(Please call 24 hours in advance for inspections)

Date of application*

Job Address *

Owner’s Name *

Owner’s Address*

Owner’s Telephone*

Contractor’s Name*

Contractor’s Telephone*

Contractor’s Email*

Description of Work*

Please check all that applies*

Drinking Fountain Garbage Disposal Water Heater Floor Drains Sinks Dishwasher

Tubs / Showers Washing Machine Sump / Ejector Pump Laundry Tubs Toilet / Urinals Miscellaneous

Total number of Fixtures checked*

Total Fixtures (x $6.00)*

Please check all that applies*

New or Remodel (2 Inspections Rough and Final) ($40) Sewer ($20) Water ($20)

Fire Sprinkler ($40 Lawn Sprinkler ($40) Gas Pipe/ Gas Meter ($2

Total $*