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CE 817 (REV. 6/78)
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS
NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
NEAREST
BATH TUB CROSS T.4����
OWNER
SHOWER
MAIL
LAVATORY ADDRESS Yli
SINK
CITY TEL. NO. J—/
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DISHWASHER
CONTRACTOR
Z4 - Nm'j, I
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL. NO.C,:�,,,,
LAWN SPRINKLER SYSTEM
STATE LIC.
LICENSE NO. CLASS
WATER HEATER
APPROVALS DATE INSPECTOR'S SIGNATURE
GAS SYSTEM OUTLETS
UNDER SLAB WORK
OUTLETS OVER
5 PER SYSTEM
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
Plan check fee
UTILITY CO. NOTIFIED
PLUMBING PERMIT ISSUING FEE $
FINAL
TOTAL FEE
PLAN CHECK VALIDATION
Plan check applicant
Nome
Address
City Tel, No.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THATTHE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
PERMIT VALIDATION
AND STATE LAWS REGULATING PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
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.
SIGNATURE
OF PERM ITT
DISTRICT NO. CESSED BY
INDUSTRIAL
WASTE APPROVAL