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I L N "I Block I Ward I "Addition or Replat
Date at o. -
OUTSIDE WORK
NIIW SEW" WATER STORMS FEES FEES RELAY S. SEWER WATER STORMS FEES
From MaID to Curb Seplic Tanks From Main 10 Curb
J'1oom Curb to BuUdlng Electric Pumps From Curb to Building
Repair
INSIDE WORK
NO. NEW REP. USED FlES NO. NEW REP. USED FEES NO. NEW REP. USED FEES
/' -~ ~ -
/ Bath Tub ¡r-- Garbage Dilpooa¡. Catch Bulns
"'). Wash BulD ./ :;-/ f Dilhwuhera ,./ /'--- Conductors
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?-- Water Cloeet ,,/ 2/ I Laundramm /..---- Greue Catch Bulns
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I SbsII: ,/ /' Water Softeners / Sump Pump 81: Ejecto.. .-/' /
( Wúor Heate.. / 1/ Sanitary Bubhlers Bar and Soda Wules
I Shower BatU ,/ 1/ Urinals
I Floor DralD8 ¡/ 1/ Denial Cuspidors
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Leundry Tuba ServIce SlDka
11UIped101U1 Valuation of the Work HerelD Described Fee Verified. Receipled and Recorded Received Permil and Inspection Fe..
.._--""""----"""- - ""- -- --. - -"""-" Oul8ide ~ao~---"""---"-""-","-- "-----------Sewer Fees
___mm,',- - - - - -, -,- -"----- - - - - - - "",-","Inside _mjc2._4':i!'-PIhg. Fees
$" - - -,- --- _____,m ,------- --- ",--- - ---.. ~~;!~h/
-- _"m,--- -- ,-- - ----, - ---- -- - ___om, -- "-" ----------ÒiY-,;;;;,;;ë;-"'-"---""'"---'-
-,----"--"----------FlDaI OK $ - _'m- -,---- -- ---"" - - -,," "--. ---_"_----m----"-
In the performance of this work the undersigned owner (or hi. euthorized agent~~~e. and hi. authorized Plumberui~ebY ar/ree to be bounden by and
submit to all statute., city ordinances, and rules and regulations prescribed by the Boar Public orks for the government of Plu bers.
It Is futher agreed by th~}dersigned that no other use. will be made of the abov ' connections fxcfpt a. herejJtl fter Ii.t~. / /
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