HomeMy Public PortalAbout5621 GRACEWOOD AVE_Mechanical__ 1
76 A 36 - CE SIS-1/76
1 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS a
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST //
CROSS ST.
FOR APPLICANT TO FILL IN OWNER RACK URI g
(PRINT OR TYPE ONLY)
MAI L
NO, TYPE&SIZE OF EQUIPMENT FEE ADDRESS E I�
1z ICE BACK OF APPLICATION n
CIT Ya A` T 1, . TEL. NO. �L f 5
FORCE AIR FURNACE, BTU �� II
CONTRACTOR
COMPRESSOR, BTU
ADDRESS ' 5 O E V
VENTILATION FAN CITY SJR TEL. NO.
LIST ALL OTHERS BELOW STATE p L C. /�
LICENSE NO. / Z) C l.-�
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INSPECTION RECORD
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Plan check fee. See reverse.
PERMIT 1S.51,,I.NG FEF: S
TOTAI. FF.F. r,
PLAN CHECK APPLICANT
LRE
ESS
TEL.NO.
RESY ACKNOWLEDSE THAT I H(�VE READ THIS APPLICATION
AT[ THAT THE ABOVE IS CORRECT AND ASREIII TO COMPLY
LL ORDINANCES AND LAW[ REGULATING HEATING, VENTI- APPROVALS DAT[ W nCTOR'S SIGNATURE
, AIR CO NDITIONINB.
ROUGH
EREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
PTER O, DIVISION 9, OF THE BUSINED AND PROFESSIONAL FINAL
F YH2 DTAT[ CALIFORNIA.
URE PE{iMIT VALIDATION f cKM.OcAeHERMITTEEHECK VALID ION CK. M.O.. CASH 1
J
0 'T 141 1 2 L)
WORI_RS'COMPENSATION DECLARATION APPLICATION FOR . P E RM I T
I hereby afkh-rn that I have a certificate of consent to self
Insure; or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or o.certlfled copy thereof (Sec. 3800, Lab. C.) 76-364C
CE-818(REV. 10/81)
Policy Qo'As6D140 Compa COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is hereby furnished..
�Certlfied copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tlon department. (PRINT OR TYPE ONLY)
Datr�L' � o ApplIcanl=Mr I y�.r� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEECERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �
COMPENSATION INSURANCE SSS ST.
(This section-need not be completed If the work Involved by ABSORPTION UNIT, BTU q KT NO. MDOMM BY
the permit Is for one hundred dollars (=100)or leas.)
I certffy that In the performance of the work for which this AIR HANDLING UNIT, CFM \`�
permit Is Issued, I shall not employ anyn In any manner V
to as to become subject to the Work" Compensation Laws. BOILER, BTU APPROVALS DATE i 1
LR2!!
Date Applicant COMPRESSOR, BTU !!4
NOTICE TO APPLICANT: If, after making this Certlficate of V1Nf1LAT10N SYSTEM FINAL
Exemption, you should become ,subject to the -Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. RIRNACE: FAU G&4VD1 //)
LICENSED CONTRACTORS DECLARATION FLOOR BTU o�(�/� ((J
I hereby affirm that I am licensed under provlslons of Chapter 9 HEATER: SUSPB4DED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALI
IL
and Professions Code,and my Ilcense 4 In full force and effect.
IL
License NumbeA?—:54 4-z, Llc. Class Z�b O
CK
Con E&2 '� T� �Date
❑ 1 am exempt under Sec
Plan check fee
an
B.BP.C. for this reason PERMIT ISSUING FEE $ Z
Date: �4230A
TOTAL FEE
Signature '#'o o a o 6 8
OWNER-BUILDER DECLARATION PIAN CI-fEcx APPLICANT
I hereby afflrm that I am exempt from the Contractor's License , I'o 3 Q 5 0
Law for the following reason (Section 7031.5, Business and NAME
-Professions Code): .0.a - 3 Q 5 0
❑ I, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation,will do the work and CIT TEL NO. 0313-86
the structure Is not Intended or offered for sale(Section
7044, Business and Profession Code). OWNER
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO.
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued CONTRACT
(Sec. 3097, Civ. C.). /J
Lender's Name "x&5 .0 1
TEL NO. - o
Lenders Address STA LIC.
I certify that I have read this application and state that the UCCNSE tJO. 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 abovo- Honed pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Appllmnt or nt Date