PLUMBING SUBCODE
TECHNICAL SECTION
B. PLUMBING CHARACTERISTICS
Date Received
Control #
Date Issued
Permit #
A. IDENTIFICATION—APPLICANT: COMPLETE ALL APPLICABLE INFORMATION. WHEN CHANGING
CONTRACTORS, NOTIFY THIS OFFICE. CALL UTILITY DIG NO: 1-800-272-1000.
Block Lot
Qualification Code
Work Site Location
zip codemunicipalitystreet
Address
e-mail
Tel.
Owner in Fee:
Exp. DateContractor License No.
Federal Emp. ID No.
FAX:
Home Improvement Contractor Registration No. or Exemption Reason
Sink
Floor Drain
Shower
Lavatory
Bath Tub
Urinal/Bidet
Water Closet
Backflow Preventer
Interceptor/Separator
Sewer Pump
Washing Machine
Hot Water Boiler
Steam Boiler
Gas Piping
Fuel Oil Piping
Water Heater
Hose Bibb
Drinking Fountain
Dishwasher
LPGas Tank
Greasetrap
U.C.C. F130 (rev. 11/09)
Internet version
Applicant: When submitting this form to your Local Construction Code
Enforcement Office, please provide one original plus three photocopies.
JOB SUMMARY (Office Use Only)
PLAN REVIEW
Joint Plan Review Required:
Approved by:
Date:
CA
[ ]
CO
SUBCODE APPROVAL for CERTIFICATE
[ ] [ ]
CCO
SUBCODE APPROVAL for PERMIT
Date:
Approved by:
[ ] Bldg. [ ] Elec. [ ] Fire. [ ] Elev.
No Plans Required
[ ]
Plumbing Plans Approved[ ]
Partial -Underslab Utilities Approved[ ]
Approved by:
Date:
Approved by:
Date:
Est. Cost of Plumbing Work $
Private Well
Public WaterWater Service Size
Private Septic
Public SewerBuilding Sewer Size
ProposedPresentUse Group
Contractor: Tel.
Address
e-mail
Gas Piping
Gas Equipment
Sewer
Water
Rough
Slab
Type:
Dates (Month/Day)
INSPECTIONS
LPGas Tank
Fixtures
InitialApprovalFailureFailure
TCO
Solar
Fuel Oil Piping
Final
D. TECHNICAL SITE DATA
DESCRIPTION OF WORK
[ ] Licensed Plumbing Contractor [ ] Exempt Applicant
C. CERTIFICATION IN LIEU OF OATH
I hereby certify that I am the (agent of) owner of record and am authorized to make this
application and perform the work listed on this application.
Print name here:
Applicant sign/Contractor
sign and seal here:
Stacks
Sewer Connection
Water Service Connection
Other
TOTAL FEE
State Permit Surcharge Fee
Minimum Fee
Administrative Surcharge
$
$
$
$
$
FIXTURE/EQUIPMENTQTY.
FEE (Office Use Only)
