HomeMy Public PortalAbout4945 HALLOWELL AVE_Mechanical__ A'C'AK'_RS'COMPENSATI'ON76A364G DECLARATION 76 . 64 (2-80) Q Il—P lam. C!r-�1 T�O �I FOR P E R YVk T
F1 "e"by af,irm that I have A certificate of consent to self
insure,ar a certificate of Workers'Compensation Insurance,or HtATING-VENTILATING-AIR CONDITIONINGv
. certified tupy 1heraof(Sec. 3800,Lab. C.)
Policy No. Company. _ Pee =
Ce�rtif rony.is hereriy.-furnisl�'. COUNTY OF LOSANGELES Lip
!� Ce• I i J i2lopt•,,s fila" he coo Ay•huildin, inspection ( BUILDING.
u +I pa o-nnnt� FOR APPLICANT TO FILL IN,
Date_ _T lam// tpplicau, II (PRINT OR TYPE ONLY) ADDRESS
((( LOCALITY
CLAI'lt lCkTE OF EXEMPTION FROM WORKERS' NO. TYPE•OF APPLIANCE OR EQUIPMENT , FEE
COMPENSATION INSURANCE NEAREST �.
(This section need'not be.completed if the'wdrk involved ABSORPTION UNIT, BTU• CROSS ST. d
-by.,ihe pptniit is f0t'ane•hundred dollars (Sl 00) oI less.) - DISTRICT NO. PRO ESSE Y O
1 certifythat! in the gtformance of the work for.which this AIR HANDLING UNIT,CFM
p c�l o t �
O'•
permJ1 is issued,J shall not.employ any person in any manner
ro as to hacome-subject to the Workers' Compensation Laws. BOILER, BTU �.
APPROVAL$ -DATE INSPECTOR'S SIGNATURE- W
Date— — Applicant_ COMPRESSOR,BTU ��� / �7 d
ROUGH
NPTICE TO APPLICANT: if, after making,this Certificate of VENTILATION SYSTEM
m cpptian, you,should becorne subject to the Workers'- FINAL
Compcusauon'provisions oY the Labor Code, you must forth- EVAPORATIVE COOLER
with"crimply with such provisions or this permit-shall'be VALIDATION
deemec revokiid
FURNACE: FAU � GRAVITY
L;CENSEI)CONTRACTORS DECLARATION FLOOR: BTU- ,
•I herc'oy a win that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (cor_Itriencing with Section 7000) of Division 3 of the Busi- WALL
news and Professions Code, and my license is in'full force and
J,i
eicensK Numbar_�es //)
- Lic. Class
0 i am caernpt from the licensing requirements as I am a
'icets°d architect or a registered professional 'engineer I Plan check fee 25%of above.
acting in my professiopal •c;,pacity� (Section 7051, Bus-
and Professions Code), PERMIT ISSUING FEE $ v�
Lic,or-Reg.No, - Date TOTAL FEE 17
HOMF.OWNER-BUILDER DECLARATION p�AN CHECK APPLICANT -
' hereby a:fi;m thct I- am exempt: from- the Contractor's NAME
License Lav; for thy following reason (Section 7031.5, Busi-
"sa and Prufe,,sions Code): ADDRESS
D�
� - 1
1, 'as owner of the property, wiil`.do, the work and the- CITY. TEL. NO.
structure,is not intended or 'offered-for sale. (Section
7044,Business and Professions Code)-
OWNER `-0.8 7.8•A
owner of tar" property,-am•exclusively, contracting
t.ii*. lieensed, contractors to construct the project MAIL
7044,Business and Profes§1oAE Code). - ADDRESS t '
Ct7NSTRUCTION LENDING AGENCY CITY TEL. NO. �GJ� _ 2;°y°, -1700
_ „ affirm that thare is a construction lending agency /J a o l0 1 ' , 0 0•v
ti-c performance of.the work for which this permit is CONTRACTOR yJ� - , . • ,
r t:.:3097,Civ.C.). (/ 0 a 2A-81
' Name ADDRESS
:i ;ddress CITY li TEL.NO. ya_7d7.
1 ce-"Ay that ; have read this application and state that theSTATE LIC:
1.,lurmation is correct.I agree to comply with all County LICENSE NO.' _� CLASS
_,;_:i and State laws regWati�' .,ca.:•g, Ventilating and
�; t-c t„= ,•-^ ^r »nd hereby ac.norize rept sentatives of ,lis SEE REVERSE FOR EXPLANATORY LANGUAGE
vur , w enter ups.' the above-mentir ned proper'y for
Si3na:.,� rermIttre Date'
c
76 A364 --CE 816-1/75
APPLICAT FOR PLRMI
HEATING - !VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER
RESS
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
71 CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
(� CITY• TEL. NO.
FORCE AIR FURNACE, B 0(_(�
CONTRACTOR C
COMPRESSOR, BTU �D
ADDRESS ��
ep-
VENTILATION FAN CITY TEL. NO.
?% 3
LIST ALL OTHERS BELOW STATE V /L CLASS ZO
LICENSE NO 4+
DISTRICT NO. GROUP ZONE SEDµBY
r•
INSPECTION RECORD
d
O
U
O
F-
0 U
W
d
N
Plan check fee. See reverse. z
I'F IJ:
PLAN CHECK APPLICANT '7�p i)
NAME
ADDRESS
CITY. TEL.NO.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING. AIR CONDITIONING.
ROUGH ���zj
HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION n
OF CHAPTER 9, DIVISION 3_'oe THE BUSINESS AND PROF SSIONAL FINAL
CODE OF THE STATEIZ25IFORNI
SIGNATURE PERMIT VALIDATION CK. M.O. CASH
OF PERMITTE _
PLAN CHECK VALIDATION CK. M.0. CASH
7 3 3 FEB 22 4 1 D
7 v6'