HomeMy Public PortalAbout9491 OLEMA ST_Mechanical__ ISA954E- C.9,108-9/79 APPLICATION FOR PERMIT {�
,Y HEATING - VENTILATING - AIR CONDITIONING u
BIJL NG AND SAFETY ISION
FOR APPLICANT TO FILL IN BUILDING )
(PRINT OR TYPE ONLY) ADDRESS C � 71P
LOCALITY
NO. TYPE 0FAPPLIANCE OR EQUIPMENT FEE NEAREST '
CROSS ST.
ABSORPTION UNIT, BTU
OWNER s5
AIR HANDLING UNIT, CFM MAIL JJ��
ADDRESS 9qqi O f e rn a
BOILER, BTU CITY I �e TEL. NO, a?J'7-5 C
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COMPRESSOR, BTU CONTRACTOR rj.t VS
VENTILATION SYSTEM ADDRESS f OA j<
EVAPORATIVE CO ERCITY;e 1 TEL. NO. S -i�f �(
FLOORCE: FAUFURNABTU IT} LICE SE NO. �SATE V CL G c36
HEATER: SUSPENDED UNIT_ DISTRICT NO. GROUP ZONE PROLE SED BY y
WALLix
a
INSPECTION RECORD
r LL
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Plan check fee 25%of above.
PERMIT ISSUING FEE $
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-
LATING, AIR CONDITIONING.
I HEREBY CERTIFY THAT I AM OT ACTING IN VIOLATION APPROVALS DATE INSPECTO SIGNATURE
OF CHAPTER 1 DIVIS 3, OF THE SINESS AND PROFESSIONAL
CODE OF THE STATE F ALI NI ROUGH
SIGNATURE
OF PERMITTEE.CJ&I M ' FINAL
.m PERMIT VALIDATIONCK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH
523i r- UV X041 D 1 5.550 �-=
�OI RKER'S COMPENSATION DECLARATION 2D-0 64C PW 9189
►�. APPLICATION FOR PERMIT ���;n� C( ' E =3
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy there ec.3800 ab.C.) j
Policy No. ompany COUNTY OF LOS ANGELES UEPT`OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ C rtified is filed with the co FOR APPLICANT TO FILL IN BUILDING
t/building inspec' ny ADDRESS
p (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
L
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERT KATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �� '�
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU ��+ (!-�
APPROVALS DATE IN3TOR'8 IGMATURE
Date Applicant VENTILATION SYSTEM JpEf
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such I FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY GQ
LICENSED CONTRACTORS DECLARATION 0 FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is' full force and effect.
License Number Lic.Class _ d� >
/� ®
Contracto K Date `-� ACCT.4 CC
El I am exempt under sec. Plan check fee 3303 80.50
C
B.&P.C.for this reason PERMIT ISSUING FEE$ 1 ITEMS
F
Date: TOTAL FEE d p TOTAL BG e 5ED u
Signature CHECK 80.50 V
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION CHANGE .00 6
I hereby affirm that I am exempt from the Contractor's License Law NAME J
for the following reason (Section 7031.5, Business and Professions
Code):
e): ADDRESS
1, as owner of the property, or my employees with wages 0000'D001 220/96
as their sole compensation, will do the work and the CITY TEL.NO. i 4914 1 AMIlo-1`
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER '
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). '/q
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for 4ADDRESS
the performance of the work for which this permit s issued
(Sec.3097,Civ.C.).
Lender's NameTEL.NO.
Lender's Address LIC.
I certify that I have read this application and state that the above CLASS
information is correct. I agree to comply with all County ordinances
and Sta laws relating to building construction,and hereby authorize
represe tatives of this County t enter upon the above- 'ention d
prop for inspection p s s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SWW
RE 0 I OR AGN DA