HomeMy Public PortalAbout6138 LOMA AVE_Mechanical__ 76 A3P4- CE 818- 643
APPLICAT N FOR PERMIT
t HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST \
CROSS ST.
FOR APPLICANT TO FILL IN OWNERe� 6 '
(PRINT OR TYPE ONLY) L
MAIL
NO TYPE OFAPPLIANCEOR EQUIPMENT FEE ADDRESS 4O///
CITY �j 'P11 A'7-/TEL. NO. ':2 ��O 7s'
ABSORPTION UNIT, BTU
CONTRACTOR G
AIR HANDLING UNIT, CFM �
ADDRESS
BOILER, BTU CITY -TEL. NO.
COMPRESSOR, BTU STATE r1 LIC
LICENSE NO. ( lam' CLASS
VENTILATION SYSTEM DISTRICT NO p GROUP ZONE 2CESSED BY
EVAPORATIVE COOLER -5-
FURNACE:
.J rFURNACE: FAUGRAVITY
FLOOR BTU INSPECTION RECORD
HEATER: SUSPENDED UNIT=
WALL
•t CD
�
L U
ZZs',v� CD
0
U
W
Z
Plan check fee 25% of above See reverse. "
PEMMIT ISSUING FEE S
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 DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING
ROUGH
I HEREBY CERTIF HAT I AM NOT ACTING IN V OLATION
OF CHAPTER 9, DIVI 3, OF BUSINESS AND PROF SSIONAL FINAL
CODE OF THE STAT CALI RNI
SIGNATURE PERMIT VAI IDATI CK. M 0 CASH
OF PERMITT
PLAN CHECK VALIDATION GK M 0 CASH '
2 1 4 qpp 7 4 1 U 1 5.7 5 ='8
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
WORKERS'COMPENSATIONveaDECLARATION /,� ®P® �CA�� N .F®R�PERMIT
- 'I hereby offirm that ! have a certificate of.consent to self 4°�Ir [� Ii C7 kr ��J® -
I�. insure,'or,a-certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIS CONDITIONINGor o 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.
Certified copy is filed with the county building inspec-- FOR APPLICANT-TO FILL-IN BUILDING 6,1-5
/ ?
tion department
• (PRINT OR TYPE ONLY) ADDRESS 6 ✓
DateApplicant LOCALITY.
NO TYPE OF APPLIANCE OR EQUIPMENT FEE G
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 NOPROCESSED BY
the permit is for one hundred dollars (;100)or less.) /
AIR HANDLING UNIT, CFM UX
-1 certify that in the.perfor'mance of the work for which this
permit is issued, I shall not emploY.' any person in any manner
so as to become subject to the kers'Compensation L s BOILER, BTU APPROVALS DATE INSPECTOR'S NATURE
COMPRESSOR, BTU - ROUGH Z
Date Qpplica - oee
NOTICE TO APPLICANT If, t r making this Ceti Cate of VENTILATION SYSTEM FINAL
Exemption, you should be me subject to the' Workers'
Compensation provisions of .`Labor Code^you,must forth- . EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall'be
deemed-revoked FURNACE FAU GRAVITY -
LICENSED CONTRACTORS_DECLARATION, FLOOR BTU
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. WALL
and Professions Code,and my hcense•is-`in full force and effect'" " d
License Number Lic Clas's V
1 i �
ConO
Contractor Date '
❑ - <`
I am exempt under Sec a
Plan check fee 7 5 8,Q A H
B&P C for this reason
Date PERMIT ISSUING-FEE $
TOTAL FEE # O ° ° °'° $
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 'O °
1 hereby affirm that I am exempt from the Contractor's License �- i
Law for the following reason (Section 7031 5, Business and NAME --°'O °, `3 0. 0
Professions Code)
1, as owner of the property, or my employees with ADDRESS 0 7 3,1 ,&8 7
wages as their sole compensation,will do the work and " • "
the structure is not intended or offered for sale (Section CITY TEL NO ^
7044, Business and Profess Ions'Code) r '
O
WNER
El1, as owner of the property, am,exclusively contracting with licensed contractors to construct the project (Sec- AILtion 7044, Business and Professions Code) C/
CONSTRUCTION LENDING AGENCY CITY
I hereby affirm that there is a construction lending agency for ` o ..
t he'performance of the work for which this permit Is issued CONTRACTOR "
(Sec 3097', Civ G ) - - -
ADDRESS
Lender's Name
CITY _.TEV NO _ 1
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
ord nonces and State jaws relating to building construction, _
d hereby authorize representatives of this County to enter
p n the above-me e I pro erty for inspection purposes SEE REVERSE FOR'EXPLANATORY LANGUAGE
ignature of Applicant or Agent " Date - - -