HomeMy Public PortalAbout5216-5218-5220-5222-5224 VILLAGE CIRCLE DR_Mechanical__ 1
76 A364 - CE 818-1'75 •-
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONOIJAONING
COUNTY OF LOS ANGELES 7EST
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DEPARTMENT OF COUNTY ENGINEER /�rz
BUILDING AND SAFETY DIVISION ` f
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FOR APPLICANT TO FILL IN(PRINT OR TYPE ONLY) (NO. TYPE&SI,ZEOFEQUIPMENT FEE
SEE BACK OF APPLICATION -
-_ CITY TEL. NO.
FORCE AIR FURNACE, BTU' r'
CONTRACTOP-
COMPRESSOR, BTU • Cz .�
ADDRESS 7 r
VENTILATION FAN
CITY TEL. NO.�'-';
LIST ALL OTHERS BELOW STATE e- LIC.
LICENSE NO. - CLASS
DISTRICT NO. GROUP ZONE PROCESSED BY
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INSPECTION RECORD O
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Plan check fee. See reverse.
PF:N\li'f ISS( INC FI:I•: S 3 00
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THEABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCESAND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATINS'. AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THA M ACTING IN VIOLATION -
OF CHAPTER 9. DIVISION 3, '1' INESS AND PROFESSIONAL FINAL
CODE OF THE STATE OF C R
SIGNATURE ,•� �� —. PERMIT VALIDATION = -
OF PERMITTEE
PLAN CHECK VALIDATION CK. M.0. CASH
402 -.,x 1441 43. I •
WORKER'S COMPENSATION DECLARATION 20-ooasDPW s/a9 APPLICATION FOR PERMIT LAME GREEN
76A364C
I heretyl affirm Mat 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. C.) . . _ il
Policy No. G961113003C:ompany Cal COMP COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
® Certified copy is hereby furnished.
® BUILDING
Certified copy is filed with the county building' S ection FOR APPLICANT TO FILL IN ADDRESS 5222 Village Circ1e Drive
department. % (PRINT OR TYPE ONLY)
Date 5/28/96 Applicanhr �i �' 7�'i /, LOCALITY Temple City
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
cRoss ST. Baldwin
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASS
(This section need not be completed if the work involved by the MAPEBOOK 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 P J
become subject to the Workers' Compensation Laws. ✓ 111L-�LLr+[-��
1 COMPRESSOR,BTU 30,000 26 60
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 IL GRAVITY
Ice
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 7S,000 261 60 VALIDATION
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 and WALL
Professions Code, and my license is in full force and effect.
Replacement of heating and
License Number 221751 Lic.Class C-20 ail" conditioning units
E1
5/28/96 C
I-li.1.T.T
Contractor <�' Date
33C!3
Plan check fee
I am exempt under Sec.
B.&P.C.for this reason PERMIT ISSUING FEE $ 27 30 TCI
f ITEMS I.
Date: TOTAL FEE 8 50 ITAL g'e
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Signature (HECK
PLAN CHECK APPLICANT `—"J•c�
OWNER-BUILDER DECLARATION Chm-4GE
I hereby affirm that I am exempt from the Contractor's License Law NAME , `ri0
for the following reason (Section 7031.5, Business and Professions o `'
Code): ADDRESS )000 !—j I; �, �f`}7.r7h
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO 6 63-3 1 �� C.,
structure is not intended or offered for sale (Section 7044, r-"I .2
Business and Professions Code). OWNER Dianne Evans
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 5222 Village Circle Drive
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Temple C i uy TEL.No. 448-9580
1 hereby affirm that there is a construction lending agency for 0111".the performance of the work for which this permit Is issued CONTRACTOR Bryant Heating & Air Condition.
(Sec. 3097,Civ. C.).
ADDRESS 1350 E. Las Tunas Dr.
Lender's Name
CITY San Gabriel TEL.NO. 818 286-1141
Lender's Address STATELIC.I certify that I have read this application and state that the above LICENSE NO. 221751 CLASS C-20
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
rty forin ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5/28/96
SIGNATURE OF APPLICANT OR AGENT DATE