Application for PLUMBING PERMIT
Building Services Division
1700 Civic Drive ۰ DuPont, WA 98327
P: (253) 912-5216 ۰ F: (253) 964-1455
www.dupontwa.gov
Permit Number: ______________________________
Application is hereby made for permit to do the following work: Commercial Residential
New Installation Addition Replacement Irrigation/Backflow Device
DESCRIPTION OF WORK______________________________________________________________________________
Quantity
Quantity
Quantity
Backflow Device
Hose Bibbs
Sink/Drain
Bath Tubs
Laundry Drain
Urinal
Dishwasher
Lavatory
Water Closet
Drinking Fountain
Roof Drain
Water Heater
Floor Drain
Shower
Other ___________
Project Address: Parcel Number:
Owner of Building: Phone Number: ( )
Mailing Address (if different from Project address):
Applicant: Phone Number: ( )
(contractor, fill out next section)
Address:
Contact Person: Email: Phone Number: ( )
Contractor: Phone Number: ( )
Address:
State Contractor Number: City Business Licence:
Project Contact Person: Phone Number: ( )
I certify that I am the: Owner Contractor Agent
I hereby certify that I have read and examined this application and state
that the above information is correct. I agree to comply with all City
Ordinances and State Laws, whether specified herein or not.
***By leaving the contractor information section blank, I hereby certify
further that contractors (General or Subcontractors) will not be hired to
perform any work in association with this permit.
Applicant / Authorized Agent Signature Date
Printed Name