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I Lo.I 11'0. I Block I Ward I Addition or Replat
OUTSIDE WORK
Date
NEW SIWEI WAT" STOIMS filS FilS .I'AY S. SEWER WATE. STOIMS FIlS
From MaiD to CW'b Septic Tanks From Main to Curb
F>om CW'b to BuDding Eleclric Pumps From Curb 10 Building
Rapair
INSIDE WORK
NO.
NEW
"P.
USID
NO.
NEW
.IP. 1 USED
FEES
NO.
NIW
.EP.
FEIS
USED
FlES
Bath Tub
Gubaga Diapooa1a
Ca1ch Bu1ns
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Wuh BasiD
Dishwashers
Conduclors
Water Cl_t
Laundramats
Greue Catch BasÙ1l
I--
BIDk
Water Softene..
Sump Pump Be Ejeclo..
Wator Heaters
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Saniluy Bubble..
Bu and Soda Wastes
I I,m
Shower Baths
Urinals
1-
Floor Dr8laa
Laundry TubI
Dental Cuspidors
Serrice SiDb
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Valuation of the Work HereiD Described
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$.
.
Fee Verified. Receipted and Recorded
Received Permit and Inspaction Fees
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City Tree",er
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In th" perl~rmlnce of this work the undersigned owner (or his luthorbed agent) of said premises Ind his authorired Plumber hereby agree to be bounden by and
submit to III statutes. city ordinlnces. and rules and reguillions prescribed by the Board of Public Works for the government of Plumbers.
" ),derslgned thlt no olher uses will be mede of thl ebove connlctions exclpt as herlinlftlr listed.
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