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76A667A ICE 817B) - 11/76
APPLICATION FOR P[ I
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN (PRINT
OR TYPE I
BUILDING
ADDRESS 21467 Cold Springs Lane
NUMBER
FIXTURE OR ITEM
®
FEE
LOCALITY Diamond Bar California
WATER CLOSET
BATHTUB
NEAREST
CROSSST. Diamond Bar Blvd
SHOWER
OWNER Diamond Ridge AJT Venture
LAVATORY
MAIL
ADDRESS
SINK
CITY TEL. NO.j 4
DISHWASHER
CONTRACTOR Industrial Turf-,( 714
CLOTHES WASHER
ADDRESS P.O. BOX 2247
SWIMMING POOL RECEPTOR
3
00
CITY Laguna Hills Ca:EL NO 837-123
LAWN SPRINKLER SYSTEM
STATE LIC
LICENSE NO. 204588 CLASS C-2 7 A
mm
DISTRICT NO. .l GROUP ZONE (PROCESSEDD BY
WATER HEATER
GAS SYSTEM OUTLETS
OUTLETS OVER
S PER SYSTEM
INDUSTRIAL
WASTE APPROVAL
T
INSPECTION RECORD
Plan check fee
PLUMBING PERMIT ISSUING FEE $
6
00
TOTAL FEE
9,00
Plan check applicant
Name
APPROVALS DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
Address
ROUGH PLUMBING
City Tel, No.
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
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 CALIFO71A OR THAT I AM THE
LEGAL OWNER OF, AND INTEND T R IDE IN T E ABOVECRIBED RESIDENTIAL
PROPERTY. /
SIGNATURE qq %
OF PERM ITTEE + ��v� /
PLAN CHECK VALIDATION CK. M.O. CASH
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
UTILITY CO. NOTIFIED
FINAL
PERMIT VALIDATION
CK.
M.O. CASH