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APPLI TION FOR PER
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS �/ /�(1 jY✓Y
BUILDING AND SAFETY DIVISION LOCALITI'�, h • ! f7-r 4!:2*-zf
NEAREST
CROSS S N4
FOR APPLICANT TO FILL IN OWNE
(PRINT OR TYPE ONLY) MAIL
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NO. TYPE&SIZE OF EQUIPMENT FEE ADDREAUf ? Cffl /z
SEE BACK OF APPLI TION f _ / p
1 CITY ,12 C..I Z TEL. NO. � d/ �
FORCE AIR FURNACE, BTU / v�
CONTRACTOF�`�"
COMPRESSOR, BTU
ADDRESS
VENTILATION FAN CITY TEL. NO,
LIST ALL OTHERS BELOW STATE LIC.
LICENSE NO. CLASS
DISTRICT NO GROUP ZONE PROCESSED BY
INSPECTION RECORD
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Plan check fee. See reverse. z
PI !1\IIT itiSI:I�C FEE S
TOTAL. FEL:
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO. ;
LREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION '
ATE THAT THE ABOVE IS CORRECT AND.AGREE TO COMPLY
LL ORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALSDATE INSPECTOR'S SIGNATURE
,AIR CONDITIONING. ROUGH
EREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION
PTER 9, DIV( N 3, OF THE BUST AND PROFESSIONALF THE STAT 0CALIFORNIA. FINALTURE A � PERMIT VALIDATION cK- M.o. CASH
RMITTEE /! `•��� \�.,
PLAN CHCPR VRLIDATION. id. M.O. CASH
6 3 0°-OCT 1.9 4-1 .D