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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMSIE, COUNTY ENGINEER ADDRESS
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY '
FOR APPLICANT TO FILL IN NEAREST —
CROSS ST. '
NUMBER FIXTURE OR ITEM OWNER ;
WATER CLOSET 4
f ` , :__�_ _� MAIL
ADDRESS
BATH TUB
CITY TEL. NO.
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LAVATORY _
ADDRESS
SINK `
DISHWASHER CITY TEL. NO.
CONTRACTOR'S STATE 0
LAUNDRY TUB REGISTRATION NO. COUNTY ❑
CLOTHES WASHER DISTRICT NO. GROUP E ESSED BY
WATER HEATER
GAS SYSTEM � ' INDUSTRIAL
WASTE APPROVAL r
INSPECTION RECORD a
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$1.00 PER ITEM
OR FIXTURE $ I 7 APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
TOTAL FEE - ROUGH PLUMBING
GAS PIPING
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A LI ATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR :THAT I AM THE LEGAL OWNER OF THE ABOVE GAS TEST
DESCRIBED RES16"T1AL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTEE - FINAL
VALIDATION ROBERT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENG'R