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' APPLICATION FOR PLUMBI G PERMI
COUNTY OF LOS ANGELES 3
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGIN R ADDRESS
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY ,
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FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE ry OWNER
WATER CLOSET $1.25 f-� MAIL
BATH TUB 1.25 ADDRESS
SHOWER 1.25 CITY TEL. NO.
LAVATORY 1,25 ' CONTRACTOR
SIN% 1.25 ? ADDRESS,&,
DISHWASHER 1.25 CITY TEL.
LAUNDRY TUB 1.25 CONTRACTOR'S / STATE [I
REGISTRATION NO. �lL� COUNTY ❑
CLOTHES WASHER 1.25 _` DISTRICTNO GR P P OtES 4 B
WATER HEATER 1.50 S Lzcam,
GAS SYSTEM OUTLETS 1.50 INDUSTRIAL p�
WASTE APPROVAL 0
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD U
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3- 30-4's !NCE4-- Nasi' 'ioo UJI
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A OVA S DATE PIfCTOR'S SIGNATURE
PERMIT $ 2 00 UNDER a41" 'bRK (Xi",
/ ROUGH PLUMBING '3�'��-
TOTAL FEE .-, GAS PIPING S-1 0 p ,
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER S
PLUMBING. -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED CAT
PLUMBING FIXTURES Z/
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST '�
CALIFORNIA OR THAT I AM THE fj
LEGAL OWNER OF,AND INTEND TO 5'a
RESIDE IN,THE ABOVE DESCRIBED RES] ENTIAL PROPERTY. UTILITY CO. NOTIFIED I ILL.. L-
SIGNATURE
OF PERMIT
T .x"
FINAL �+ .,) P..�, ;:-' , ,' _•�..�/"''.
VALIDATION ROBERT A. `WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENG'R
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