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APPL ION FOR P IT
HEATING - VE ILATING - AI ONOITIONING
op
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALITY 1
NEAREST
]CROSS ST. 1rr s• yr.i,,,
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY) t r
MAIL
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
CITY,,-f' TEL. N S b'3
FORCE AIR FURNACE, BTU
CONTRACTOR
COMPRESSOR, BTU qo
ADDRESS
VENTILATION FAN CITY TEL. NO.
LIST ALL OT ERS BELOW STATE LIC.
LICENSE NO. C
DISTRICT N0. GROUP ONE
_,SED BY
INSPECTION RECORD
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F-
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Plan check fee. See reverse. ?
IIE11111T I.SSI I\(: h'I;1:
TurAl.
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 gqD,ATE INSPECTOR'S SIGNATURE
EATING. AIR CONDITIONING. ROUGH
I HEREBY CERTIFY TH I AM NOT ACTING IN VIOLATION
OF CHAPTER 9, DIVISION 3 OF HE BUSES D PROFESSIONAL FINAL �,�/�-���
J
CODE OF THE STZ
I VI
SIGNATURE , PERMIT VALIDATION M.o. cnsH
OF PERMITTE
PLAN CHECK VAUIDATION CK. M.O. CASH
41 .11.40V 2 3 41 0 1 2.0 0 b�:ro
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