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' 76 A364- CE BIB- 5-73 -
LICATION FO nMIT
HEATING.- VENTILATING IR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY ,
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) _7
MAIL
NO. TYPE OFAPPLIANCEOR EQUIPMENT FEE ADDRESS 4)
CITY , fy TEL. NO.0gg 57_Z?c�
ABSORPTION UNIT, BTU l
CONTRACTOR 2Z j -
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY '�� 7 TEL. NO.
2
COMPRESSOR,-BTU STATE LI C.
LICENSE NO. / l CLASS ` 3
VENTILATION SYSTEM DISTRICT NO. GROUPZONE P ESSED BY
EVAPORAT,IVE COOLER Of� _/
FURNACE: FAUGRAVITY v INSPECTION RECORD
FLOOR BTU
HEATER: SUSPENDED-UNIT-
WALL
USPENDED UNIT_WALL 36744
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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, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH
1 HEREBY C RT Y THAT, I AM NOT 'AC IN IOLATION
OF CHAPTER 9, O I ON 3, F THE B (NESS A D P ESSIO NAL FINAL
!!n % A
CODE OF THE STAT F CA ORNIA O A
SIGNATURE q1T7D.ATON cK. ' M.O. CASH
OF PERMITTEE•PLAN CHEC ALIDATION CK. M.O. CASH
1'"7 5 p 8.O.0 awe
f
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
�76A364C ,
I-hereby affirm that I have a certificate of consent to self insure, APPLICATION 'FOR PERMIT. LIME. : GREEN
or a certificate of Worker's Corriperisation Insurance, or a certified HEATING-'VENTILATING -.AIR CONDITIONING
copy thereof(Sec 3800 Lab. C.) ;
Policy No. Company COUNTY OF LOS'ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ' Certified copy'is hereby furnished. /4
❑ Certified copy-is filed with the county building'inspection FOR APPLICANT TO FILL IN SS ADDR S
department., (PRINT OR TYPE�ONLY)'
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE-. � e,
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This sction need not be completed if the work involved b the ASSESSOR
( eP Y � � MAP BOOK PAGE' PARCEL
'.permit'is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY ,
I.certify that in the performance of Ahe work for which this permit •'
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. ,�-Y�--
/ COMPRESSOR,BTU '
APPROVALS DATE- INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE'TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE. FAU G VITY
LICENSED CONTRACTORS DECLARATION �.= FLOOR BTU CSO 3 VA ID TION ,
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT=
(commencing with Section 7000) of Division 3 of the Business and HEATER WALL
Professions Code, and my license is in full force and effect. //��
V
License Number Lic.Class
Contractor Date PC*C a 1r• '' O
❑
I' Plan i U
am exempt.underSec. check fee i}IJ,7 1Ce_LO
B&P.C.for this reason PERMIT ISSUING FEE$ ' 7� 1 T-�M� h
Date: ' TOTAL FEE TOTAL 109c=l u
SignaturePLAN CHECK•APPLICANT CHH"K ' e(/)
OWNER-BUILDER DECLARATION' Li �1 11'I'°,, 02
I hereby affirm that I am exempt from_the Contractor's License Law NAME , CHANGE
for the following reason (Section 7031 5, Business and'Professions
`fCode): ADDRESS t i t
y�AA/IL I, as owner'of the property, or my employees with wages-
0000—V0IV 1 11/ 4 9
as their sole compensation, will do the work and the CITY TEL NO.
structure is not intended or offered for sale (Section 7044, 632 i AM 3 52
❑
Business and Professions Code) . OWNER i'V1 qL �� I t f t
I, as•owner of the property,-am exclusively contracting MAIL �� 1 2
with licensed contractors to construct:the project (Sec- ADDRESS q��7 C r(7QTSOI,.r ID�/
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY' l�! OI TEL.NO _� S
I hereby affirm that there is a construction lending agency for CONTR
is issued ACTOR l� ,
the performance of the work for which this permit '
(Sec 3097,Clv.C) . , •
' - 1, ADDRESS
Lender's Name •- - -
CITY TEL NO
Lender's Address STATE LIC
I 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
representatives of this County to enter upon the above-mentioned
property ffo�rction purrpos/ey�,.. SEE REVERSE FOR EXPLANATORY LANGUAGE
�IGNA E OF APPLICAN OR AGENT DATE ,