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7SA364fA.-a IriS-„i7S APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
BUILDING AND SAFETY DIVISION
F FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS
LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CROSS ST- ,
ABSORPTION UNIT, BTU
OWNER
AIR HANDLING UNIT, CFM, MAIL All
ADDRESS
BOILER, BTU CIT TEL. NO.
COMPRESSOR, BT CONTRACTOR I rnf.ls-
VENTILATION SYSTEM ADORE
EVAPORATIVE COOLER CITY -TEL. NO. y�
FURNAC F U GRAVITY STATE Ve'�� —�/+� LIC.
FLOOR BTU LICENSE NO. vi74 , 0 CLASS
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HEATER: SUSPENDED NIT_ DISTRICT NO, GROUP ZONE ROCE D BY �-
0
WALL c7
iC3 '
0
INSPECTION RECOR
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Plan check fee 25% of above.
PERMIT ISSUING FEE $
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-
LATING,AIR.CONDITIONING.
I HEREBY CERTIFY THAT I•AM NOT ACTING VI ATION APPROVALS DATE INSPECTOR'S SIGNATURE
OF CHAPTER 9, DI ;OF
N 3, OF THE BUS I SS AND ROF SIONAL
CODE OF THE STA C LIFORNIA. ROUGH /
SIGNATURE FINALl��j". /
OF PERMITTEE
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PLAN CHECK VALIDATIOCK. M.O. CASH PERMIT VALIDATION cK. M.O. -CASH
62.1.rAAUG 12. 4.1 .� :. � 19.5-0 d-9E