(if different from applicant's name)

I certify that the information submitted is corrected to the best of my knowledge and understand that any falsification is reason for the Local Plumbing Inspector(s) to deny a permit

New Plumbing Yes
Relocated Plumbing Yes

Single Family Dwelling Yes
Modular or Mobile Home Yes
Multiple Family Dwelling Yes
Other (specify below): Yes

Master Plumbing Yes
Oil Burnerman Yes
MFG'd. Housing Dealer/Mechanic Yes
Public Utility Employee Yes
Property Owner Yes

Type of Fixture
Hosebib / Sillcock
Flood Drain
Drinking Fountain
Indirect Waste
Water Treatment Softener, Filter, Etc.
Grease / Oil Separator
Roof Drain
Fixture (subtotal) Column 1

Type of Fixture
Bathtub (and Shower)
Shower (separate)
Wash Basin
Water Closet (Toilet)
Clothes Washer
Dish Washer
Garbage Disposal
Laundry Tub
Water heater
Fixture (subtotal) Column 2

Maximum of 1 Hook-Up

Hook-Up: to public sewer by those cases where the connection is not regulated and inspected by the local sanitary district.
Hook-Up: to an existing subsurface wastewater disposal system.
Piping Relocation: of sanitary lines, drains, and piping without new fixtures.

Transfer Fee ($10.00)


Fixture (subtotal) Column 1
Fixture (subtotal) Column 2
Total Fixtures
Fixture Fee
Transfer Fee
Hook-Up & Relocation Fee
Permit Fee (total)