PLUMBING PERMIT APPLICATION □ Residential □ Commercial □ New □ Alteration

CITY OF BROOKFIELD For Office Use Only: PROP. TAX ID: Inspection Services Department 2000 North Calhoun RD, Brookfield, WI 53005 PERMIT # 262-796-6683 DATE ISSUED: http://www.ci.brookfield.wi.us □ BLDG PERMIT PLUMBING PERMIT APPLICATION □ Residential □ Commercial □ New □ Alteration Street Address: ________________________________________________________________________ Suite/Unit No. ___________________ Applicant is: □ Contractor □ Homeowner Owner/Occupant Name: Phone: Contractor: _______________________________________________________________ Phone: _____________________________________ Street Address: ________________________________________________ City: ________________________ State: ______ Zip: ___________ State Credential No: Check box if E-mail: you would like your permit emailed. For Office Use Only: FIXTURE OR ITEM QTY FIXTURE QTY FIXTURE ____ Air Admittance Valve ____ Interceptor Laterals & Connections ____ Area or Deck Drain ____ Kitchen Sink ____ Back Flow Preventer ____ Laundry Tub The prices listed below are for the first 100’. Over 100’ is an additional $.48 per foot. ____ Bar Sink ____ Lavatory QTY FEE TOTAL ____ Bathtub ____ Lawn Irrigation Sanitary Bldg. Drain $59.50 ____ Beer Tap ____ Manhole / Bldg. Drain Branch ( __________linear ft.) ____ Beverage Dispenser ____ Pedicure Chair Sanitary Bldg. Sewer ( __________linear ft.) $59.50 ____ Bidet ____ Pot Sink ____ Carbonator ____ Pressure Reduce Valve Storm Drain ( __________linear ft.) $59.50 ____ Case Drain ____ Prep Sink ____ Catch Basin ____ Roof Drain Water Service ( __________linear ft.) $59.50 ____ Coffee Maker ____ Service/Mop Sink Backwater Valve (Req’d for new single-family homes) $59.50 ____ Dental Device ____ Shampoo Sink ____ Dishwasher ____ Shower Stall/Mixer Exterior Line Repair: □ Drain □ Sewer □ Water $59.50 ____ Drinking Fountain ____ Sink Seal/Abandon: □ Sewer □ Water $59.50 ____ Emergency Eye Wash ____ Sump Pump Connection to City Water Size: ____ Ejector Pump ____ Urinal $59.50 ____ Floor Drain ____ Washer Connection (Pressure exceeding 80 psig requires PRV) ____ Garbage Disposal ____ Water Closet (Toilet) Meter Setup/Deduct Meter (Brass ball valves Required) $59.50 ____ Hose Bibb ____ Water Heater Re-Inspection Fee $59.50 ____ Hub/Receptor ____ Water Outlet ____ Ice Compartment ____ Water Treatment Device Additional Footage .48¢ ____ Ice Maker ____ ____________________ Other/Misc: Quantity X $15.00 Subtotal = Subtotal = GENERAL: The application must be filled out completely & submitted with the required fees or it will be Fixtures Subtotal = rejected and returned. The Conditional Plan Approval must be submitted with application for projects that require DSPS plan review. Water service and sewer repair, and water heater replacements will be considered emergency work. Permit is to be submitted within 24 hours of the start of the job. Laterals Subtotal = NOTE: Plumbing work shall not be started until the approved plumbing permit is TRIPLE FEE x 3 received by the contractor/homeowner. Work started prior to receiving an = (where applicable) approved permit will be required to pay a TRIPLE fee. Please allow 48 hours for permit processing. Total Permit Fee $ INSPECTIONS: Request by phone 262-796-6683. The following information must be given: *Minimum Permit Fee is $59.50 ● APPLICATION NUMBER ● AM (8:30am-Noon) or PM (Noon-2:30pm) The minimum permit fee is not refundable. Applicant Signature : The undersigned applicant agrees to comply with the ordinances of the City of Brookfield and all laws of the State of Wisconsin. Applicant is obligated to ensure that all required inspections and final inspection is made. Master Plumber / Homeowner: ______________________________________________ Date: ________________________ S:\Handouts\APP MASTERS\2020\plumbing permit application 2021.docx May-21 PURPOSE OF INSPECTION DATE INSPECTION NOTES INSPECTION S:\Handouts\APP MASTERS\2020\plumbing permit application 2021.docx .

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