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BUILDING AND SAFETY DIVISION
FOR APPLICANTTO FILL IN IPRINTOR TYPE) BUILDING_//
NUMBER FIXTURE OR ITEM ® FEE ADDRESS
WATER CLOSET LOCA Y
NEAREST
BATH TUB CROSS
SHOWER OWNE
LAVATORY MAIL
ADDRESS
SINK CITY TEL. O:
DISHWASHER C CI(FIC INSTALLERS
CLOTHES WASHER A1:0920 E. GRAND AVE.
SWIMMING POOL RECEPTOR �` �pyp�
LAWN SPRINKLER SYSTEM C'1EMPLE EL CITY �..
j STATE LIC.
WATER HEATER LICENSE NO CLASS
GAS SYSTEMOUTLETS DISTRIUIJ,O1. ��7gOUP ONE ROCESSE BY y
OUTLETS OVER �_) a
5 PER SYSTEM INDUSTRIAL
v
WASTE APPROVAL
INSPECTION RECORD t~.]
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N
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Plan check fee
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE
Plan check applicant
Name APPROVALS DATE INSPECTVC5 SIGNATURE
UNDER SLAB WORK
Address ROUGH PLUMBING
City Tel.No. GAS PIPING ..:r .K/ I r
F I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT
- THAT THE ABOVE ISCORRECTAND AGREE TOCOMPLYWITH ALLCOUNTY ORDINANCES
�.AND STATE LAWS REGULATING PLUMBING. HOT WATER HEATER /yry 7 1
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS 1 PLUMBING FIXTURES
REO UIREO BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST I q M
LEGAL OWNER OF.AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
PROPERTY. UTILITY CO.NOTIFIED I �I
SIGNATURE
OF PERMITTE If, FINAL
PLAN,CHECK VALIDATION..r �. F�4'E 6i'c'g^ M:o.�"[cns�� PERMIT VALIDATION . M.o. CASH ,
POLICY HOLDER: p �
553 A'( 27 5 10. Jl14`s
POLICY HUMBER: _--1 e1--q— r? �.
76AC67-CES V.8S! -
APPLICATION FO'R PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING/
BUILDING AND SAFETY DIVISION ADDRESS'— ' T
JOHN A. LAMBIE. COUNTY ENGINEER CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITYFOR APPLICANT TO FILL IN NEAREST
CROSS ST.NUMBER FIXTURE OR ITEMOWNERqTWATER CLOSET MAIL /BATH SUB. ADDAESS -��SHOWER CITY[j7)/Qf� (511LAVATORY CONTRACTORSINK ADDRESS
DISHWASHER CITY LAUNDRY TUB CONTRACTOWSSTATEAEGISTRATION NOCOUNTY ❑
CLOTHES WASHER DISTRICT NO. GROUP ZONg senor roq INSPeCn On
WATER HEATER ` = AEON/
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL i
INSPECTION RECORD .�.�
/IM �
APPROVALS
rDESCR)BED-RESIDENTIA
51.00 PER ITEMDATE INSPECTOR'S SIGNATURE
OR FIXTURE S L/Z)O UNDER SLAB WORKROUGH PLUMBINGPERMIT s 1 00GAS PIPINGTOTALFEE /7 D0 GAS VENT
BY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLICATION HOT WATER HEATERLY
L COUNTYTATE THAT H ORONANCEE ABOVE ISSC ANDECSTATE LAWST AND E EGUATING PLUMBING FIXTURES.Y CERTIFY THAT I AM PROPEflLY REGISTERED AND/OR GAS TEST AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE UTILITY CO. NOTIFIED
D-RESIDENTIA L PROPERTY.GNATURE
MTTEE FINAL /jI'f pD Y"'L C•-:-L'l'Vq,��/-'
VALIDATION ROBERT A. WOOD,
SUPERVISING MECHANICAL ENG'R
C8.
M.0. CASH
!�;,i 503 10 3 5 .00
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