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APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING iy .� ��
DEPARTMENT OF COUNTY ENGINEER ADDRESS G�7
BUILDING AND SAFETY DIVISION LOCALITY E���L e4k- 7 /
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER J.
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
CITY TEL. WO4pd.-'-aenj-
FORCE AIR FURNACE, BTU
CONTRACTOR
COMPRESSOR, BTU ADDRESS A
VENTILATION FANCITY '� J NO.
LIST ALL OTHERS BELOW STATE D LIC. n
LICENSE NO. O 196,-6 �IXQe�
DISTRICT NO. GROUP QOCES.ED BY
INSPECTION RIECORD
n.
O
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O
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R.
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Plan check fee. See reverse. Z
P
PER)IIT ISSFIVC FEE, S
TOTAL. FGI?
PLAN CHECK APPLICANT
NAME
ADDRESS
CI TY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL, ORDINANCES AND LAWS REGULATING HEATING, VENTI- l APPROVALS DATE INSPECTOR'S SIGNATURE
LAT IN G.AIR CONDITIONING.
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I HEREBY CERTIFY THAT I AM ROUGH
NOT ING IN VIOLATION
OF CHAPTER 9, DIVISION 3, OF THE BUSINE AND PROFESSIONAL FINAL /�2Z�� / '✓•�..+.,.,,,�
CODE OF THE STATE OF CAL RNI
SIGNATURE PERMIT VALIDATION M.O. CASH
OF PERMITTEE <�f
PLAN CHECK VALIDATION CK. M.O. CASH
68 1-ACCT 14 4 1 0 _. 1 .2.0 U ALIb
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