HomeMy Public PortalAbout6284 PRIMROSE AVE_Mechanical__ 76 A364 — CE 818 — 9-71 APPLICATION FOR PERMIT
HEATING - .VENTILATING - AIR CGN01TIONING
COUNTY OF LOS ANGELES FNEARE
��
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ( Y
.FOR APPLICANT TO FILL IN(PRINT OR TYPEONLY) MAIL
NO. TYPE OFAPPLIANCEOR EQUIPMENT FEE C ' TEL. NO.ABSORPTION UNIT, BTU ®TOR
AIR HANDLING UNIT, CFM /,f
ADDRESS -� /YO fjTr_-
BOILER, BTU
CITY f TEL. NO.,�O/(/7�?J�G
COMPRESSOR, BTU STATE LIC.
LICENSE NO.2,5,JY CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP 1 ZONEPROCESSED BY
EVAPORATIVE COOLER ? / o
FURNACE: FAU_GRAVITY O
FLOOR BTU INSPECTION RECORD v
ce_
HEATER: SUSPENDED UNIT_ r O
WALL
W
Cn
/yii�� CL
A%
Plan check fee 25% of above. See reverse.
PERMIT ISSUING FEE 8 a 00
TOTAL FEE' Gj U
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
I HEREBY 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 INSPECTOR'S SIGNATURE
LATING,AIR CONDITIONING.
I HEREBY CERTIFY T T 1 AM NOT ACTING IN VIOLATION ROUGH
OF CHAPTER 9, DIVISIO OF THE BUSINESS AND PROFESSIONAL FINAL Gr.�'••' )
CODE OF THE STATE 0 C IFORNIA. _ r� '�•+'�
SIGNATURE PERMIT VALIDATI CK. M.O. CASH
OF PERMITTE
PLAN CHECK VALIDATION CK. M.O. CASH
L o '_1 2 8 S 12 APR 4 4 1 D 8.00Nej
SEE BACK OF APPLICATION FOR COM PLETE_E9E SCHEDULE
WORKL•-RS'COMPENSATION DECLARATION I CEA 8618 C(2-80) l� �o/'� I®� ®� 0�
I hereby affirm that I have a' certificate of consent to self
insure,or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec.380(0,Lab.C.),,�j�
Policy No. Company sll�"* e r Out
COUNTY OF LOS ANGELES BUILDING AND SAFETY
El Certified copy is hereby furnished.
IT Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
de rt ant. t_ n ADDRESS R Mra$e
Date Applicant- �'�J (PRINT OR TYPE ONLY) (�
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Tern le (2,t-
CERTIFICATE
INSURANCE NEAREST }
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. T m Le C�, [ O
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO. PROCESSE a Iv
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM cc
permit is issued, I shall not employ any person in any manner S • O
so as to become subject to the Workers' Compensation Laws. BOILER,BTU H
/ 3p GQO APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant ! COMPRESSOR,BTU 10 ROUGH �;� "' 9 N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. ! FURNACE: FAU R VI Y
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 0 Q�
1 hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- WALL
ness and Professions Code, and my license is in full force and
effect.
License Number M919 Lic,Class ea�
Contractor,_ Date �'jl3 F53
❑ I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$
Lic.or Reg.No. Date TOTAL FEE ' r 2 6 A
$
PLAN CHECK APPLICANT
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from- the Contractor's NAME o 0 3 Q 5 0
License Law for the following reason (Section 7031.5, Busi- e 0 0
ness and Professions Code): ADDRESS
❑ I, as owner of the property, will do the work and the 0 6 1 3—F 3
structure is not intended or offered for sale (Section CITY TEL.NO.
7044,Business and Professions Code). r'8<)6
�
❑ OWNER p0 AU2r
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project .MAIL
(Section 7044,Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY '� � TEL.NO.
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR
issued(Sec.3 Civ.C.). /aa Lohce,rr,er
Lender's Namee ADDRESS
Lender's Address CITY ��� TEL.NO. YtQ_S750t
I certify that I have read this application and state that theSTATE LIC.
above information is correct.I agree to comply with all County LICENSE NO. a CLASS GCIAD
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning,and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
i� tt�ion purpc�
Qk
ate
signature of Permittee D �7�