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76A964C
CE 616(REV S/76)
®> APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN BUILDING /►+ / /liO 1�) le
(PRINT OR TYPE ONLY) ADDRESS J (O �1� C. (� �✓
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST / )
CROSS ST 1/
ABSORPTION UNIT BTU OWNER ON4 ,
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MAIL
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AIR HANDLING UNIT CFM ADDRES / r� Oe PR,��/y��
BOILER BTU J TEL;29�V/ 6
COMPRESSOR BTU CONTRACTOR
14y 4
VENTILATION SYSTEM ADDRESS
EVAPORATIVE COOLER CITY TEL NO
FURNACE FAU GRAVITY STATE LIC
FLOOR BTU LICENSE NO CLASS
HEATER SUSPENDED UNIT_ APPROVALS DATE INSPECTOR S SIGNATURE
WAL
G ROUGH �)
FINAL L� �-
INSPECTION RECORB
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Plan check fee 25%of above 9
PERMIT ISSUING FEE$ Z
TOTAL FEE
PLAN CHECK APPLICANT PLAN CHECK VALIDATION
NAME ROIV1?
ADDRESSS*-606 w DLA die.
CIT /J
C-/Z>l TEL N
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 VENTILATING AIR
CONDITIONING PERMIT VALIDATION @ 7 3 3,2 A
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF
CHAPTER 9 DIVISI 3 OF THE BUSINESS AND PROFESSIONAL CODE `
OF THE STATE OF FOR
NIA
# • •'• • 41
SIGNATURE +
OF PERMITTEE 20 - 1300
DISTRICT NO PR SED BY 0.1 ZOO=u
IQ22=79