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76A667AY
CE161 T(REV 6/781
APPLICATION / OR PLU ING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �I/Q�
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NUMBER FIXTURE OR ITEM ® FEE ADDRESS
LOCALITY
WATER CLOSET NEAREST
BATH TUB CROSS ST 1 G�
SHOWER OWNER `
LAVATORY MAIL —:2-6
!,
ADDRESS L V" /OF
.
SINK CITY --re
/r 4 TEL NO ✓ �/
DISHWASHER U CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY ✓ TEL NO
LAWN SPRINKLER SYSTEM STATE LIC
WATER HEATER LICENSE NO CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER p0 9
PLUMBING FIXTURES
GASB TEST Nb
Plan check fee UTILITY CO NOTIFIED
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Plan check appllco PLAN CHECK VALIDATION
Name
Address
City Tel No '
/
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE ;2 7 0 6.9 A
THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION # 0 0 O 0 05
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE 2'� 0 Z 3(�O
LEGAL OWNER OF AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL lJ
PROPERTY +. � I l3,o O V
SIGNATURE 0
OF PERMITTEE
1
3-79
DISTRICT NO OCES D BY
Q Y
INDUSTRIAL
WASTE APPROVAL