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7GA364E ICE•818A)•9/77 APPLI�CO ORPF, TT
HEATING. - VENTILATING' - A CONDITIONING
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDING
ADDRESS
(PRINT OR TYPE ONLY)
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Imp l.e 0
' NEAREST �
CROSS ST
ABSORPTION UNIT,BTU '
OWNER u K
AIR HANDLING UNIT,CFM MAIL
ADDRESS z
BOILER,BTU CITY TEL NO
COMPRESSOR,BTU - CONTRACTOR �IV G�•
VENTILATION SYSTEM - ADDRESS
EVAPORATIVE COOLER CITY TEL' NO3. / V)3
FURNACE: FAU_GRAVITY STATE LIC
FLOOR BTU LICENSE NO.Q`a� j CLASS
'
HEATER SUSPENDED UNIT ' DISTRICT OO]� GROUP zoNE OC ESSED�/BY
WALL -
//
INSPECTION RECORD O
V
c
O
Plan check fee 25% of above.
PERMIT ISSUING FEE$ Z
TOTAL FEE —
PLAN CHECK APPLICANT
NAME,
ADDRESS
CITY TEL.NO
IHEREBY 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, VENTILATING. AIR '
CONDITIONING
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF APPROVALS DATE - INSP TOR'S SIGNATURE -
CHAPTER 9, DIVISIO 3, OF THE;BUSIN SS AND PROFESSIONAL CODE
OF THE•STATE OFC OF THE,-
ROUGH
SIGNATURE FINAL
OF PERMITT
PERMIT VALIDATION CK M CASH
'PLAN9-Ae&P�NS1xTIOFT`
POLICY HOLDER: ,-' c 3`7,O.ti11AY -10 4,:1',D 1, 3.0,G
POLICY NUMBER:
Os
75 A,364 r'CE 818- 5-73
PPIPILLICAVON FOR. PERMIT"
HEATING - V'ENTILA" ING - A'IR C•ONOYTIONING , 1
COUNTY'OF LOS ANGELES' BUILDING �:.
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY a_
NEAREST .
CROSS ST.
FOR APPLICANT. TO FILL IN OWNER .-
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE- ADDRESS
_CIT TEL. NO,
ABSORPTION UNIT, BTU.
CONTRACTOR g
AIR' HANDLING UNIT, CFM
ADDRESS g
BOILER,- BTU CITY TEL. NO.
COMPRESSOR, BTU STATE LIC.
LICENSE NO. - �� CLASS
VENTILATION SYSTEM DISTRICT No. GROUP ZONEPRO SED BY
EVAPOR'A'TIVE COOL i
/ FURNACE: FAU�GRA Y INSPECTION RECORD
FLOOR BTU
HEATER: SUSPENDED UNIT_
WALL-'
r
' o
• U
O
U
W
' - fn
Plan check fee 25% of above: See reverse.
Z
PERNIIT'ISSUING FEE $. 3 00
TOTAL F'EE. ZZ 1,0
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 ALLORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE' INSPECTOR'S SIGNATURE
LAT ING, AIR CONDITIONING•. •I
• ROUGH
I HEREBY C Y THAT 'AM .NOT ACTING IN VIOLATION '
OF CHAPTER 9 IVISION 3, OF_ HE BUS NESS A OFESSIONAL FINAL
CODE OF THE TATE.OF CALIFO IA.
SIGNATUR - PERMIT VALIDATION- `cli... M.0. CASH. -
OF PERM ` • 1._ '
'P.LAN'CHECK VALIDATION' CK, M.o.,' CASH'
8: 2°.51"A?R -�4 4 1 D. 1. 3. ,0
SEE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE '