Type of installation
Gas piping
Backflow preventor
Stack repair
Drain tile repair
Main water service line
New ________Repair ______
Sewer repair
Sanitary ______Storm ______
New sewer connection to main
Sanitary ______Storm ______
Other
Application for Plumbing/Sewer Permit
Address of construction ____________________________________________________________________________
Owner’s name ___________________________________________________ Phone ___________________________
Owner’s address __________________________________________________________________________________
Contractor ______________________________________________ Business phone ___________________________
E-mail address ________________________________________________________
Contractor’s address _______________________________________________________________________________
Applicant’s signature Print name Date
Street City State Zip
Section 1 – General Information
PLEASE PRINT OR TYPE
Section 2 – Description of Property and Project
Contractor is required to schedule a rough-in inspection before any concealment.
By signing the application, the applicant certifies that the installation will comply with the regulations of the Newburgh Heights
Building Code and State Codes.
TO THE BUILDING COMMISSIONER: This application is submitted for a permit to erect, add to, alter or repair a structure as described
in this application and any drawings which accompany it. The acceptance of the permit shall be considered an agreement on the part of the
applicant or his agents to comply with the Building and Zoning codes of the City of Newburgh Heights, or other orders, requirements or
specifications slated in the permit.
In signing this application, the contractor or owner’s agent certifies that the work is authorized by the owner or record.
Applicant is Owner Contractor Owner’s agent
Permit No. Date Received
Estimated cost of Project $
Date
Type of Structure
Single family
Two family
Three family
Apartment
Commercial
Other (describe)
Type of Work
New structure
Addition
Alteration
Repair
Demolition
Replacement
Other (describe)
Type of installation
Interior water lines, type
Water closet
Urinal
Bathtub
Shower
Lavatory sink
Kitchen sink
Sink, type
Dishwasher
Disposal
Laundry tray
Type of installation
Stand pipe
Floor drain
Air admittance valve
Water heater
Sump pump
Sewage ejector
Hot tub/spa
Drinking fountain
Interceptor
Grease trap
Catch basin
Root drain
# of units # of units# of units
Village of Newburgh Heights Housing and Building Department
3801 Harvard Ave., Newburgh Heights OH 44105 Phone: 216-641-4654
