HomeMy WebLinkAbout1375A \1'ORFI:RS'CO`dl'IitiS:1Tl0�:DCCI.:�RAT10,7 76A�64C
1 herchy affirm �h,� � �,:,,�r ,<<.,��f,�:,�e �r��„s,.n, ��sz�� �E.B,a�z.eo! A P P L IC AT I O N FO R P E R M IT �
9ns��rc,��r a crrti(icste n�p;nrkrra'Comprns�tion Insurance,or HEATING•VENTILATINGAIR CONDITIONING
a etrtifird cnpc thcrcnt($ec.3e0a.I_!n.C.) ,
Pulicy Nu. Cnmp:m� �
! ❑ C.•rtificd rnpr is herehy furnisli d. COUNTY OF LOS ANGELES E3UILDING AND SAFETY
� ('artificJ cnp}�i�lit=d�sith thr countr buildinc inspectinn �UILDING // � n-
d�p;,r�ro����. FOR APPLICANTTO FILL IN �ooRess /�G 9 /t�.�� /.�`�•
D�te :1�i;li:;�nt (PRINT OR TVPE ONLV)
LOCALITV -�I- '
C}�;RTII�IC:1'Il�:()I�I:\l�..'.1!'TIC)\I'It0`,1\':Oti}:I'12S' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE F.�-��^-�
CO:.iPCV;,1T10\'1\SURA?%CE NEAREST
(This seciion need r.o[ i�e completr�.l if 11ie wurk invofved FlnSonPTION UNIT,�TU CROSS ST. �-¢.(.��� O
6y the p:rmif it for o�r Ivin:lrc�J dollars (S100) or Iess.) oisTaicTNo. aaeee=sr ev U
I a�crtify �het in th.•p�rfnrntai�cr�if tlic��virA f��r��hich IhiS IAIR HANDLING UNIT.CFR1 /� . �
permi�is issued.[sh�ll not employ any prrson in an}�m�nner / 9 I O
�n as tn hrcnm±cur�j..ct�n thr^:orkcrs' 'n:npcnsatinn Laws. i�,i� :,.6TU.�/-C-'���'(J OO I-
I //�� APPROVALS �nTE IN:PECTC�'SS�GNnTUnE W.
1)ati•�"3�(t1J..1��li.::n���.f� I. COA9PR[SSOR.�TU F10UGH � .
1
.'�OT1CG T():�t'I'I.iC;:1\'f: If,all<r m�iAin��[tii+C�•rfific��f V[NTILATION SYSTLM Z
}:rem�tinn, rou shr,ui,f hr���me >��I�jei't tn the 11'rirkrrs' FINAL -
Compcns�tinn proeicinn�e�f�h�•I.nhar C��de,}�nu must forth�
��ilh c mply ��ith .urli �r�ivi�inn� nr Ihis rermi[ �h311 he EVAPORltTIVE COOLER VALIDATION
JeemeJ,rrvokrd.
FURNACF: FAU_GRAVITV_
I.ICI:\SIiUCOV-fRACT�)ILS�I"CLARaT1ON FLOOR� DTU
I hereh��;�f(irm Il��it 1 am lice.^..rJ un:i:•r�rn��isirinc�if Cha�ter HEATER: SUSPENDED UNIT
9 (commcncin�wilh S.ction"0�01 nf Divi�ion 7 of thc I)usi- WALL
nrac:mJ 1'mfes•in.^.c C'ode.snd m� li:rns:�is in full fo«r�nd
cffrct.
Licensr Numher �__ I.ic CP�ss .
Cnntr::ctor Datr
� 1�m e�empt 1'rnm [he Iicrn.ing roquircments as 1 am a
uc��ns��t ,r�n��rn �>r o r�;���c��c f p��>t�•�d����i � ��r��r Plan check fee 2590 of above.
:�ctinq in ••:•� ^rofr«'.,;^�l cap:::ity (Srctinn '051, Ous�
inecs�nd���oi��..too�co��e). I PERMIT 1SSUING FEE S p�s'(J ��3 Z 5 A
i TOTAIFEE .�D
I.ic.or Itce.\n. Date �`f ��. ... . .8
ff(]\I7;O:`:\i�;2�lil:ll.n�R I)i'('I.:\IiATInV pLAN CHECK APPLICANT f�, ���'�3 Q 5�
1 i�erei,e- �ffirm [h��t 1 .�m c��r.ip� tr��m-�hz L'ontrc[�ir's NAME � � \� ` � •�• •3Q50�
l.irense I.:i�r for t6c f�qinw.:ne rc:i�nn (S.clinn 7071.5. Rusi- .
nr�e,�n-1 1'r�frs�in�i�C���_l: ADDRCSS
❑ �. :i<<r.tn�� �r�i��•„ :.r.,,,;n,o, u,.., ,.p ,�� tr,e � � 0 2�3�8 4
sttucinrr i ut intenJrd �+r offrrcd fur slile (Sec�ion CITY TEL.NO.
' 703.i.H���inr�v.�n;t f'ri�fr.���,�n.!'r�de1. . . • ' .
1,as u�rncr of ihc prnperq•.:irn ecdurivrly rontrsMing OLS'NER
❑ _ er���i.aa�.,CODCCISO
�,-t�n rcc�,<r,� �d�,i�:��«,�s » ��,��«�<< n,� ��„�e��� MAII
(tiei�liun 70;4.Ilucir±.s an.I Profc«{��-.�Code). nDDRESS��,.�� �1 Q���R_�('`
-a
COI�STRL'CTIOV Lf`dDI\C.\(:I(vCY CITYO � TEL NO.q�1�-1QC�_
I herrhy :iitirm �h��t ther, is a cunstruction Irndin�_ezncy
lal.rc'Ac�, � �
f�ir the pc;(orm�nrc nt t'ir �•:urF; f��r i��hii�h tliis ��r�mit is CONTRACTOR •
Is�ued(S�•C.JOY7.C�iv.(;.).
t.en���r��:��„�• noor,�ss
I.rnder's Addrett CITY TCL.NO. •
1 certify�tli�t I h.i��e r�•�i�l ihis:��,�,lii��iti�n.�nd slste that ihr STATE LIC.
� ah���e infnrm��tinn i:cnrrect.1:: rer�n r�rtl'IS'��ilh all Cuunty LICENSE NO. CLASS ' ..
� ordin:incr.:md St:irt�I:ncs r:ul�:�tin�Ficetinc.Ventilatin,v,and " .
� Air Cnnditinnin.^.,anJ h�reD���au�hmiie repres�•ntati��ts of this SEE RISVERSI:FOIi F.XPI,AN.4TOItY LANGUAGE '
I Ca�mty lu rnC:r u�+nn thr .iho�e.mrntinnrd properlr fur . . .
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