HomeMy WebLinkAbout1489A (8) 3�7 �
\CORKF.RS'CO'•iP1iN5ATIOhDLC1.AK:1Tf0Y 76A364C APPLICATION FOR PERMJT O��f`
CE�818(2801 �O `��
I hrreby affirm that I h3ce a'certifica[e of consent tn self ' ^
insure,oracertificaten(µ'�rkrrs'Cumpensstinnlnsuranee,o� HEATING-VENTILATING-AIR CONDITIONING �
a eerfified.e�Wnoy thereof(Sec.330/q��I.ab.C.) � �
PolicY No��LnQ7j��:'�mpan}tiT![�Y_'r�Q�� . . .
I ❑ Ceruried copy is he�eby furnis�ird. COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certified copy is(iled with�hr c�mnty building ins ection . -
�ar n�t FOR APPLICANTTO FILL IN BUILDING
Date Appiic:mt_ _ _ _ (PRINT OR TVPE ONLY) �AD�RESSa�O �'��(f �)��
� LOCALITY�� �r
CIiRTIF1CATli OF EXF.\1PTfON FROS11401ihdRS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE i
� - CO.'�IPIiV5A7ION INSURAtiCli . NEAREST�yf ✓f/�� � �7�
7his sec�ion necd not he completed if the �vork involved ABSORPTION UNIT,OTU CROSS ST. ��J �vS O
�y the permit is for one hundred dollsrs (S10D)or less.)� ' oisraicrno. vaor-,>¢rov . V
1 certify thst in Ihe perfurmance of Ihe�aurk fnr�chich this � A�R HANOLING UNIT,CFM11 �
pCnnit i5 issued,f shall not empiny any prrs��n in a�y msnner _
— so as to Uemme�ubjrct to the�Corkers'Compertsatton La��•s. � BOILER,BTU � `'�� �
/� /�-�J N� APPROVALS DATE �"�SPECTOF+'SS�GNATURE U
Uate Applic�nt / - COMPfiESSOR,BTU="� • � • ✓`�+ ROUGH a
N
NOTICG TO APPLfCANT:If,;�fler making�his Certificate of � VENTILATION SYSTEM <`� 2
Exemption, you shnuld hecome su6jec[ to the Nnrkers' � FINAL �(JYYp
C�mprn5stion prucisinns nt the L�hor C�ide,you musl(arth- -
w��n rnmply w;!h r�:n �.o:•:S�o:; o: t�,;; �,e�mt� ����n hr EVAPORATlVECCCLER VALIDATION
deemed revnktd. �
FURNACE: FAU_GRAVITY �
LIC}CNS1iDCONT7tACTORSpiCCLAi2AT10�1 FLOORr BTV . -
i herehy affirm Ihat 1�m lirensed under provisions<if Cha�ter HEATER: SUSPENDED UNIT
9 (cnmmencing wilh Sectinn 9000)of Uivkiun 3 of the Ausi- � WALL � -
ness and Protessions Cnde,and my license ic in full force and .
ef(ect. / /+ �7
Licrnse Numbcr_L�S b.BS I.ic.Class_C1_Pdf o - . � .
Contractor�l�N�el.+.fl�:_ pate�=J_�=O_(
� I am exempt from the licensing reyuiremen[s as 1 am a �,� 4 a 9 A
lirensed architect or a registered profasion�l engincer P�an CheCk fEe 25°0 of dbove.
actin; in my pmfescion�l c3pacity ($ection 705I, I3us-
iness and Professions Codzj. . PERMIT ISSUING PEE S g #�,• •_•Q�
Lic.or Strg.i.u. � Uste TOTAL FEE � ���� •�:e 2�j 5�
}iOStl:O�\'VGR-I3UII,UER DEC[,AR.\TION PLAN CHECK APPUCANT ��j.�D �:��a'.v 2��Q�-
U
I herehy �ffirnl [hat I am excmpt fr��m�lhz Conlractor's NAMF ' , 0���.� 4 i a�
Licence I.a�v(r�r Ih^fnliowing rea<on (Section 7D31.5, [lusi- , U
ness and Prnfeacinns Code): AODRESS � � --
❑ I� 85 owncr af the{��rnprrty,�ci1l Ju the u�ork and the CITY TEL.NO.
strutture iz na[ intendrd ur affered (or sale (Sectipn
7043,Bucinrss and Ptofassions Cod2). �
� 1,as o�vnrr nf the pruperl)',am exclusively cnntracting OWNER�J ��..��.�Son�.LnG
� with licenszd contractnrs to cons[ruct the project M11AIL O� /— • \
(Section 7�44,I1usinecs and 14ofrssions Code). �1DDRESS���j'�'O/�e�� C.Li.�tJ L�
CONSTRL'CTION LfihUMG,�CGNCY CITY TEL NO.
1 herehy affirm that ihere is a cunstniction IendinK�Fency ��—��9�/
ibr [he Ferformance �f ihe �rork for �chich ti�is permit is CONTRACTOR tiC�;n�����'�(on '
issued(Scc.3097,Civ.C.). � � y�/�/-� `�
Lender'sNnmr ADDfiESS �L�/(��S_�(_/lti!/4 �"/ `�/�� .
Lendtr't AdJress n _a��/, ����/'/�/
CITY ��J� TEL.NO. � �
1 crrtify Ih�t 1 have resd this:iO3'��cation and-st;�te Ihat the p�/ /� -7 � - -
above infnrm�ti�n ic c�irec[.I seree t�comply«�ith all Cuunty LI ET SE NO. �S8 p d C ASS Ci�RQ , �
urdinances;md State Is�ct rreulating Hestinc,Vrn[ilating and . �
Air Conditioning,vud hcrehy;udhoriee represi•ntatires of[his SEE RF;VERSE FOR IiXPLAN.�TORY LANGUAGG �
Cuunty to en[er-upon the ubove�men[ioned property for
insp�ctinn purpnsrs. ' �_�I ,
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Signature of Permit. Date � . . . .
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