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APPLICATION FOR PCIIMIT
HEATING - VENTILATING - AIR'CQNDITIONING (�
COUNTY OF LOS ANGELES FADDRESS
NGj l NJ
DEPARTMENT OF COUNTY ENGINEER .��`BUILDING AND SAFETY DIVISION ITY STST. F .
FOR APPLICANT TO FILL IN OWNER f
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(PRINT OR TYPE ONLY)
MAIL
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPL,}C,ATION
CITY T L. NO.
FORCE AIR FURNACE, BTU '.-- _4)
CONTRACTOR +r�,J.'' .> :
-COMPRESSOR, BTU ""
ADDRESS
VENTILATION FAN CITY TEL. NO. W '`
LIST ALL OTHERS BELOW STATE "' t r'. LIC.
LICENSE NO. CLASS '
- DISTRICT NO. GROUPONE �RRBSE SS ED BY
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INSPECTION RECORD O
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Plan check fee. See reverse.
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I'\(" FIEF: S 3 00
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 ALLORDINANCES AND LAWS REGULATING HEATING, VENTI- APPROVALS DATE INSPECTOR'S SIGNATURE
LATING, AIR CONDITIONING.
ROUGH
I HEREBY CERTIFY T OACTING IN VIOLATION OF rHAPTER 9. DIV(SIO 4TH;EM;�. INESS ANO PROFESSIONAL FINAL
CODE OF THE STATE, yI F '
SIGNA?URE, ( >f PERMIT VALIDATION CK. M.O. CASH
OF PERMITTEE- t
PLAN CHECK VALIDATION CK. M.D. CASH
40M9,1 . 1441 w � '