANDLING UNIT;CFM
DISTRICT NO. PROCESS BV
I�certify that in the: erformance of the work for which this permit
issued, I shall not employ any person irc any manner so as to• ' tBOILER,BTU
become subject to the Workers,'Compensation Laws.
1' COMPRESSOR,BTU'
e, _ APPROVALS
DATE INSPECTOR'S SIGNATURE
Date l Applican4
_ " f"L- VENTILATION SYSTEM � � .. '
P Y 1 g fi ate of ROUGH
provisions lof the sou:must fothwrth oomCi mwensation
NOTICE TO APPLICANT If; after akin Is Certific
h'such EVAPORATIVE COOLER FINAL
. y comply .,
provisions or this permit shall be deemed revoked. FURNA FAU GRAVITY
LICENSED CONTRACTORS DECLARATION- I FLOO TU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 S SPENDED -UNIT
,(commencing with Section 7000) of Division 3 of the,.Business and HEATER: WALL
Professions Code,avid"my license is in full force and effect.
License Number. Lia Class
Contractor' Date • V
❑,
I am exempt under Sec., Plan Check-fee
B:&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE -1 0
Signature '- PLAN CHECK APPLICANT, ` - CL
OWNER-BUILDER DECLARATION' �!-� Z
I hereby affirm that I am exempt from the Contractor's License Law. NAME o
for'tfie,following'reason.(Section 7031.5Business and'Professions D'
Cgde): 4 t 8
®
ADD RE
I, as owner of the'property, or'my•employees with wages -
as their sole compensation, will do the work and the
P CITY. TEL.NO. T ,t
structure is not intended or.offered for sale(Section 7044, 1lF
Business and Professions Code). - OWNERIia f
ElI, as owner.of the tproperty, am exclusively contracting 1- •'j a° m ;
MAIL (ngypp./' �// z_
with licensed contractors.to construct the'project (Sec- ADDRESS ( I-ILtr�' ]tiy ,7i-i
tion 7044, Business and Professions Code).
CITYTEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm-that'there is ma,construction lending agency for CONTRACTOR
the performance of the work for which'this 'permit Is issued t'
(Sec.3097,Civ.C.). D _
i
ADDRESS V. 4 . 0
Lender's Name - t
CITY L TEL.NO. �! g_:. fil l!o r�,
Lender's Address STATE LIC'. -
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 building construction,and hereby authorize
re fesentatives of this County to enter upon the above-mentioned '
p perty for inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
UR F LICANT,OR AGENT DATE