HomeMy Public PortalAbout5321-5323 VILLAGE CIRCLE DR_Mechanical__ 76 A364- CE 818- 56-73
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELESAD'L SS Sax/ 532
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCAL r•
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
No. TYPE OFAPPLIANCE OR EQUIPMENT FEE ADDRESS
CITY • EL. NO. A7 �? 0
ABSORPTION UNIT, BTU
CONTRACTO r
AIR HANDLING UNIT, C-FM
ADDRESS
BOILER, BTU �r q r
CITY TEL. NO, dV / V o
COMPRESSOR, BTU 3 -Y►'aL- Q� STATE LIC. _
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE PROCESSED BY
EVAPORATIVE COO ER v •'a T �pQ a
FURNACE: PAUVI
_G TY INSPECTION RECORD
FLOOR BTU 00
HEATER: SUSPENDED-UNIT-
WALL
USPENDED UNIT_WALL
CD
O
V
• W
CL.
N
Z
Plan check fee 25% of above. See reverse.
PERMIT.ISSUING FEE O
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO,
LBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
E THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
IR CONDITIONING. ROUGHEBY CERTIFY THAT I AM NOT ACTING IN VIOLATION ER 9, DIVISION 3, OF THE BUSINESS AND PROFESSIONAL FINALTHE STATE OF CA FORNIA.
URE PERMIT VALIDATION CK. M.O. CASH
MITTEE
PLAN CHECK VALIDATION CK. M.O. CASH
�1. 5 5 EB' 11 4 1 n3 4:b U a
WORKER'S COMPENSATION DECLARATION 20.0048 DPW 9/89 {
I hsqbyti76A364C APPLICATION FOR PERMIT
aHhm thtsii I have a certificate of consent to self Insure, t 1
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATIN. -AIR-!��ONDITIONING �
copy thereof(Sec.8800 Lab.C.)
Policy No. 511 13zs-2Company �a- �� �` COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
certified co is filed with the cdunt building BUILDING _ ()`C GSL /� r'
copy y g inspection FOR APPLICANT TO FILL IN ADDRESS v ("
departme t. �F7zp,�0fns (PRINT OR TYPE ONLY) r
Date y Applicant-Y'�^T 4 H�S F y i LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($1100).or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTUO�
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
• APPROVALS DATE INS TORE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER 9L
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU C3RAV
ITY��� D VALIDATION
LICENSED CONTRACTORS DECLARATION - FLOOR BTU ((,�,O+
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number G
d 1-90A-) Lic. ass �`ff
r
contractor �� �< Date Z ALC
❑ I am exempt under Sec. Plan check fee p�
o� o[
B.&P.C.for this reason PERMIT ISSUING FEE$ H
Date: TOTAL FEE p�9 U.
Signature PLAN CHECK APPLICANT U,
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
Code): ADDRESS i-i G
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. Vim- -2.55
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER L�L 'SEC`•'
❑ I, as owner of the property, am exclusively contracting MAIL i 1~E}}(, 52-95
with licensed contractors to construct the project (Sec- ADDRESS ��;Z- V L L- ••/
/:,
�+ —
tion 7044,Business and Professions Code). C•`�E'- =°1•-
NO�/E , Z
CONSTRUCTION LENDING AGENCY i, TEL. t(;�. 11j;
I hereby affirm that there Is a construction lending agency for Ls1Hl1�—
the performance of the work for which this permit Is issued CONTRACTOR �4� C.9� C 05;r t
(Sec.3097,Civ.C.).
Lender's Name ADDRESS 6'7 l .. t*" } ,i•14,'�F 5
CITY u $01 GG TEL.NO.Z q 5—G 1 913933 1 x'1312:13`2
Lender's Address
I certify that I have read this application and state that the above C.
CENSE No. CLLASS `
information is correct. I agree to comply with all County ordinances
and State I s relating to building construction,and hereby authorize
rep nta es of unty to enter upon the above- entioned ,
p er f r ins actio urposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE
J � l C! .
SI ATU FAPPLIC OR DAT