HomeMy Public PortalAbout6273 ROSEMEAD BLVD_Mechanical__ 76A36,V-C�E818-8-68 1\I tl
HEATING - VENTILATING - AIR CON®iT90NIN
COUNTY OF LOS ANGELES L–
DEPARTMENT OF COUNTY.ENGINEER_
BUILDING AND SAFETY DIVISION BUILDING ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 7 �/n
.COLEMAN W. JENKINS, SUPERINTENDENT QF BUILDING LOCALITY ?
NEAREST
n FOR APPLICANT TO FILL IN CROSS ST.
(Print or-type only)
OWNER
No.. TYPE1OFAPPLIANCE OR EQUIPMENT FEE MAIL
ADDRESS
ABSORPTION SYSTEM, BTU CITY TEL. NO.
AIR HANDLING UNIT, CFM CONTRACTOR N� C6jpc
BOILER, HORSEPOWER ADDRESS
COMPRESSOR, HORSEPOWER CITY 5' EL. NO.
440012 �
STATE LIC. _ G
VENTILATION SYSTEM LICENSE NO. CLASS,
DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE COOLER / �✓
FURNACE: FAU GRAVITY
FLOOR—BTU L- INSPECTION RECORD
HEATER:.SUSPENDED UNIT
WALL
CD
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Z
NEWADDITION PERMIT $. 3 00
ALTER—REPAIR— TOTAL FEE $
Plan check applicant
Name
Address
City 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, VENTI- APPROVALS D TE SP CTOR'S SIG TURE
LATING, AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION ;:-FINAL
OF CHAPTER 9, DIVISION 3 THE BUSIN S AND P OF SIONAL
CODE OF THE STATE OF 1 F.
JACK R. ALLEN,SUPERVISIN ECHANICAL ENG'R,
SIGNATURE PERMIT VALIDATION CK. M.O. CASH
OF PERMITTE
PIAN CHECK VALIDATION
.50SE �ACQ 2 4 2 3';�? SEF'i_7 4 1 D 1 0.50-
SEE
E BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
' WORKERS' COMPENSATION DECLARATION
~ITh firm tAat I have a icL 'of consent to self 'APPLICATION FOR PERMIT
;e' certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof Sec. 3800, Lab. C.) 76A364C
p _ _ _ CE-818(REV. 10/81)
Policy Nol oa—2�—cJ3� ompany S� 1/�I`r EAV-�
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
tion department. ADDRESS �J273 S^ t
I
� (PRINT OR TYPE ONLY)
Date J, � ) 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. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNITCFM
,
v U
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 become subject to the Workers'Compensation Laws. BOILER, BTU '1/} APPROVALS DATE INSYE R'S SIGNATURE
Date Applicant COMPRESSOR, BTU / Ov VV ROUGH -
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTE / U'J FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- !i EVAPORATIVE COOLER �1 O �� VALIDATION
with comply with such provisions or this permit shall,be a` pC
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 30 60
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT -93425A
'(commencing with Section 7000) of Division 3 of the Business WALL - .l-
and Professions Code,and my license is in full force and effect. _ # o 0-o-0 o 8
License Number "�'"' F 1 13 Lic. Class ,Z o _ ' r :-- ► 1 0 090.50_. V
09
Contractor YA 1�mz A/-S Date 1+— � � J 1.07—8 U. 0.
❑ I am exempt under Sec. LU
Plan check fee IL
B.&P.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law•for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their,sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 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 issued CONTRACTOR
(Sec. 3097, Civ. C.). I7 r♦ fIA I SYS�^ J ,
ADDRESS
Lender's Name p
CITY �aet�_ ] I_ TEL. NO. ��1 •,�\
Lender's Address w
I certifythat I have read this application and state that the STATE CL
pp LICENSE NO. 3 CLASS C�Z�
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
hereby authorize representatives of this County to enter
uP, the above-men Toned ro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date