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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO BUILDING
ADDRESS
HARVEY T BRANDT COUNTY ENGINEER r
LOCALITY C
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST Lowe r J S
1
NUMBER FIXTURE OR ITEM 75 FEE OWNER �l 1l Q
MAIL
WATER CLOSET
BATH TUB 1 75 ADDRESS
SHOWER 1 75 L� CIT ` . TEL NO
LAVATORY 1 75
•J CONTRACTOR
SINK 1 75 ADDRESS
DISHWASHER 1 75 CITY TEL NO
CLOTHES WASHER 1 75 STATE LIC
LICENSE NO CLASS
SWIMMING POOL RECEPTOR 1 75
DISTRICT NO I GROUP ZONE F CESSEQ BY
LAWN SPRINKLER SYSTEM 1 75 `1 r hQ
WATER HEATER 1 75 INDUSTRIAL ('p
WASTE APPROVAL z G
GAS SYSTEM OUTLETS 1 75 e
17 I SPE TI RECOR V
OUTLETS OVER 30 l//��
5 PER SYSTEM C
W
a
N
Z
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE
APPROVALS D TE I ECTOR s it ruRE
Plan check applicant UNDER SLAB WORK /� 3
Name ROUGH PLUMBING ')
Address GAS PIPING
City Tel NO GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST
I HEREBY CERTIFY THATLOAM AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LICENSED AS REOUI RED BY L05 ANGELES COUNTY AND STATE OF
CALI FORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED R7)NT PROPERTY FINAL
SIGNATU RE
OF PERMITTEE i
PERMIT VALIDATION CK M O CASH
PLAN CHECK VALIDATION V CK M O\J CASH
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