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APPLICATION FOR PLUMBING PERMIT {�
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BUILDING AND SAFETY DI ISION
r Af
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ,,/
NUMBER FIXTURE OR ITEM @ FEE ADDRESS J
WATER CLOSET LOCALITY
NEAREST
BATH TUB CROSS ST
SHOWER ONNER f use
LAVATORYMAIL
ADDRESS
pip
SINK CITT TEL NO
DISHWASHER CONTRACTOR
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL NO
LAWN SPRINKLER SYSTEM
STATE LIC
/ WATER HEATER LICENSE NO CLASS
DISTRICT NO NE yRESSED Y O
GAS SYSTEM OUTLETS � D� LGROUP
'� / J CDOUTLETS OVER � ��• V� �
5 PER SYSTEM V
INDUSTRIAL
WASTE APPROVAL yJ
s INSPECTION RECORD Z
Plan check fee
PLUMBING PERMIT ISSUING FEE $ 5U
TOTAL FEE
Plan check applicant
Name APPROVALS DATE INSPFSqTOR 5 SIGNATURE
UNDER SLAB WORK
Address
ROUGH PLUMBING ��-
City Tel No 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 HOT WATER HEATER
PLUMBING
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY UTILITY CO NOTIFIED
SIGNATU RE /J
OF PERM(TTE
PLAN CHECK VALIDATION CK M D CASH PERMIT VALIDATION cK M 0 CASH
` 054rNOV 1 5 u 2254 ,&%
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