2003, 10-13 Permit App: BLD-03-02758 Plumbing Reversaliikane
Valley
PLUMBING PERMIT APPLICATION
PROJECT \_
ADDRESS: B aL N,_ tJ,JIDQ(IR�Sc
DESCRIPTION
PERMIT
USE:
OWNER:
X
PHONE (Daytime Contact):
`
MAILING ADDRESS: gay N. _ (P3 6c
v vl
C �,� {S0D • (��
(street)
(city/stat) (zip)
CONTRACTOR:
LICENSE #:
Co LA te.._ t g ► RI
D . COLJA ha: tNQ-- On ft,..1
MAILING ADDRESS:
rt ' E. sere GFtP2nhe.aMc
PHONE #:
sog 92y -Sti gs
tit 49016
(street) (city/state) (zip)
PLUMBING' FIXTURES
BANRCARD NUMBER
AUTHORIZED SIGNATURE:
DESCRIPTION
DETAILS
# OF UNITS
X
GGA
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
IAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD,
PREP/CULINARY/MEAT
X
56
=
6
DISHWASHER
X
56
=
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
56
=
11
FLOOR DRAINS
AREA, CASE, COIL, TRENCH,
CONDENSATE
X
56
12
FOUNTAINS, DRINKING
X
56
=
13
WATER PIPING/DRAIN-IN
WASTE, VENT,'
PLUMBING REVERSAL
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
X
56
=
(e•(2
14
SEWAGE EJECTOR
GRINDER, SUMP PUMP
X
56
=
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
=
CASH • CHC ❑
FAXED PERMITS
SUBTOTAL
(0.00
r
MENU . 'N`''
•
PLUS PROCESSING
FEE
$35.00
DATE:
WILL ONLY BE ACCEPTED WITH PAYha;Nr
OF A MAJORCREDIT CARD
EXPIRES:
TOTAL PERMIT FEE
DUE
t4
l °D
BANRCARD NUMBER
AUTHORIZED SIGNATURE: