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76 A364- CE BIB-1/76
APPLICATION R PERMIT
HEATING - VENTILATING -.AIR CONDITIONING
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGINEER ADDRESS
BUILDING AND SAFETY DIVISION LOCALIT 1
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN CAO
(PRINT OR TYPE ONLY)
MAIL
No. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION ��
CITY TEL. NO.
FORCE AIR FURNACE, BTU
CONTRACT C
COMPRESSOR, BTU
ADDRESSA 157
VENTILATION FAN
LIST ALL OTHERS BELOW srrATE LIC.
LICENS NO. CLA��/
' , DISTRICT N0.100F. S ' GROUP aNE ESSED Y
Uv
INSPECTION RECORD
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Plan check fee. See reverse. z
PRR\11T I.SSI:I\C FEE S ,
TOTAL. FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT 1 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 THAT 1 AM NOT ACTING IN V.Iqj.ATION
OF CHAPTER 9, DIVISION 3, OF THE BUSIN S NO PRO IONAL ,..FINAL
CODE OF THE STATE OF CALIFORNIA.
SIGNATURE PERMIT VALIDATION cK. o. CASH
OF PERMITTE Q-
Lj
PLAN CHECK VALIDATION CK. M.d., CASH
66 5 6AN 1341 0 1 2.00 ®;;0