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176A364 - CE818'- 3-69 /
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING -moi
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY i
COLEMAN W•JENKINS,SUPERINTENDENT OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER / 2�
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE .ADDRESS
ABSORPTION SYSTEM, BTU CITY �t TEL. NO.
CONTRACTOR
AIR HANDLING UNIT, CFM �J
ADDRESS
BOILER, HORSEPOWER
CIT L. N
COMPRESSOR, HORSEPOWER STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE COOLER
FURNACE: FAU GRAVITY XXKIa+�^r
INSPECTION RECORD
FLOOR BTU
HEATER: SUSPENDED UNIT
WALL
CL-
0 O
V
oc
O
V
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a
NEW-ADDITION-PERMIT $ 3 00 Z
ALTER_REPAIR_ TOTAL FEE $
PLAN CHECK APPLICANT
NAME
ADDRESS .!
eZ
CITY EL. NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICAT ION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING,VENTI- APPROVALS DATE. IN SIGNATURE
EATING, AIR CONDITIONING.
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF ROUGH '
CHAPTER 9, SION 3, BUSINESS AND PROFESSIONAL FINAL
CODE OF THE S ORNIA.
SIGNATURE JACK R. ALLEN, SUPERV N CHANICAL ENG'R.
OF PERMITTEE
PERMIT VALIDATION CK. .0. CASH
PLAN CH EC VALI ION
t o t 2,7—,!-)V SIP 7 4 1 D 1 0,5 O r,
-E BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
76A364C np p (� @ (� �/�
WORKERS'COMPENSATION DECLARATION CE 818 (2-80} G=� I� I� C AT�O N FOR R PERM T
I hereby 'affirm that I have a' certificate of consent to self
insure,or a:certificate of Workers'Compensation Insurance,or H[EA-TING_V ENTIL.AYING-AIR CONDITIONING '
a certified copy thereof(Sec.3$00, Lab.C.)
Policy No. Company O S
❑_Certified eopy ishereby.furnished. COUNTY OF LOS ANGELE (((// P-UI LDING,AND SAFETY
I-
Certified copy is filed with the county building inspection BUILDING
department.
❑ FOR APPLICANT TO FILL lid
(PRINT OR TYPE ONLY) AD
Date Applicant DRESS- �
- - -
77
LOCALITY JF
CERTIFICATE
6✓ .
CERTIFICATE OF EXEMPTION FROM WORKERS' 'N O, TYPE QFz,APPLIANCE OR EQUIPMENT, FEE
COMPENSATION INSURANCE
NEAREST
CROSS ST. �/�` —
(This section.need not be completed if the-work involved . ABSORPTION UNIT, BTU- - a0°
by the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this 'AIR HANDLING UNIT,CFM
DISTRICT NO PROC�''EO�'• � "
permit`is i-sued-, I shall not employ a-y person in Any manner
so as to ,ec'ome .,ubject 10 the W%.Kers'/OzZl-
NO
on`',aws. BOILER, BTU
�i` OVALS• '`DATE. INSPECT.OR'S SJGNA-..RE�antCOMPRESSOR,BTU WAPPRu ROUGH -Z TxCE TU APPLICANT': if, after making this Certificate of VENTILATION SYSTEM
Ex'mption, you. should become subject to the Workers' _ FINAL "" Z.
Compensation provisions of the Labor Code, you must forth
with comply with such provisions.or-this permit shall be EVgPORATIVE COOLER VALIDATION
deemed revoked. FURNACE: FAU ` GRAVITY
L1 EN EDCONTRACTORSDECLARATION FLQGR BTUdw
—
C.
hereby affirm thitt 3 am licensed under provisions of Chapter HEATER:.'' LADED UNIT .• Ir
9-(commeheing with Section 7040) of Division 3-of the to
/ WALL
ness and Profesilons Code,-and my license is-.in full force and
effect: '-
-License Number Lic.Class
Contractor Date
❑. I am exempt from,the licensing requirements'as I am a.
licensed, architect or a registered prdfessional engineer Plan check fee 25%o Of Ocke
acting in my professional capacity (Section 7051 Bus -
iness and Professions Code).
T.ISSUING F
h---'I
PEFiMI EE $
Date . z _- TOTAL - -. -
�. E
--Ltc:or Re' � - - .- ..
ON PLAN'CHECK APPLICANT.
HOME OWNER-BUILDER DhC,LA1ZAT.!
I herepy.-affirm that I am exempt from-the Contractor's- NAME
Licbinse.Law for the following reasod (Section-7031.5,"Busi-
mess and,Professions Code): ' -_ ADDRESS 3
I, as owner of the' property, will do the work and the
structure is not intended or offered for sale (Section CITY TEL.NO
.7044,Business and Professions Code). 2r2,3,50-
0
• OWNER ' �Y• c�
1, as owner of the property, am exclusively.cogtracting
with licensed contractors to construct the ' project MAID t
(Section 7644, Business and Professions Code). ADDRESS
CITY -� (] ��7! 82
CONSTRIJCTION LENDING AGENCY �19j �)�i� TEL.NO.. I.
I hereby affirm that there is a construction lending-agency.
for: the, performance of the work for which this permit is
CONTRACTOR _
issued(Sec.3097,Civ.C.). -
Lender's Name ADDRESS' S i i�'
f
Lender s Address CITY \ TEL.NO.
I certi that I have read this application and state that the
Y pp. STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO' ��_ CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,'-and hereby autlorize representatives of this -SEE REVERSE FOR EXPLANATORY LANGUAGE "
County�+o enter upon the �=ve-me- Toned 'r�perfy for '
inspe, n purposes._
Signature
Signatat�of Permittee r— nate �� � ���•,