Plumbing Permit 64 E
BUILDING DIVISION PLUMBING PERMIT 64 E. Walnut St. APPLICATION FORM Westerville, OH 43081-2308 t. (614) 901-6650 f. (614) 901-6666 PERMIT # (Office use only)
DATE PARCEL # BLDG PERMIT # (If applicable) PROJECT PROJECT NAME ADDRESS (Include Suite #)
CITY STATE ZIP
PROPERTY OWNER
NAME CONTACT
ADDRESS
CITY STATE ZIP
PHONE EMAIL
CONTRACTOR
BUSINESS NAME STATE LICENSE # (Required for commercial) CONTACT
ADDRESS
CITY STATE ZIP
PHONE EMAIL
DESCRIPTION OF WORK
COST OF CONSTRUCTION
(FORM CONTINUES) PAGE 1 OF 2 v6/17/2019 BUILDING DIVISION PLUMBING PERMIT 64 E. Walnut St. APPLICATION FORM Westerville, OH 43081-2308 t. (614) 901-6650 f. (614) 901-6666
FIXTURE # FIXTURE # FIXTURE # Air Admittance Valve Eye Washer Sink, 3 Compartment Air Hammer Arrestor Garage Catch Basin Sink, Bar Automatic Clothes Washer Hot Water Recirc. System Sink, Exam Room Backflow Preventers Ice Bin Sink, Floor Back Water Valve Ice Machine (not within refrigerator) Sink, Food Prep Bath Tubs Interceptor, Garage/Oil Sink, Hand Washing Bed Pan Washers Interceptor, Grease Bidet Sink, Kitchen Interceptor, Solid Coffee Maker Sink, Utility/Mop Laundry Tub Dental Cuspidors Sterilizers Lavatories Dilution Sump Sump Pump Lift Station Dish Washers Tempering Valve Pedicure chair Drinking Fountain Trap Primer Piping System, Sanitary Drain, Floor Urinal Drain, Hub Piping System, Stom Washing Machine Drain, Roof Storm Piping System, Water Water Closets Drain, Room Secondary Remove & Cap Fixture Water Storage Tank Drain, Trench Rough In Future Fixture Expansion Tank Showers Whirlpool Tub Other Total Fixtures (All Columns)
RESIDENTIAL FEES COMMERCIAL FEES Application Fee & 1st Fixture $60.00 Application Fee & 1st Fixture $200.00 Fixtures @ $15.00 each Fixtures at $20.00 each $15.00 x ______$20.00 x ______1% State Assessment 3% State Assessment Total Due Total Due
The undersigned hereby applies for a permit to do plumbing and an inspection of same at the following location and in accord with Chapter 4101:2-51 of the Ohio Administrative Code, and all regulations of the Franklin County Board of Health and City of Westerville.
SIGNATURE OF APPLICANT DATE
PRINTED NAME OF APPLICANT PHONE NUMBER
PAGE 2 OF 2 v6/17/2019