2003, 08-04 Permit App: BLD-03-02131 Plumbing Reversal, Fixtures SVOVial .ne
4000 Valley
• PLUMBING PERMIT APPLICATION
PROJECT � 869 6.... ..y/ PERMIT
ADDRESS: 1��- USE:
OWNER: PHONE(Daytime Contact):
MAILING ADDRESS: (J _.
(street) (city/tate) (zip)
CONTRACTOR: LICENSE#:
D, C.Ov.Q,03.\z.\�4z., CSA(‘.< -1-. do.Lik tc_* 18 I k`2
MAILING ADDRESS: PHONE#:
roc/ Ciay_511 Ss
19-(3 11 e 5e U ��e.c‘�el t3 49016
(street) (city/state) (zip)
PLUMSINO FIXTURES
DESCRIPTION DETAILS #OF UNITS X COST EQUALS AMOUNT
1 TOILETS WATER CLOSET,BIDETS I X $6 = •
2 URINALS - X $6 =
3 TUBS r X $6 =
4 SHOWERS(PER TRAP) BATH,STALL,ON-SITE BUILT X $6 = •
5 SINKS LAVSBASINS,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 w
PLUMBING REVERSAL =
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
0 CASH 0 CHECK
°TS BE 11111131111110 0 .-_. WITHPAn M PLUS PROCESSING
FAXED Pr $35.00
OF A MAJOR CREDIT CARD FEE
TOTAL PERMIT FEE
DUE
DATE: EXPIRES: .
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: