HomeMy Public PortalAbout5333 LOMA AVE_Mechanical__ 76A3&4 -`cER,e -,3-69 APPLICATION FOR PERMIT
-" HEATING - VENTILATING - AIR CONDITIONING
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DEPARTMENT COUNTY OF COUNT
DEPY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY
COLEMAN W.JENKINS,SUPERINTENDENT OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN
OWNER"
(PRINT OR TYPE ONLY) "
' MAIL ,
NO. TYPE OF APPLIANCE OR EQUIPMENT _ FEE ADDRESS
ABSORPTION SYSTEM, BTU CIT /�t7/�+ TEL. N0. •-tj I
AIR HANDLING UNIT, CFM' CONTRACTOR -�
ADDRESS
BOILER, HORSEPOWER
CITY TEL. NO.
COMPRESSOR, HORSEPOWER STATE !1 �-. /1 if_ LIC.
LICENSE N0.L�� A4-4- CLASS '
NTILATION SYSTEM A DISTRICT NO. GROUP ZONE PROCESSED BY
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EVAPORATIVE COOLER t�� ( JIAef?e5-
FURNACE: FAU GRAVITY- v
FLOOR BTU INSPECTION RECORD
HEATER: SUSPENDED UNIT
WALL
l A rU o
O
r W
NEW_ADDITION_ PERMIT $ 3 00 Z
ALTER--�-REPAIR— TOTAL FEE $
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION '
s AND-STATE THAT THE ABOVE I CORRECT AND AGREE TO COMPLY '
WITH ALL ORDINANCJTI
WS REGULATING HEATING,VENTI- APPROVALS DATE IN ECTOR'S S NATURE
LA71NG, AIR COJF
I HEREBY CEAM NOT ACTING IN VIOLATION OF ROUGH �• a,¢
CHAPTER 9, DIVTHE BUSINESS PROFESSIONAL FINAL
.:ODE OF THE.STF0 IA.
IGNATURE - JACK R. ALLEN, SU ERV ECHANICAL ENG'R.
)F PERMITTEE
PERMIT VALIDATIO CR. M.O. 'CASH
'LAN CHECK VALIDATION
. 'Lo 4 0 5 6 JAN 21 4 1 D 8.0 0—
ACK OF APPLICATION FOR COMPLETE FEE SCHEDULE _
WORKER'S COMPENSATION DECLARATION 200046 DPW 9/69 APP��`,yeA��®DYl FdR ,PERTMME
I��L��,[[[���
76A364C (��yy I�I �u L� " .
I hereby affirm that I have a certificate of consent to self insure,
or a Carlificate oO'Iorker's Compensation Insurance, or a certified �'. HEATING -VENTILATING-*AIR CONDITIONING „
copy thereof(Sec.3800 Lab.C)
Policy.No. Company COUNTY OF LOS ANGELES. ., ADEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy Is hereby furnished.
❑ Certified copy Is filed with the county building Inspection FOR APPLICANT.TO FILL IN f BUILDING '
department. (PRINT OR TYPE ONLY). ADDRESS
Date Applicant LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT `nFEE
CERTIFICATE OF EXEMPTION FROM WONEARESTRKERS'. CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be"corn )sled If the work involved b the- ASSESSOR
( P Y MAP BOOK •, PAGE PARCEL• •.
permit is.for one hundred dollars($.100)or less) AIR HANDLING UNIT,CFM {�
I certify that in•the performance of the work for which this permit. DISTRICT NO PROCESSED BY ,
is issued, I shall not employ any person In any manner so as to BOILER,BTU
become sub) ct to a Workers'Compen Laws.
} I COMPRESSOR,BTU - ✓ ��
APPROVALS ,_ DATE - INSPECTOR'S SIGNATURE'
Date Apphc VENTILATION SYSTEM
NOTICE O PLICANT: If, aft making this Certificate'of ROUGH
Exempt) n,yo should become su ct to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL -11f
provisions or this permit shall be'deemed revoked FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU o e VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with'Section 7000) of Division 3 of the Business and HEATER,.. WALL
Professions'Code,,and my license is in'full"force and'effect ~
License Number Lic.Class [ - O ` �� t r I3-30,5
Y
-------------
SA �"
3 Contractor Date /
❑ I exempt under,Sec. Plan check f1313 -TOTAL,
�LI tL Z77 -70 Q
'B.&P.C.for this reason PERMIT,ISSUING FEE$ Gj Q ,U
AE_•i.
Date. TOTAL FEEi: i ,i Ili 'W
a.
Signature ~~
-OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT z
I hereby affirm that I am exempt from the Contractor's License LawNAME to D 1Jl�lal�'fal�l� 10/,- =°' �`-
for the following reason (Section 7031.5,.Business and Professions _ t
Code): ADDRESS q - .�:.iW Lt`t
❑ I; as owner of the property, or my employees with wages w
as their sole compensation,-will-do the;work and the CITY TEL NO '
111
structure'Is not•Intended or offered for sale (Section 7044,
Business and Professions.Code). OWNER
❑ I, as owner of the'property, am exclusively Contracting MAIL. -
with, licensed contractors to construct the project (Sec-,• ADDRESS yl
' tion 7044, Business and Professions Code). - --
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. CONTRACTOR
(Sec. 3097,'Civ C.)
' ADDRESS - .. .j •' .. T -
Lender's Name
' IL
'- TEL N -a1' ''t" -/ l .... .. .. ••.. - - ,.
Lender's Address Jr
�'
E. '.I LIC• _�..I certify that I have read this application and state that the above NSE NO.` CLASS"
information Is correct. I agree to comply with all County ordinances $
and State laws relating to budding construction,and hereby authorize-'
representatl a of this County to enter upon the above-mentioned
propert nspectio purpo S. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGN E OF T OFrAOVKT D E -