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76 X364 CE 8 I 1/76
APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS
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DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY ( r
NEAREST II
CROSS ST k
FOR APPLICANT TO FILL INr'
OWNER p
(PRINT OR TYPE ONLY)
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V0 TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
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FORCE AIR FURNACE BTUt*lq
CONTRACTOR /S
COMPRESSOR BTU
ADDRESS �: Q
VENTILATION FAN CITY
LIST ALL OTHERS BELOW STATE LIC
LICENSE NO CLASS G•�
1 T NO GROUP ZONE I PROC SEED BY
INSPECTION RECORD
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Plan check fee See reverse
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101 \1 1 1 1
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 DATE INSPECTOR S SIGNATURE
LATING AIR CONDITIONING
ROUGH
I HEREBY CERTIFY TH XF OT AC NG IN VIOLATION
OF CHAPTER 9 DIVISION 3 INE 0 PROFESSIONAL FINAL 11-7-76
CODE OF THE STATE OF CA
SIGNATURE 0- PERMIT VALIDATION CK M"SH
OF PERMITTEE
PLAN CHECKVA (DATION CK M o CASH
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