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76A364-CE818-1-68 APPLICATION FOR PERMIT
HEATING - !VENTILATING - AIR• CONDITIONING
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BBUILUILDING
OHNDA. LAMBIEING AND SCCOUNTY AFETY ENGINOEER ,ADDRESS 3 /1/f A'
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY 725-:-M P/ 1
NEAREST `
FOR APPLICANT TO FILL IN cRoss S+_3570/
(Print or type only)
OWNER SURZ)AM
NO.. TYPEIOFAPPLIANCE OR EQU I,PMENT FEE -
MAIL
ADDRESS (/
ABSORPTION SYSTEM, BTU CITY TEL. NO..?e&I Sa V
AIR HANDLING UNIT, CFM CONTRACTOR
U
BOILER, HORSEPOWER 5C ADDRESS S MAA1 Z,9 V l7-,+
COMPRESSOR, HORSEPOWER CITYJSTATE p TEL. NO (llQ <•
VENTILATION SYSTEM LICENSE NO QJ Q C ASS �3@
DISTRICT NO. G OUP ZONE ow /f/' PRO ESSED By
EVAPORATIVE COOLER
FURNACE: FAU GRAVITY \J 6
FLOOR—BTU INSPEC ION RECORD
HEATER: SUSPENDED UNIT
WALL O'
U
' W
O.
N
- Z
NEW ADDITION— PERMIT $ 3 00
ALTER—REPAIR— TOTAL FEE $
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREETOCOMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING -
HEATING, VENTILATING, AIR CONDITIONING.
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION -
OF CHAPTER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL _
CODE OF THE TE OF CALIFORNIA. APPROVALS DAT q IN E TOR'S'SIGN TURE
OFPERi41Z ROUGH
OF PER I
FINAL
IDATION JACK R. ALLEN
CK. M.O. CASH SUPERVISING MECHANICAL ENG'R.
ecc went nc APPI i—Tin.FnR.MUPI.FTF FEE SCHEDULE
RS'CONiPENSATION DECLARATION- 76A364C n�j
"hereby affirTM�' flat I''have a' certificate of consent,to Self. CE:. $T8,(2-80) APPLICATION If- O Ifs lf- lam' R'uVU��
insure;or a certiricate of Workers'Compensafion`Insurance,or "
TIENT
a certified-copy thereof(Sec.3800,Lab C.) - I INGi
HEATING LATIi�IC=AI.R COWDITION
Pcilecy No: Company „
•
-[]`,Certified copy is hereby furnished
COUNTY OF:LOSANGELES' • BUILDING AfiID SAFETY
Certified copy'is filed with`the county building inspection - BUILDING
department, i . FOR APRLtCANT TO FILLl N
ADDRESS /
Date - Applicant ('PRINT.OR TYPE,ONLY)
•
® �
LOCALIrTY
TYPE-OF APPLIANCE OR,EQUIPM'ENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
— - -
COMPENSATION INSURANCE NEAREST
(T
GROSS ST: G�}-`La�
his seetion need not' be completed if the work'involved:: ABSORPTION UNIT, BTU
by the permit is for one hundred dollars ($-IDU),or 1es50- DISTRICT NO. PROCESSED BY 0
,I certify that-in the performance_of the work for which this Al R•HANDLING UNIT,CFM [V-_Q- �f
permit-is issued, I shall not.employ any person in any(nanner .
so,as t become subject to ,,, V o k`rs' Co gei atio' Laws. BOI'LER,'BTU 0
1 APPROVALS DATE INSP TOR'S SIGNA URE W f
Date' _ Applica t ��0
COMPRESSOR,B;TU
NOT IC- TO APPLICANT: If, after-making-this Certificate of VENT,ILATION;SYSTEIVI U)`
ROUGH
Exemption, you should "become subject to.the Workers' F(NAL
_� _
Compensation. provisions of the Labor Cude, you must forth- VALID i I;ON
DOLE
with comply with such-p'rovisions or:this permit shall be EVAPORATIVE C.
deemed revoked.
RAVITY
LICENSED CONTRACTORS,DECLARATION FLOGFI; FAUYBTU:-::;
G
I hereby affirm that•I am licensed under provisions of Chapter HEATER:, SUSPENDED�. UNIT .
9,(commencing'with Section 7000)'of Division 3'of the Bust Y WALL
mess and Professions Code, and-my license is in full force and i
effect. 71
License Number!l�2' ! sic.Class
— i -.
CIA/ f�
e•
Contractor Dat
: b
I am exempt from the licensing requirements as I am a
licensed architeet or a registered professional engineer Plan Check fee 25%Of above:'
acting in my professiohaLcapacity (Section 7051, Bus-
odd).mess and Professions CPERMIT ISSUING FEE.$'
I .
.I .
� Lie.or Reg.No.- ' Date _ TOTAL FEE l _
HOMEOWNER-BUILDER DECLARATION PLAN'CHECK'APPLICANT
I hereby affirm that •I' aM. exempt',from-the Contractor'sNAME
Z—!
License Law`for the following.reason (Section 7031 5 Susi- - w�+I+
ness and-Professions Code): : .ADDRESS', �y� /ZI ACCT.
6 �- - e
tI��-} { .s
I as owner of'the property, will do the work and the CITY _4' TEL. NO. U( a o7
0 -
structure is not intended or ;offered for sale (Section (1/ -e -
7044, Business and Professions Code),
OWNER
I as owner of the property, am exclusively contracting [telr[ Li'
Av_ ^_ y �j j-_,�' �1;�"75
with licensed contractors to construct the project MAIL y ` / { n �
(Section 7044,'B.usiness and Professions Code): ADDRESS ( //++�� A47 a(�i
. .. �, '�/ '--• TEL.N� � r 1rT1,
CONSTRUCTION LENDING AGENCY, -CITY,
`I hereby affirm 'that there is .a constru, ion lending agency
p permit is CONTRACTOR
t
for the erformance C. the'work for .iic� this • (�/�• i t jQ�
.
'issued (Sea 3097,Civ.C.). � _ - � .
Lender's Nariie DRESS
A �T 7
•
"011 6/14/W-.$9
Lender's Address G 1`103'1
ITP 479_ T,EL NO: `x"
n
39?1 1 t 'I
I certify that I have read this application and state }hat the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO: _� N' CLASS
:l ordinances and State laws regulating Heating, Ventilating and
ditioning;and hereby authorjze representatives of.this ;SEE REVERSE'FOR EXPLANATORY LANGUAGE'
' G unt o enter _: �n 'he above=mento ied property fot ,
it spe n�,urpo,es.
":gnature of Permittee Da`h.