Application for PLUMBING PERMIT
Building Services Division
1700 Civic Drive ۰ DuPont, WA 98327
P: (253) 912-5217 ۰ F: (253) 964-1455
www.dupontwa.gov
Permit Number: ______________________________
Application is hereby made for permit to do the following work: □ Commercial □ Residential
□ New Installation □ Addition □ Replacement □ Irrigation/Backflow Device
DESCRIPTION OF WORK______________________________________________________________________________
Project Address: Parcel Number:
Owner of Building: Phone Number: ( )
Mailing Address (if different from Project address):
Applicant: Phone Number: ( )
(contractor, fill out next section)
Address:
Contact Person: Email: Phone Number: ( )
Contractor: Phone Number: ( )
Address:
State Contractor Number: City Business Licence:
Project Contact Person: Phone Number: ( )
SCHEDULE OF FEES
(OFFICE USE ONLY)
Filing fee $ 30.00
Fixture Count
Residential ______@ $10/fixture $_______________
Commercial _____@ $15/fixture $_______________
Subtotal $_______________
Plan Review Fee (75% of Permit Fee) $______________
(Due @ submittal)
Deposit Rec’t#______________ $_______________
TOTAL $_______________________
I certify that I am the: □ Owner □ Contractor □ Agent
I hereby certify that I have read and examined this application and state
that the above information is correct. I agree to comply with all City
Ordinances and State Laws, whether specified herein or not.
***By leaving the contractor information section blank, I hereby certify
further that contractors (General or Subcontractors) will not be hired to
perform any work in association with this permit.
Applicant / Authorized Agent Signature Date
Printed Name
click to sign
signature
click to edit
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