HomeMy Public PortalAbout4910 GOLDEN WEST AVE_Mechanical__ 7E A36e-' CE ale-1/7e
_. APPLICATION FOR PERMIT YL �
HEATING - VENTILATING - AIR CONOITIO.-NING=-
COUNTY OF LOS ANGELES BUILDING
'DEPARTMEN-t OF COUNTY ENGINEEtFk ADDRESS
BUILDING AND SAFETY DIVISION LbCALITY-
NEAREST
CROSS ST. '
I=OR APPLICANT TO F LL �yN�.
(PRINT OR-TYPE ONLY) ,
MAI L
No.. TYPE&SIZE OF EQUIPMENT PEE PkbDRESS
,SEE LACK OF APPLICATION
CITY ' TEL. NO.
FORCE AIFi FURNACE, BTIF y
[�ITRACTOR
COMPRESSQR, BTU
A. R ESS
VENTILATION FAN TEL. Nd. f 4
-LIST ALL OTHERS BELOW STATE LIC.
LICENSE NO. CLASS
EGGS
DISTRICT No. no n S o r
INSPECTION RECOge
O
U
O
U
W
Klan Check fee. See reverse.
PF.RIIIT ISSIfL^1� �F:1: S'
TOTAI, FEF.
PLAN CHECK APPLICANT
NAME .
A D D RE-SS
CITYTEL.NO.
I HERESY ACKNOWLEDGE THAI t HAVE READ THIS APPLICATION
AND STATE THAT THE AEOVt"IS.CORRECT AND AGREE TO COMPLY
WITH ALL ORDJNAMCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE WSPECTOA'S SIGNATURE
LATINS, AIR CONDIT+ONIRS. .
• f2000H
1 HERESY CERTIF T 1 AM NOT ACTING IN VIOLATION
OF CHAPTER D, DIVI N 'J OF TN SIRESS AND•P orJ<SSIONAL FINAL
CODE OF THE STAT F C 0
SIGNATURE %
OF PEkMITTEE PERMIT VALIDATION c M.O.. CASH
PLAN.CHE VALIDATIO K. M.D. CASH
WORKERS COMPENSATION DECLARATION APPLICATION FOR P E RM I T
I hetreby affirm that I have a certificate of consent to self
Insure, ofi a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora cgrilfied copy thereof (Sec. 3800, Lab. G)
' 20.0646 DPW 9/88
Policy No Company
❑ Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT oR TYPE ONLY) ADDRESS 4cYeo C-1pLp"%.Ar ,.rT A V Pi. .
Date Applicant — LOCALITY 7-ri-M c�T
NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE
CERTIFICATE OF DTMNPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROS ST. NA L VJ 'D
(fhb section twed not be coro
completed If the-work Imhred by ABSORPTION UNfF, BTU pe5TR1CT NO. PROCESSED By
the permit Is for one hundred dollars (;100) or isms.) v
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM 2�5C70
�D!
permit Is Issued, I shall not employ any person In any manner
so as to become subject to the Warkers'Compensation BOILER, BTU APPROVALS DATE INWECTOR•S SbC'K,TtJRE
Darts Qct Ilcant
/� COMPRESSOR BTU �'60d �/�- ROUGH —0
NOTICE TO APPLICANT: If, after making this Certifl ofKFUR
TILATION SYSTEM FINAL
Exemption, you should- become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- PORATIVE COOLER VALIDATION
with comp)y with such provisions or this permit shall be demur
ed revoked. NACE: FAU
LICENSED CONTRACTORS DECLARATION OR BTU I�
1 hereby affirm lfwt I am Ilcensed under provisions of Chapter 9TER. SUSPENDED UNIT_
(commencing with Section 7000)of Division 3 of the Buslnew WALL
and Professlons Code,and my license is In full force aril effect.
License Number Ila. Class , O
Contractor Date
❑ I am exempt under Sec. 0
Plan check fee
B.BP.G IL
for this reason PERMIT ISSUING FEE $ OU a
N
Date: TOTAL Z
FEE B�D
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors License ,
Law for the following reason (Section 7031.5, Business and NAME
Professlons Code): j
® I, as owner of the property, or my employees with
ADDRESS V
wages as their sole compensation,wllI do the work and ACCT."
the structure Is not Intended or offered for sale(Section CITY TEL NO.
3K7 55.al
7044, Business anOWNER
❑ WNER
d Professions Code) O
I, m owner of the property, am exclusively contracting 1 ITEM
with licensed contractors to construct the project (Sec- MAIL
tion 7041, Business and Professions Code). ADDRESS TOTAL 55 - 00
CONSTRUCTION LENDING AGENCY CITY TEL. tIO.
I hereby affirm that there Is a construction lending agency for � � J`5.1
WAHGE 0
the performance of the work for which this permit Is Issued
CONTRA
the
(Sec. 3097, Ov. G�
ADDRESS
Lender's Name
CITY TEL NO. 0
0 0TO-M 12/12/90
Lender's Address STATE UC tFfF14 1 AN
V:2'U
I certify that I have read this application and state that the UCENSE NO CLASS
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
upon the above-mentioned for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SlgrwNre of Applkant or Date �*