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APPLICATION FOR A PLOMBING PREMIT, XTPR2 OM-BITE SERVICRS

APPLICATION DATE:

I/We hereby make application and provide plang under the provieiona of tha
pertinent Bylaws for permission to construct, repair or alter the
following on-site services and agree to comply with all the requirements
of the said Bylawa and to indemify and keep harmless the Hunicipelity
againat all claims, liabilities, judgements, costs and expenses of
whatever kind, which may in any way accrue againeat the said municipality
in consequence of, and incidental to, the granting of the Permit, if
lasued.

"BUITLDOING BITE ADDRESS:

PARTIAL LEGAL DESCRIPTION: Lot #
GANER

Name

Address Address

City City

Postal Code Telephone/Fax Postal Code Telephone/Fax

Manhole(s) Meters of Pipe

Interceptor(s) Water Main

Catch Basin(s) Sanitary Sewer
Lawn Drain(a) Storm Sewer

Fire Hydrant(a) Lawn Drain(a)

Sandtrap(s) Sunp(s)

Pump Chamber (us) Treach Drain(e)
Rain Water Leade:(s)

wh Kk RK HHA Wa do not plan review at the
WOFFICE USS CULY counter. Incomplete drawings may
*Permit No.? delay your perait application.
* Your signature acknowledges your
*Zoning$ | acceptance of this policy.
WFee Paid: APPLICANT
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Telephone

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