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' APPLICATI FOR PERflHIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING /
DEPARTMENT OF COUNTY ENGINEER ADDRESS �p S L iLe—
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESSejS_ ;V 09el,
[P
ABSORPTION UNIT, BTU CITY TEL. NO.
CONTRACT0
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU n A CITY TEL. NO.
COMPRESSOR, BTU . `�� STATE LIC.
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NqO. GR/OUP ZONE 20CESSED BY
EVAPORATIVE COOLER
a
/ FURNACE: FAU GR VITY
FLOOR BTU INSPECTION RECORD
HEATER: SUSPENDED UNIT_
WALL
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Plan check fee 25% of above. See reverse.
PERMIT ISSUING FEF $ 3 00
'TOTAL FEE
PLAN CHEC 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
,LAT ING, A I R CONDITIONING. .
ROUGH
I HEREBY CERTIF HAT I.
CHAM y0T A TING IN VIOLATION ��� ` "'
OF CHAPTER 9, DIVI ON OF HE SIN D PROFESSIONAL FINAL v'
'CODE OF THE STATE OF LIF(9 IA
SIGNATURE - PERMIT
OF PERMITTEE VALI D.A I N CK. M.0. CASH
-
PLAN
CHECK,VALIDATION cK'. M.O. CASH
7-2 4r'-'JUN. .12 4,;1 :o -.1. 3.0, 0 A
SEE BACK,OF APPLICATION FOR COMPLETE FEE SCHEDULE '
4,by I�that I COMPENSATION DECLARATION 720-0046 6A364C PW 9/89 APPUCATM�'FOR 'pI�G�1�10� LIN
I hereby affirm that I have a certificate of consent to self insure, �1 1//1C,ti^JI�IUnUIUJu�\\`'�JI�
or a certificate of worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
Co y th of(Sec. 3800 LaJ. C.)
Company COUNTY OF LOS ANGELES DEPT OF-PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the-co ty building inspection FOR APPLICANT TO FILL IN BUILDING /�; A
t. ' (PRINT OA ADDRESSTYPE ONLY)!�MVPKA
" (f!Date , Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 117
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST '
CROSS ST:
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR ,
(This•section need not be completed if the.work involved by.the MAP BOOK_ PAGE PARCEL
permit is for one hundred dollars($100)or less.), AIR'HANDLING UNIT,CFM -
DISTRICT NO., PROCESSED BY
I,certify that in the performance of the•work for which this permit
is issued; I shall not employ-any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
ro
COMP BTU �� 1-1�.1 APPROVALS DATE INSPECTOR'S SIGNATURE
ApplicantVENTILATION SYSTEM
Date _ ,
NOTICE TO APPLICANT: If, after'making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the'Labor Code, you must forthwith comply with such FINAL F..
provisions or this permit shall be deemed revoked. FURNACE: FAU G AVITY V
LICENSED CONTRACTORS DECLARATION l FLOOR BTU VALIDATION
I;hereby affirm that I'am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is'in full force a+nndd/effect.
License Number Lic.Class
Contractor Date O
❑'
I am exempt under Sec. Plan check f@@ V
Q
B.&P.C.for this reason PERMIT ISSUING FEE$ �
Date: TOTAL FEE W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ()
r., Z
hereby affirm that I am"exempt from the Contractor's License Law NAME, D
for the following reason(Section 7031.5; Business and Professions ='
Code)' ADDRESS t-•. a
I, as owner of the property, or my employees with wages - w•I as
as their sole compensation, will do the work and the CITY TEL.NO. '5607 :r ok.Il
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER =s Cf I•-' A
❑ I, as owner of the property, am exclusively contracting MAIL > �� •TOTAL '37 = 00
with licensed contractors to construct the project (Sec- ADDRESS [�,
tion 7044; Business and Professions Code). j CHECK r I I
CONSTRUCTION LENDING AGENCY" CITY •� TEL.NO. r r`
I
hereby affirm that there is a construction lending agency for y► ""��' ��
the performance.of the work for which this permit Is issued CONTRACTOR J� D
(Sec.3097, Civ. C.). t
ADDRESS I II_I_il r { Y 1 `'
Lender's Name _
CITY TEL N0� - -..psi lr. _ P °F
Pi Ej
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
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
pro " r spection.purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAT E OF APPLICANT OR AGENT ATE -