(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)