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76.669 - CEB19 5/7APPLICAt 0 FOR PLU BI( PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 60,� 1 / n
COLEMAN W. JENKINS. SUPT. OF BUILDING - LoceiTlY
Ale.
FOR APPLICANT TO FILL 1N (PR NT OR TYPE) NEAREST
CROSS 37.
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET 1.50
MAIL
7 BATH TUB 1.50 ADDRESS r
SHOWER 1.50
CI I ' " A TEL. NO.' - -3
LAVATORY 1.50 CONTRACTOR I 4'�
SINK 1.50 ADDRESS G V
DISHWASHER 1.50 C TEL. NO.
CLOTHES WASHER 1.50 STATEl: LIC
.
LICENSE N / v CLASS
11
SWIMMING POOL RECEPTOR 1.50 1 DISTRICT NO. GROUP N ,PRO ESSE BY
LAWN SPRINKLER SYSTEM 2.00 h O
WATER HEATER 1.50 INDUSTRIAL
WASTE AP AOVAL O
GAS SYSTEM OUTLETS 1.50 WSPECTIOIJ RECORD I.I
OUTLETS OVER 50 Z
5 PER SYSTEM
73 CL
N
z
a
Plan check fee 25.0 0( above. See reverse. /
i l�sv
PLUM[91NG PE RAIIT ISSIIING FEE S -
'1'OTAL FEE
APPROVALS DATE INSPECTOR SSIGNATURE
Plan check applicant UNDER SLAB WORK
Nance ROUGH PLUMBING
Address GAS PIPING
GAS VENT
City Tel. No. HOT WATER HEATER
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCE! AND STATE LAWS REGULATING GAS TEST
PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSED A$ REQUIRED BY L09 ANGELES COUNTY ANO STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN. THE ABOVE OE RIBED RESIOEN A PROPERTY. FINAL v �
r
.SIGNATURE JACK R. ALLEN, SUPEPVISIN HANICAL ENG'R.
OF PERMITTEE
PERMIT VALIDATION cK. M.o. CASH
PLAN CHECK VALIDATION CK. M.o. CASH
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