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HomeMy Public PortalAbout6436 LOMA AVE_Mechanical__ 7CA364E (CE-61BA)- 11/76 APPLICATION FOR PERMIT • '� HEATING - VENTILATING - AIR CON®BTG COUNTY OF ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN BUILDING ADDRESS (PRINT OR TYPE ONLY) LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE - °. NEAREST CROSS ST. 71 ABSORPTION UNIT,BTU _ OWNER AIR HANDLING UNIT,CFM MAIL ADDRESS BOILER,BTU CITY TEL.NO. COMPRESSOR,BTU UO G CONTRACTOR VENTILATION SYSTEM ADDRESS EVAPORATIVE COOLER CITY u,�,v�/�. TEL.NO. ��,�6� FURNACE: FAU F GRAVITY STATE TT�-7 �yY LIC. 0 FLOOR - BTU LICENSE NO. V L O CLASS $,J� HEATER: SUSPENDED UNIT- DISTRICT NO. GROUP ZONE PROCESSED BY WALL INSPECTION RECORD ®' O V CL Plan check fee 25% of above. PERMIT ISSUING FEE$ TOTAL FEE — PLAN CHECK APPLICANT NAME ADDRESS CITY TEL.NO. 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ORDINANCES AND 4192 EATING, VENTILATING, AIR CONDITIONING. I HEREBY CERACTING IN VIOLATION OF APPROVALS DATE INSPECTOR'S SIGNAT E CHAPTER 9, DIV 1510 AND PROFESSIONAL CODE OF THE STATE OF CROUGH SIGNATUREOF PERMITTE PLAN C ALIDATION CK. M.O. cnsH PERMIT ALIDATION K. M.O. CASH 4 4 01-JUI 7 4.1 Q 2 32 5 �3 .✓� ©5 Q WORKER'S COMPENSATION DECLARATION 46 DPW 9/89 APPLICATION FOR PERMIT IME GREEN; 76A3 I hereby affirm that I have a certificate of consent to self insure, 76A364C or a certificate of Worker's Compensation Insuran , or a certified, HEATING-VENTILATING-AIR CONDITIONING co��Ay/Jtge of(Sec.3800 Lab.C.) /e57 Policy N 11,0361d � 6[ /Company /t? �' ❑ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ! Certified copy is hereby furnished. Certified copy is filed with the count bu., .Ziri t' h FOR APPLICANT TO FILL IN BUILDINGde artme tt... `�` (PRINT OR TYPE ONLY) ADDRESS p ( O 01Date ( " Applicant — LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CFXTIFICATE OF EXEMP N FROM WORKERS' NEAREST CROSS ST. COMPENSAT INSURANCE ABSORPTION UNIT,BTU (This section need not be co pleted if the work involved by the ASSESSOR MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU n` become subject to the Workers' Compensation Laws. COMPRESSOR,BTU APPROVALS DATE INSP OR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers' CompensationS �I EVAPORATIVE'COOLER7-7 q provisions of the Labor Code, you must forthwith comply with such FINAL � l `� provisions or this permit shall be deemed revoked. FURNACE: FAU GR�TY LICENSED CONTRACTORS DECLARATION / FLOOR BTU 6' Y �Q VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full,force and effect. e 1/6 V 3 do License Number Lic.Class Contractor ` – " `- 7� c�Date G v o L' V El D I am exempt under Sec. Plan check fee Or � B.&P.C.for this reason PERMIT ISSUING FEE$ __ _ __. C•�• . Date: TOTAL FEE � ITEMSWa Signatureco OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL 62. 25 25 Z I hereby affirm that I am exempt from the Contractor's License.Law NAME ` CC .- 1u 1�•if 2c for the following reason (Section 7031.5, Business and Professions ^� A ~ �o e �' frN� CHECK �ao�• Code): CHANGE ADDRESS _ _.. ...... .. .. ... 1.•�f71YVG -.00 I, as owner of the property, or my employees with wages' -' as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, �j�/ i / /�) Business and Professions Code). OWNER o Yt 5 J �1 kd' r/* OOD-1`0001 7 3/2 /93 I, as owner of the property, am exclusively contracting MAIL r, 3852 1 x`M12•15 with licensed contractors to construct the project (Sec- ADDRESS 6 c 3 o K OL tion 7044, Business and Professions Code). ` ( n �/J( CONSTRUCTION LENDING AGENCY CITY { �•'7 -t r`. TE ^NO. , L herppCONTRACTOR eby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued (Sec.3097, Civ. C.). ADDRESS T� Lender's Name CITY r(4F c` TEL.N0.(y rf yy f.7Z - Lender's Address STATE Y6 ra LIC. J7 I certify that I have read this application and state that the above LICENSE NO. 3C1— /� CLASS (� information is correct.- I agree to comply with all County ordinances and State laws lating to building construction,and hereby authorize representati sof this C unty to enter upon the above-menti ned prop ection urposes. Gy SEE REVERSE FOR EXPLANATORY LANGUAGE S ATURE OF APPLICANT OR AGENT DATE