2004, 04-26 Permit App: BLD-04-04197 Plumbing ReversalQTY OF ;
011e
ley
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS: 1 \
'..-\�1
s\(\.
# OF UNITS
PERMIT
USE:
OWNER:
EQUALS
1
PHONE (Daytime Contact):
MAILING ADDRESS:
c 1 e
CA 0,\UINI�
$6
=
(street)
(city/state) (zip)
CONTRACTOR:
D , CovAC.
2-\ -N,Z._r.
X
LICENSE #:
d -0. 4I. Q.0 * j g i R,`Z
=
MAILING ADDRESS:
19-(3t8' E.
3
G-Ktoe ,.
PHONE #:
507 iciaH -ELI SS
It -es ta_ 990 u
$6
=
(street)
{city/state) (zip)
PLUMBING FIXTURES
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
DESCRIPTION
DETAILS
# OF UNITS
X
COST
EQUALS
AMOUNT
1
TOILETS
WATER CLOSET, BIDETS
X
$6
=
2
URINALS
X
$6
=
3
TUBS
X
$6
=
4
SHOWERS (PER TRAP)
BATH, STALL, ON-SITE BUILT
X
$6
=
5
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD,
PREP/CULINARY/MEAT
X
$6
6
DISHWASHER
X
$6
=
7
CLOTHES WASHER
X
$6
=
8
GARBAGE DISPOSAL
X
$6
=
9
WATER SOFTENER
X
$6
=
10
ELEC HOT WATER TANK
NOTE: IF GAS SEE MECHANICAL
X
$6
=
11
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
X
$6
=
12
FOUNTAINS, DRINKING
X
$6
=
13
WATER PIPING/DRAIN-IN
WASTE, VENT,
PLUMBING REVERSAL
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
X
$6
=
14
SEWAGE EJECTOR
GRINDER, SUMP PUMP
X
$6
=
15
WATER USING DEVICE
ICE AND/OR COFFEE MAKER,
HOSE BIB, STEAMER, PROOFER,
CARBONATOR, SWAMP COOLER
X
$6
16
CROSS CONNECTION
DEVICE
VACUUM BREAKER, CHECK
VALVE, AND R.P.B.P.D. FOR:
VATS, SUMPS, TANKS, BOILERS
X
$6
=
17
SPRINKLER SYSTEM
X
$25
18
INTERCEPTORS
GREASE TRAP, SAND TRAP,
CHEMICAL HOLDING TANK
X
$6
=
19
MEDICAL GAS per outlet
NITROUS, OXYGEN
X
$6
=
20
MISC PLUMBING FIXTURE
X
$6
=
SUBTOTAL
i4
• CASH • CHECK • . ■—_.-_':
PLUS PROCESSING
FEE
$35.00
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT
OFA MAJOR CREDIT CARD
TOTAL PERMIT FEE
DUE
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: