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APPLICAi1G6F R PLUM N PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
NUMBER FIXTURE OR ITEM ® FEE ADDRESS
WATER CLOSET LOCALITY
NEAREST
BATH TUB CROSS ST
SHOWER OWNER VICKI le 1<1_,4 us S ,
LAVATORY MAIL
ADDRESS
SINK CITY TEL NO
DISHWASHER CONTRACTOR 4c,4611.4
CLOTHES WASHER ADDRESS /6 C WAq,LW ul
SWIMMING POOL RECEPTOR
CITY �LO L TEL NO �
LAWN SPRINKLER SYSTEM STATE �J LIC
WATER HEATER LICENSE NO 7I 7y'/q OA55
GLIAS SYSTEM OUTLETS FRLUMBING
VALS DATE INSPECTOR S SIGNATURE
OVER TS&ER WORK
BING V a
HEATER Q
IXTURES IrL
GAS TEST N
Plan check fee VFINAL
TIFIED Z
PLUMBING PERMIT ISSUING FEE S
TOTAL FEE O
rNome
applicant CK VALIDATION
Tel No yI0433A
KNOWLEDGE AT I HAVE READ THIS APPLICATION AND STATE # L• 5
OYE6CORRECT AMD AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
LAWS REGULATING PLUMBING PERMIT VALIDATION 2 a 0 0
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS
REOUMED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE K M A 1 0 0 0 5
LEGAL OWNER OF AND 11(TE�RESIDEE ABOVE 0 EO RESIOENTULL
PROPERTY
SIGNATURE
OF PERMITTEE
�QISTRICi NO PR CESSED B
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INDUSTRIAL
WASTE APPROVAL