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7SA364E C:dBI8B 9/78 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING LJ
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS
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LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CROSS ST
ABSORPTION UNIT BTU ,
OWNER
AIR HANDLING UNIT CFM MAIL
ADDRES Q
BOILER BTU 77�� CITY TEL NO /
COMPRESSOR BTU U
CONTRACT R
VENTILATION SYSTEM ADDRESS
EVAPORATIVE COOLER CITY ` TEL NO,
FURNACE FAU GVITY STATE ,LIC
FLOOR BTU J g LICENSE NO CLASS
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HEATER SUSPENDED UNIT_ DISTRICT No GROUP ZONE PR ED BY °—
WALL v
o
INSPECTION RECORD f w
C.
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Plan check fee 25% of above
PERMIT ISSUING FEE $
TOTAL FEE
PLAN CHECK APPLICANT '
NAME
ADDRESS }
i
CITY TEL NO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING VENTI
LATING AIR CONDITIONING
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION APPROVALS DATE INSPECTOR S SIGNATURE
OF CHAPTER 9 DIVISION 3 OF THE BUST SS 0 �RFESSIONAL
CODE OF THE STATE 0 ALIFO IA ROUGH s
SIGNATURE_ FINAL
OF PERMITEE
PLAN CHECK V LID ION c,, M o CASH PERMIT VALIDATION CK M D CASH
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