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APPLICATION FOR PLUMBING PERMIT
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I COUNTY OF LOS ANGELES , /BUILDING AN SAF�3(�
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iFOR APPLICANT TO FILL IN IPRINT OR TVPEi qDDRE55�v OV - �
NUM6ER FI%TURE OR REM � FEE
e � WATERCLOSET � OqRE51
li BATHTUB � CROSSST
SHOWER � OWNER
�LAVATORY ,(� M1AIL
v U ADDRE55 � /
SINK QU CITV TE,N�����Z�
I DISNWASHER CONTRACTOR
� CLOTMES WASMER � ADDRES$ �J3�
� SWIMMINGPOOLRECEPTOR
� CITY TELNO. �j,_� �
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i STATE �J �/ IIC. �
WATERHEATER � LICENS%NO. / b CLA
GASSYSiEM �OUTlETS �J APPROVALS ' ATE 5 CTOP' NATUR
OUTLETS OVER UN�ER SLAB WORK
5 PER SYSiEM ROLIGH PLUMBING L
il; GAS PiPING � V
f GAS VENT � pp
HOiWATERHEATER i O�-.
PLU�NBING FI%TURES yuj
GAS TEST yj
Plan check fee uriutrco.NonFieo �
PLUMBING PERMIT ISSUING FEE S
� TOTALfEE � � � FINAI
Plon chetk oppl�conr PLAN CHKK VALIOA I N ,
Name
Address
Cay Tel.No. � :� !1' ���,
�I I NEREBY ACKNOWLEDGE THAT 1 HAYE PEAO TNIS AVVLIC�T�ON�NO ST�TE � �;�.� � � (,.� � ��
THAT THE ABOVE IS CORRELT ANO AGPEE TO COMPLY W ITH AlL[OUNTY OROINANCES �
qND STATE 1�W5 REGULATIYG PLUMBiNG. � PERMIT VALIOATION � '�, n C, r
� I XENEBY CEFTIFY THAT I AM PPOVERLY PEGiSTERED�HO/OF LICENSEO AS ' (l�`
i FEOVIRED BV LOS ANGElES COUNTY AAD STATE Of C�LIFOPNIA OR THAT I 11N TNE , � -
LEWI OWNER OF,hND INTEN�TO PESIpE IN TNE ABOVE DESCRIBED PESI�EITIAL � �
PPOPEflTY.
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ISIGNATURE � � '
OFPERMITTEE � - �
DISTRICE NO. ,PROCESSED BY ' '
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"� INOUSTRIAL . '
'I N'ASTEAPPROVAL ' � � �
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