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Fixture Type: - <br />Qty ? <br />Fixture, Type: :; <br />Qty <br />Fixture Type: <br />; <br />Fixture Type: <br />Bathtub or combination <br />bath/shower <br />Drinking fountai o ate. <br />cooler (per he.. <br />Wash fountain <br />Gas piping outlets <br />Bidet <br />Food -waste ri - . er, <br />commerc• • - <br />Receptor, indirect <br />waste <br />Clothes washer, domestic <br />Floor d : i . <br />Sinks <br />Dental unit, cuspidor <br />Sho r Ingle head trap <br />Urinals <br />Dishwasher, domestic, <br />with independent drain <br />La L <br />!/ <br />Water Closet <br />Building sewer or trailer <br />park sewer <br />, • 'n water system — per <br />` drain (inside building) <br />er heater and/or <br />ven <br />Additional medical gas <br />inlets/outlets — six or more <br />Industrial waste <br />pretreatment interceptor, <br />including its trap and vent, <br />except for kitchen type <br />grease interceptors <br />- <br />Repair or alteration of water <br />piping and/or water treating <br />equipment <br />Repai . r alteration <br />of drain a or vent <br />piping <br />Medical gas piping system <br />serving one to five <br />inlets/outlets for specific gas <br />PLUMBING AND GAS PIPING CONTRACTOR INFORMATION <br />Company Name: <br />Mailing Address: <br />City <br />Contact Person: Day Telephone: <br />E -Mail Address: Fax Number: <br />Contractor Registration Number: Expiration Date: <br />Valuation of Plumbing work (contractor's bid price): $ <br />Valuation of Gas Piping •rk (contractor's bid price): $ <br />Scope of Work (please prov • e detailed information): <br />Building Use (per Intl Building Code). <br />Occupancy (per Int'I Building Code): <br />Utility Purveyor: Water: Sewer: <br />Indicate type of plumbing fixtures and/or gas pipin <br />Q:Uppliationaonns-Applications On LincU -2106 -Permit Application doc <br />Revised: 9-2ro6 <br />bh <br />e eing installed and the quantity below: <br />State <br />Zip <br />Page 5 of 6 <br />