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APPLICATION FOR PLUMBING PERMIT
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING /' i J�
NUMBER FIXTURE OR ITEM @ FEE ADDRESS —T [�, I�t^, �Jc1A A
WATER CLOSET LOCALITY T=M,PLE Cory
BATH TUB NEAREST o_4 A_24
CROSS ST
SHOWER OWNER #AMAIL
LAVATORY ADDRESS-44:c
SINK CITY 1 L`lfl�, C(1 TEL NO
DISHWASHER CONTRACTOR
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CLOTHES WASHER
ADDRESSq
SWIMMING POOL RECEPTOR /
V ��
LAWN SPRINKLER SYSTEM CITY O TEL NO
STATE ^7 C LIC J� >-
WATER HEATER LICENSE NO G L CLASS CL.
O
U
GAS SYSTEM OUTLETS ✓ �� DISTRICT NO GROUP Z�NE RID SSED BY �
OUTLETS OVER f V lll'y� z� '� F-
5 PER SYSTEM F-
INDUSTRIAL w
WASTE APPROVAL N
INSPECTION RECORD Z
Plan check fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
Plan check applicant
Name APPROVALS DATE INSPECTOR S 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 L05 S COUNTY ND STATE OF GAS TEST "2
CALIFORNIA OR THAT I AM THE LEGAL 0 E O A INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESI DENTI L ROPER Y UTILITY CO NOTIFIED
SIGNATU RE
I
OF PERMITTEE FINAL
PLAN CHECK VALIDATION M o CASH PERMIT
cK VALIDATIO cK o cases
9 2 59'.nPR zb 5 ® 1 3.5=0 ago