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CE-BIB (REV.11/]B)
APPLICATION FOR PERARIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN AUDDRILDEss 3�`fN 4 /AlelW,rI a
(PRINT OR TYPE ONLY)
LOCALIT L oL /_
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE L G
NEAREST
CROSS ST.
ABSORPTION UNIT,BTU OWNER �J�'' s ,A7
I ,` EL./'Y
AIR HANDLING UNIT.CFM MAIL c
ADDRESS J �,
BOILER.BTU
/w/ e CITY TEL.NO.Lf'j_i
COMPRESSOR.BTU ✓ I� CONTRACTOR I
VENTILATION SYSTEM ADDRESS
EVAPORATIVE COOLER CITY / TEL NO.
FURNACE: FAU K STATE LIC.
FLOOR -BTU O �� LICENSE NO. CLASS
HEATER: SUSPENDED—UNIT— APFROVALSDATE INSPECTOR'S SIGNATURE
WALL
ROUGH L d
FINAL �' ^L� f v
INSPECTION RECORD p�
{O�-;
Plan check fee 25% of above. 6
N
PERMIT ISSUING FEE$ bO ?
TOTAL FEE ��
PLAN CHECK APPLICANT PLAN CHECK VALIDATION '
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL
ORDINANCES AND LAWS REGULATING HEATING. VENTILATING, AIR R 8 8 6 Z A
CONDITIONING. PERMIT VALIDATION Ap
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF ry e e e * 4 1
CHAPTER 9. DIVIS 0 3. OF THE BUSINESS AN PR ESSIONAL CODE '
OF THE STATE A FORNIA. 't e o 4 ZOO
SIGNATUFE
OF PERMITTEE 7.
o o /j 7.000
DISTRICTND. [ROC15SED By .
0405=80
o�
WORK EkS'COMPENSATION DECLARATION 7GA364C APPLICATION
1p 1p py q� I� PERMIT 1 hereby affirm that 1 have a certificate of consent to self CE-818 (2-80) A Ir Ir L IC A 1 I O 1 tl FO YR Ir E R M I 1
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified 2 c0000y t)/heyrre�oof(Se��.v380
tw?,ff/J,_ 0.``}}••��,,;��'h'.C.) //,,JJ
Policy Company„/
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILL IN ADDRESS
Date Applicant (PRINT OR TYPE ONLY) -�—
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST _
(This section need not be Completed if the work Involved ABSORPTION UNIT, BTU CROSS ST. 0
by the permit is for one hundred dollars (SI00) or less.) DISTRICTNO. PROCESSED Sy U
I certify that.in the performance of the work for which this AIR HANDLING UNIT,CFM e7 cr
permit is issued, I shall not employ any person in any manner 'f i)A /L w0 - �r 6 ��/� O
so as to become subject to the Workers' Compensation Laws. / BOILER, BTU C ya/(/K�—
APPROVALS DATE INSPECTOR'S SIGNATURE tU
Date Applicant COMPRESSOR, BTU
ROUGH __ y
NOTICE TO APPLICANT: IC after making this Certificate of VENTILATION SYSTEMof Z
Exemption, you should become subject to the Workers' FINAL —
Compensation provisions of the labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU— GRAVITY_ 1
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
-
I hereby affirm that I am licensed under provisions of Chapter 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 force and
effect.
License Number Lie.Class—
Contractor-
lass Contractor Date '
1 am exempt from the licensing requirements as I am a ,
licensed architect or a registered professional engineer Plan cheek fee 25%Of above.
acting in my professional capacity (Section 7051, Bus- PERMIT ISSUING FEE $ Dee
iness and Professions Code). -/A/
1
Lie,or Reg.No. Date TOTAL FEE e,n/
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 0,0 7,7 A
I hereby affirm that 1 am exempt from- the Contractor's NAME Q
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS 2 ole 27.00
El 1, as owner of the property, will do the work and the NO.
structure is not intended or offered for sale (Section CITY TEL. 'e 01e.27.00=
7044, Business and Professions Code).
❑ c
I, as owner of the property, um exclusively contracting OWNER 6 0 8-8 1
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL.NO. ,
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name ADDRESS
Lender's Address CITY TEL.NO.
1 certify that I have read this application and state that the S7ATE LIC.
above information is correct. 1 agree to comply with all County LICENSE NO. CLASS
ordinances and State regulating Heating, Ventilating and
Air Conditioning, a . her by authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to a ter apo tmentioned C oPertY for
_
inspr� on p pr.es.
Ignalure of l.rr,rttee ate _ -.