1993, 05-18 Permit App: 93003671 Plumbing Fixtures a
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PLUMBING PERMIT APPLICATION FORM Df) I
InformatlWorksheet
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JOB STREET ADDRESS: l,- -/, -,5 f
CTY/ AT : rc,, /T PARCEL NUMBER: gsD1 4 6 l
GOWNER: (miT Je C /. PHONE NUMBER: ?y - 4 O l
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MAILING ADDRESS: (Zip)
f (Street) (City/State) J
CONTRACTOR: ��A.:5 6 U JIt d� r,� LICENSE NUMBER:3 Li l o 7O
/ PHONE NUMBER: l{ < 2/die"-{
MAILING ADDRESS: 2/3 A(' iviof,TPS1 I's OrqC))`4 S u. 7 (O 7
(Street) (City/State) (Zip)
PLUMBING WORKSHEET/FEE SCHEDULE
NUMBER X EACH
DESCRIPTION OF UNITS UNIT =AMOUNT
x6.00 =
TOILETS =
s _3 ; , x 6.00
SHOWERS <:; ' : •... x 6.00 =
�.}}}:til<,•:;+}. x 6.00 -
KITCHEN SINKS x 6.00
fMjF.�4•µh. l�g� . .,�.y �K3, Ln•q:i•Y'a >�'Y}C•`S h1`:`` �.G q;: ... ..
• i Q,. it, 'I S,in'<.'.S7. �..'a,v? f , %Fii11.
v , ���� ��� � :
GARBAGE DISPOSAL x 6.00 =x 6.00 =
t 3 'O
�Vf:��' ..�'KM '�nY{v� yM1 ... ..
�. X6.00
UTILITY SINKS , I x 6.00 =
;;� k t ,. � �"�� .�••.: :,... x 6.00 = •
FLOOR DRAINS x 6.00
M$ •a+. ti.<:---.,;7:',:-.
.Yr .i: hSy, ) :�;2 ,tY'+
'•.�c:'s.,':`':�e:frx.','`:.
BAR SINKS
x 6.00
xva D:a '3'• f .4:��dA :i 'IY`"� ''',` ‘'',i, ',`% }R ,,:,u' :': x 6.00
=
..
LAWN SPRINKLER—FOR EACH BACKFLOW DEVICE x 6.00 =
<: ix 6.00 =
3rr.Ga;d.'+i. .,......n.__:,... ,a, s,-',:*;-'' x 6.00
WATER SOFTENER «� x 6.00 =
��Y� .
DRINKING FOUNTAIN X 6.00 =
SUBTOTAL $
PLUS: PROCESSING FEE +$ 25.00
NOTE: MINIMUM PERMIT FEE IS$35.00 EQUALS:TOTAL PERMIT
FEE DUE _$
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SIGNATURE � -t/!��- ,�
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