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76 A364 - CE B•IB - 9-71 APPLICATION FOR PERMIT 1
HEATING - VENTILATING ,-. AIR CONDITIONING
COUNTY OF LOS-ANGELESBUILDING �—
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY 3
NEAREST
CROSS ST. 22aL
FOR APPLICANT TO FILL IN OWNER -
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE OF APPLIANCE OR'EQUIPMENT FEE ADDRESS � .
CITY TEL. NO.
ABSORPTION UNIT, BTU
CONTRA TOR
AIR HANDLING UNIT,-CFM
ADDRESS
BOILER, BTU CITY TEL. NO.
COMPRESSOR, BTU STATE- LIC.
LICENSE NO. ,IZ CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE CO LER r VCD
FURNACE: FA'U -GITY
INSPECTION.RECO R c�
FLOOR BTU
HEATER: ,SUSPENDED UNIT CD
WALL c w
C,
Z
Plan' check fee 25% of above. See reverse.
PER\,IIT ISSUING FEE S 3 00
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO. j
"1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT'THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS R GU EATING HEATING, VENTI- APPROVALS DATE.. 'INSPECTOR'S SIGNATURE
EATING, AIR CONDITIONING. -
ROUG H
I HEREBY CERTIFY-.,THAT I AM CTING VIOLATION
OF CHAPTER B,�DIVIS'0 OF TH BUS SS ND ROFESSIONA FINAL
CODE OF THE STATE O LIFORN -
SIGNATURE PERMIT VALIDATION CK. IM.o. cnsr+
OF PERMITTE -� -
b
PLAN CHECK V L DATION CK. M.O. CASH
,Dy 1 .5.' 0-
S EE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE' ,7
y �
•• ,. ER'S COMPENSATION.DECLARATION ` 20-0046 DPW 9/89 ,
I hereb' Thai'-.have a certificate of consent to self.insure, 76A364C APPL���AT'' N FOR, PER11111T.`. EEN
or a certificate of Worker's Compensation Insurance, or.a certified
copy thereof(Sec.3800 Lab. C.)' "
HEATING=I VENTILATING -AIR CONDITIONING
COUNTY, LOS ANGELES '-DEPT OF PUBLIC WORKS BUILDING AND'SAFETY.DIV
Policy'No. Company
Certified copy is,hereby'furnlshed. e '
dCertified copy is filed with the county building inspection FOR APPLICANT TO FILL-114. '
epartment. (PRINT OR TYPE ONLY) ADDRESS
,
1 LOCALITY
Date ''I Applicant ( NO. TYPE OF APPLIANCE OR EQUIPMENT. ", FEE' .`
Dte
GI
CERTIFICATE OF EXEMPTION FROM'WORK NEAREST
:;COMPENSATION INSURANCE
CROSS ST I
- - :. ,ABSORPTION UNIT,BTU .. ._y
..ASSESSOR
.(This section need not be completed if the work involved by'the MAP:BOOK PAGE'' PARCEL
permit;is.for.one hundred dollars($100)or less.) AIf3 HANDLING UNIT,CFM
DISTRICT NO: PROCESS V
I certify that in,the;,performance of the work.for which this permit r
Is'issued, I'shall'not em to an erson in any manner so as to ? BOILER,BTU
P Y YP Y 8
become subject to the Workers'Compensation Laws.' ••*:• •
r 'COMPRESSOR,BTU' '''APPROVALS,: DATE ;INSPECTOR'S SIGNATURE
- .- - -
Date Applicant VENTILATION SYSTEM r i..
NOTICE ,TO APPLICANT:-If, after making this Certificate of _ ROUGH' ,
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provislons'of the'Labor Code, you must forthwith comply.with.such - ``'
provisions or this permit shall be deemed revoked. FURNACE. FAU GRAVITY ° FINAL
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I'hereby affirm that I am:licensed under,provisions of Chapter 9 SUSPENDED UNIT
(Commencing with•.Section,7000) of Division'3 of the Business and HEATER: WALL
Professions Code,and'my license is in full force and effect.
(-V-
License Number Lic,Class v : WJ �' }'
Contractor AIR-� Date z OO .. t"" O.
0, I am exempt under Sec. Plan check fel
GSD . ✓ 0
B.&P.C.for reason PERMIT ISSUING FEE$ o
Date: TOTAL FEE';
b
Signature
.• W
PLAN CHECK APPLICANT.. U)
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License taw NAME
_ ,for the following reason (Section,7039:5, Business and Professions '`- Le re'
Code): ADDRESS q
1, as owner'of the property, or my employees with wages
as,their sole.compensation, will do the:work and the CI pp TEL.NOiL
structureds not intended or offered-for sale (Section 7044, I V ov--�SF�� {t iL
Business and Professions Code). OWNER €_•� 1, f s.
I; as owner.'of the property; am,exclusively contracting MAIL
with licensed contractors to construct the project`(Sec- ADDRESS } f
tion 7044;Business and Professions:Code). / T i �I 7-{ 05
CITY TEL NO
CONSTRUCTION LENDING,AGENCY Inc
I hereby affirm that there is a construction lending agency for CHECK
f� f
the performance of the work for which.this permit Is ,issued: : CONTRACTOR t o - r� /► ��G t
(Sec.3097, Civ.C.)_ F-� F Jv Ln.`.�I � U
.ADDRESS -
l
Lender's Name. , `.' ` r r..`.
CITY A� 11I2O(�l i►4 TEL.N0:3rJ���J3�; nn-ri -foilr
C)0, rJ u i J lft
Lender's Address STATE l��Q' LIC. �./ v 3
I certify that I have read this application and state that the above LICENSE NO.O �<J���._ CLASS'li�w,`"'�-��-CD Y fJ�?f 1 ' t,- +f-I
information is correct. I agree to comply,with all County ordinances
and State laws relating to:building=.nstruction,and hereby authorize r?
representatives of this County to enter upon the above-mentioned
prop t .fo ection purposes.
SEE REVERSE FOR:EXPLANATORY LANGUAGE
SIGNA R O AP LICA O AG NT DATE '.' - • "' 'I - -