APPLICATION
FOR
PLUMBING
PERMIT
VIiiage
of
Freeport
Dept.
ol
Bulldlngs
46H,OmnAvo.
Pre
oport,
N.Y.
11520
(518)
377·2242
Date:----------
Permit
No.:--------
I,
____
-:::-::-:---------------..,..,..,------------
Namo
Address
llcenud pl
umbor
for
lht
VIiiage
of
Froeport,
N.Y.,
do
horolly
apply
for
a
permit
from
the
Suporinlondent
ol
Bullclln91
to:
0
ln1t
1tl
new
nxturoa
et:
O
Rep
l
ace
oxlsUng
at:
D
Other:
0
1stFloor
0 2ndfloor 0
Base
ment
lnlhepremlsea
tocatodatNo.
_______________________
_
0
owner
0
Leasee
______
--::-----------------------
Namt
Address
pieml1esoccupledu
_________________________
_
No.
Flxwrn
----To
llett
----
Kltchtn
slnk1
----
Wash
tubs
Bath
tuba
Lavator!ea
Shower
bath
stall
Urinal•
Dlohwnher
Ore110
traps
----
Wuh/Dryormachlnei
Oat
hot
wator
heater
----
Oas
boiler
----
Gae
boiler/hot
water
eombo
unit
Gas
atovt
Reconnect
ofwa\er/seweraervlce
Dlsconnoct
of
water/sewer
service
__
Backnow
Dtvlco
----Other
Yea
__
No
__
Oil
to
Gas
convers
i
on
GAS
TEST
(Pleaao
clrclo
tr
On
T8'\
la
nseded)
Permit
Fees
Art
Non·Refund1bl•
FEES:
IF
THIS
IS
A
RECONNECT
• •
PRIOR
TO
BACK
FILLING
PLEASE
CONTACT
THE
WATER
DEPT
AT
516·377·2379.
EST.
COST
____________
_
AFFIDAVIT
OF
CONTRACTOR
STATE
OF
NEW
YORK
COUNTY
OF
________
}
SS:
---------------being
duly
eworn,
dtpoua
end
eay1
thal
he
11
the
contr1clor
employed
by
the
above
namod
owner,
owners
or
IH1H
uthorlted
\o
perform
the
work
dosctlbodi
that
componcallon
Insurance
has
beon
obtained
and
11
In
lull
force
and
clfocl
In
accordance
wllh
t
ho
provision•
of
tho
Workman'•
Comp•
Law,towl\:
HemeollnauranceCo.
_________________________
_
Po
U
cy
No:
______
______
explroa:
______________
_
App
li
cant'•
Signature:
_________________________
_
Addron:
_________________________
_
Telophont:
_____
____________________
_
Sworn
to
belore
mo
this
___
d•yof
______
20_
Notary
Public
Above
appUcaUon
Is
hereby
approved
to
Install
lho
above
dncrlbed pt
umblng.
· ·
Joseph
M1dlg1n
Superlnlandent
of
Bulldlngc
MUST
CONTACT
INSPECTOR
FOR
ALL
REQUIRED
INSPECTIONS
OR
APPEARANCE
TICKETS
WILL
BE
ISSUED
ln8J)t.ior:
------
Rn.
nnou
..
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