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APPLICATION FOR PLUMBING PERMIT
C>2C
BUIL NG AND SAFETY (VISION
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
NUMBER FIXTURE OR ITEM @ FEE ADDRESS a21
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WATER CLOSET LOCALITY
BATH TUB NEAREST
CROSS ST.
SHOWER OWNER
LAVATORY MAIL
ADDRESS
SINK CITY TE L,:OW�-
DISHWASHER CONTRACT
CLOTHES WASHER
A D D R
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM 0�
STAT LIC /
WATER HEATER LICE SE N0. B CLASS
GAS SYSTEM OUTLETS
DISTRICT NO. I GROUP NE OCES ED BY O
3
OUTLETS OVER 0 0 O
5 PER SYSTEMV
INDUSTRIAL
WASTE APPROVAL W
a
INSPECTION RECORD
Plan check fee
PLUMBING PERMIT ISSUING FEE $ 6--U
TOTAL FEE
Plan check applicant
Name APPROVALS DATE INSPECTORS SIGNATURE
UNDER SLAB WORK
Address ROUGH PLUMBING
City Tel. No. GAS PIPING
I 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 HOT WATER HEATER
PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL^ OPER TY, UTILITY CO. NOTIFIED
SIGNATU RE
OF P E R M I T T E / FINAL
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION <ZY M,O. CASH
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