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°'APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANO SAFETY DIVISION
I FOR APPLICANTTO FILL IN(PRINT OR TYPE, ABUILDI
DDRESS AJ G L �U '�i �� / ✓L'
NUMBER _FIXTUREORITEM ® FEE _
WATER CLOSET LOCALITY
BATHTUB NEAREST
CROSS ST.
SHOWER OWNER '�.I'.J) '!J'. -.T) ./'•J�.-7 v'l..
LAVATORY. MAIL ADDRESS J���"�11 ,J r _
SINKCITY I- J a �,i•.t_ �.TEL.NO.: i
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR 11
CITY jr
rte- TEL.NO.
LAWN SPRINKLER SYSTEM _
STATE I %( /(� L tic. -`L _
i' WATER HEATER LICENSE NO. •] CLASS
GAS SYSTEM OUTLETS DISTRICT NO. r.GROUPt ZONE PROCESSED BY
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OUTLETS OVER - IS
�.; 5PER SYSTEM INDUSTRIAL O
WASTE APPROVAL V
INSPECTION RECORD W
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Plan check fee IL
$
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PLUMBING PERMIT ISSUING FEE$
TOTALFEE
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�F Name APPROVALS DATE INSPECTOR'S SIGNATURE
I. UNDER SLAB WORK
I:
Address - ROUGH PLUMBING
f' City 1 Tel.No. GAS PIPING
�. I YEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT
'{ THAT THE ABOVEIS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
E AND STATE LAWS REGULATING PLUMBING. HOT WATER HEATER
I I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FI%TURES
I REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST
I LEGAL OWNER OF.AND INTEND TO BESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
PBOPEBTY.. }�i , UTILITY CO.NOTIFIED
SIGNATURE `J
I OF PERMITTEE FINAL
I
PLAN CHECK VALIDATION CN. M.D. cnsH PERMIT VALIDATION CN. N.C. CASH
y..
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