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05 o V®®® p��p PLUMBING
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COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS41
NUMBER
_
NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET LOCALITY �
NEAREST
BATH TUB CROSS ST. 119W I.-Alvc)
SHOWER OWNER
MAIL LJ
LAVATORY ADDRESS L5,5
SINK CITY TEL.NQ.-�(
DISHWASHER CONTRACTOR ``nn
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CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL.NO,
LAWN SPRINKLER SYSTEM STATE LIC.
WATER HEATER LICENSE NO. CLASS
GAS SYSTEM OUTLETS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER UNDERSLA"ORK Z7
5 PER SYSTEM ROUGH PLUMBING / (� �� ' �� �:•i��� }}
/ 64-) GAS PIPING p
GAS VENT
HOT WATER HEATER
0
PLUMBING FIXTURES
GAS TEST
Plan Check fee UTILITY CO.NOTIFIED
PLUMBING PERMIT ISSUING FEE$ i + 1
TOTAL FEE FINAL 7� ..��"
ON
Plan check applicant PLAN CHECK VALIDAT '
Name
Address
LRED
Tel.No �i-ZeS
EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANDS ATE
ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES `, 1
E LAWS REGULATING PLUMBING. PERMIT VALIDATION
EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS ^_} O ,)
BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE }
NER OF.AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
.RE M ITTEE O l
DISTRICT NO. PRO SED BY O E 2
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INDUSTRIAL
WASTE APPROVAL