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I Lo.I No. I Block </ / I Ward I Addition or Replst
OUTSIDE WORK
Date
NOW SEW" WATER STORMS FEES FEES RELAY S. SEWER WATER STORMS FEES
From MaiD to Curb Saptic Tanks From Main to Curb
!\rom Curb to BuDding Electric Pumps From Curb to Building
Repair
INSIDE WORK
NO. NEW RIP. USED liES NO. NEW REP. USED FEES "0. NEW REP. USED FEES
,/ :/ - - - - - -
J Batb Tub 1/vt> / Garbage Diapol8!s I/.cro Catcb Basins
./ -
r Wash Basin b,ov Dishwashers 1- Conductors
- - - -
'7 Water CI_t ./ !;2.ûV I LaundrlLD18oU ./ , tJz" Grease Catch Bas1ne
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I SbIk / ,()V Water Softenars / Sump Pump Be Ejectors -- ~oV
I Water Heaters / II.m2 sanUary Bubblers Bar and Soda Wastes
I Urinals
Shower Baths
J "oar DraIDs ,/ ¡, cP..J Dental Cuspidors - -- -
Laundry Tube Serrice Sinks
Inapecllons ;~;~:r.:..::~::.:::=.=: Fee Verified, Receipted and Recorded Received Permit and Inspection Feeo
-7Tlr""ïTIG7lr'r-.........0u~ide .......",.."""..........Sewer F...
...",..............",..._....",.................-.",Ins.de ..../.¿..~....PIbg. Fees
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In the performance of this work tho undersigned owner (or his authorized agent) of said premises and his authorized PIUmb;(!,J:~~rea tt ba A.ounden by and
submit to all statutes, city ordinanc.., and rules and regulations prescribed by the Boord of Public Works for the government of u er
It Is futher agreed bJ1Ke undersigned thot no other uses will be mede of the above connections except 85 hereinalt."... ¡step( /77' \// /"
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