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76A386E C:03I86 9i75 APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
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BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN ADDRESS 0 U.L
(PRINT OR TYPE ONLY)
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CROSS ST
ABSORPTION UNIT BTU
OWNER
AIR HANDLING UNIT CFM MAIL
ADDRESS
BOILER BTU CITY TEL NO
COMPRESSOR BTU CONTRACTOR
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VENTILATION SYSTEM ADDRESS 1-2
EVAPORATIVE COOER CITY
FURNACE FAUGR ITY STATE , V LIC
FLOOR BTU LICENSE NOgZ32 Z CLASS 22 Q
HEATER SUSPENDED UNIT_ DISTRICT NOGROUP I ZONE PROC ED BY CDWALL 0(5 l c�
O
1--
INSPECTION RECO w
CL.
Plan check fee 25% of above
y PERMIT ISSUING FEE $ —
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
s
CITY TEL NO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALLORDINANCES AND LAWS REGULATING HEATING VENTI
LATING AIR CONDITIONING
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IHEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION APPROVALS DATE INSPECTOR S SIGNATURE
OF CHAPTER 9 DIVISION OF THE BUSINESS AND PROFESSIONAL
CODE OF THE STAT 0 IFOR ROUGH
SIGNATURE
OF PERMITTE FINAL
j PLAN CHECK VALIDATION CK M 0 PERMIT VALIDATION CK M o CASH '
AS
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