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APPLICATION, FOR PI..,UMBIN ERMI`i'. �
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANDAFETY IVISION BUILDING
JOHN A. LAMBI . COUNTY NGINEER ADDRESS IQ(/j/f a
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY Gl
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET MAIL
BATH TUB ADDRESS
SHOWER CITY TEL. NO.
LAVATORY CONTRACTOR (tel .
SINK ADDRESS ` Al, G-
DISHWASHER CITY,ya! TEL NO.CONd�
CTOR'S 'TE
LAUNDRY TUB REGISTRATION EAT ON NO. 79 5 COUNTY ❑ x
CLOTHES WASHER DISTRICT NO. GROUP ZONE - ESSED BY
WATER HEATER ,S '
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
P.
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OH FIXTURE $'I 70
APPR VALS DATE, INSP TOR'S SIGNATURE
PERMIT $ 2 00 UNDER ORK
TOTALFEE ROUGH PLUMBING a Z3
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH B ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OPS GAS TEST G
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTEE t 7L.L�I/� Al
FINAL C J� �
®P /VALIDATION ROBERT A. WOOD.
H.0. CASH SUPERVISING MECHANICAL ENG'R
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