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CE 817 (REV. 6/7811
(e)s
APPLICATION FOR PLUMBING PERMIT
FOR APPLICANT TO FILL IN (PRINT OR TYPE)
NUMBER
FIXTURE OR ITEM
@
WATER CLOSET
BATH TUB
SHOWER
LAVATORY
SINK
DISHWASHER
CLOTHES WASHER
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM
WATER HEATER
BUILDING AND SAFETY
BUILDING
ADDRESS
FEE
61
IF
ILOCALITY
NEAREST
CROSS ST._
OWNER
MAIL
ADDRESS
CITY
CONTRACTOI(,
ADDRESS
CITY
STATE
LICENSE NO. Cj
APPROVALS DATE
GAS SYSTEM OUTLETS
OUTLETS OVER
PER SYSTEM
F-5
I
PI,, check
ck fee
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
TEEMf.
TEL. NO.
LIC
CLASS
INSPECTOR'S SIGNATURE
UNDER SLAB WORK
ROUGH PLUMBING
GAS PIPING
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES R
GAS TEST
J
UTILITY CO. NOTIFIED
FINAL
PLAN Kf CHECK k/ A I In A ri
rion check applicant
Name
Address
City Tel. No.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THAT THE ABOVE ISCORRECT AND AGREE TOCOMPLY 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 CALIFORNIA OR THAT I AM THE
LEGAL OWNER,, ND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
PROPERTY.
SIGNATURE �,--
OF PERMITTE
NO. PROCESSED BY
INDUSTRIAL
WASTE APPI
PERMIT VALIDATION
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