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76.A364,ti cE;IB.: 9-;,I APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES [NEAREST
DRESS �ZZ fV� �QI�Qh� W&-%T
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION CALITY
OSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
NO TYPE 0FAPPLIANCE OR EQUIPMENT FEE ADDRESS
ABSORPTION UNIT, BTU r,
CITY 'T C, TEL. NO. Z b 1'71,
CONTRACTOR OW may`
AIR HANDLING UNIT, CFM
ADDRESS
BOILER, BTU
CITY TEL. NO
COMPRESSOR, BTU STATE LIC
LICENSE NO. CLASS
VENTILATION SYSTEM DISTRICT NO
rGROUP �V11
�&;IIED
E 8Y
EVAPORATIVE COOLER �aX /!�
FURNACE: FAU GRAVITY v C:)
BTU 12�;UUD -7 INSPECTION RECORD
FLOOR
HEATER. SUSPENDED UNIT_ o
F-
WALL v
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Plan check fee 25% of above. See reverse.
PERMIT ISSUING FEE 8 3 00
TOTAL FEE
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 LAWS REGULATING HEATING, VENTI- APPROVALS DATE IN ECTOR'S SIGNATURE
LATING, AIR CONDITIONING
ROUGH
I HEREBY CERTIFY THA I M NO ACT G IN VIOLATION [[
OF CHAPTER 9, DIVISION E BU ESS PROFESSIONAL FINAL
CODE OF THE STATE OF FO IA
SIGNATURE PERM[ ALIDATION cK' i M 0 CASH
OF PERMITTE I
PLAN CHECK VALIDATION M 0 CASH ✓I
h , 3 4 '7 - r3 GGA 4 1 p 1 0;5,0, d
SEE9ACK OF APPLICATION FOR COMPLETE FEE SCHEDULE