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2004, 01-27 Permit App: BLD-04-03468 Plumbing ReversalVW Tey PLUMBING PERMIT APPLICATION PROJECT( ADDRESS: 11 l -3 %A�0 , �ot A(.(E7 PERMIT USE: OWNER: m?..,t1,210oniS l� PHONE(Daytirne Contact): '93-(r RS1 MAILING ADDRESS:„ 1. (street) (city/state),SA n t.i2, (Zip) CONTRACTOR:LI ,�`_ ENSE#: MAILING ADDRESS: 19-81.8" 6 sprojut_ GE -OP N�F.Pc PHONE #: sn 9a9_E L{SS Via_ 49016 (street) (city/state) (zip) PLUMBING FIXTURES BANKCARD NUMBER: AUTHORIZED SIGNATURE: DESCRIPTION DETAILS # or um=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 56 = ' 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 t 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 56 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 11115,"• CASH • CHECK 1:1.r���•- ■ -- - I PLUS PROCESSING FEE $35.00 FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT OF A MAJORCtZDIT CARD TOTAL PERMIT FEE DUE BANKCARD NUMBER: AUTHORIZED SIGNATURE: