' : ‘ ate 8 wig . +” late aN, a 44, ms wane ao Whe, 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 w aReceipt s Bil o¢_). BC) ACY w ® Name *Conmente 3 w * w * ae = SA guature we 1 w Re eae KR ARR HARK Telephone a aU si tet s