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�'4'A301-`E BIS - 9-71 7- NTILATIN
CATION FORLIT
HEATING G - R CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS Z
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO. TYPEOFAPPLIANCEOR EQUIPMENT FEE ADDRESS
CITY t EL. NO.
ABSORPTION UNIT, BTU le
CONTRACTOR
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU CITY TEL. NO.
COMPRESSOR, BTU STATE �'] Q J LIC. C� Z
LICENSE NO. ! ✓ / CLASS ✓
VENTILATION SYSTEM Dl�nr^R`cr N0. SROUP zone ED BY
EVAPORATIVE COOLER r og o oo
FURNACE: FAU_GRAVITY INSPECTION RkCORD U
FLOOR BTU CC
HEATER: SUSPE UNIT_ C:)
WALL
a.
Z
Plan check foe 25% of above. See reverse.
PERMIT ISSUING FEE S 3 00
TOTAL FEE p�
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE In CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE MPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH �
I H[R[BY CERTIFY TH I A G IN VIOLATION
OF CHAPTER 0, DIVISION D OF 7 B AND PROFESS NAL FINAL -
COOE OF THE STATE OF C IA.
SIGNATURE PERMI VA TION cK. M.O. CASH
OF PERMITTEE
PLAN CHECK VALIDATION CK. lCASH
?P 3 5 2 4T) OCT1 0 4 1 D 8 00h.
SEE BACK OF APPLICATION FON AFI[SCHEDULE
777
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I here* affirm� I hove a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certlfied opy thereof (Sec. 3800, Lab. C.)
❑
Policy ompan; { CJI�� .yY�OiU 818(REV. 10/81)
Poll
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certtfled copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUR-DING
tion d rt enT. ADDRESS
a � l� (PRINT OR TYPE ONLY)
Date fe Applicant �' LOCALTTY
NO. TYPE OF APPUANCE OR EQUIPMENT FEE
CERTIFICATE OF EXE&APTION FROM WORKERS' CROSS ST. IE—leu
/C/lT
COMPENSATION INSURANCE
(This seetlon need not be completed If that work imroh+ed by '°`aSORPTION UNIT, BTU DISTRlcr NO.,� PR0Qs56 Br
the perm Ft is for one hundred dollars (=100)or less.)
I certffy that In the performance of the work for which this AIR FIANDUtJG UNIT, CFM
permit Is Issued, I shall not employ anyn In any manner
to as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE OR's S4G41TURf
Date AmllcanT C'OMPRM R, BTU' OO fJ O RCOGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILAT}ON SYSTEM FINAL
Exemptlon, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATfVE OOOIER VALID ATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU VTTY O
. LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WA1J.
and Professions Code,and my license is In full force and effe
c
t. s—
License Number O t� c. Class v V
Contractor t
❑ 1 am exempt under Sec
Plan check fee
B.BP.C. for this reason' 'n
PERMfT ISSUING FEE $ 0 8 1,.1 A' z
Date:
Signature TOTAL FEE # o'o o 0,0 8
OWNER-BUILDER DECLARATION PLAN CHEO(APPLICANT
I hereby affirm that I am exempt from the Contractor's Llcensepop. 1 0 . 4275
Law for the following reason (Sectlon 7031.5, Business and NAME
Profeulons Code):
ADDRESS ' o a 0 4 2 7 5 iS
I, as owner of the property, or my employees with
El
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section C]ll �' 1 0.0
3
7044, Business and Professlons Code).. +
OWNER
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAR �
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITYGYM NO ���
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued OONTReOTOR���/)O '
(Sec. 3097, Clv. C.).
Lender's Name ADDRESS 3 '
Lander's Address /,s ' TEL NO.���—��f�
STATE �7 Q UG
I certify that I have read this application and state that the LKB-S NO. / a 0 aASS O
above'Informatfon b 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 ab-o enrio property for Inspect) Pu SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or AQenr Date