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I Lot No. I Block I Ward I Addition or Replal
OUTSIDE WORK
Date
NEW SEWE8 WA'" S'ORMS FIES FEES RELAY S. SEWER WA'ER STORMS FEES
From MaID to Cub Septic Tanks From Main t<> Curb
From C...I> 1\0 BuUdIng Electric Pumps From Cub to Building
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Repair p---
INSIDE WORK
NO. NEW REP. US... FlES NO. NEW R'P. USED I ;EES NO. NEW REP. USED FEES
&th Tub Garbage Dispooak Cetch B..1Ds
Wuh Bum DishwMhen Conductors
- - - - -
Water Cl_t LaUDCÙ- Gre..... Catch BulDs
SbIk Water Softeners Sump Pump BE Ejectors
Wmr Healers sanUary Bubblers Bar and Soda Wutes
8h<.>w",,~ UriDIIls
FlOO1' »raID¡¡ Dental Cuspidors
Laundry Tubs Serrice Sinks
IIIIpeci!o"" Valuation of the Work HereIn Descrîbed Fee Verilîed. ReceIpted and Recorded ReceIved Permlt and ¡""peetlon Fees
------.-----.--.-Outaide $..-..---l.;¿.._'!:_--------------..--.--- -_.._-----/...~--Sewer Fees
-....--------._.._--wide ..-....---...-..--...Plbg. Fee.
-------------- $....-----------..---------..--------------------- _.._-I--!~-__Tofal
-----------Final OK: $..---..------......-........-..--------....-- "--"---"-----------cliiï Tr..¡-ü;ë;--"""-"""---'" Date /02-029- 7~
In the performance of this work the undersigned owner (or his authorired ag""t) of said premis"s and his authorized Plumber h.reby ogre. to b. bounden by and
submit to all statutes, city ordinances. and rules and reguiations prescribed by the Board of Public Works for the govommont of Plumbers.
It Is futher agreed by the undersigned that no other uses will be ",ad. of the above connections except .s hereinalter listed.
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