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APPLICA� O 5 PLdJ M B E RM IT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS .BUILDING `iZ r�1 G��� �Oro
NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET LOCALITY -re-M `r,
NEAREST
BATH TUB CROSS ST LIvE OA
SHOWER OWNER 1dL', y C7t A�►
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ADDRESS /Z AI�SS4r�t�r-0
SINK CITY �Cry,P,C 4Ir(e TEL N026k:j (,Z(1.7
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY NO
LAWN SPRINKLER SYSTEM STATE LIC
WATER HEATER LICENSE NO CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR S SIGNATURE
OUTLETS OVER UNDER SLAB WORK 7
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING V
GAS VENT pt
HOT WATER HEATER 0
PLUMBING FIXTURES
0.
GAS TEST 1A
Plan check fee UTILITYCO NOTIFIED
PLUMBING PERMIT ISSUING FEE$
FINAL
TOTAL FEE
PLAN CHECK VALIDATI
Plan check applicant
N
Name
Address
City Tel No
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE r �2 0 2 12 A
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION # 0'0'0 O O 5
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE 2 0 0 (� (\0
LEGAL OWNER OF AND INTEND TO RESIDE IN THE ROVE DESCRIBED RESIDENTIAL v
PROPERTY
10 O O l9 o O V
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SIGNATURE 0 5 0 5) 8 0
OF PERMITTEE
DISIRLCT
. OCE ED BY
INDUSTRIAL
WASTE APPROVAL