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76 A364 +� CE 816 - 9-71 APPLICATION FOR P MIT
HEATING - VENTILATING - AIR CONOITIONIN
• COUNTY OF LOS ANGELES 8UILDESS
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY
i
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER r �
(PRINT OR TYPE ONLY)
MAIL
NO. TYPEOFAPPLIANCEOR EQUIPMENT FEE ADDRESS j8/ tdyt / Lei d
CITY C TEL. NO.
ABSORPTION UNIT, BTU ,
CONTRACTOR
AIR HANDLING UNIT, CFM
ADDRESS f ��..
BOILER, BTU CITY TEL. NO.^ 3G,,s-ey
COMPRESSOR, BTU Z 5 v. STATE LIC. C• 36
LICENSE NO. CLASS 15C- >-Q
VENTILATION SYSTEM DISTRICT NO. GROUP ZONE CESSED BY
EVAPORATIVE COO ER �',�
FURNACE: FAU GRAVITY INSPECTION RECORD C:)FLOOR BTU 4/4010119
HEATER: SUSPENDED UNIT_
WALL v
Lu
0-
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Plan check fee 25% of above. See reverse.
PERMIT ISSUING FEE S s 00
TOTAL FEE
i
PLAN CHECK APPLICANT
A
NAME
ADDRESS
OI TY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCESAND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INS CTOR'S SI ITURE
LATING,AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY THAT 1 AM NOT ACTI G IN VIOLATION
OF CHAPTER 9, DIVISION 3, 0 THE BUSINESS D PROFESSIO L I FINAL Ct
CODE OF THE STATES CALI RNIA/:;�-
SIGNATURE T PERMIT VALIDATIO CK M.O. CASH
OF PERMITTEE
PLAN CHECK VALIDATION CK. M.O. CASH
A0 7 2 6 1 N JUL 31 4 1 0 1 3.G n
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE