HomeMy Public PortalAbout9659 GARIBALDI AVE_Mechanical__ 76^36 . I W0J11-I1C76 APPLICATION FOR PERMIT
-
00 L) HEATING - VENTILATING - AIR CONDITIONING
X09 k ."_ ..
9 `� COUNTY OF I OS ANCiHLEB
/J P�� FQ� DEPARTMHNT bF COUN'T,f'EN0INEER
a BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BuIpANG
(PRINT OR TYPE ON}Y) ADDRESS
LOCALITY L
NO. TYPE OF APPkIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST.
ABSORPTION UNPT,BTU
OWNER
AIR HANDLING UNIT,CFM MAIL "
ADDRESS
BOILER,BTU Cry TEL NO. /O .
COMPRESSOR,BTU 43, O CONT FIACTOKAi r
VENTILATION SYSTEM ADDRESS "
EVAPORATIVE COOLER CJet TEL NO.
FURNACE: FAU G STATE LIC. _
FLOOR B-n LICENSE NO. �QgczqoCLAS
HEATER: SUSPENDED-.UNIT- DLTM PCT MD. cTpuP Z07. ED WY
WAI I
INSPECTION RECORD O
V
IN
O
Plan check fee 25%of above.
PERMIT ISSUING FEE$
TOTAL FEE
PLAN CHECK APPLICANT -
NAME,
ADDRESS
CITY - TEL NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATS THAT THE ABOVE IS CORRECT AND.AGREE TO COMPLY WITH ALL
ORDINANCES AND LAWS REGULATING HEATING, VENTILATING, AIR
CONDMONING.
I HEREBY CERTIFY THAT AMI N T ACTING IN VIOLATION OF APPROVALS .DATE lKsr[CTDII'S,Sl6MATURE .
CHAPTER D, DIVISI 3, G TWE BU$I D PROFESSION CODE -
OF THE STATE OF O IA. ROUGH
D IG NjATU RE.. FINAL
O F PERMUTE,
PLAN CHEC ALIDATION cK o. CASH PERMIT VALIbATION
# 7 1.['" 1241 Q� 2 32
i
. + "RKERS' COMPENSATION DECLARATION AP PLICATION FOR P E RM I T
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A38.1C
CE-818(RFV. 10/81)
Policy No. Company
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the county building Irnpec- FOR APPLICANT TO FILL IN BUILDINGLal
tion department. PRINT OR TYPE ONLY ADDRESS
l ) .
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST � P
COMPENSATION INSURANCE CRSS ST
(This sectlon need not be completed ff the work Involved by ABSORPTION UNIT, BTU DLNiTZICT tq. PRoa<SUD BY
the permtt Is For one hundred dollars ($I DO)or leu.) NR IIAND1JtdG UNIT, CFM �L
I certify that In the performance of the work for which this
permit Is Issued, I shall not employ any person In any manner
to as to become subject to The Workers'CompensationLaws- BOILER, BTU APPROVALS DATE OWS SIG&A
COMPREBTU
Date d �Q Ilcant ;� '�(� SSORROUGH
—
NOTICE TO ICANT: If, after making this Certlfitate oY VENTILATION SYSTEM RNA
Exemption, you should become subject to the Workers'
Compensation provlslonz of the Labor Code, you must forth- EVAPORATIVE COOLER VALID A N
with comply with such provlslohs or this permit shall be
deemed revoked. RIRNACT: FAU GRAVITY
i LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEALER: SUSPENDED UNIT
I (commencing with Section 7000) of Division 3 of the Business W�
and Professions Code, and my license Is In full force and effect.
J od
License Number Llc. Clans ,
Contractor Date G
❑ I am exempt under Sec. d
Plan check fee
B.BP.C. for this reason' Date: $O 6 3 7 A z
PERMIT ISSUING FEES O
TOTAL FEE # o o•o�° • 8
Signature
OWNER-BUILDER DECLARATION PLAN O-ECY APPLICANT I ° - 20.50
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME a u • 2�q 5 Q 6
Pr9feulons Code):
1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and 9.Q.9 8 8
the structure Is not Intended or offered for sale(Section QTY NO.
7044, Business and Professlons Code}
OWNER
❑ I, as owner of the property, dm exclusively contracting MA
with licensed contractors to construct the project (Sec- ADpREss6/1 ZcA 6-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY QTT� L Tli NO.4dP,qq6,
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued rOR
(Sec. 3097, Clv. C.).
ADDRESS
Lender's Name
QTY NO.
Lender's Address
STATE Of UC
I certify that I have read this application and state that the LICENSE NO. CLASS
above Informatlon Ia 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"operty for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applkant or Agent fDat•