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APPLICATION OR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ]�77
MAKE CHECKS PAYABLE TO ADDRESS �O a3 V(E 'C HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY N& C' 7-Y
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST / EH DA/
CROSSST LNUMBER FIXTURE OR ITEM 0 FEE
WATER CLOSET 2 00 D OWNERS NLEXj MAIL1BATH TUB 200 ADDRESS � V4Y 7, PLE CTSHOWER 200 d CITY 'r k C rY TEL NO
LAVATORY 200 CONTRACTOR E L
SINK' 200 v ADDRESS
DISHWASHER 200 CITY I TEL NO
CLOTHES WASHER 200 STATE LIC
SWIMMING POOL RECEPTOR 200
LICENSE NO CLASS
DISTRICT NO GROUP ZONE PRO SS BV
LAWN SPRINKLER SYSTEM 2 00 U5`7 pG pL T' - -2—
WATER
WATER HEATEfl 200 IN STE A�APGfiGOVALI
GAS SYSTEM OUTLETS 200 INSPECTION RECORD
OUTLETS OVER
5 PER SYSTEM 30 L V
fl&
0
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d
H
Plan check lee Se. R.ve,..
PLUMBING PERMIT ISSUING FEE B
TOTAL FEE I A ROVALS DATE INSPECTOR S SIGNATURE
Plan check applicant c UNDER eb*"ORK ✓f
Name L l ROUGH PLUMBING _
Address (- V �- LE i.01D GAS PIPING
city SEH ple C r Tel No V y�7 1 GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND
STATE TXAT THE ABOVE IS CORRECT AND AGRC! TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING GAS TEST
19ER[BY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR, UTILITY CO NOTIFIED
LIC6MSEO AS REOUIRED BY LOS ANGELES COUM TY AND STATE OF
CAL(IO RMIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ANDY DEECR 1990 RESIDENTIAL PROPERTY FINAL
SIGNATURE
OF PERMIYTCE
PERMIT VALIDAT N cK M 0 CASH -
PLAN CHECK VALIDATION CK M o caaM
9 a a� I�w 2)0 5 0 1 3.5 0 •�
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