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7BA364 - CES18 - 3-69 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING�`ggQ�;-
COUNTY OF LOS ANGELES FUI7G ,4�. �j
DEPARTMENT OF COUNTY ENGINEER "
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W.JENKINS,SUPERINTENDENT OF BUILDING -t/V
FOR APPLICANT TO FILL IN
(PRINT OR TYPE ONLY) i
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ADDRESS / " Y k"-4t—
ABSORPTION SYSTEM, BTU CITY iq -, TEL. NO.
AIR HANDLING UNIT, CFM CONTRACTOR
.f _ i21
BOILER, HORSEPOWER ADDRESSe,
CITY !. TEL. NO. �• 0 q-7g�
J COMPRESSOR, HORSEPOWER .3 1)0 STATE r^+ LIC.
LICENSE N0. -3 51; cFS CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP O PROCESSED BY
EVAPORATIVE COOLER � �`� � K
FURNACE: FAU GRAVITY �D
FLOOR BTU 1iJti�'O v� INSPECTION RECORD
HEATER: SUSPENDED UNIT
WALL
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NEW.kt'--ADDITION_ PERMI T $ 3 00 Z
ALTER_ EPAIR_ -TOTAL FEE $
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL. NO.
1 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. APPROVALS DATE INSPECTOR'S SIGNATURE
IHEREBY CERTIFY THAT 1 AM NOT ACTING IN VIOLATION OF ROUGH
CHAPTER 9, DIVISION 3, OF,-TN USINESS AND PROFESSIONAL FINAL [,
CODE OF THE STATE OF CA 0
SIGNATURE .� JACK R.. ALLEN, SUPERV . ECHANICAL ENG'R.
OF PERMITTEE
PERMIT VALIDATION CK. M.O. CASH
PLAN CHECK VALIDATION
- 5'5 Z. GP JUd23"4 1 'D
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
(
W01t KI SS'C OMPl.NSATION DECLARATION CEA 81 SC(2-80) A P P C A p �®II�I FOR P E R UVII T
I hereby affirm that 1 have a' certificate of consent to self
insure, or a Lertificate of Workers'Compensation Insurance,or ! HEATING-VENTILATING-Alps CONDITIONING
v�jher• (Sec.3800,Lab.C.) A/
Policy No.t�4 Company I A A 1
Certified cop)•is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
C'ertifiod//coopQpy i;filed with the co Inty bu(I I' g inspection I FOR APPLICANT TO FILL IN BUILDING ♦/�� 9,� Q
D
DatedCp pplicant (PRINT OR TYPE ONLY) ADDRESS `7' � '� �v
LOCALITY
CERTIFICATE OFEXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE ! NEAREST n
(This section need not be completed if the work involved ABSORPTION UNIT,BTU CROSS ST. L�(,�]ej� CL
by the permit is for one hundred dollars ($100) or less.) i DISTRICT NO. PROCESSED BY V
I certify that in the performance of the work for which this I AIR HANDLING UNIT,CFM �j�
permit is is-1 I shall not employ any person in any manner ,/ O
so as to become subject to the Workers'Compensation Laws. I BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE V
Date ApplicantCOMPRESSOR,BTU ROUGH — a
NOTICE TO APpL1CANT: If, after making this Certificate of VENTILATION SYSTEM _ N
Exemption, you should become subject to the Workers' FINAL �'/� , - —�--• z
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR: BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- .I WALL
ness and Professions Code,and my license is in full force and
effect. // e--- -5_2
License Number-105-0-7— Lic.Class JJ
Contractor LS Date
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer Plan check fee 25%of above.
acting in my professional capacity (Section 7051, Bus- '
iness and Professions Code). PERMIT ISSUING FEE$ KIP
Lic.or Reg.No. Date I TOTAL FEE J�
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPb`IAETOR IA P-0-091A3
3r6 1 A
I
I hereby affirm that I am exempt from- the Contractor's NAME 8808 EAST.LA$ I
License Law for the following reason (Section 7031.5, Busi- UABRIEL, AS TU ASDRIVE rk'0 0'0 0 0 8
ness and Professions Code): ADDRESS
I, as owner of the property, will do the work and the I TELNO. 2 0 o33,50
CITY .
structure is not intended or offered for sale (Section 7Z4{p _
7044, Business and Professions Code). 0 0 0 3 3 5 0-rJ
I, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project MAIL e 1 6-82
(Section 7044, Business and Professions Code). ADDRESS ZZ1�
CONSTRUCTION LENDING AGENCY CITY / ` TEL.NO.
I hereby affirm that there is a construction lending agency ' CONTRACTOR CALIFORNIA POO
for the performance of the work for which this permit is I
` issued (Sec.3097,Civ.C.). 8806 EAST LAS TUNAS DRIVE
Lender's Nalne ADDRESS
1 0
Lender's Address
I CITY TEL.NO.
I certify that I have read this application and state that the STATE �j LIC. _s
above information is correct.I agree to'comply with all County LICENSE NO. O /b� CLASS
ordinances and State laws reguI ing :ieat(Itg, Ventilating and
Air Conditioning,and herr y thori;e representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County enter opo Ile above-menti ned property for j
Ci
_ i n purposes. !,
S na c rY Permi at
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