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76A667 CE817 12/59 TEMPLE CITY
APPLICATION FOR PLUMBING PERMIT �
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUIDAGL kMNR1 ES� ETY QIVSION BUILDING
JOONTv NGINEER
ADDRESS S
t WILLIAM A JENSEN SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET MAIL
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BATH TUB ADDRESS
CITY TEL NO s
SHOWER
LAVATORY CONTRACTOR
SINS ADDRESS
DISHWASHER CITY TEL NO36('
CONTRAC R S STATE ❑
LAUNDRY TUB I REGISTRATION NO COUNTY ❑
CLOTHES WASHER DI TRICCTN /G UP ZONE P O BY
WATER HEATER L/ v
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
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P4
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W
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$I 00 PER ITEM
OR FIXTURE $ //(/1/ APPROVALS DATE INSPECTOR S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK
TOTAL FEE 1 3 VIV
ROUGH PLUMBING
GAS PIPING i
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING HOT WATER HEATER
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES o
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE GAS TEST p
DESCRIBED RESIDENTIAL OPERTY UTILITY CO NOTIFIED
SIGNATURE T 9 l�� 9 Aj
OF PERM(TTE � v' FINAL 1
®� VALIDATION ROBERT A WOOD
cK e 0 CASK SUPERVISING MECHANICAL ENG R
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