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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �r
JOHN A LAMBIE COUNTY ENGINEER ADDRESS VO �� `7'J 4zln
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WILLIAM A JENSEN SUP 7 OF BUILDING y" ,
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
Q / 91- e NUMBER FIXTURE OR ITEM EACH FEE CROSS STaa
WATER CLOSET $125 OWNERMAIL � /BATH TUB 1 25 ADDRESS0SHOWER 1 25 CITY SEL NO �Q
LAVATORY 125 CONTRACTOReQ
SINE 1 25 ADDRESS
DISHWASHER 125 CITY TEL NO
LAUNDRY fUB1 25 CONTRACTOR S STATE ❑
REGISTRATION NO COUNTY ❑
CLOTHES WASHER 1 25 DISTRICT NO GCESSED BY
WATER HEATER 1 50 J -
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GAS SYSTEM OUTLETS 1 50 INDUSTRIAL
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM 30 INSPECTION RECORD Off.
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APPROVALS DATE INSPECTOR S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK a�� �,.�►y
ROUGH PLUMBING
TOTAL FEEI GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING HOT WATER HEATER Oy`fr
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
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LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PRO UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTEE FINALjo
VALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENG R
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