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HomeMy Public PortalAbout5665 LOMA AVE_Mechanical__ %7 y z"_ '. A364 - CE.816-1/75 APPLICATION FOR PERMIT HEATING - VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES BUILDING j� Q / / DEPARTMENT OF COUNTY ENGINEER ADDRESS �V 2-e BUILDING AND SAFETY DIVISION LOCALITY -- NEAREST z a., CROSSST. FOR APPLICANT TO FILL IN OWNER (PRINT OR TYPE ONLY) �U5 5 MAIL -7 NO TYPE&SIZE OF EQUIPMENTFSE ADDRESS SEE BACK OF APPLICATION / CITY TEL. NO. Z�773 FORCE AIR FURNACE, BTU CONTRACTOR �GE%G�lG � C� COMPRESSOR, BTU ADDRESS VENTILATION FAN CITY TEL. NO. LIST ALL OTHERS BELOW STATE C' LICENSE NO. �G Z_-7-:I— CLASS DISTRICT NO. GROUP ZONE PROCESSED BY e3 INSPECTION RECORD r EL O U O H U W Plan check fee. See reverse. PF;H)11"I' ISSI [VG FK -1 S 00 00 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 DATE INSPECTOR'S SIGNATURE LATING, AIR CONDITIONING. ROUGH I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF CHAPTER 9, DIVISION 3. (NESS AND PROFESSIONAL FINAL CODE OF THE STATE OF OR IA. SIGNATURE PERMIT VALIDATI CK, M.0. CASH OF PERMITTEE �, -y►�t�,� ..�.�P - -Sri•LAN CHECK VA DATION cK. M.o. CASH VORKERS COMPS SA` 1691 6 7 2�t3AY 30 4 1 D WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT 1 hereby affirm that I have a certifica)e I5f bons2nt to,self insure, or a certificate of Workefs':Cgmpensotion Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Set. 3800,'L'ab. C.) 76A364C 20-0046 DPW 9/88 Policy'No. Company ❑` Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS � + (PRINT OR TYPE ONLY) Date Applicant LOCALITY. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. - (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. P ESSED 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 !� ` permit is issued, I shall not employ any person in any manner �J so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS VATE INSPECTOR'S SIGNATURE Date. Applicant f COMPRESSOR, BTU Z �t ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA ID TI with comply with such provisions or this permit shall be deem- ed revoked. 1 FURNACE: FAU_2K_GRAVITY LICENSED CONTRACTORS DECLARATION I FLOOR BTU :120, — I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business I WALL and Professions Code,and my license is in full force and effect. A ,L� a License Numbers! Lic. ClassZ © ,V�� ��--r , O _ / L C_-/ u Contractor 1 ) r� Date c— Cq` ® 0 ❑ - I am exempt under Sec. U Plan check fee B.&P.C. for this reason. CL Date: PERMIT ISSUING FEE $ H � TOTAL FEE Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Low for the following reason (Section 7031.5, Business and NAME Professions Code): I, as owner of the property, or my employees with ADDRESS f;CT,$ wages as their sole compensation, will do the work and CITY - TEL. NO. ��r� ity G the structure is not intended or offered for sale(Section ye30 =''- 7044, Business and Professions Code). .r ❑ OWNER 1 ly I, as owner of the property, am exclusively contracting �' 1T"'`�`) with licensed contractors to construct theroject Sec- MAIL TOTAL �* tion 7044, Business and Professions Code). ( ADDRESS V Y< t i'1 ATt!L 75 CONSTRUCTION LENDING AGENCY _ t:t ;._,r 5 CITY TEL. NO. (.(� _,, 1 hereby affirm that there is a construction lending agency for v l Lr 1 h S, ft the performance of the work for which this permit is issued CONTRACTOR I T Z N L r L' J �_ , CHANGE (Sec. 3097, Civ. C.). Lender's Name ADDRESS L f rLL r-VQ CITY Lkq C� TEL. NO. � - t31300-0=0111/13-189 : Lender's Address STATE LIC. 2- 6725 1 AM ? '`, I certify that I have read this application and state that the LICENSE NO. CLASS Z, aboveinformation is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon e above-menti ed Droperty f r inspection purposes.' SEE REVERSE FOR EXPLANATORY LANGUAGE gr ure.of f ica t'or gent Date ©s