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I Lot No. I Block I Ward I Addiiion or Replat
OUTSIDE WORK
Date
NIW SEW" WATER STORMS ,'EES FEES .EtAY S. SEWER WAUl STORMS FEES
From MelD to Curb -<Jif JlL 4 ~-a Septic Tanks From Main to Curb
From c...b to Building Electric Pumps From Curb to Building
Repair
INSIDE WORK
NO. NIW u,. USED "'S NO. NEW ..,. USED FEES NO. NEW 'E,. USED FEES
-
Bath Tub Garbage Disposals Ca!ch Bulm
-
Wub Bubs Dishwaahen Conductors
- - - - -
Wille CI_t LaundrlUll&ls Graue Catch Basbss
Sink Water Softeners Sump Pump 81: Ejectors
Water Heaters Sanitary Bubblers Bar and Sod.. Wastes
Shower Baths Urinals
FIOOI" Drabss Dental Cuspidors
Laundry Tubs Service Sinks
Inspections Valualion of the Work Herein Described Fee Verified, Receipted and Recorded Rec~ed ]',:vmli and Inspeclion Fees
-- -.--..-.-.-----. -..--... Outside $---- -------- _,3.2-.G2_:=__--------..------ --_3._---_--_---Sewer Fees
-----.----------------Inside V¡;L ":"=--....PIhg. Fees
------77/fZ2--~-- $-----------..------------------------------- -----¥---_.--.--Toial
----- Zt--FInaI OK $---------- --------- ---------- -- ------------- ------ --- ---- ----- ----CliY-Ÿ;;;.üró;- ---------------- Date q --- /Ia - 7:;;-
In the performance of this work the undersigned own.r (or his authorized age"t) of said premises and his authorized Plumber hereby agree to be bounden by lUtd
submit to ail stalules, city ordinances, and rules and regulations prescribed by Ihe Bo~f Public Works for Ih. government of Plumbers.
I! Is fulher agreed by Ihe undersigned Ihal no olher uses will be made of the above eonnedi."s ex<epl as herelnalier ilsled.
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----------- -.- Pin. Ino""" 1<'-_7
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