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76A3G110"•CE8I86'-9/76 _ A•P'PLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING r
_ ,(PRINT OR TYPE ONLY) ADDRESS le
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NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY NEAREST
7
CROSS ST. •`' /�Y10•- � �,cC+t� '
ABSORPTION UNIT, BTU ` ,Jr/
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AIR HANDLING UNIT, CFM OWNER MAIL r
ADDRESS ,� G r �= i f S/
BOILER, BTU CITYj� ` L�r� TEL. NO.
1--Ir
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COMPRESSOR, BTUU CONTRACTOR
VENTILATION SYSTEM ADDRESS
EVAPORATIVE COOLER CITY TEL. NO.
FURNACE: FAU GRAVITY STATE LIC.
FLOOR U 7 LICENSE NO. CLASS
HEATER: SUSPENDED UNIT_ DISTRICT NO. GROUP /ZONE oCESS o Y
WALL O
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INSPECTION RECOR
C-2
W
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N
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Plan check fee 25% of above.
PERMIT ISSUING FEES % S
TOTAL FEE % S
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-
LATING, AIR CONDITIONING. '
I HEREBY CERTIFY' THAT I AM NOT ACTING IN VIOLATION APPROVALS DATE INSPE53CIq'S SIGNATURE
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL /
CODE OF THE STATE OF CALI IA. ROUGH 2- .�
SIGNATURE `/�]/ A '+ L
FINA /d
OF PERMITTEE
PLAN CHECK VALIDATION PERMIT VALIDATION CK. M.O. CASH
I CK. M.O. CASH
9':0.3: Lc :2.7 4 �. 0 1. 9.5 0 A-_It
' WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION--FO-R__PERMIT
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING��-
or a certified-copy thereof (Sec, 3800, Lab. C.) 76A364C ----- - y _
20-0046 DPW 9/88
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES` BUILDING AND SAFETY
•, a ,
Certified copy is filed,with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 1107
J
(PRINT OR TYPE ONLY)
t�`Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE V �`
CERTIFICATE OF EXEMPTION FROM WORKERS- NEAREST Q
COMPENSATION INSURANCE CROSS ST ��(//�I/ �✓ �J
This section need not be completed if,the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROCE E Y
the permit is for one hundred dollars ($100) or less.) �./ f
•I certify that in the performance of the work,for which this AIR HANDLING UNIT, CFM (!i/� U
permit is issued, I shall not employ any person in any manner
so as to become"subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE NSPECTOR' IGNATURE
Date APPlicarf�G�jJcv/E
L✓� COMPRESSOR, BTU ROUGH
NOTICE TOAPPLICANT: If, after making this.Certificate of VENTILATION SYSTEM FINAL
Ekemption, you';should become subject, to- the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA IDATIO
with comply with such provisions or this permit shall be deem-
ed revoked. ; FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that']am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT_(commencing with'Section 7000)of Division 3 of the-Business WALL
and Professions Code,and my license is in full force and effect.
License Number Lic. Class- 0
Contractor Date- DC
❑ I am exempt under•'Sec. 0
Plan check fee
B.&P.C. for this reason t H
Date:' PERMIT'ISSUING FEE $ J00 Z
• Signature TOTAL FEE ,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License'
Law for the following reason (Section 7031 5, Business-and NAME
Prgfessions Code): v
�jL�� I, as owner of the property; or my employees with ADDRESS
wages as their sole compensation,will do the work and F�L• •T.a
CITY....,_. TEL NO
the structure is not intended or offered:for sale(Section -,;
7044, Business and Professions Code). OWNER 330. 25.00
I, as owner of the property, am exclusively,contractingITEMS ,
with licensed contractors to construct the project (Sec- MAIL,
tion 7044, Business and Professions Code). ADDRESS, - TOTAL
OTAiL 2
CONSTRUCTION:LENDING AGENCY CITY TEL NO --e (30
I herebyaffirm that there is a construction lendin agency for, CHECK �
9 9 Y t•,1,�1_3
the performance of.the work for which this permit is issued CONTRACTORf; �i�jl]E
(Sec. 3097, Civ. C ). - .!]-
ADDRESS
Lender's Name _
CITY TEL NO. UR�-lo-0Ii1I y-
Lender's Address - �!
STATE LIC "'
I certify that I have read this application and state that the CENSE NO CLASS jj f rlM,1 vl]
above 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
upo the above- entioned property for inspection purposes. ;
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or.Agent Date