2004, 05-13 Permit App: BLD-04-04343 Plumbing ReversalS1olcLanems"``
,.001 Valley
PLUMBING PERMIT APPLICATION
PROJECT _
ADDRESS: 1 I. b I 1 E, tin ex
,\ I
DETAILS
# OF UNITS
PERMIT
USE:
OWNER:
EQUALS
AMOUNT
1
PHONE (Daytime Contact):
MAILING ADDRESS:
X
$6
=
(street)
2
(city/state)SpO Lia, (Zip)
CONTRACTOR:
aD. Col,Q 2.\ {Ne_
X
$6
LIq ENSE #:
Co4(.C.0 18l P.,l
fort
3
MAILING ADDRESS:
19-S1g6„Sp2
iea_
GAs;,aec
X
PHONE q#: p' (� L �/ (
L5-07{�l`tet -ig�7
LSa 49016
(street)
SHOWERS (PER TRAP)
(city/state) (zip)
PLUMBING FIXTURES
BANKCARD NUMBER:
AUTHORIZED SIGNATURE:
DESCRIPTION
DETAILS
# OF UNITS
X
Curr
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
I.=
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
1 }
■ CASH • CHECK ■
NM= ■ .L1'''_i
PLUS PROCESSING
FEE
CNT $35.00
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYME
OF A MAJOR CREDIT' CARD
TOTAL PERMIT FEE
DUE
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: