2003, 07-17 Permit App: BLD-03-02054 Plumbing Fixtures aTt rltirr�
I po e
,Walley
• PLUMBING PERMIT APPLICATION
PROJECT / ( PERMIT
ADDRESS: /5 1 g t USE:
OWNER: PHONE(Daytime Contact):
MAILING ADDRESS:
(street) (city/state) (zip)
CONTRACTOR:tW �LI:J\Z.�{NQ 0i ,i DENSE# :
MAILING ADDRESS: PHONE#:
507 9cy-E L( Ss
19-(318" E. ,5p ua �IN �}e,11-e_s Via- 49014
(street) (city/state) (zip)
PLUMBING FIXTURES
DESCRIPTION DETAILS #OF wars 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 LAVS/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 -
4:,
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
❑ CASH 0 CHECK ❑ . 0 '-I PLUS PROCESSING Q
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT $35.00
OF A MAJOR CREDIT CARD FEE
TOTAL PERMIT FEE
• DUE
DATE: EXPIRES: .
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: