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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES I BUILDING AND SAFETY
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FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS "t02
NUMBER FIXTURE OR ITEM ® FEE �r
LOCALITY Tem le Citi Unit-30 WATER CLOSET r f NEAREST
1 BATH TUB QQ CROSS ST
1 SHOWER 3QQ `OWNER Fairhaven CO
LAVATORY MAIL
ADDRESS
1 SINK 3 100 CITY ,r TEL NO r
DISHWASHER CONTRACTOR Dorsey Plumbing CO.
' 1 CLOTHES WASHER QQ ADDRESS goo -pal TnArpR
dSWIMMING POOL RECEPTOR
r` LAWN SPRINKLER SYSTEM CITY Le Verne TEL NO —Q82
� t STATE LIC
` �1 WATER HEATER 3100 LICENSE NO 4 CLASS —
GAS SYSTEM OUTLETS ' APPROVALS DATE IN CTOR S SIGNATURE
00
OUTLETS OVER UNDER SLAB WORK
` 5 PER SYSTEMQ"
ROUGH PLUMBING i
GAS PIPING • O
GAS VENT VI V
r A HOT WATER HEATER ' 0
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I, PLUMBING FIXTURES
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IPlan check fee ' UTILITYCO NOTIFIED Z
PLUMBING PERMIT ISSUING FEE$ QQ , r
TOTAL FEE43 QQ
FINAL
TPlan check applicant PLAN CHECK VALIDATION
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Name rr •
Address
by Tel No
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE O 1 A
THAT THE ABOVE IS CORRECTAND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING ,PERMIT VALIDATION
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1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS `Y
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE '
LEGAL OWNER OF AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL `q 8 * 43.00
PROPERTY r
I s' t• • • 430006
SIGNATURE v i
OF PERMITTEE 4
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DISTRICT NO P CES Q BY 1 r
INDUSTRIAL
WASTE APPROVAL
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