2003, 11-17 Permit App: BLD-03-03087 Plumbing Reveresal CITti OE
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• PLUMBING PERMIT APPLICATION
PROJECT PERMIT
ADDRESS: —t - I 6, USE:
OWNER: `k�i_ ,Q,, PHONE(Daytime Contact):
MAILING ADDRESS: F, S' ___
(street) (city/state) (zip)
CONTRACTOR: LICENSE#:
MAILING ADDRESS: PHONE#:
1 1 S t 8' g. `fie - �`R.e s 3 e,e-ea_ 990 16
(street) (city/state) (zip)
PLUMBING FIXTURES
•
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 LAYS/BASINS,BAR,FLOOR, X $6
KITCHEN,LAUNDRY,UTILITY,
JANITOR,PHOTO,X-RAY,FOOD,
PREP/CULINARY/MEAT
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, $6
CONDENSATE X
12 FOUNTAINS,DRINKING X $6 =
13 WATER PIPING/DRAIN-IN INSTALLATION,ALTERATION, X $6
WASTE,VENT, REPAIR,REVERSALS `
PLUMBING REVERSAL 1 =
14 SEWAGE EJECTOR GRINDER,SUMP PUMP X $6 =
15 WATER USING DEVICE ICE AND/OR COFFEE MAKER, X $6
HOSE BIB,STEAMER,PROOFER,
CARBONATOR,SWAMP COOLER •
16 CROSS CONNECTION VACUUM BREAKER,CHECK X $6
DEVICE VALVE,AND R.P.B.P.D.FOR:
VATS,SUMPS,TANKS,BOILERS =
17 SPRINKLER SYSTEM X $25
18 INTERCEPTORS GREASE TRAP,SAND TRAP, $6
CHEMICAL HOLDING TANK X =
19 MEDICAL GAS per outlet NITROUS,OXYGEN X $6 =
20 MISC PLUMBING FIXTURE X $6 =
- SUBTOTAL
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❑ CASH 0 CHECK 0 . 0 _____2f1.1 PLUS PROCESSING
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT $35.00
OFA MAJOR CREDIT CARD FEE
TOTAL PERMIT FEE
DUE
DATE: EXPIRES: .
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: