2004, 11-22 Permit App: 04009125 Plumbing Reversal dTF of >
(1 44 cil ')-a -
.000 Valley
PLUMBING PERMIT APPLICATION
PROJECTPERMIT
ADDRESS: -73a/ L_ )0I.
USE:
OWNER: PHONE(Daytime Contact):
MAILING ADDRESS:
(street) (city/state) (zip)
CONTRACTOR: LICENSE#: 0
MDCowING ADDRESS �C•\'N•� 0A PONE#R p Q,c_ik 1 d 11�l
SO 7 CI:Jy -E t-1 g
1�8 18' g, `lD' Ua- G- 2 ft FLQ c "tea_ 990 u
(street) (city/state) (zip)
PLUMING'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
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
• 1111•11111111:
VISA l4e.F_
I2 CASH 0 CHECK 0 0 '_1 PLUS PROCESSING
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT $35.00
OF A MAJOR CREDIT CARO FEE
• TOTAL PERMIT FEE
DUE
DATE: EXPIRES: .
BANKCARD NUMBER:
AUTHORIZED SIGNATURE: