2003, 05-07 Permit: BD03-394 Piping aTy o° r
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PLUMBING PERMIT APPLICATION
PROJECT PERMIT
ADDRESS: i/C Li e ) 1 b� /qv USE:
OWNER: Cc i le t YI T V'L 6 tYL e S C IJ PHONE(Daytime Contact): f L/
MAILING ADDRESS:
-CA/ii.�-
(street) (city/state) (zip)
CONTRACTOR: LICENSE#: H 5 co Alf 162 3
MAILING ADDRESS: PHONE#:
qq .,)J L
(street) (city/state) (zip)
• PLUMBING FIXTURES
DESCRIPTION DETAILS #OF UNITS X COS. EQUALS AMOUNT
1 TOILETS WATER CLOSET,BIDETS X $6 I.
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 6 C C
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
❑ CASH p CHECK d 0 _-1: ''.. PLUS PROCESSING
FAXED PERMITS WILL ONLY BE ACCEPTED WITH PAYMENT $35.00
OFA MAJOR CREDIT CARD FEE
• TOTAL PERMIT FEE //
• DUE 0 e(
DATE: • EXPIRES:
•
BANKCARD NUMBER: '
AUTHORIZED SIGNATURE:
r27,71/ •6-7:-/3 - 3
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