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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO BUILDING
ADDRESS
HARVEY T BRANDT COUNTY ENGINEER r
LOCALITY /�AA4lj
FOR AP CANT TO FILL IN (PRINT OR TYPE) NEAREST e
NUMBER IXTURE OR ITEM p FEE CROSS ST _
WATER CLOSET 2 00 OWNER
MAIL
BATH TUB 200 ADDRESS Ah )y
/ SHOWER• 2 00 CITY TEL NO
LAVATORY 200 CONTRACTOR
SINK 2 00 ADDRESS
DISHWASHER 2 00 CITY TEL NO
C LOTH WASHER 200 STATE LIC
SWIMG POOL RECEPTOR 200 LICENSE NO CLASS
DISTRICT NO GROUP ZONE P CES BY
LAWN SPRINKLER SYSTEM 200 5tO1b ' �,�
WATER HEATER 2 00 INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS 2 00a
INSPECTION RECORD
OUTLETS OVER / 8
5 PER SYSTEM 30
O
1-
Cu
W
rn
Plan check fee See Reverse 2
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE
APPROVALS DATE INSPECTOR 9 SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel NO GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
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 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 �7
RESIDE IN THE ABOVE DESCRIBED RESIDENTIA PROPERTY FINAL
SIGNATU RE
OF PERMITTEES ((( 1 bnl,�
PERMIT VALIDATION CK M o CASH
PLAN CHECK VALIDATION CK M O CASH
2 rAUG 26 5 0 82 5 ®�a