HomeMy WebLinkAbout1654A ��•oiaxr�cs•co�.n�r�s:�T�o�;nrct.:�a:�'rro� 76A364C
� �,r<<.�,> :�«��,,, ��,,� , �,:,t �«<<����,<<� „f��,,,«�„�t�,���f �E.e,a�z.so� APPLICATION FOR PERMI i �
insure,or a certifics�a u!5ltirkers'Cnmpensation Inaurance,o� ; HEATING-V ENTILATING-AIR C�N�ITIONING
a eertifieJ�c/n,yp-�s�thercof(Sec.3P00,I,ah.C-.f) i
I'�Ilcy.'.'o'i7_Gg�('��mli�n��—s��/C�NNb_
� Crniticd c�py is hcreby turaish_d. ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
� Cer�ified cop}�ii fikd�ci[h the cnim[y building inspectinn BUILDING
�rp�rim�f•nr FOR APPLICANTTO FILL IN
1)3te�=Z'`�_�":\{�j;licant_TN�y��Z_C��Ji7_ (PRINT OR TVPE ONLY) A�DRE55 3 Z55 �Dir�mcuD r�a_1�Lv>>
CliRTI1lG\TL OI�LX}�_�.IPTIDti!=R0!.1 H;p(tIiGRS'
i NO. TYPE OF APPLIANCE OR EQUIPM17ENT FEE LOCALITV 'D��m���� �A�
CO`dPl�:1S:\TIOS 11S1!R:\\Cf. NEAREST' ry }
(This sectinn need nr�t i�c cnmplcteJ iC the �eo�k im�ol�•ed aoSORP710N UNiT,O7U CRoss ST.B�t.Y} �N� �� �'�IR•�AIL 7 d
Uy thc permit is for on� Iwndrrd dr,ll�r� (S1�D) ur Icss.) OISTRICTNO, PAOCESSEO v �
1 certify iL�at in ❑�e perfnrmance nf the�cur};for wliich this � AIR HAN�LING UNIT,CFM11 �Q �C`��� �
permit is itsued.I sl�sll noi empiny�:my persnn in:my mannrr - O
�n;ic to beeome subject m the\5'orkerc'Comprnsation Ls�as. � BOILER,6TU F—
� /+,PPF{OVAL$ �ATE INS�ECTOR$SIGNATl1f1E U
�ste :1Ppliecnt ' � J` ICOA7PRESSOR,OTU ��0� ROt1GH /. � .�irL �
�
YOTICI:TO:\P!'LICANT:If,aftar ma..im,:�his Crrtifica�e o( � ' Z
i;eemptiun, ruu �hnuld hecnme schjret tn the \1'urkrrs' i VEN7ILATIONSYSTEM FWAL n��l� _ J
Comprnsatinn prorisinns nf thz LaL•or Codc,ynu mus[fnrth- 1
�v���� �„�„�,y .,;u� .���� �,.���s��,�s o< <n�s �z�m�� ,n,n he (G"nPonnn��e COOLER VALIDATIO"!
Jrrmed rrcoked. � FURNACE: FAU—GRAVITY .
LICLXSI;DCO\Tit:\('TOf251)E;CI.:Vt:\7'10\ PLOOR� BTU
I herch}�s(firm tlut I�rn iic�ensed nm!::r prnrisinns of Chsptrr i � HEATEFl: SU EN�ED UNIT
9 (cnmmrncing with c.i•tion^00�)nf I)iri�inn 3 ot Ihr Rusi- I � lV!j. /�y�-rYl Q 0
ness and Prnlr«i�+nc Cnde,and my iicencs ic in full(nrce and �
efkct. g : � '��/ ��7 p0
Lirrnsc 4umher?$s��7 Lic Cl:iss_��' ! � �}� � ,n _`
Cnntr�ctnr_.JfI�JG=7t.. �) �7� �C�.�_... �!-� �f� 00
� 1?ite 2�ZY_$Z r �:GM2.�`.�-✓�-� j
� 1 nm etempt frnm the licrn<in;requiremenLc ss 1�m a �
licenaed xrchitect nr a n�,ictrrr:l profca<iunal enginerr plan check fee 259b Of ebOve.
:�cting in my pmlr��inn_I ripa:ity (Sectinn '051, pus� �Q
�ne�.c:md��rol��ssinn<Codc). . I , PERMIT ISSUING FEE S
Lic.or�tes.No. uate ; I TOTAL FEE � SD
IiO.`.tF:O'S-VCR�i3GILDCR D1'CI.AR.�TIOti �
PLAN CHECK APPLICANT
1 iiereh,v affirin ��i��t I :�m rxrmpl (rom�the Contr�ctor's �� �NAR1E "nhL�y �'I„4�t:V
Licen4e l.u�v fot[he follm��ine rv_isun (Sec�ion 7031.5, 13uci� � . '-0�� (�rj,(j-A
n^ss�n�11'r<�f:ssi�>:isC���e): . AODfiES� ��.?J knr�e_rrr�B_�Ya. {{ p
❑ �< <,�,. ,.� �.,,,r ,, , ,.. .�:;.;.:.`
I, ��(tlir rtu iill ii�i�I�� �r4 nil [hn 1 ,tt'. O
slrucfurr'�is n�t intrni!eJ �r��fftreJ f�rr c��le (Stction � CITV A��,�m TEL.NO.���D7�L
���.
�naa,�a��.�nr.��n,i r<<�r,�.a„�,s c,�a�•a. � �I'• 13 fl 5 p
� owNen ,
1,as ow'ner of the prnperty,am exclusierty coMracting �V�t�J�Ct.��.i�(`��c�CHLt2CH •�• �'35�5.0-��
i�ilh licencr�l cr���trictnrc �� cnn�iruc[ the �+r�ijret I h1AIL +� . . .
(Sectinn^044,Dusirest and Prnfe=�ine�Code). AODRESS l D��D7�y/D�
�0224-82
COtiSTIiUCT10\LIf4DItiG A(;F:tiCY CITVa1RM�b g/¢n TEL.NO.�s�G��(�
1 hrreby :iffirm ihs[ thrrt i a cunstrucliun Icnding agenrl' � CONTR1ICTOR /7 n
fnr thc perfnrinsncr oF Niclivurk for �ohich this pc•mi[ is D�us K• rf.{f.�.�/_�L_4C�NST
iscued(Scc.3097,Civ.C.).
I.enJet's�antr ADORESS ��g j keq_�ra�erL I�Z,v�, , �
LenA:r's AdJress , � . �
CI7V ����EI� TEL.NO.'�C�_O 7SZ - .
I cer�ify� that 1 hace read Ihis al`I'lication snd st�te ihst the S� 7q7E LIC. f^�_+
�h���e infnrmatinn ic cc�rrrrt.l�pr����i��r��m��t�'��-ilh all Cuun[y LICENS[N0.3S�J�87 CLASS > . . .
orAinances�nd Statc I�u�s re��ulatin^Hestinc.\'rntil�ting:md
Air Cur tinning,;md hrrchy�uthnrivc rrprescnt:niccs af this � SIiF,RF;Vt:it$li POH IiXNLANATORY I,ANGIIAG� � �
Count� n entc/r �pnn Ihe zbuvr�menfianed ��orr�iy n>�
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