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2004, 04-12 Permit App: BLD-04-04057 Plumbing ReversalCITE OF pole PLUMBING PERMIT APPLICATION PROJECTPERMIT ADDRESS: io 1 g L v. 7->,„ ( 1 S DESCRIPTION DETAILS USE: OWNER: COST EQUALS AMOUNT PHONE (Daytime Contact): MAILING ADDRESS: CN/ -`C2_._ X $6 (street) (city/state)] (zip) CONTRACTOR:‘ LICENSE #: `- = MAILING ADDRESS: 1 ctS t8" C, ,5p - x).0 e.R-es PHONE #: 5O Ci Calf- E L{ g t3 a_ 99016 $6 (street) {city/state) (zip) PLUMBINGFIXTURES BANKCARD NUMBER: AUTHORIZED SIGNATURE: DESCRIPTION DETAILS # OF UNITS X COST EQUALS AMOUNT 1 TOILETS WATER CLOSET, BIDETS X $6 = 2 URINALSX $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 i ( X $6 _- 14 SEWAGE EJECTOR GRINDER, SUMP PUMP X $6 = 15 WATER USING DEVICE ICE AND/OR COFFEE MAKER, -•X HOSE BIB, STEAMER, PROOFER, CARBONATOR, SWAMP COOLER $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 111111111.111 .Ala-, ■ CASH ■ CHECK II.I�os • .__.- _='' PLUS PROCESSING FEE $35.00 FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT OFA MAJOR CREDIT CARD T ATR'_ ......... TOTAL PERMIT FEE DUE BANKCARD NUMBER: AUTHORIZED SIGNATURE: