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76 A 36 - CEO18-1/75
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONOITIONITN�G
COUNTY OF LOS ANGELES AoloR E55
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY (
NEAREST f
M
CROSS ST.
FOR APPLICANT TO FILL IN OWNER Ile
(PRINT OR TYPE ONLY) MAIL
_
Y0 TYPE&SIZ E O F EQUIPMENT FEE AD DRESS S C_,,
SEE BACK OF APPLICATION
CITY TEL. NO.
FORCE AIR FURNACE, BTU I
-
CONTRACTOR e_We j /
COMPRESSOR, (BTU -✓ h
ADDRESS o� U .
VENTILATION FAN CITY // N
TEL. O. oL)
CiFIi7� '�
LIST ALL OTHERS BELOW ,LICENSE NO..<+ IZ3 CLASSIC 31'- '
DISTRICT NO. GROUP ZONE PROCESSED BY
INSPECTION RECORD
a
01
0
U
K
r
U
W
a
Pian check fee. See reverse.
111-10111, ISSI'IN'G FEF; S 3 00
170
PLAN CHECK APPLICANT
NAME
ADDRESS
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 LANVS flE LATING HEATING, VEN11- APPROVALS DATE INSPECTOR'S SIGNATURE
unxc. AIR CO HE moNlxc. \ ROUGH
1 HEREBY CE IFY THAT 1 A OT ACTING IN VIOL TION
OF CHAPTER
S.
VISIO 3, OF TX B (NES ANO P FES IONPL FINAL •sOI�
CODE OF THE S TE OI CAL FOR NI �M{� -
SIGNATUREPERMIT VALIDATION cK. M.D. cnsX
OF PERMITT
PLAN CH C VALID TION CK. M.D. CASH
3 5 7PJUL 9.4:1 D $,Q 0 e98