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APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS f T
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
No. TYPE 6 SIZE OF EQUIPMENT FEE ADDRESS
f[H BACK OF APIPLIGATION
CITY TEL. NO.
FORCE AIR FURNACE, BTU
1 CONTRACTOR G+
7 COMPRESSOR, BTU
ADDRESS ) IV
VV_§NTJ"TIP.N FAN= = CITY= - - B TEL. NO- d;eT y
LIST ALL OTHERS BELOW STAT LIC.. /7
} LICENSE NO.Z d �� CLASS C
i
OUP1ZONE OC[ BY
i INSPECTION RECO
}f}� r
1 d
O
I 0
O
I-
U
W
D..
Plan check fee. See reverse.
PF;R1iIT I.SSI;INIG FEF: S 0
TOTALI, FEF:
PLAN CHECK APPLICANT
NAME
f ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
ANDSTAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATINS, AUR CONDITIONING.
RO UG H
I HEREBY CER I AM NOT ACTING IN VIOLATION
OF CHAPTEp 9, SIGN S, F THE BU/IN PROFESSIONAL DNAL
CODE OF THE AT[ OF FORNIA
SIONATUR PERMIT VALIDATION K. M.0. CASH
OF PER TT
PLAN CK VALIDATION CK. M.O. CASH
0 6 5 ,SAN 641 9.0 0 s'1
r
WORKEFrS COMPENSATION DECLARATION 20-004E DPW 9/89
I hereby affirm that I have ■oertifioate of consent to self Insure, 76AW4O APPLICATION FOR PERMIT
or a m-tifloate d Worker's Compensation Insuranoe, or a oerdfled HEATING-VE,NTI,LgTING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
❑o"No. 1191168 ccrn ,.State/Fund COUNTY OF LOS ANGELES DEPT OF-PUBUC WORKS BUILDING AND SAFETY DIV.
Cerdited copy is hereby fumWwd.
CwthW copy is Tied with the camty bufldng h,apeotlon FOR APPLICANT TO FILL IN ABDDDIING 10238 E G
t. (PRINT OR TYPE ONLY)
Date 3-14-9m LOOA " Temple City
., NO. TYPE OF APPLIANCE OR EOLNPMENT F�
CERTSCATE OF EXEMPTION FnDM CF006
EAREST8 ST.
COMPENSATION INSURANCE ALIS }DN UNIT BTU
(fhb section need not be oomploted If the work Invofvsd by the MAP BOOK PAGE PAFKA
permit Is for one hundred dollar 4100)or Mss.) AIR HANDLING UNIT CFM
orrncrrn ano®e®ev
I certify that In the performance of the work for which this permit
Is Issued, I shall not employ any person In any manner so as to BTU P
become subject to the Workers'.Compensatkm Laws. , �O
AL COMPRESSOR BTU
_ . xrv+�vo LB an saracrare erw+xruve
-Pale Appkant VENTILATION SYSTEM
NOTICE TO APPL1C__ANJ-:-It4anELr rpAklhg this CerLif c'nJet_QfFI
_ _ _ _.- _— OIf0 j - _ >-..-----
Exirfil'on,you should become eubleo{to the W&r ere'(omperiaation EVAPORATIIVI-z SFA FNAL
pravlslons of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked. RJRNACE FAU
.. LICENSED CONTRACTORS-DECLARAT) N BOOR en/ VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 8 HEATER:, 8USPENDIED UNIT
(obmmsnoing with Section 7000) of Division 3 of the Business and WALL
Prof ns Code,and my Iloense Is In full force and effect _
Lk,..t4,rb, 589544 ULqem C-20
a
Calibe3Z HtratiJ 3-14-91O
anu rr . J- 7. Plan check fee U
1,8111 exempt under Seo.
B.}P.C.for this reason PERMIT ISSUING FEE_ Q O
Dotty. TOTAL FEE d'LIJ
Solature
PLAN CHECK APPLIC.AXT tin
OWNEFI-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.6, Business and Professlons ACCT.
Eli
(erode): �S$
�F. -n
I, u.owner of the property, or my`employees with wages 3307
as their sole compensation; will do the work and the CITY TI3_NO. ��.I�
structure is not Intended or offered for sale (Section 7044, 1 I TEM
IJ
Business and Profsssbns Code). I John Cermak
❑ TOTAL 37 - 00.
I, as owner of the property, arts exclusively contracting _
MAIL �+v �7 ��n
with licensed contractors to construct the project (Seo- ADDRESS same J!.W
tion 7044, Business and Professions Code). -
CONSTFiUCTiOt4 L IEWYNQ AGENCY CfT Y TEL No, 8/442-2629
•Xj
I hereby affirm that there Is a construction lending %anoy for ,
the performance of the work for whloh thio permit Is IssuedCONTRACTOR Caliber Heatingand Air
(Sec.3087,Ctv.C.).
ADDRESS 195 South C Street Ste 2501
Landers Name crrY Tustin TH 40.-669-9320 - :- - 6166
L.endeea AddressSTATE LIC,
I certHy that I have read this application and state that the aboIJCt?t8
ve E NO. 589544 GLA88 r 9 n
.-
Intormatlon is omTect I agree To compiy with aJl County ordinances
and Stade laws relaiing to building conal uctlon,and hereby authortm
repreeentatNw of this County to enter upon the above-mantbned
pro,peq for Inspection purposee. SEE REVERSE FOR MUnA"TORY LAMMACIE
OR A!r DATE