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HomeMy Public PortalAbout6111 LOMA AVE_Mechanical__ CE•818(REV.6/78) ©5 APLI.CATION FOR PERMIT HEATING VENTILATING. - AIR CONDITIONING COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT•TO FILL IN BUILDING a (PRINT OR TYPE ONLY) ADDRESS LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE • NEAREST- \ CROSS ST. - ABSORPTION UNIT,BTU �^ - - OWNER' AIR HANDLING UNIT,CFM MAIL ADDRESS 1 � BOILER,BTU CITY .EL. COMPRESSOR,BTU CONTRACTOR VENTILATION SYSTEM - ADDRESS EVAPORATIVE COOLER - - CITY t EL.N FURNACE: FAUGRAVITY STATE. LIC. FLOOR - BTULICENSE NO'. _ CLASS •.,,' HEATER:. SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE WALL ROUGH _ . - - r FINAL ll , INSPE'CTIO'N RECORD 09 Plan check fee 25% of above. PERMIT ISSUING FEE$ TOTAL FEE PLAN CHECK APPLICANT PLAN CHECK VALIDATION NAME ADDRESS CITY TEL. NO. , IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND ;?3359A n'Z Z C f1 11 STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL J 5 7 A ORDINANCES AND LAWS REGULATING HEATING, VENTILATING,.AIR - CONDITIONING. -PERMIT VALIDATION 1# 010,01'0 4 1 IHEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION 0N, CHAPTER 9, YNSION 3, OF THE BU ESS AND PROFESSIONAL CODE - 2,A 10 2 7 0 0 OF THE STATE ORNIA. - ' SIGNATURE L - OHO O 2 7,O O U OFPERMITT �'7 DISTRICT NO. PROCE 0 ,321 -- / 9 'WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby'affirm that I have a certificate of consent to self insure,-or a certificate of Workers' Compensation Insurance, ,aA3a4c HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/81) Policy,No. Company ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY r - ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING G'` I {�� LO/Y1�1 /, �� tion department. (PRINT OR TYPE ONLY) ADDRESS A Date Applicant LOCALITY ��n tA`F 1 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /I COMPENSATION INSURANCE CROSS S7. , Jyl pjAL (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC SSED the 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 is issued, I shall not employ any person in any manner BOILER, BTU T R so as to become subject to*the Workers'Compensation . Laws ) APPROVALS DATE INSPEC 'S SIG uRE Date Applicant �d.(1[�[ .lVi/� �. COMPRESSOR, BTU v L v Q ROUGH �— NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL _ Exemption, you should become subject to the Workers' J Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAtIDATIO �.. with comply with such provisions or this, permit shall be deemed revoked. / FURNACE: FAU G A'ITY nj /i LICENSED CONTRACTORS DECLARATION / FLOOR BTU 0[J I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. O License Number Lic. Class , Contractor Date O t" ❑ I am exempt under Sec. Plan check fee B.BP.C. for this reason' PERMIT ISSUING FEE $ SSD Date: 20.9 Q 8 A Signature TOTAL FEE # o oto to 0 8 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , ) o o 30.50 Law for the following reason (Section 7031.5, Business and NAME Professions Code): 4 440 0 0 3 0,5 0.0 ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. ) Q 4 t-8 8 7044, Business and Professions Code). �( OWNERCO j, I / ES R L�1 I, as owner of the property,.am exclusively contracting V �/ . ` with licensed contractors to construct the project (Sec- MAIL. tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY C i..r�f TEL. NO. 219'-/,.5 357 I hereby affirm that there is a construction lending agency for �s the performance of the work for which this permit is issued CONTRACTOR wN C' ► (Sec. 3097, Civ. C.).. ADDRESS Lender's Name CITY TEL, NO. Lender's Address STATE LIC. I certify that I have read this application and state that the LICENSE NO. CLASS above information 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date -