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CJ-81V'8(REV.11/78)
es APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDINGgy
CI
(PRINT OR TYPE ONLY) LOCALITY
ADDRESS
L
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST /J
CROSS ST.
ABSORPTION UNIT,BTU
OWNER
AIR HANDLING UNIT,CFM MAIL
ADDRESS !�
BOILER,BTU CITY QL�CJ� TEL.NO.
COMPRESSOR,BTU. �� CONTRACTOR
VENTILATION SYSTEM
ADDRESS
EVAPORATIVE COOLER CITY Q I�� TEL.N
FLOOR
FURNACE: FAU BTU GRAVITY �� LICENSE NO:
ATE A�;J CLASS ��
HEATER: SUSPENDED UNIT_ APPROVALS DATE INSPECTOR'S SIGNATURE
WALL
ROUGH
FINAL
IN8PEC 10 RECO D �r
-OzlwA
Plan check fee 25% of above. _
PERMIT ISSUING FEE$
TOTAL FEE
PLAN CHECK APPLICANT Xpl-
PLAJY CHECK VALIPATIPN
NAME /i✓�� 1, G y
ADDRESS
CITY TEL.NO.
IHEREBY 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, VENTILATING, AIR O 6 -1..5 1'
CONDITIONING. PERMIT VALIDATION
I HEREBY CERTIFY THAT AM NOT ACTING IN VIOLATION OF f` 0 0 0 0 (� I
CHAPTER 9, DIVISIO OFT NESS AND PROFESSIONAL CODE ,
OF THE STATE OF ORNI ✓ o o 2 7 C',
SIGNATURE '
OFPERMITTEE i. a •� '
DISTRICT NO. PROCESSED BY '
76A384 - CESIS - 3-69 APPLICATION, FOR PERM
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING Ll�,e Sr.
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY G.
COLEMAN W.JENKINS,SUPERINTENDENT OF BUILDING NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY) OWNER �(�
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE MAIL i ...I'1�►,r� `„
ADDRESS �j�• VX-
ABSORPTION SYSTEM, BTU CITY: C TEL. NO.
AIR HANDLING UNIT, CFM CONTRACTOR
ADDRESS �O� ® ON (J
BOILER, HORSEPOWER
CITY TEL. NOZ 0^�,,r/
COMPRESSOR, HORSEPOWER r _
LICE SE NO. bU CLASS C-/!/
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE COOLER 'C
FURNACE: FAU GRAVITY ,( 1
FLOOR BTU INSPECTION RECORD
HEATER: SUSPEN E U IT
WALL •
c
c
L
' o
F
• u
NEW �4DDITION_ PERMIT $ 3 00 v
ALTER_REPAIR_ TOTAL FEE $
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.N0.
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING,VENTI- APPROVALS DATE INS CTUR'S IG ATURE'
LATING, AIR CONDITIONI
`` '
I HEREBY LER F T A I A NOT CT N6 N VIOLATION OF ROUGH ' 'Z
CHAPTER 9, DIV SI N 3 F T BUST S AN ROFESSIONAL G
CODE OF THE ST OF LI 0 FINAL
SIGNATURE JACK R. ALLEN, SUPERV '67CHANICAL ENG'R.
OF PERMITTEE '
PERMIT VALIDATION cK. M.O. CASH
PLAN CHECK VALIDATION
LACo 4 5 9 4--r-41 FEB 25 4 1 0 8.0.0~ V
'EE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE '
ERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I�� m that I have a certificate of consent to self
+ rtificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
LA-certif u opy thereof(Sec. 3800, Lab. C.) CEA 818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ADDRESS 06 .
tion department. (PRINT OR TYPE ONLY) a
Date Applicant LOCALITY /
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. ('// PROCE SED BY
the permit is for one hundred dollars(;100)or less.) AIR HANDLING UNIT,CFM 5_1
UO .
I certify that in the performance of the work for 5hiAthis permit is iss ed, shall of empI y person in anner
so as t0 be Om b' J TO the Or r5 Compen n LOWS. BOILER,BTU APPROVALS DATE INSP OR'S SIGNATURE
Date / pplicant COMPRESSOR,BTU ROUGH
NO O PPLICANT: If, a Is CertiI..
VENTILATION SYSTEM FINAL
Exe tion, you should me s le to the 'Compensation provisions f e Labor Code, you m - EVAPORATIVE COOLER VALIDATI
with comply with such ovisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 WALL
and Professions Code,and my licenseis in full force and effect. Off.
License Number Lic. Class , S;
®G
Contractor Date
❑ I am exempt under Sec.
Plan check fee
H
B.BP.C. for this reason, PERMIT ISSUING FEE$
Date:
TOTAL FEE • -6)
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , c 9 1 5 5 A
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): 0 a o 0 0 8
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ° - 20,50
CITY TEL. NO.
the structure is not intended or offered for sale(Section o 0 0 � _ .
7044, Business and Professions Code). L—
OWNER ✓ 031 1 —8 8 8 c�
8
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL i
tion 7044, Business and Professions Code). ADDRESS I✓� p
CONSTRUCTION LENDING AGENCY TEL,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACT,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
obo rmation is correct. I agree to comply with all County
Inanc and State laws relating to building construction,
and her y authoriz r presenia Ives of this Co my to enter
upon th above-m t' no property for ins ect' urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
igq�t A i int or Age o ote