2004, 08-05 Permit App: BLD-04-07260 Plumbing Reversallame
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,,Valley
PLUMBING PERMIT APPLICATION
PROJECT /
ADDRESS: 7a0/ C V'
DESCRIPTION
PERMIT
USE:
OWNER: 7-c M Hn d/
X
PHONE (Daytime Conta(5):
MAILING ADDRESS: 9 A-Vhx—
-AMOUNT
(street)
(city/state) (zip)
CONTRACTOR:
D, CoL 3-a1c�2 On n23-1--.
LICENSE #:
e_e> up,Q,c_r, 181 F.,`(
MAILING ADDRESS:
1`C(311 6. RipPAgucr_
GRP 2nPc.P2c
PHONE#: '
soCt 9 a _5 4 gg
t.3a_ 9901/
(street)
(city/state) (zip)
PLUMBING' FIXTURES
BANKCARD NUMBER
AUTEIORIZED SIGNATURE:
DESCRIPTION
DETAILS
A' of cows
X
COST
EQUALS
-AMOUNT
1
TOILETS •
WATER CLOSET, BIDETS
X
$6
2
URINALS
X
'$6
=
3
TUBS
X
56
=
4
SHOWERS (PER TRAP)
BATH, STALL, ON-S(TE BUILT
X
56
5
SINKS
LAVS/BASINS, BAR, FLOOR,
KITCHEN, LAUNDRY, UTILITY,
JANITOR, PHOTO, X-RAY, FOOD,
PREP/CULINARY/MEAT
X
56
6
DISHWASHER
X
- $6
.
7
CLOTHES WASHER
X
$6
=
8
GARBAGE DISPOSAL
X
$6
.
9
WATER SOFTENER
X
56
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
$6
13
WATER PIPING/DRAIN-IN
WASTE, VENT,
PLUMBING REVERSAL
INSTALLATION, ALTERATION,
REPAIR, REVERSALS
/
l
X
56
=
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
.
18
MEDICAL GAS per outlet
NITROUS, OXYGEN
X
$e
.
20
MISO PLUMBING FIXTURE
X
56
.
-
❑ CASH 0 CHECK
FAXED PEBBIIIST WILL ONLY BEACCEPTED
OP A MAJOR CREDITuw
neTS. "w"^r^
SUBTOTAL
PLUS PROCESSING
FEE
$35. 00
WITH PAttAEM
TOTAL PERMIT FEE
DUE
BANKCARD NUMBER
AUTEIORIZED SIGNATURE: