CITY OF TOMAH PERMIT



CITY OF TOMAH PERMIT #___________

APPLICATION FOR PLUMBING PERMIT

819 SUPERIOR AVE, WISCONSIN, 54660

|JOB LOCATION |MASTER PLUMBER |

| | |

|CONTRACTORS NAME |STATE LICENSE NUMBER (MP #) |

| | |

|COMPANY NAME |PHONE NO. |

| | |

|COMPANY ADDRESS CITY |

|ZIP |

| |

Description of Work: _______________________________________________________________________________

_________________________________________________________________________________________________

|SEWER & WATER TO BE USED FOR THE FOLLOWING: ( NEW ( EXISTING |

|BUILDING USE: |

|WATER SERVICE: (INCHES) MATERIAL FROM TO |

|SANITARY SEWER (INCHES) MATERIAL FROM TO |

FIXTURES CONSISTING OF:

|KITCHEN SINK | |MOP SINK | |

|BAR & SODA- EACH TRAP | |BAR SINK | |

|BATH TUB | |SEWERAGE EJECTOR | |

|BRADLEY | |STACK CONNECTIONS | |

|DISHWASHER | |SHOWER STALLS | |

|DRINKING FOUNTAIN | |SUMP PUMP | |

|FLOOR DRAIN | |URINAL | |

|GARBAGE DISPOSAL | |WATER COOLER | |

|HOSE BIBS | |WATER CLOSET | |

|WATER HTR- GAS OR ELECTRIC | |WATER SOFTENER | |

|LAUNDRY TRAY | |WASH BASINS | |

|WASH FOUNTAIN | |AUTOMATIC WASHER | |

|SPRINKLER SYSTEMS | |MOBILE HOME HOOK-UP |$15.00 |

ESTIMATED COST _______________

FEE SCHEDULE

COST FEE

Up to $1,000.00 $25.00

$1001.00 to $2500.00 $40.00

$2501.00 to $4000.00 $45.00

$4001.00 to $6000.00 $50.00

$6001.00 to $8000.00 $55.00

$8001.00 to $10,000.00 $60.00

Over $10,000.00 $60.00 plus $2.50 per thousand

In excess of $10,000.00

TOTAL FEE :______________

-FAILURE TO OBTAIN PERMIT PRIOR TO WORK, EXCEPT EMERGENCY CASES: -FIRST OFFENSE, DOUBLE FEES

*****master plumber shall call for all inspections

CALL 374-7429 FOR INSPECTIONS- 24 HOUR NOTICE REQUIRED

CALL 374-7430 FOR INSPECTION OF SEWER TAPS

________________________________________ _________________________________________

MASTER PLUMBERS SIGNATURE DATE

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