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APPLICATION FOR PERMIT
HEATING - VENTILATING - AIR CONDITIONING
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COUNTY OF LOS ANGELES ;BUILDING j
DEPARTMENT OF COUNTY ENGINEER ADDRESS / A Ion
BUILDING AND. SAFETY DIVISION LOCALITY
NEAREST
CROSS ST.
FOR APPLICANT TO FILL IN OWNS
(PRINT OR TYPE ONLY)
MAIL
NO. TYPE&SIZE OF EQUIPMENT FEE ADDRESS
SEE BACK OF APPLICATION
CITY TEL.
FORCE AIR FURNACE, BTU roe M_ PIC
CONTRACTOR
COMPRESSOR, BTU Me a -
ADDRESS L
VENTILATION FAN CIT S EL. NOI_ .o®
LIST ALL OTHERS BELOW STAT LIC.
LICENSE NO. I}� CLASS
DISTRICT NO. GROUP ZONE PROC SED BY
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INSPECTION RECOR
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Pian check fee. See reverse.
PEII\llT I.SSFI\G FEE S
TOTAI, FEE
PLAN CHECK APPLICANT
NAME
ADDRESS
CITY TEL.NO.
I HEREBY ACKNOWLEDGE THAT I HAVE READ,THIS APPLICATION
x 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.
1 HEREBY CERTIFY THAT I AM NOT ACTING IN VIOLATION ROUGH /1
OF CHAPTER 9, DIVISION 3, OF THE BUS N AND PROFESSIONAL FINAL
CODE OF TXE STATE CALIF IA. G ��
SIGNATURE PERMIT VALIDATION CK. M.O. CASH
OF PERM ITTEF&A_ �
W INN q
PLAN CHECK VALIDATION CK. M.O. CASH
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