HomeMy WebLinkAbout1531 BASSWOOD AVE; ; SE679889; Permit4 L
FOR APPLICANT TO FILL IN
a7 LEGAL DESCRIPTION LOT NO.
LICENSE NO. LICENSE NO.
L NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
OVERFLOW SEEPAOE PIT. DRAINFIELD EXTN.. cerrsppot., DRYWBLL, MANHOLE 0 $5.00
HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $1.50
CONNECT ADDITIONAL BLDG. OR
ALTER REPAIR OR ABANDON HOUSE
SEPTIC TANK, SEEPAGE PIT OR PITS
WORK TO HOUSE SEWER
0 ./3.00 F
0 $1.50
SEWER OR DISPOSAL SYSTEM 8 $2.00
@S
1 PUBLIC SEWER
OWNER'S
AUTHORIZATION 1- TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN CONTRACTOR TO CONNECT THE ABOVE DESCRIBED BUILD. ING TO THE PUBLIC SEWER.
SIONED THIS DAY 6F OWNER OR OWNER'S AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE R~D THIS
ERTY. SIGNATURE
BU lLDl NO ADDRESS
NEAREST CROSS ST. 4-
OWNER
MAIL ADDRESS
CITY TEL. NO.
CONNECTION DATA Lateral Charge Computation
30' H., 10 V. @ 4" = __ 6" = -
Add. Horiz. @ 4" = ___ 6" = -
Add. Vert. @ 4" = __ 6" = -
Total Construction Cost
10% Service Charge
Total Lateral Charge
Let. No.: Logged in Plat:
LINE COST DATA
A. D. & Assmt. No.
LINE COST:
C. C. @- / dwelling
P. S. @- / dwelling
OTHER
TOTAL
Grand Total, Lateral, etc.
FOR SEWER LOCATION
i v)
st. NORTH
ENGINEERING SEWER DEPT. I Signed
/
Filled Out, Signed and Validated
PERMIT VALIDATION
~ . .. .~ . , .. ..
APPROVALS DATE
. . - .
INSPECTOR*S SIGNATURE
BUILDING DEPARTMENT
ADDRESS BUILDING /y>! &d &.
NEAREST CROSS ST.
I
GROUP I ZONE
InsDection Record
-SI GRADING PLAN NOn TOTALFEE YES
I ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS REGULATI NG PLUMB I NG.
1 CERTIFY THAT I AM PROPERLY REGISTERED AND LI-
I AM THE LEGAL OWNER
SIGNATURE
VALIDATION This is a Plumbing Permit When Properly Filled Out, Signed and Validated. hrmit wid if work is not commenced within 60 days of date of issuance.
UNDER FLOOR WORK
ROUGH PLUMBING
GAS PIPING
GAS VENTS
PLUMBING FIXTURES
MISC.
I
GAS TEST
UTILITY CO. NOTIFIED
FINAL
I_-