Permit No.

Date Received

PLEASE PRINTProject Address: Unit # City/Township / Village (not Cinti.) Is the project new construction or a remodel?

New Construction Remodel/Alt. Demo

Commercial Facility Name Residential Owner Name How will the building be occupied:1 family 2 family Condo Apt Commercial

Building Permit #: MSD / STS Permit #:

Please indicate the number of each type of fixture you plan to install in the box provided below each fixture type:

Other Fixtures:

Other Fixtures:

Fixture Charges

1 Fixture = $50 6 Fixtures = $130 11 Fixtures = $210 16 Fixtures = $290 21 Fixtures = $370

2 Fixtures = $66 7 Fixtures = $146 12 Fixtures = $226 17 Fixtures = $306 22 Fixtures = $386

3 Fixtures = $82 8 Fixtures = $162 13 Fixtures = $242 18 Fixtures = $322 23 Fixtures = $402

4 Fixtures = $98 9 Fixtures = $178 14 Fixtures = $258 19 Fixtures = $338 24 Fixtures = $418

5 Fixtures = $114 10 Fixtures = $194 15 Fixtures = $274 20 Fixtures = $354 Additional Fixture +$16

Water Line ft Water Line Fee $ Total Fixtures Fixture Fee $0-250 ft = $50; Additional 10 ft +$1

The above listed fixtures drain to: STS

$

Plumbing Contractor Contact Name: Office Phone Number:

Plumbing Contractor Contact Cell Phone: Plumbing Contractor Contact E-mail Address:

Payment Type: Escrow # Check To pay with a credit card, go to www.hcph.org

Contractor Check List: All application Fields Completed Drawings/Plans Included Fee Included

Registered Plumbing Contractor: Signature:

FOR OFFICE USE ONLY:Amount Received: Receipt #: Plan Examiner Approval:

Date: Inspection Dates Dates Final

Sanitary Sewer

Total Fee Due

In consideration of permission given, the undersigned does hereby covenant and agree to comply with all the plumbing laws of the State of Ohio and the regulations of Hamilton County General Health District and acknowledges the permit must be secured before commencing work.

0

REQUIRED FOR PERMIT TO BE PROCESSED

Water Closet

Ldry Tray Shwr

+ Add Water Line Fee & Fixture Fee +

Gar Disp

Ldry Tray Shwr Gar Disp

Bath

Storm Ldr

AirAdmit Vlv

Inter-ceptor

New Fixtures

APPLICATION FOR PERMIT TO INSTALL PLUMBING

SinkLav. UrinalWasher

BoxDish Wshr

Sump Ejector

□ No upper rough insp. w/o sewer permit #

□ Hold application for building permit #

Water Closet

Bath Lav. Sink

Drinking Fountain

Water Heater

Floor Drain

AirAdmit Vlv

Washer Box

UrinalDish Wshr

Inter-ceptor

Sump Ejector

Floor Drain

Storm Ldr

ReplacementFixtures

Testable Backflow Devices:

Drinking Fountain

Water Heater

X $25.00 $0.00

# Devices Fee Per Device Total Fee

ATTN: Plumbing250 William Howard Taft Road, 2nd FlCincinnati, Ohio 45219