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HomeMy Public PortalAbout9860 VAL ST_Mechanical__ ION WORKER'S I have a certificate of consent to 76A348DPW9le9 APPLa;;ATION FOR PERMIT LIME GREEN 7aA364C I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.QqDq(C.) • 0�No, ompany i e 15-i ll e COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ® ertified copy is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING y gi p ADDRESS a- e artment. • (PRINT OR TYPE ONLY) Data Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WO KERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT�BTU OR (This section need not be completed if the work Involved by the MAP OOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT.CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER.BTU r r become subject to the Workers'Compensation Laws. d -e _-, COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I VALI TI dN I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is In full force and eMia affectt..'� License Number Lic.ClassaL— f _ i Contract(&R • R Date C ❑ I am exempt under Sec. Plan Check fee Q BAP.C.for this reason PERMIT ISSUING FEE$ •e) Date: TOTAL FEE i' Signature PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason(Section 7031.5, Business and Professions 011111. Coe): ADDRESS WC :a I, as owner of the property, or my employees with wages 33W col(_ as their sole compensation, will do the work and the CITY , TEL.NO. structure is not Intended or offered for sale(Section 7044, - 3 s iirll� MAIL - Business and Professions Code). OWNER ` !Sf ❑ 1, as owner of the property, am exclusively contracting >0�AL 25 . 00 with licensed contractors to construct the project (Sec- ADDRESS i -;_ -- tion 7044, Business and Professions Code). ''HECK CONSTRUCTION LENDING AGENCY CI LL ,1 ' TEL.NO. _ I hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). ADDRESS w&uav_ Lender's Name CI TEL.N46�O L3 5 72 1 AM }OC' Lender's Address STATE �W� I certify that I have read this application and state that the above LICENSE NO. CLASS agn information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize re esentatives of this County to enter upon the above-mentioned o rty fr in c' urpo SEE REVERSE FOR EXPLANATORY LANGUAGE al SIGNATU F APPLICANT OR AGE DATE ' 76 A364VCE 818-1/75 APPLICATION FOR PERMIT HEATING - VENTILATING - AIR CONDITIONING COUNTY OF LOS ANGELES ADDRESS DEPARTMENT OF COUNTY ENGINEER 1,19 BUILDING AND SAFETY DIVISION LOCALITY NEAREST CROSS ST. FOR APPLICANT TO FILL IN OWNER (PRINT OR TYPE ONLY) anvil-101 MAIL / NO. TYPE&SIZE OF EQUIPMENT ' FEE ADDRESS gf667 C / SEE BACK OF APPLICATION CITY�/ 1 r TEL. NO. FORCE AIR FURNACE, BTU i CONTRAC OR COMPRESSOR, BTU -V O cl cl ADDRESS VENTILATION FAN CITY .� TEL. N1 j LIST ALL OTHERS BELOW STATE LI LICENSE NO. �C CL SS V Z o T N0. GROUPZON PR SSED BY INSPECTION RD 1L O U O F- U W 0_ Plan check fee. See reverse. A. z PEIt111'I' I.SSliING FEE S , TOTAI. FLT: i PLAN CHECK APPLICANT 5 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- kFINAL APPROVALS DATE INSPECTOR'S SIGNATURE LATING,AIR CONDITIONING. I HEREBY CERTIF HAT I AM NOT ACTING IN VIOLATION ' OF CHAPTER 9, DIV 3, OF THE BUSINESS AND PROFESSI ALCODE OF THE ST NV.SIGNATURE IT VALIDATION CK. M.O. CASH OF PEI / 7 PLAN ECK VALIDATION CK. M.O. CASH Q 2 0 h AI©tF �_5 4 1 1 2.0 0 arc