DATE :
PLUMBING PERMIT APPLICATION
5043 CHESTER LANE, RACINE WI 53402
262-835-6435
PERMIT NO:
RECEIPT #:
OWNERS NAME:
PHONE NUMBER:
TOTAL ESTIMATE OF PLUMBING WORK: $
JOB SITE ADDRESS:
FIXTURES & CONNECTIONS
(NUMBER OF ITEMS THAT APPLY)
Water Closets
Bath Tubs
Hot Water Heaters
Dishwasher
Garbage Disposal
Catch Basin
Sinks Urinals Bar Connection
Laundry Trays
Floor Drains
Showers
Storm Sump
Water Softener
Other
Wash Basin
Wash Machine Box
Sanitary Sump
Grease Trap
Sill Cocks
R P Valve
Automatic Air Admittance Valve
# of fixtures @ $14.00 per fixture
Connection to main sewer, holding tank/mound $75 plus $.55 per ft. for each ft over 100 ft
Water service connection @ $75 plus $.55 per ft. for each ft over 100 ft
Storm sewer installation $75 plus $.55 per ft. for each ft over 100 ft
Building sewer abandonment @ $57.00
Septic Tank abandonment @ $57.00
Well abandonment or registration @ $57.00
Sanitary building drain @ $57 plus $.55 for each ft over 100 ft
Storm building drain @ $57 plus $.55 for each ft over 100 ft
MINIMUM FEE: $57.00 With exception for water heater replacement which shall be @25.00
REINSPECTIOIN FEE: $125.00
ALL FEES
EFFECTIVE JANUARY
1,
2006
*******************************************************************************************
It is hereby agreed between the undersigned (as owner or agent) and the Village of Caledonia, that for and in consideration of the premises and of the permit
for the execution of plumbing installation for pipes, drain, fixtures, etc. as above described, to be issued and granted by the inspector of buildings, that the work
will be done in accordance with the descriptions set forth in this statement, and it is further agreed to alter or install same in strict compliance with the
Ordinances of the Village of Caledonia, with Wisconsin Statues and Administrative Code, and to obey any and all lawful orders of the Plumbi
ng Inspector of
the Village of Caledonia.
PLUMBERS
NAME:
PHONE:
STATE
OF
WISCONSIN
LICENSE#:
CONTRACTOR
LICENSE#:
BUSINESS
ADDRESS:
CITY:
STATE:
ZIP:
APPLICANTS
SIGNATURE:
APPROVED
BY:
DATE:
PLUMBING INSPECTOR P:\ENGINEER\FORMS\Bldg\Plumbingpermitapp.doc
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signature
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