Property Address:
(if different from applicant's name)
Applicant's Information:
Date:
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
Permit Information:
This application is for:
New Plumbing
Yes
Relocated Plumbing
Type of structure to be served:
Single Family Dwelling
Modular or Mobile Home
Multiple Family Dwelling
Other (specify below):
Plumbing to be installed by:
Master Plumbing
Oil Burnerman
MFG'd. Housing Dealer/Mechanic
Public Utility Employee
Property Owner
License Number:
Column 1:
Hosebib / Sillcock
Flood Drain
Urinal
Drinking Fountain
Indirect Waste
Water Treatment Softener, Filter, Etc.
Grease / Oil Separator
Roof Drain
Bidet
Other:
Fixture (subtotal) Column 1
Column 2:
Bathtub (and Shower)
Shower (separate)
Sink
Wash Basin
Water Closet (Toilet)
Clothes Washer
Dish Washer
Garbage Disposal
Laundry Tub
Water heater
Fixture (subtotal) Column 2
Hook-Up & Piping Relocation
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)
SEE PERMIT FEE SCHEDULE FOR CALCULATING FEE
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Totals
Fixture Fee
Transfer Fee
Hook-Up & Relocation Fee
