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CE817i(REV.11/78) ` �!
. YAPPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY F
FOR APPLICANT TO FILL IN(PRINT OR TYPE! BUILDING �M�, '
ADDRESS V " n
NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
WATER CLOSET Q
NEAREST L'J
BATH TUB CROSS ST. (J
SHOWER OWNER
LAVATORY AA MAIL
V ADDRESS
SINK CITY A TEL.NO. Aq
DISHWASHER CONTRACTOR AA
CLOTHES WASHER ADDRESS -r d1) p
SWIMMING POOL RECEPTOR
CITY ' & r TEL.NO.
LAWN SPRINKLER SYSTEM ATE LIC.
WATER HEATER LICENSE NO.? ,S f CLASS `
GAS SYSTEM OUTLETS APPROVALS RATE
INS ECTOR'S SIGNATURE
OUTLETS OVER UNDER SLAB WORK ���_••�
5 PER SYSTEM ROUGH.PLUMBING 44 iy�
GAS PIPING °
GAS VENT v
@S
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST ,� ` 96
Plan check fee UTILITY CO.NOTIFIED i g
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Plan check applicant (( PLAN CHECK VALIDATION
Name '
Address vs 0
City Tel.No. �, n
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE Z20
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION o ° O o c 5
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS
REQUIRED BY LOS ANDEINT COUNTYTO R ANDES NATE OF CALIFORNIA OR EDHAT I ENTIAL - 1 9, 0
LEGAL OWNER OF. THE ABOVE DES
PROPERTY. `
SIGNATURE n a G 1 —8 C ,
OF PERMITTEE l: J
DISTRICT NO. P CESSED BY
INDUSTRIAL
WASTE APPROVAL