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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES CITY OF TEMPLE CITY INSP
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO ADBUILDING X 4910 AGNES A
HARVEY T BRANDT COUNTY ENGINEER
LOCALITY TEMPLE CITY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST A_,a_2A
NUMBER FIXTURE OR ITEM ® FEE
WATER CLOSET 2 00 OWNER WINDHAUSEN, JERRY
MAIL ABUVE
BATH TUB 200 ADDRESS
SHOWER 200 CIT' TEMPLE DCAITY TEL No 285-2303
LAVATORY 200 CONTRACTOR TRANE HCC
SINK 200 ADDRESS 2034 NORTH PECK
DISHWASHER 200 CITY So ]El- xftpp
- 2
CLOTHES WASHER 200 STATE LIC
LICENSE NO 265094 CLASS C-20
SWIMMING POOL RECEPTOR 2 00
DISj_8U NO JGFICUP ZONE OC ED BY
LAWN SPRINKLER SYSTEM 200
WATER HEATER 200 INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS00 INSPECTION RECORD v
OUTLETS OVER
5 PER SYSTEM 30
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Pian check fee See Reverse
PLUMBING PERMIT ISSUING FEES o
TOTAL FEE ,
APPROVALS DATE INSPECTOR 6 SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING J
Address GAS PIPING
City Tel NO GAS VENT v
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THEABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LICENSED AS 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 RESID TIAL PROPERTY FINAL wP'af�
SIGNATURE .12e- • ,� p�
OF PERMITTEE
PERMIT VALIDATION CCK O CASH
PLAN CHECK VALIDATION CK M O CASH '
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