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76 A364- CE 818-1/75
4 APPLICATION FOR PERMIT
HEATING. - VENTILATING - AIR CONDITIONING
COUNTY OF LOS ANGELES ADDRESS d. !f
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION LOCALITY• �'
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNER
(PRINT OR TYPE ONLY)
MAIL
No. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
CITY / TEL. NO.
FORCE AIR FURNACE, BTU 5 / -
CONTRACT R
COMPRESSOR, BTU
ADDRESS
VENTILATION FAN CITY TEL. NO.
LIST ALL OTHERS BELOW' STATE LIC.
LICENSE NO. CLASS
DISTRICT NO. GROUP ZONE PROC ED Y
INSPECTION RECORD
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Plan check fee. See reverse. z
Pl:11\11'I' ISSLIKG F1':F: S
I'OTAI, F EI':
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
'I HEREBY ACKNOWLEDGE THAT I HAVE READ THISAPPLICATION
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
1 HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION �
OF CHAPTER 9, DIV1510N 3, OF THE BUSINESS AND PROFE5jl�OL FINAL
CODE OF THE STATE OF CALIFORNIA!
SIGNATURE J �,� MIT VALIDATION CK. M.O. CASH
-OF PERMITTEE
PLAN CHECK VAtIDATION CK. M.O. CASH+
3 4=BSEP 8 41 1 5.7 5 ���