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APPLICATION FOR PLUMBING PERMIT
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN (PRINT OR TY PEI ABUILDING
DDRESS
NUMBER FIXTURE OR ITEM raa FEE n
WATER CLOSET NEARESLOCALIT
/� e )j-71 .�C
CROSS ST. �G. � ! !►- )
BATH TUB `
/ SHOWER OWNER A' �� I 1�NlA-1`Y
LAVATORY MAIL 0 �/
ADDRESS
SINK CITY � 4�� TEL. NO.lfa—&67
DISHWASHER CONTRACTOR
CLOTHES WASHER --
SWIMMING POOL RECEPTOR ADDRESS o
CITY UV NO.
LAWN SPRINKLER SYSTEM
STATE LIC
WATER HEATER LICENSE NO. CLASS
CD
DISTRICT NO. GROUP ZONE OC ED BY v
GAS SYSTEM OUTLETS Q �l C
OUTLETS OVER 8 F-
5PER SYSTEM INDUSTRIAL
WASTE APPROVAL
H
INSPECTION RECORD Z
Plan check fee
PLUMBING PERMIT ISSUING FEE $ —�
TOTAL FEE f
Plan check applicant
Name APPROVALS .DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
Address ROUGH PLUMBING /
City Tel. NO. GAS PIPING l
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 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT i AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATU RE U /�
OF PERMITTEE102:�� FINAL D--.77-77-11
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PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION cK. M.O. CASH
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