HomeMy Public PortalAbout5522 GRACEWOOD AVE_Mechanical__ zuzuF='c¢Gt#e=f/z■ tl APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
r
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY),
LOCALITY
NO. TYPEOFAPPLIANCEOR EQUIPMENT FEE NEAREST
CROSS ST..
ABSORPTION UNIT, BTU IVAV
OWNER
AIR HANDLING UNIT, CFM MAIL
ADDRESS
BOILER, BTU CIT TEL NO.
COMPRESSOR, BTU CONTRACTOR K�/V
VENTILATION SYSTEM ADDRESSff/ ,
EVAPORATIVE COOLER CITY TEL. NO.
FURNACE: FAUGRAVITY STA LIC.
FLOOR BTU LICENSE NO. CLASS C-
HEATF;R: SUSPENDED UNIT_ D15TRICT NO. OROUR ZONE oC[slED BY
WALL
'G:
INSPECTION RSCO.RDIy
Plan check fee 2596 of above.
PERMIT ISSUING FEE 5 �.
TOTAL FEE
PLAN CHECK APPLICANT
NAME
ADDRESS .�-
CITY TEL.NO.
I HEREBY ACKNOW DS! T T I HAVE READ THI 111LICATION
AND STATE THAT TH ASOVE D CORRECT AND AS TO COM SLY
WITH ALL ORQINAN !S AND AWS REOULAT IN E INS, '
VENTI-
LATING, AIR CONDIT ONINS.
I HEREBY CER FY T I A NOTAC IN IN VIQLATION APPROVALS DATE Do RI SI
OF AFTER G, DIVI 10 THE S !S A PROFESSIONAL ,
COD THE STAT[ .C I ROUGH
OF PERMIT FINAL D-ate
OF
CR, M.O. CASHPERMIT VALIDATIO CK. M.O. CASH
T N
POLICY HOLDER: v � - U Z6 4,1- a 9.0 O !-l"
POLICY NUMBER;
(Y k6?
Y10
� moi A
7cA3e4-�cEele -1i7o APPLICATION .F.OR PERIfIIIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY.OF LOS .ANGELES BUILDING {
-DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY
JOHN A. LAMBIE. COUNTY ENGINCQR
COLISMAN W. JENKINS, SUrtRINTKNOWNT OF BUIL.DINO NEAREST
CROSS ST. `
FOR APPLICANT TO FILL IN OWNER qV �
(PRINT OR TYPE ONLY)
MAIL
NO. YPEUFAPPLIANCEOR EQUIPMENT FEE 'ADDRESS
CITY ro
TEL,. NO, ro$�Q
-ABSORPTION SYSTEM, BTL
CONTRACTOR t
AM HANDLING UNIT, CFM
ADDRESS 74 d t7 a O d
B' ILEP,-HORSEPOWER CITY TEL, NO.
COMPRESSOR, HORSEPOWER' S A E LIC_
.17
LICENSE NO. L CLASS
VENTILATION SYSTEM D STRICT NO. CLAD GROup SON[ GSED BY
EVAPORATIVE COOI ER � Q8
FURNACE-.. FAU. GRA ITY INSPECTION RECORD
FLOOR_BTU
HEATER: SUSPENDED UNIT_
WA L L
H
NEW—ADDfTION— PERMIT s 3 00 -
ALTER—REPAIR— TOTAL FEE S /�
PLAN CHECK:APPLICANT
NAME
ADDRESS
dl TY T-EL.NO.
_ ••1 H[R[EY ACKNOWLEDGE,'THkT I HAVE READ THIS APPLICATION'
ANDS
TAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT}( ALL ORDINANCES AND LAWII REGULATING HEATING, VENTI- APPROVALS - D TE CTO11'S ISNATURt
LATING, AIR CONDITIONING.
ROUGH 7
I H[RtSY CERTIFY THAT I AM NOT ACTINS IN VIOLATION
OF CHA►TER 9, DIVISION S, OF THE BUSINESS AND PROF SIONAL FI�L lit'�
COD[ OF THE STATE P IIA. - �T
81014ATURE + JACK R. AL-LWN,SUPERV SINd CHANICAL FENG'R.
-DF PERMITT PERMIT VALIDATIONCK. M.O. CASH
PLAN CHECK.VAI-JDATIO
2 4 3--l- U'2 0 4 1 D -. 5,5
SQ SACK OFAFPLbf-ATK)II FOR COMPIsft F[r-SCHIDULE
l el.364-4,H81 B–B-BB APPLICATION FOR PERMIT [�
w. HEATING - VENTILATING - AIR CONDITIONING U
COUNTY OF LOSANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING -^!— rj
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ✓ ✓ /[
COLEMAN W. JENKINS, SUP=RINT=NDKNT QF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRS ST. ,fir d
(Print or type only)
OWNER
N O.. TYPEJO F APPLIANCE OR EQUIPMENT FEE
A MAIL
ABSORPTION SYSTEM, BTU CITY TEL NO.
AIR HANDLING UNIT, CFM CONTRACTOR
BOILER, HORSEPOWER ADDRESS
COMPRESSOR, HORSEPOWER CITY TEL. NO� 0
STAT LI C. ji
VENTILATION SYSTEM LICENSE NO. CLASS
mm
DISTRICT NO. GROUP ZONED BY
EVAPORATIVE COOLER �}
FURNACE: FAU GRAVITY— L/O(3
FLOOR—BTU INSPECTION RECORD
SUSPENDED—UNITHEATWUALLuP d5-4 p p
dm dff
c.>
1 0
a.
NEW—ADDITION— PERMIT S 3 00
ALTER—REPAIR— TOTAL FEE S 6
Plan chock applicant
Name
Addr"
Ci "&x4otTel. No
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DAT[ DO TOM'S SIGNATURE
LATING, AIR CONDITIONING.
RO UG H
IHEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION FINAL
OF CHAPTER D, DIVISION 9, OF THE SU D PROFESSIONAL
CODE.OF THE STAT[ OF CALIF RNIA
JACK R. ALLEN,SUPERVISING MECHANIU�
910NAT URE PERMIT VALIDATION. CK. M.O. CASH
OF PERMITTE
PLAN CHECK VALIDATION
L � s 9 1% a29 4 & 06-00N 1
SEE BACK OF APPLK:ATIOM FOR COM PLST[FEE SCHEDULE
' == 'G• °'•"' "''• . APPLICATION FOR PERMIT
HEATING. - .VENTILATING - AIR CONDITIONING .
COUNTY OF LOS AN-GELES
` D91PARTM9NT OF COUNTY ENGINEER
BUILDING AND$AFtTY DIyISION
BUILDING
FOR APPLICANT TO FILL IN ADDRESS
(PRINT OR TYPE ONLY) ADof
LdcALrrY T:-:-H O/- C2lT
NO. TYP�'OF APPLIANCE OR ECUIPMEN7 FEE
- NEAREST
CROSS AT.
ABSORPTION UNrf,BTU �n.J
OWNE / //�!JT
• AIR HANDLING UNIT,GFMT MAIL.
_ADp RESS
BOILER,BTU CrrY - TEL NO. _D
COMPRESSOR,BTU CONTRACTOR
VENTILATION SYSTEM ADDRESS/1,?Q
EVAPORATIVE COOLER crry � TEL;,NO.
FI)RNAGE:, FAU�GRAVITY STATE LIC.
FLOOR BTU LICENSE NO. _ CLASS .
HEATER:, SUSPENDED UNQ DISTR]CT NO. CROUP ZONE FROG F. HD BY
J INSPECTION RECOFZD
Plan check fee,25% of above.-
PSMT ISSUING FEE$
TOTAL FEE
PLAN CHECK APPLICANT
NAME ?
ADDRE88 / ,p
CnY' TEL NO.,�,7-
I HEREBY ACKNOWLEDGE THAT-1 HAVE READ THIS APPLICATION AND -
STATE1rHAT THE ABOVE.IS CORRECT AND AGREE TO COMPLY WITH xLL
ORDINANCE$ AND LAW$ REGULATING HEATING, VENTILATING, AIR "
CONDrFIONING.
1 HEREBLj AL NOT,ACTING IN VI O OF. AtPROYAL�S DATE IFnPccrOri's;aNATDIrc .
CHAPTER fl, DBWSINES$AND PRO, IONAL DE {tOUGfHOF THE STATE
S IO NATU F;E FINAL.
OF PE RM f7TE
I PLAN CHECK VALIDA ION. OL M.O. CASH PERMrT VALIDATION cK r-0. ' uaH
.00 AW
A"LICATION FOR PER IT
BEATING =. VEITRATINO AIR CONDITIONING
COUNTY OF LOS ANG0,125 , BUILDING ANO SAFETY ,
FO ftAPP LIC,9 NM TO FILL IN. ADDaESS552
(PRINT OR TYPE ONLY}. _ .
.NO. TYPE OF�APPL(ANC-tORE�OLIIPPA ENT. FEE:.
NEAREST
CROSS Sr. G/v
ALI$ORPTION ljhl T,Qtl7 T .. OVJNER� ..
AI-R'-HAN SING #".CFm
AD REBS
BOILER,BTU
Cl TEL NO. .Zit
COMPRESSOR.BTU .CON*RACTOR� - .
VENTILATION SYSTEM ADDRESSCAip
EVAPORATIVE-,QOL�R- CfTY `.. ( �T.J,.NO..
Av
PURNACEc FAU 6RAVffY STATE _ LIC,
'F LA Q. BTU LICENSE NO. L.S3 "
HEATER: SUSPENDED-l1Nl'f� AP rRQy^[q DAVE, .IILSPLO?ORS Sp1UTU1tE
WAL
ROUGH
INBPErtAjON RECORD
Plan'check#fie 25% Of above.
PERMIT ISSUING FEE�
TOTAL fEl
PLAN CHEck.APPLIc PLAN CHECK VALMATI N
NAME - -
ADDRESS
,_No. 21 q
' f NEREM A4KNOWLEHAVE DGE THAT I HE READ•TH [JC 'ool'00 APP
ATIOH AND� � � � � I �.
STATE THAT THE ABOVE IS-CORRECT'AHp AGREE TO COMPLY WMT ALL,' "
ORDINANCE,t AND LAWS,REGULA60NG HEATING, •vENtTiLATiNG, AIR• � 4 •zlo o .1 ;7 0,0
CONDITIONING. - _ -
' I'H€RE9Y CERTI FY•T}iAT f ALMALMNOT'ACTING IN V16t.ATION- OF ERmrr VAL'IDAtION - ;oio Io�1�,Q.Q•� .
CHAPTER fl, DLV ION'b, OF E BUSI AND, PROFESSIONAL CODE 'Z
•PF THE SFATI=O FOF;N O lSL '1 1 r* O .
SIGNATURC -
OFPERMIrfC
D LSTR I CT N0. - PROCCSSCD DY -
SkION
I rr Oeff►r*+ti*Dt we v?c�nl{IcaCte of�c�oni0ent to lelf l CE�H1�8C(2-80) ,,APPLICPsi tl �O1�1 FOR P�IRIVaI 9�
lruvte,, or a certincateofWork.ers'CompensatiouInsurance,or HEATIP�IG- EJzVTILATIPIG. W�3ITIONIWG
■cert co�,�tlhQer'eof(Sea. 3800,Lab.C,.) /�
Po y o f
ified copy is hereby furnishdd. COUNTY.OF LOS AN-GE BUILDING AND SAFETY
Cettifled copy is tiled with the cqunry bullding inspection . -
dap t POR APPLICANT TO;FiLt fiV' Bu)L,tzt(14. -
Date Appitcant t (PRINT OR TYQ�bhFL;Y) RDDF3E38 '
CEF(([11CATE O E}t£MPTION E Moil
`
NO. TYRE'OF APl'LJANCk'Ofj EQUJPM7=tdT FEE t bCALITY
C.QMPENSA''ION INSURANCE, N'EA"ST
Mgectbti noed ,not be-caanppkod It tie wrork invotved' AB3QRPTION U IT•BTU • ' tfRoss ST.
ite permit to f r oue'hund�d 464tis 0190) & Ie,t.) QtATRicrk¢. . P - g^
1 '
T oer•tify thgt in Me-pedq.rbwncn of Elie woA'fot p+bicb this Al DLING�NI
permit is Iiaubd, I-shO not errtploy fihy' Pori m 13itiy manner
So at to.becolne tubject-tb the wofjchte' Campensatfgn--Caw$. $OIL'S
t APPROVc�18. :pA 11 °a�Iarv�ruR�
Date_^_ApWit4nt DMPP R''BTU LQ
ROUGH
NOTIQE 'FO APkJ,ICAI(T'. If, atter'titgkingt{hls CORtftc{tE oS � S• ' � _._._.
Fxemptlon, You sho0ld hbbOme •lU>S�P too the Y(ort�1' E3ITILATIQNI'SXS7EK Y'. ngAC ,
Componsitlbn Vp o*wrui crit the Libor Code.you strum fbrtb-
wlttl comply .With Guth.pro3isfons or.• this pi5Mft shall' be, :rVAPbRAT1YE000�.ER' .ALtbAT10N
deanre4'revokod: r- SUR : U GRAVITY _
.I,ICE]hLS�D�OM'RAt 6kS b CI ARATION, FLb er It
Y h rib affirm Mai sNb'Iloenled under pretrbtons of Chapter tWAT,E,R'.. :SU DED UNIT
anmmgbetng wfth'Sa0lotr 7000) 0?t)iv ggn-3 of tha.'13ns> "WALL
nep and°Ptofefsiorm Coda,aPd my llcensai, iia full'-fotcp and
aff9Ct: •y ; -
LlcegsbIuMtler
�Drtttactor •at'p` T y l
or
71
1 a.m. bx Sroto ttie licenatnQ rgz{utrdrnerT#a w4 ra t•,
llbausad' arrbitebt`or 4 Fe¢$tbred prgfeas�onal r;aer Plan Bleck
rGitn� Im mr profeystonal apathy (4actldn 705j,, $ua.
ineat and ProtatslonaCo.Ne ; PERMIT ISSUING FEF-
-Lie.
rEE S
3�c.of R .'No: �-Data T�tAIF ;EFE
ITfOM•E QWNER-iILnLbRR P]�CJiARATION '
'"' PLA N'CHECK'APP4i�A`N'1"- ��•
I rriereby affirm thai `( 4xii ezawpt -from-tiuo-.C6ntryRctdrfs NAMp
1 icensa Law -for the following,reaaoa (Sect�on'703].5.Bust- ,
nbij and Wofekvia u;Code): gDDRH38 ; nn
1, is owner Of'fhe ProparSyF'wi11 do fhy work and the ZEL. NO, • ,� 247 n
'stiuctune fi.not Inttnded'or offdi d. for sale (Section -Ca TY• low. ,
764ft', $yaineY and ProfeWons Code).. }'• a i,a (t .
.I, ti owner.of the propbrty, am, exalgKtoelY cbhtrac4lAli 1„� +O O
WfC.h, Ilcen}ed .contrictors to'c4pAffuct • hb project :MAIL t.
(Sastiga 7044, Bitaingts and Ptofeesiofa Cod )• ADDRE89- lI' O► _
�• � Ol�O0
Q.ONS RUCTION I.,04DMG Xc,ICY TEL.NO.
I hereay'alfi{m at there s.a -corlatructtotl lendhir ktbn
for the perf6r riancd bf the ,work' ,[Qt'which this phrmrt is”
laaued Sec. 9097,Clv.C.).
Lender s None,
. ADDRESS• a
Lanribr's AddCeasCITYL.NO1C6�ify t"t I Hare readthis 4pPliatlon and state that theaboytl thformatfon Is cozrett.I akr"tp comply with all County SPATEtNil C ...
Otdinancea and State lave regulal' g Haf 2,Ventilating and
All Cboning;and hereby cuthorixe Tapreadntatfres of this ; $EE kBVt�,SE"FOR'�h'PJ,'ANATQkY �.f1'CIl�A(r
Cc ty. o Vr �pon the' abavemgntio pro arty,for,
pecti -
Si of tee, to
__
A,(I I<K I R� "A i-A I i()N
APPLICATION FOR PERMIT
I hereby affirm that I iall I C,rfficaic of consent to ,
insure, or a certate o� Work,.�r,' nnpt-nsation Insurance,
a certified copy thereof(Sec. C.) HEATING-VENTILATING-AIR CONDITIONING
Yo y No.'- C conpan'-,
Certified copy is hereby furni.hed. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspection BUILDING
department. FOR APPLICANT TO FILLIN ADDRESS
Date A p p I i,,a i I I (PRINT OR TYPE ONLY)
LOCALITY X
CERTIFICATE Or I-XI-11,1PTION FROM-\VORKERS' N�T PE OF APPLIANCE OR EQUIPMENT FEE
>
COMP 1,NSATION NEAREST
IL
CROSS ST. C
(This section need nut be completed if the work involved ABSORPTION UNIT, BTU (J
by the permit is for one hundr-d dollars (5I00) or less.) DISTRICT NO PROCESSED BY
I certify thdt in th.,, th� -,kork for which this AIR HANDLING UNIT,CFM—======= U.1
_J
permit is issu,�d, I shJh not enwto\ any person in any manner LL
sous to become su')jcct to the Vorkers' Compensation Laws. BOILER, STU-.----.--
APPROVALS DATE INSPECTOR'S SIGNATURE
Eel
Date-- -Nppficanr COMPRESSOR, 8TU i
ROUGH
NOTICL TO APPI_t�. A'1�I__' i ri;JJn,i ihis Certificate of VENTILATION SY,,lt T E M cc
Exemption, vou s FINAL
:�,Wct to tlie. Workers' _*f 0
Compensation pr4litons ;,�d you must forth- 7 ,0-
EVAPORATIVE LER VALIDATIC4
with compiv with ,uch ri,.,rvis�,ns Chits permit shall be W
FU
1.1 C E IN S 1,1 D U0 N-I,k A I S i I !1-1,1? \T I ON FLOOR,--- BTU-
deemed revoked. RNACE: TAU-- GRAVITY—
I hereby affirm that I iin 1.c;t, provisions of Chapter HEATER: SUSPENDED UNIT
9 (commencing with Stcrli)zi of 1?ivisjon 3 of the Busi- WALL
ness and Profession.s ('ode. ano n;% i:--_e is in full force and
effect.
License Numbe
. ,t
Contractor *°� 4)d
MI am exempt from the licciisin, requirements as I am a
licensed architect or a Tegi�teu,A pr._)fessional engineer Plan check fee 25%of above,
acting in my professional apLicin (Section 705I,.'Bus-
iness and Professions Code). PERMIT ISSUING FEE $
Lic.or Reg.No.- TOTAL FEE
H0MF.0WNI-.R-13I!j;,f1,1.R Dh(:!.ARATICIN PLAN CHECK APPLICANT
I hereby affirm that I au: e-,unnpt from the Contractor's NAME
License Law for the follovinneason (Section: 7031.5, Busi-
and Professions Code):
AC IIR
A
1, as owner of the propert\ do the'w1ork and the, Ct
not intvndeJ �r wt TEL. NO
structure is f 'Sale (Se�tion C, 0
7044,Business and P, Code').
OVVr\
as owner of the property. am exclusively contra I cting OWNER
with licensed conniuctors to construct the project MAIL
ADDRESS
$usiness and Professions Code)
CITY
'CONSTRIJIC1 ION IANDING AGENCY P 'TEL. NO.
e�by affirm that there i construction lending Agency
he performance of the work for which this permit is C 0 N 7'9 A-C T'd R
(Sec. 3097.Civ. C.).
AD _RtS1,
D,
r's Address------- CITY TEL.NO.
fy that I have read this application and state that the STATE LIC.
information is correct. I agree to complywith all County LICENSE No. CLASS
ances and Stateie,ulaiim� Heating,
Ventilating and
'iynclktioning, and iuiliorii_ representatives of this SLE REVERSE VOR EXPLANATORY LANGUAGE
1,
Ity 'o enter ul)ii th,_ ib, e-mcntioued property for
C
tio I�4�
dry of Permittee
I
WORKERS'COMPENSATIO'� 1)r:CI_ tlz rl: .` APPLICATION FOR ° PERMIT
c
I hereby affirm that I have a ertificate of :on enr t c &IE (2-30
insure, or a certificate of Workers Comt .)t ;•-on Insuran . r
a certified HEATING-VENTILATING-AIR CONDITIONING
G pg�t� repd`(Sec. 3500 L,ah t,C ) *"
Policy No. ompany --
❑ Certifies)copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certd opy is filed with the county' huildin insr cti�in BUILDING 1 ^ k' r' y
a d if' r�` FOR APPLICANT TO FILL INADDRESS
} ti ..`,iJ
Date ' 'Applicant �~ t]`+' J L+ (PRINT OR TYPE ONLY)
� LOCALITY ro 1.. d
CERTIFICATE OF EXEMPTION I ROM YdORt<I'I2S' NC
TYPE OF APPLIANCE OR EQUIPMENT FEE __._-.— - D
COMPENSATIONINSURANCE - - - NEAREST ✓/��+ U
4
(This section need not be completed if the B
work involved ABSORPTION UNIT, Tu _`— CROSS ST.
_ w
-J
y the permit is for one hundred .dollars (SIOQ) or less.) DISTRICT NO. PROLES <:D"'g Y _
certify that in the performance of the wark for v:hich this AIR HANDLING UNIT,CFM— — �" /'! LL
permit is issued, [ shall not employ any person in-any manner � }
.o as to become subject to the Workers' Compensation La.es. BOILER, BTI - U_
APPROVALS DATE INSPECTOR'S SIGNATURE Q
late Applicant ;OviPrIESSCF BTu_--
S
---- ------S` � ROUGH _ __ 0
TICE TO APPLICANT: If, after making this Ceriihct e of VENTILATION SYSTEM ;`j '.. FINAL 0-
m ptionton o should become subject ito the Worker ' _
p
p provisions of the Labor Code, you must torte- w
h comply with such provisions or this perinit shall he iEVAPORATIVE COOLER VALIDATION 1-
med revoked. --- -_-- - --
iFURN.ACE: FAU - GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS 14 L. I'ATION FLOOR BTU_
hereby affirm that I am licensed under pnnisionsof Chapter !HEATER- SUSPENDED UNIT
(commencing with Section 7000) co Di inion 3 of rhe Busi WALL
ss and Professions Code 300 rr, I�:_,,Pse is in full force and - �`--
feet.
,ense Number— ___ __ t Ic:
,retractor__--_- -_
I am exempt from the ,"! -An� _
licensed architect or a regi '"o of above.
acting in my professional - ---- - -
iness and Professions Code). PERMIT ISSUING FEE $
or Reg.No. -_____ _hut,_ __- TOTAL FEE
HOME OWNER-WALDI R Ill'"CL,Ai':.',i 1, PLAN CHECK.APPLICANT
eby affirm that I am from NAME -
,se Law for the following rea�u. I -
nd Professions Code): Apra CSS
r - - -- ----- 6
as owner of the pro{ :rtp. v, the irk and the
TEL. NO.
ructure is not intended m n d for 1_ ( crti:;n r M w 0 e
44, Business and Profes.iwr, -
' r
s owner of the property am eief .i eIc ion i tin"
licensed contractors to nst-u�t thr project 1/•.;, -i-
tion 7044. Business and Piot`e:sions Cotte). � �uR�SS • a •
CONSTRUCTION 1.1 NiANC AG}'_NC1 ICITI SEL. NO. t
affirm that there Is ,i :uo,tiu�tioii f ndin)i ,igenci� - { 1 -{
performance of the work for which this pe nett is CONTRACTOR i I
tc. 3097,Civ.C.). ------- ADD
ame
,ddressi i i
---------- - CITY Ii\f � - TEL. NO.
at I have read this u>>lication and state th,rt the -� -7
kl STATE i` CLASS
mation is correct. I agree t comply Nsith all County LICENSE NO „
and State laves reguiatinrc lioatin , Ventil:iiin :.r;d
ning, and hereby .wrhorii. i 4 ies�mato,,, -I tIhis SEI. REVERSE FOR Ek PLAN,ITORY I NGUAGI
nter upyn the jibove_ ntioin d IV fur
reds 7S.
3
' t
rmittee j llz;