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78A E0617 10 67
APPLICATION FOR PLUM ING PE IT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER FNEAREST
BUILDING AND SAFETY DMSION JOHN A LAMBIE COUNTY ENGINEERCOLEMAN W JENKINS SUP T OF BUILDING FOR APPLICANT TO FILL IN (PR NT OR TYPE)
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET 1 50
� MAIL
BATH TUB 1 50 ` ADDRESS
SHOWER 1 50 CITY NO
LAVATORY 1 50 ! CONTRACTOR
SINK 1 50 ADDRESS3
DISHWASHER 1 50 CITY TEL NO ZZJT
CLOTHES WASHER 1 50 STATE LIC c3
LICENSE NO CLASS
SWIMMING POOL RECEPTOR 1 50 DISTRICT O GRO P FNE PRO D
LAWN SPRINKLER SYSTEM 2 00 INDUSTRIAL
v O
CL
U
WATER HEATER 1 50 WASTE APPROVAL
GAS SYSTEM OUTLETS 1 50 INSPECTION RECORD U
OUTLETS OVER 30 d
5 PER SYSTEM
Plan check fee 2S% of above See reverse
PLUMBING PERMIT ISSUING FEE S 2 00
TOTAL FEE
APPROVALS DATE INSPECTOR S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
r
GAS VENT
City Tel NO 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 GAS TEST
PLUMBING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF n
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE A GCRIBED RESIDENTIAL PROPERTY FINAL
SIGNATURE JACK R ALLEN SUPERV SICcK
HANICAL ENG R
OF PERMITTE
PERMIT VALIDATIONM 0CASH
PLAN CHECK VALIDATION CK M 0 CASH
L AL0 7 5 8 9 DEC 9 5-D 65,0-
C%