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76;A364- CE 818- 5-73 APPLICATION •FOR PERMIT`'�'-• Gam"_
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• HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES. FNEAREST
ING
DEPARTMENT OF CO.UNTY ENGINEER ESS
BUILDING AND SAFETY DIVISION LITY'`
S ST.FOR APPLICANT TO FILL IN R
(PRINT OR TYPE ONLY)NO. TYPE OFAPPLIANCEOR EQUIPMENT FEE ESS
CIT TEL.
ABSORPTION UNIT, BTU
CONTRALTO ��
AIR HANDLING UNIT, CFM
ADDRESS C�L�
BOILER, BTU CITY TEL. NO, v a
COMPRESSOR, BTU� 000 � STATEf f LIC.S ()
LICENSE NO. ir Q CLA - V
VENTILATION SYSTEM DISTRICT No. GROUP I ZONEPRO SEED BY
EVAPORATIVE COOLER. d
FURNACE: FAU_GIIT Y INSPECTION RECORD
FLOOR -'BTU
HEATER: SUSPENDED UNIT_
WALL
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Plan check fee 25%of above. See reverse. z
PERMIT ISSUING FEES 7100
TO E ? OD
.PLAN CHECK APPLICANT
NAM '
ADDRESS
CITY T E L.N 0,2�00,21 e
I kiEREBY ACKNOWLEDGE TH 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENT'1- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THAT 1 AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISION 3, OF THE BUST SS AND PROFESSIONAL FINAL
CODE OF.OF THE STATE O CAL FORNIA. _
SIGNATURE PERMIT VALIDATIO ' CK. M.O. CASH
OF
PERMITTEE
PLAN CHECK VALIDATION CK. M.O. CASH o 0 N
0. n o 0 NO
'O o 0 0
0 00
10 O 'O —• p'
CH
WORKERS'COMPENSATION DECLARA'[]ONI CEA 8 B '(2-80) A P P L� C AT�O � FOR PER Illi T
I hereby affirm that I have a' certificate of consent to self
insure, or a certificate of Worker%'Compensation Insurance.or i I IAT IWG-VG=�TIL.ATI�G-A01R CONDITIONING
a certified copy thereof(Sec.3800.Lab.C.)
Policy Company COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspectionBUILDING
department. FOR APPLICANT TO FILL IN
ADDRESS
Date Applicant (PRINT OR TYPE ONLY)
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Pz/f •/�
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the Work involved ABSORPTION UNIT,BTU CROSS ST. �(4 S 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY V
I certify that in the performance of the work for which this i AIR HANDLING UNIT,CFM
[r
permit is issued, I shall not emplo any person Iplaly manner ct::) at&2
0
so as to become subject to the rkers'Comp nsa 'on Laws. BOILER, BTU
Yr'� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR,BTU ROUGH
NOTICE TO APPLICANT: If, after making this C tficate of VENTILATION SYSTEMFINAL z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or this permit shall be VALIDATION
deemed revoked. FURNACE: F A U GRAVITY
LICENSED CONTRACTORS DECLARATIONFLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and it
effect. s3 LL ( e "� �
License Number J J Lric.Class�-
Contracto Date /—
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADDRESS .J /� l ` (j 9 6 2 f,
1, as owner of the property, will do the work and the �+� ,
structure is not intended or offered for sale (Section CITY v /=� Y TEL.NO �Q� o;0 0 0 o F
7044,Business and Professions Code).❑ ��OWNER a / /i .��y� J� [ 65U
I, as owner of the property, am exclusively contracting ��
with licensed contractors to construct the project MAIL / �
o o '
(Section 7044,Business and Professions Code). ADDRESS r
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 0 7 1 4—e2
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3097,Civ.C.). t2.
Lender's Name ADDRESS X-t-
Lender's Address CITY j/f��j�/J TEL.NO.
I certify that I have read this application and state that the STATt LIC. `
above information is correct.I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating.Ventilating and
Air Cond' 'oning,and hereb a thorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County t enter upon a above-mentioned property for
insp o purpo� !J
—/�
Si a ure of Permittee Date