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APPLICATION FOR PLUMBING PERMH
COUNTY OF LOS ANGELES iqj
DEPARTMENT OF COUNTY ENGINEER l
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO BUILDING _ !
ADDRESS
HARVEY T BRANDT, COUNTY ENGINEER LOCALITY /
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
NUMB @ FEE
ER FIXTURE OR ITEM CROSS ST
WATER CLOSET 200— OWNER W /1
MAIL
BATH TUB 200 ADDRESS ��m
SHOWER 2 00 CITY TEL N
LAVATORY 2 00 CON GPFIC INSTALLERS STALLERS
SINK 200 ADD 10920 E GRAND AVE
DISHWASHER 200 CITY E O
CLOTHES WASHER 200 STATE LIC
LICENSE NO p� CLASS
SWIMMING POOL RECEPTOR 2 00
DISTRICT NO IGROUP ZQ NE PRMESSED BY
LAWN SPRINKLER SYSTEM 200 " 0 I
WATER HEATER INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS 200 a
INSPECTION RECORD O
OUTLETS OVER
5 PER SYSTEM 30 A-07—
O
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Lu
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Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE S
TOTAL FEE
APPROVALS DATE INSPECTO 5 SIGNATURE
Plan check applicant UNDER SLAB WORK
1.1011
Name ROUGH PLUMBING
Address - GAS PIPING
City Tel NO GAS VENT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST
I L
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOFIED
LICENSED AS REQUIRED BY OTI
S ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED SID TIAL R PERTY FINAL
SIGNATU RE
OF PERMITTEE
PERMIT VALIDATION CK M 0 CASH
PLAN CHECK VALIDATION CK M G CASH `
2 6 0 a�� 9 5U '7.5 0 A",
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