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TE.�ppA[ �d ateAl+,,iTe ' APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR NRI IONING
ge
v COUNTY LOS ANGELES
DEPARTMENT COUNTY ENGIN
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN BUILDI G S
(PRINT OR TYPE ONLY) ADDRESS
LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST los
CROSS 5T
ABSORPTION UNIT BTU
OWNER
AIR HANDLING UNIT CFM MAIL ,4 S T
L
ADDRESS
BOILER BTU CITY I /gym /- TEL NO U _(�
COMPRESSOR BTUypdd� /) 1 l
(/ CONTRACTOR
VENTILATION SYSTEM ADDRESS kk7
EYAPOfl ATIVE GOOIER ISTA
TEL NO.*,16_ .719
FURNACE FAU�GRAVITY LIC
FLOOR BTU /e�ggo /DE NO CLASS
HEATER SUSPENDED UNIT— STRICTNNO GROUPZONE ESSEDBYWALL 7 INSPECTION(RECORD O
79
_ o
Plan check fee 25% of above
PERMIT ISSUING FEE$ a.
---�
TOTAL FEE 7
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL NO
1HEREBY 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
I HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION OF APPROVALS DATE I IGNATURE
CHAPTER 9 DIVISION 3 OF THE BU ESS AND PROFESSIONAL CODE +�
OF THE STATE OF CA/LI-F�ORNIA ROUGH /O n
SIGNATURE / / VA . - FINAL
OF PERMITTEE
PLAN CHECK VALIDATION CK Mo CASH PERMIT VALIDATION yam- Mo t'cAsH
'<<°'CCOMPENSAT10Pf
'OLICY HOLDER: �,t.�b O O�JUL 7 q,1 0 2 7.0 0 Aye
POLICY NUMBER- 31 2,5 L `�