Fillable PLUMBING APPLICATION OWNER/APPLICANT STATEMENT PROPERTY OWNER INFORMATION OWNER/APPLICANT (Town of Winslow)

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PLUMBING APPLICATION OWNER/APPLICANT STATEMENT PROPERTY OWNER INFORMATION OWNER/APPLICANT (Town of Winslow)

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U.S.A. forms for Town of Winslow

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PLUMBING APPLICATION
Maine DHHS/CDC – Division of Environmental & Community Health
PROPERTY ADDRESS ISSUING MUNICIPAL OFFICE
City, Town, or Plantation Town/City
Street/Subdivision Lot # Permit # Total Fee $
PROPERTY OWNER INFORMATION
Date Issued Double Fee
Name (Last, First)
Applicant Name (Last, First)
Local Plumbing Inspector Signature
License #
OWNER/APPLICANT MAILING ADDRESS
FEES
State
$ Local $
Street
LOCATION
Map #
Lot #
City
Internal plumbing fixtures and piping may not be installed until a permit is
issued by the Local Plumbing Inspector. The permit authorizes the owner
or installer to install the plumbing system in accordance with this
application and the Maine Subsurface Wastewater Disposal Rules.
State Zip Code
OWNER/APPLICANT STATEMENT
I certify that the information submitted is correct to the best of my knowledge
and understand that any falsification is reason for the Local Plumbing
Inspector(s) to deny a permit.
CAUTION: INSPECTION REQUIRED
I have inspected the installation authorized above and found it to be in
compliance with the Maine Plumbing Rules Application.
Signature of Owner/Applicant
Date
LPI Signature
Date (Rough-In)
Copy:
Property Owner
Town State
Date (Final)
PERMIT INFORMATION
This application is for: Type of structure to be served: Plumbing to be installed by:
New Plumbing
Single Family Residence
M
aster Plumber
License #
Relocated Plumbing Modular or Mobile Home Oil Burner Installer License #
Multiple Family Dwelling
Mfd. Housing Rep. License #
Other (specify below) Public Utility Rep. License #
Property Owner
Column 1 – Hook-Up & Relocation Column 2 – Fixtures Column 3 – Fixtures
State of Maine
Department of Health and
Human Services/
Center for Disease Control
and Prevention
Environmental &
Community Health –
Subsurface Wastewater
286 Water Street
State House Station 11
Augusta, ME 04333
207-287-2070
HHE-211
R
evised 7/24/2018
Maximum 1 Hook-Up Type of Fixture Qty Type of Fixture Qty
Hook-Up (a) Hosebib/Sillcock Bathtub (and Shower)
Hook-up to public sewer in those cases
where the connection is not regulated
and inspected by the local sanitary
district.
Floor Drain
Shower (Separate)
Urinal Sink
Drinking Fountain Wash Basin
Hook-Up (b) Indirect Waste Water Closet (Toilet)
Hook-up to an existing subsurface
wastewater disposal system.
Treatment Softener, Filter, etc.
Clothes Washer
Grease/Oil Separator Dishwasher
Piping Relocation Roof Drain Garbage Disposal
Relocation of sanitary lines, drains,
and piping without new fixtures.
Bidet
Laundry Tub
Other: Water Heater
Total Column 1
+
Total Column 2
+
Total Column 3
=
Enter Total Fixtures
/
H
ook-Ups Below
PERMIT TRANSFER ONLY $10.00
Total Fixtures / Hook-Ups
Per-Fixture Fee
TOTAL PERMIT FEE
$
$
WINSLOW
0
0
0
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PLUMBING APPLICATION OWNERAPPLICANT STATEMENT PROPERTY OWNER INFORMATION OWNERAPPLICANT (Town of Winslow)

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Completed 17 July 2020

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