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07/22/2004 13:59 6125291064 BARNES PLBG PAGE 02
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<br /> Detailed description of work: V 3; _..k' ; T91� ... ',f r t
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<br /> Fixtures: (Indicate total number of e:.to11)
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<br /> Bathtub 4P-: Lavatory(R.I) —Swim Pool
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<br /> 'Clothes Washer • Lavatory __Tub Shower(R.I)
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<br /> �' Urinal
<br /> w RPZ Valve _U
<br /> �Dishwasher
<br /> Drinking Fountain .,,–Roof Drains —Vac Breaker '
<br /> Floor Drain Sewage p
<br /> C wa Pula Water Closet
<br /> _Flammable Waste Taub 1_Slop Sink
<br /> ' _Water Closet(R.!) .�
<br /> Grease Trap .!Shower i,•,Water Heater
<br /> .. 1 Kitchen Sink/Disposal —Staixtlpipe/Washbox . —Water Meter !
<br /> Laundry Tray —Sump Pump _Water Softener.••
<br /> —Other(dosc"ibn) .
<br /> g gas i .Y3. n
<br /> If gas water heater,indicate who will be doing as piping. 3#. ,
<br /> Ad are tzr3.Q..,'{ • ) j /"^. 4J J1(a/. , Phone# f,.• -.g,"".�GIw ..'f.,'•!;tr,•
<br /> State Mechanical Bond* (--)P.....!..H.rn ❑ Please check if on file
<br /> • All Fees are based on valuation, including cost of labor and materials.
<br /> The minimum fee is $45.00+state surcharge. I
<br /> TOTAL JOB VALUATION: $ ' 0 C i
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<br /> PERMIT FEE ' $ a'-.5–. c°'.C> (1 Ye%of Total Valuation–ailninium of 545.00)
<br /> . SURCHARGE $ 7 S 0_ (.0005 x Total Job Valuation–t4'nimum.$r50)
<br /> . TOTAL DUE $?:>?, . S E5 (make checks payable to: City of Elk,River)
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<br /> ITIIIEC IS AN APPUCA.TION FOR A PERMIT-IT IS NOT VALID UNTIL PROCESSED'
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<br /> NAME OF APPLICANT °) . , • a. ':';.: 'L. ;y'�/J,,,7'-_ . ,..\-
<br /> Please type a_r\r ppriat !■
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<br /> • fi,Ti�NATURE OF APPLICANT . �
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