Dental Office or Clinic Permit Application

NOTE: PLEASE REFER TO THE PDF VERSION OF THE PERMIT APPLICATION
Dental Permit Application Form

*Required

Section 1. FILING STATUS (Check One)

* Filling Status

New or Proposed Point of Discharge to Sewer

Existing, but Un-permitted Point of Discharge to Sewer

New Ownership

Section 2. COMPANY INFORMATION

A. City of Los Angeles Business Tax Registration Certificate (BTRC) – Account No.

*B. Legal Business Name

Ownership Type

* Ownership Type

Sole Proprietor

Partnership

Corporation

Limited Liability Corporation

*C. Company Doing Business As (dba)

D. Business Officers Names and Titles (Proprietors/Partners/Corporate Officers)

1st Business Officer:

*First Name

*Last Name

*Title

2nd Business Officer:

First Name

Last Name

Title

3rd Business Officer:

First Name

Last Name

Title

E. Facility Location

*Street #

Fraction

Direction

*Street Name

Street Type

Direction

Unit Type

Unit #

*City

*State

*ZIP

*Contact Person First Name

*Contact Person Last Name

Area Code + Telephone # (Numbers Only)

Ext

Title

Email

F. Billing Address

check here if same as 3 E. above

First Name

Last Name

*Street #

Fraction

Direction

*Street Name

Street Type

Direction

Unit Type

Unit #

*City

*State

*ZIP

Attention First Name

Attention Last Name

Area Code + Telephone # (Numbers Only)

Ext.

G. Mailing Address

check here if same as 3 E. above

check here if same as 3 F. above

First Name

Last Name

*Street #

Fraction

Direction

*Street Name

Street Type

Direction

Unit Type

Unit #

*City

*State

*ZIP

Attention First Name

Attention Last Name

Area Code + Telephone # (Numbers Only)

Ext.

H. Property Owner/Management Company

check here if same as 3 E. above

check here if same as 3 F. above

check here if same as 3 G. above

First Name

Last Name

Street #

Fraction

Direction

Street Name

Street Type

Direction

Unit Type

Unit #

City

State

ZIP

Attention First Name

Attention Last Name

Area Code + Telephone # (Numbers Only)

Ext.