HomeMy Public PortalAbout9636 VAL ST_Mechanical__ 76 A36A- CEO15-1/T5 ,
APPLIC ION FORP RMIT
HEATING - VENTILATING - AIR CON011IONING
COUNTY OF LOS ANGELES BUILDING 9
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
NEAREST
CROSS ST
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) A
MAIL
NO TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
FORCE AIR FURNACE eTU CITY TE
CONTRACTO
COMPRESSOR BTU
ADDRE
VENTILATION FAN
LISTA OTHERS BELOW ATELIC ��oo
LICENS NO D CLAS-'( 13
Mm"TRICT NOGR OUR ZONE PROCESSED Y
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INSPECTION RECORD
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Plan check fee See reverse
PI H\III I``51 I\f tI t 5
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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 DATE INSPECTORS SIGNATURE
LATINO AIR CONDITIONING
ROUGH
1 HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
OI CXAPTER 9 DIVISION 3 OF THE BUSINES D PROF IONAL FINAL
CODE OF THE STATE OF C IFORyLA
SIGNATURE PERMIT VALIDATION cK M o CASH
OF PERMITTEE
PLAN HECK VALIDATION cK M 0 CASH
1 3 4 1 0 12.0 () e�;6
J :;:'
WORKERS COMPENSATION DECLARATION. W �C /�//XPPLICATION FOR PERMIT
I hereby aff4m that I have a certificate of consent to self
or arcerhfed r a certificateothereoWorkers
Sec 3800 Lab nC hon Insurance 76A364C HEATING - VENTILATING - AIR CONDITIONING
PY ( )
Of(JC/OZ, CE BIB(REV IO/BI)
Policy No Company
Certified copy Is hereby furnished COUNTY OF l05 ANGELES BUILDING AND SAFETY
Certified copy Is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING n ^ L
tion department (PRIM OR TYPE ONLY) ADDRESS 7 b
YA
Date I- L� Applicant NO
X
0 TYPE OF APPLIANCE OR EQUIPMENT FEE 1
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS 57
(This stolon need tsat be complefed 0 the work In"lvod by ABSORPTION UNIT BTU Disrmcr No WD e
the permit Is for a"hundred dollars ($100)or less)
I certify that In the performance of the work for which this AIR HANDLING UNIT CFM �L
permit Is Issued I shall not employ any person In any manner
so as to become subject to the Workers'Compensation Laws BOILER BTU AwRDVAM DAn s UK
Date Applicant / COMPRESSOR BTU '�OVQ ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become sublect to the Workers _
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE EAU TY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU GR VIV
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section ,7000) of Division 3 of the Business WALL '
and Professmom Code and my license Is in full force and effect _y >
IL
aLic Class ���License Number�
V
y A/ is-31� Al{AXLe2-Y111111" o
Conhacror�(- 6 � Date r
❑ I am exempt under Sec �y
Plan check fee d
B BP C for this reason to
Dote PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 0 44.4 A
I hereby offvm that I am exempt from the Contractor s license
Law for the following reason (Section 7031 5 Business and NAME Polls / # s s,s s 98
Professions Coda)
❑ 1, as owner of the property or my employees with ADDRESS I s - 44.50
wages as their sole compensation,will do the work and4'4.5 0
the structure Is not Intended or offered for sale(Section CITY TEL NO s s
7044 Business and Professions Code)
p B -
I as owner of the property am exclusively contracting OWNER 1 6 8 8
^
with licensed contractors to construct the project (Sec "KESS b 3� VEL.
non 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITYIt I
I hereby affirm that there Is a construction lending agency for 7' ►
IQ� op
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097, Civ C ) _
ADDRESS a
Lender's Name L
(f a
Lenders Address CITY TEL NO
STATE LIC M'
I certify that I have read this application and state that the LICENSE NO oZ CLASS CO3above Information Is correct I agree to comply with all County
ordinances and State jaws relating to budding construction
and hereby authorize representatives of this County to enter
U pon the abed properly for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
1!/Y/ ?-Ic-im
Signature of Applicant or Agent Date