HomeMy Public PortalAbout9533 PENTLAND ST_Mechanical__ '76A36.E ME eISAI 11/76 APPLICATION FOR PERMIT
HEATING - VEN TING - AIR CONQIJIONING
C TY OF L 5 _NG ELES
DEPARTMENT OF COUNTY ENGINEER
( BUILDING AND SAFETY DIVISION '
FOR APPLICANT TO FILL IN BUILDING PE
533 6lTi.AND ST.
._
(PRINT OR TYPE ONLY) •1 ADDRESS 9cA, N
LOCALITY} TLY'�C LL-•', my
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CROSS ST
ABSORPTION UNIT BTU yp,,�
OWNER 022E PAUL_ A
AIR HANDLING UNIT CFM MAIL SAM ADDRESS SAM
• BOILER BTU CITY 'ffi. jE1 CITY TEL NO 285-2841
COMPRESSOR BTU 3 C rts nwTi !V -
5 CONTRACTOR 'i LY[1LVLAA,'LL lHOC _
VENTILATION SYSTEM 1� ADDRESS 2034 N. Ly(K yW
EVAPORATIVE COOLER CITY SO EL I"� TEL NO 579-7982
I FURNACE FAU A GRAVITY STATE LIC♦ '
FLOOR BTU LICENSE NO 265094 CLASS
HEATER SUSPENDED—UNIT— DISTRICTNO GROUP nE sseD RY
WALL
1 �
INSPECTION RECORD 6
p
y
Plan check fee 25% of above W
PERMIT ISSUING FEE j i
TOTAL FEE Cn
PLAN CHECK APPLICANT
NAME
ADDRESS ' L
CRY 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 VENTILATING AIR ,
CONDITIONING ` '
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF APPROVALS DATE INSPECTOR s 51 E
CHAPTER 9 DIVISION 3 OF THE BUSINESS AND PROFESSIONAL CODE '
OF THE STATE OF CALIFORNIA ROUGH
SIGNATUREFINAL — tov
OFPERMITTEE
PLAN CHECK VALIDATION CK MD CASH PERMIT VALIDATIONCK M0 cAsH` ,
2 4,5Auti 16 4 1,9.5 0i 9d
.WORKER'S COMPENSATION DECLARATION 20-0048 DPW 9189
76A364c
I hereby APPLICATION FOR PERMIT affirm that I have a certificate of consent t0 self insure,
or a clirtificpte df Worker's Compensation Insurance, or a certified HEATING -VENTILATING - AIR CONDITIONING f 1
copy thereof(Sec.3800 Lab.C.) Ll
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Poli
Certified copy is hereby furnished.
F1Certifiedcopy is tiled with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
7
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or lase.) AIR HANDLING UNIT,CFM
DISTRICT NO. ppOLEaaEO 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. p��O ��(�
COMPRESSOR,BTU
APPROVALS INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of I ROUGH
Exemption, you should become subject to the Workers' Compensation FOR CO LER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: U GRAVITY -"-VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED 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.
ri'_�i eT
License Number Lie.Class
1 ITEMS 1L
Contractor Date 0
ElI am exempt under Sec. Plan check fee `>I AL 52 ,95P
HtC1 cy.9�0
cc
B.dP.C.for this reason PERMIT ISSUING FEE $ ' -
Date:
TOTAL FEEoJCHANGE II'U
Signature 0-
PLAN CHECK APPLICANT - -W
OWNER-BUILDER DECLARATION L% !�,{ c
hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions ► ia_Ol.; 1M :_..''.
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). 6 IdWNER V V Af Zr2
I, as owner of the property, am exclusively contracting IL r ^�
with licensed contractors to construct the protect (Sec- ADDRESS 1 rG/) rHZ) 67.
tion 7044, Business and Professions Code). CITY-^
CONSTRUCTION LENDING AGENCY 1 E/HPt- F (r
TEL.NO./ 2 8r-lg`f
I hereby affirm that there is a construction lending agenvy for
the performance at the work for which this permit Ps issued CONTRACTOR
(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 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
X
/ SIGNATURE OF APPLICANT OR AGENT DATE