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CITY OF OSHKOSH 101757 No OSHKOSHPLUMBING PERMIT - APPLICATION AND RECORD ON THE WATER Job Address55 JACOB AVEOwnerPATRIARCHS SUBDIVISION LLCCreate Date05/27/2003 ContractorFOX VALLEY EXCAVATINGCategoryPlan 430 - Industrial-Exterior (laterals) Bathtub0Shower0Ejector/Grind0Dip Well0F Prep Sink0Gar Drain0 Whirlpool0Floor Drain0Water Softner0Drink Ftn0Serv Sink00 Soda Disp Lavatory00Local Waste0Wait. St.0Shamp Sink00 Lndry TrayCoffee Maker Toilet00Clothes Wshr0Ice Chest0Flr/Wst Sink0 0 Lndry Stndp Int Grease Trap Res. Sink00Bidet0Exam Sink0Catch Basin0 Disposal0 Ext Grease Trap Bar Sink000Wash Ftn0 Beer Tap0Sculry Sink Dishwasher Water Heater000Urinal0 Sump PumpDent. Oper.0Hand Sink Site Drain000Standp Rec0 Classrm SinkLab Sink0Plaster Sink Roof Drain000Ice Maker0 Breakrm SinkSterilizer0Surgeons Sink Use/Nature NSFR of Work SizeMaterialType#Conn. Type Sanitary Sewer4"PlasticLateral1New 0 0 0 0 Storm Sewer4"PlasticLateral1New 0 0 0 0 Water Service1"CopperLateral1New 0 0 0 0 $0.00 Valuation$750.00Plan ApprovalPermit Fees$75.00 Issued ByDate05/27/2003 Permit Voided In the performance of this work, I agree to perform all work pursuant to rules governing the described construction. Date Signature Agent/Owner Address1719 PARKWOOD DROSHKOSHWI54904-0000Telephone Number414-426-0256, 235-4751