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- APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO: ADDRESS 4110
HARVEY T. BRANDT, COUNTY ENGINEER
LOCALITY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
NUMBER FIXTURE OR ITEM @ FEE CROSS ST.
WATER CLOSET 1.75 OWNER
MAIL
BATH TUB1.75 ADDRESS
SHOWER 1,75 CITY TEL. NO. .j
LAVATORY 1,75 CONTRACTO
SINK �` 1.75 B. ADDRESS
DISHWASHER 1.75 CITYTEL. NO.
Aof
CLOTHES WASHER 1.75 STATE LIC
SWIMMING POOL RECEPTOR 1.75 LICENSE NO. s CLASS .13��
DISTRICT NO. GAUP ZONE ' PROCESSED BY
LAWN SPRINKLER SYSTEM 1.75
O8 I 71nl
WATER HEATER 1.75 INDUSTRIAL
WASTE APPROVAL pr_,
GAS SYSTEM OUTLETS 1.75 INSPECTION RECORD
OUTLETS OVER
5 PER SYSTEM 90
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Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEES
TOTAL FEE (J
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel. No. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. GAS TEST '
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND, UTILITY CO. NOTIFIED
LICENSEDAS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. FINAL
SI GNATU RE
OF PERMITTEE
M—i PERMIT VALIDATIONCK. M.O. CASH
PLAN CHECK VALIDATION CK. 4'.0 2�tsMG.j25
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