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76A364C 7
CE-818(REV.11/78)
®5 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
EBUILDING(PRINT OR TYPE ONLY) 5126 Persimmon
Tem 1e CItNO. TYPE OF APPLIANCE OR EG)UIPMENT FEE . Freer
ABSORPTION UNIT,BTU
OWNER Diane Davis
AIR HANDLING UNIT,CFM MAIL
ADDRESS 5126 Persimmon
BOILER,BTU CITY Temple City TEL.No.443-5488
1 COMPRESSOR,BTU 35 10 00 CONTRACTOR E. L. PAYNE CO 444- 11
VENTILATION SYSTEM ADDRESS
166 W. Live Oak Avenue
EVAPORATIVE COOLERCITY Arcadia O TEL.No- 446-61I
O. L(46-61 18
FURNAl FLOORCE: FAU BTU GR ITX _ 10
001 STATE LICENSE NO. 120228 CLASS C-20
HEATER: SUSPENDED UUNIT_
WALL APPROVALS DATE INSPECTOR'S SIGNATURE
ROUGHJ.
9L
FINAL ZQ
INSPECTION RECORD
O
8J
Plan check fee 25% of above. 0.
PERMIT ISSUING FEE$ ] 00
TOTAL FEE 27 00
PLAN CHECK APPLICANT PLAN CHECK VALIDATION
NAME
ADDRESS `C, 9 6 6 A
CITY TEL.NO. Ji ° ° ° o 4
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL ° ° 2 7 Cl C
ORDINANCES AND LAWS REGULATING HEATING. VENTILATING• AIR
coNDIrIONINc. 'PERMIT VALIDATION
I HEREBY CERTIFY AT I AM NOT NG IN VIOLATION OF
CHAPTER 9, DIVIS ON O THE BUSINES D PROFESSIONAL CODE i; 7 J•-
OF THE STATE OF C A.
SIGNATURE
OFPERMITT
DISTRICT NO. PROCESSED BY
7S364
WORKERS'COMPENSATION DECLARATfON ' CEA 818 0(2-80) f"1 r IC P1� ®9�Y FORPERMIT
I hereby affirm that I have a' certificate of consent to self
'fl
insure, or a certificate of Workers'Compensation Insurance,or / HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.3800,Lab.C.) l
Policy No.—wL1-5D4.4mAny- MTSSTCIAT INS
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
I
Certified copy is filed with the county building inspection BUILDING
dp
I�V�br me t. FOR APPLICANT TO FILL IN ADDRESS 512
Date0 81Appl(cant PATTY KERRY (PRINT OR TYPE ONLY)
N- PERSIMMON
LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSED BY 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM j� O
permit is issued, i shall not employ any person in any manner S,au 0
so as to become subject to the Workers'Compensation Laws.
BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE V
W
Date Applicant COMPRESSOR,BTU 0-
ROUGH W
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM r17 Z
Exemption, you should become subject to the Workers' I FINAL
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY—
LICENSED
LICENSED CONTRACTORS DECLARATION BTU SItl
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 1
effect. POOL HEATER 4
License Number 254846 Lic.Class C-53
Contractor SWAN POOT.S Date 4/30/81 BTU'S
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).
Lic.or Reg.No. Date I 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 ;2 5j 0 a l A
I, as owner of the property, will do the work and theTEL.NO.
structure is not intended or offered for sale (Section CITY # 0 0 0 0 ((
7044,Business and Professions Code).
OWNER 2 0 0 2 ],O O
I, as owner of the property, am exclusively contracting DIANNE DAVIS
with licensed contractors to construct the project MAIL x
(Section 7044,Business and Professions Code). [AODDRESS 5126 N E o a o 2 7 O O 53
CONSTRUCTION LENDING AGENCY TY TEL NO. 05,04-81
I hereby affirm that there is a construction lending agency NTRACTOR
for the performance of the work for which this permit isSWAN POOLS
issued(Sec.3097,Civ.C.).
Lender's Name GASH DRESLender'sAddress f'nSH TY COVINA TEL.N0966-8631
I certify that I have read this application and state that the ATE LIC.
above information is Correct.I agree to comply with all CountyCENSE NO. CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
t
ent upon the above-mentioned property for t u po s.re of er up
Data
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