Date:
Permit Number:
Plan Check #:
Project Address: Zone:
Name:
Address:
City/State/Zip:
Phone:
Fax:
E-Mail Address:
Project Contact:
Address:
City/State/Zip:
License Number:
Company Name:
Address:
City/State/Zip:
Proposed Use of Building:
License Number:
Name:
Company:
Address:
City/State/Zip:
Phone:
Fax:
E-Mail Address:
Phone:
Fax:
E-Mail Address:
License Type:
Phone:
Fax:
E-Mail Address:
Current Use of Building:
The City of Galva may require written approval from the owner
City of Galva
311 N. W. 4th Avenue
Galva, IL 61434
Phone: (309) 932-2555
Fax: (309) 932-3306
www.galvail.gov
Plumbing Permit
Application
Property Owner
Single - Family Multi - Family Commercial
Tenant Architect Designer Engineer
Purpose of Application
Page 1 of 2
Cost of Improvement (labor + materials + overhead + profit) Rounded to Nearest Dollar:
Is this permit in conjunction with a building permit?
Yes No
Contractor/Plumber
Description of
Proposed Work
(example: install
new shower and
basin in
basement)
Insurance Coverage
Requires Wastewater Review and Approval
I hereby certify that the proposed work is authorized by the owner of record and that I have been
authorized by the owner to make this application as his/her authorized agent and I/we agree to conform
to all applicable laws of this jurisdiction and those of the State of Illinois and the Federal Government.
Page 2 of 2
Signature of Applicant:
Calculated Permit Fee:
Date:
Date:
Approved by:
Approved by:
Specify: Expires:
No permit for the performance of plumbing work may issue unless the licensee provides proof of liability insurance including
"completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has
exhibited proof of same to the permit issuing office.
Check One:
Insurance Bond Other
Indicate Number of Fixtures/Equipment to be Installed
Bath Tub / Whirlpool
Beverage Dispenser
Coffee Maker
Backflow Preventor
Dishwasher
Disposal
Bidet
Case / Trench Drain
Condensate Drain
Dental Chair
Downspouts
Drinking Fountain
Fire Sprinkler
Floor Drains (Sanitary Only)
Floor Sink/Funnel Drain /On-Site Drain
Gas Boiler
Gas Dryer
Gas Fireplace (Direct or Un-Vented)
Gas Fryer
Gas Furnace
Gas Grill
Gas Log
Gas Log Lighter
Gas Oven / Broiler
Gas Meter - Relocate
Gas Pool / Hot Tub Heater
Gas Piping Only
Gas Range / Stove / Wok
Gas Roof Top Unit
Gas Regulator
Gas Space Heater
Gas Space / Unit Heater (not Portable)
Gas Water Heater
Grease Trap / Oil Seperator
Hose Bibb / Outside Faucet
Humidifier
Ice Maker
Laundry Tray / Sink
Lawn Irrigation System
Medical Gas
Plumbing Piping Only
Pressure Reducing Valve
Roof Drain
Service / Mop Sink
Shampoo Sink
Shower
Sink - Kitchen / Bar
Sink - Lavatory / Bath / Hand
Slab Openings
Steam Table
Storm Drains
Sump Pump
Trailer Sewer Connect
Trailer Water Connect
Urinal
Vacuum System - Medical
Washing Machine
Water Booster Pump
Water Closet (Toilet)
Water Heater
Water Treatment Equipment
Wet Stack
Yard Hydrant
Gas Other
Plumping Other
Sanitary Sewer Cap Off
Sanitary Sewer Tap
On-Site Sanitary Sewer
Inside Sewer Ejector Pump
Outside Ejector Pump
Sanitary Sewer Connect
Sanitary Sewer Lateral Only
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