2004, 02-09 Permit App: BLD-04-03516 Plumbing FixturesSQTY4 k OF
.ne
Walley
PLUMBING PERMIT APPLICATION
PROJECT
ADDRESS: ) I.)/ Ni '4 r r
DETAILS
PERMIT
USE:
OWNER:
COST
EQUALS
PHONE (Daytime Contact):
MAILING ADDRESS:
TOILETS
WATER CLOSET, BIDETS
I
(street)
(city/state) (zip)
CONTRACTOR:
D , CoUQ,�A" -N4Q,
0,1:34-1
2
LICENSE #:
d.o LAR c. 13 I kl
MAILING ADDRESS:
1 CT(3t g 6. 51e
u.-
GRp ,C).0 AO'
PHONE #:
sol 9D,4 _E LI gs
ei a _ 990 14
(street)
(city/state) (zip)
PLUMING FIXTURES
BANRCARD NUMBER:
AUTHORIZED SIGNATURE:
DESCRIPTION
DETAILS
# OF UNITS
X
COST
EQUALS
AMOUNT
1
TOILETS
WATER CLOSET, BIDETS
I
X
$6
=
2
URINALS
X
$6
=
3
TUBS
X
$6
=
4
SHOWERS (PER TRAP)
BATH, STALL, ON-SITE BUILT
X
$6
=42
5
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD,
PREP/CULINARY/MEAT
I
j
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
1
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
L�
1
VISA' ,l -
• CASH • CHECK •
..1111211.1 • —._> =
PLUS PROCESSING
FEE
$35.00
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT
OF A MAJOR CREDIT CARD
A TC. ,.,,,,,,,
TOTAL PERMIT FEE
DUE
`. • aTN
BANRCARD NUMBER:
AUTHORIZED SIGNATURE: