2004, 01-20 Permit App: BLD-04-03418 Plumbing Reversal CITY Orrtar .
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• PLUMBING PERMIT APPLICATION
PROJECT PERMIT
ADDRESS: i5 C 6 E i t S USE:
OWNER: PHONE(Daytime Contact):
MAILING ADDRESS:
(street) (city/state) (zip)
Cha COO"RN.�� \iN� &1 LICENSE#:
MAILING ADDRESS: PHONE#:
5O Ci `4D.,4 -E L( gs
(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 I =
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*MSC
MISC PLUMBING FIXTURE X $6 = -
. _ -
-- I" SUBTOTAL
,GCS:
.
❑ CASH 0 CHECK 0 0 _.�=': PLUS PROCESSING
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT $35.00
OFA MAJOR CREDIT CARD FEE
TOTAL PERMIT FEE
• DUE
DATE: EXPIRES:
BANRCARD NUMBER: -
AUTHORIZED SIGNATURE: