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APPLICATION R )PLUM NG PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO , ADDRESS -4852 Tem le- Cit Blvd.
HARVEY T BRANDT, COUNTY ENGINEER LOCALITY Temple CYty -
FW
PPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST Lower Azusa ,
FIXTURE OR ITEM O FEE
OWNER A' Pie inhard L + '
R CLOSET 1 73
TUB 1 75
ADDRESS 2 Temple City Blvd.
ER 1 75 CITY Temple Cit TEL NO 28 ( 14
TORY 17g CONTRACTOR Valley HeatlriplCO . ,
1 75 ADDRESS /. 1 d.(/
WASHER 1 75 CITY TEL NO 288 6812
HES WASHER 1 75 LCENSE NO14 S CLASS (/ZQSTATE LIC
MING POOL RECEPTOR 1 75DISiTNO GP NFROC SSED BY
N SPRINKLER SYSTEM 1 73 pR HEATER . 1 7S WASTE MACIVAL
SYSTEM OUTLETS 1 75 O INSPECTION RECORD
ETS OVER30 SYSTEM
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Check IBB See ReV[,ee
PLUMBING PERMIT ISSUING FEE 8
TOTAL FEE
APPROVALS DATE INSPECTOR S SIGNATURE
PlanCheck applicant UNDER SLAB WORK
ROUGH PLUMBING
ess GAS PIPING
Tel NO GAS VENT
HOT WATER HEATER
ERE DY ACKNOWLEDGE THAT I HAVE READ THISAPPLICATION
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY' PLUMBING FIXTURESALL COUNTY ORDINANCE! AND STATE LAWS LAYINGING GAS TEST
ERESY Cf RTIFY THAT I M PROPERLY OUTSRLD A D/OR UTILITY CO NOTIFIED
lD AD REOUIRfO SY D ANOlLU TY AND !TATE O
RNIA OR THAT I L[UAL OW R OF AND INTER
E IM THE ADOV f ID[D RElID N AL PROPERTY FAL i2 7ATU RE PERMITT E
PERMIT VALIDATION M 0 CASH
PLAN CHECK LIDATION CK M 0 CASH 2 6 9�NOV 12 5 p 7.5 0 e�o
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