HomeMy Public PortalAbout5345 LOMA AVE_Mechanical__ 76A364-CF-818-8-88APPLICATION'FOR PERMIT -Tw'% (5 "
4 HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER ADDRESS S� NO A-•
BUILDING AND SAFETY DIVISION �
JOHN A. LAMBIE, COUNTY ENGINEER .
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY �� -if og p
NEAREST G
FOR APPLICANT TO FILL IN CROSS ST. �Ve
(Print or type only)
OWNER �
No TYPE1OFAPPLIANCE OR EQUIPMENT FEE
A.
MAI L
ADDRESS S
ABSORPTION SYSTEM, BTU CITY TEL. NO.
AIR HANDLING UNIT, CFM CONTRACTOR d� p`
BOILER, HORSEPOWER ADDRESS
COMPRESSOR, HORSEPOWER CITY TEL. NO.
STATE LIC.
VENTILATION SYSTEM LICENSE NO. CLASS
DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE COOLER j
FURNACE: FAU GRAVITY
FLOOR—BTU INSPECTION RECORD
HEATER: SUSPENDED—UNIT-
WALL
USPENDED UNITWALL
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NEW—ADDITION— PERMIT $ 3 00
ALTER—REPAIR— TOTAL FEE
Plan check applicant
Name
Address
City Tel. No.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS D TE INSPECT R'S SIGNAT RE
LATING, AIR CONDITIONING
ROUGH
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL FINAL
CODE OF THE STATE OF CALIFORNIA
? JACK R. ALLEN,SUPERVISI G MECHANICA
SIGNATURE , PERMIT VALIDATION M O. ASH
OF PERMITTE
PLAN CHECK VALIDATION
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
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WORKER'S COMPENSATION DECLARATION -- 20.0046 DPW 9/69 MAP(�nCATMN
I hereby affirm that I heve,a certificate of consent to self Insure, f
or a certificate of Worker's',Compensafion Insurance, or a certified PERNT
11ME "
copy thereof(Sec'3600 Lab c) ; �' HEATING-VENTILATING=AIR'CONDITIONING,
Policy No "Company` I - '`COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND:SAFETY DIV. '
,-
,Certified copy,ls hereby furnished �•i I
❑ . - + - - .. •� BUILDING 1 ,
Certified •'-copy Is filed with the county building inspection', FOR APPLICANT TO FILL IN ADDRESS',53 4 5 , Lo nn Q` At �
i( '
department (PRINT OR TYPE ONLY) i
i ^.. _ LOCALITY
Date, Applicant
'~ NO, TYPE OF APPLIANCE OR EQUIPMENT,, , ,•FEE m -
• CERTIFICATE OF,EXEMPTION FROM„WORKERS' CROSS ST' •V&I �( CFNU Vh�A
='•COMPENSAT,ION INSURANCET
ABSORP.TION UNIT,BTU ��� ASSESSOR
(This section need'not•be completed,If'the work Involved by the MAP BOOK PAGE, PARCEL
permit Is for one hundred dollars($100)�or less.) AIR HANDLING UNIT,CFM
.,x YY - 1. ti - DISTRICT NO - PROCESSED BY
I certifythat In,the,performance of the work for which this permit ,
is Issued, I shall not employ any person In any manner so as to- - BOILER,BTU—
become
TUbecome subject to the Workers' Compensation,Laws ,b
{ COMPRESSOR,BTU L DATE
d
=,.INSPECTOR'S SIGNATURE
ApplicantVENTILATION SYSTEM
S -
` DateAPPROVAL` ,• • " '
NOTICE TO APPLICANT If, aft'er;