February 8, 2018
PLUMBING PERMIT APPLICATION
OWNER:
NAME PHONE #
JOB ADDRESS:
FUEL GAS SUPPLIER:
CONTRACTOR / PERMIT APPLICANT INFORMATION:
NAME: PHONE #
ADDRESS: CITY: STATE: ZIP CODE:
PLUMBING CONTRACTOR LICENSE #
MASTER LICENSE HOLDER MASTER LICENSE #
CSST CERTIFIED HOLDER CSST CERTIFIED #
NON-LICENSED INSTALLER *SEE CLAUSE BELOW
PHONE # EMAIL
USE OF BUILDING: Residential Commercial Industrial Agricultural
CLASS OF WORK: New Remodel Addition Manufactured/Mobile Home
PERMIT INFORMATION:
Total Fee $ Payment Method: Cash Check # Credit Card
Permit #
*HOMEOWNER CLAUSE: The Colorado Revised Statutes provide a homeowner the opportunity to perform the
plumbing installation provided the following conditions are true:
You are the property owner and this property is not for sale, resale, or is not rental property.
You reside or intend to reside at this property as your sole place of residence.
You are doing the permitted work yourself and have a reasonable enough knowledge of plumbing codes for a
proper installation.
Signature: Date:
Master / Homeowner / *Non-Licensed Contractor
NOTICE: This permit expires one year from the date of issuance. If a final inspection has not been requested and
approved within this year, a new permit or extension will be required.
This application is not valid without the proper signoff below.
Approved: Chaffee County Building Department Date
CHAFFEE COUNTY
DEVELOPMENT SERVICES DEPARTMENT
104 Crestone Ave., Room 125 Master Permit # for Inspection
P.O. Box 699
Salida, Colorado 81201 _____________________________
(719) 539-2124 FAX: (719) 530-9208
bdepartment@chaffeecounty.org
