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2. 
3. PLUMBING PERMIT AND INSPECTION REPORT

   Permits are available at the City Office Monday - Friday (7am-4pm). SECTION 1 MUST BE COMPLETED PRIOR TO COMMENCEMENT OF WORK

5. SECTION 1: PLUMBING PERMIT ($10.00)
6. DATE:
7. PERMIT #:
9. APPLICANT NAME:
10. ADDRESS WHERE WORK TO BE DONE:
11. TELEPHONE #:
13. LICENSE PLUMBER NAME:
14. ADDRESS:
15. TELEPHONE #:
17. DESCRIPTION OF PLUMBING WORK TO BE DONE:
19. SECTION 2: INSPECTION REPORT ($5.00)
20. DATE OF INSPECTION:
21. INSPECTED BY:
23. CONNECTING TO:

    1. CITY WATER MAIN
    2. CITY SEWER MAIN
24. 1. MEETS CODE
    2. DOES NOT MEET CODE

    1. PROPER VENTS
    2. TRAPS

    1. BACKFLOW
    2. MATERIAL
26. REMARKS, IF ANY:
28. SECTION 3: FEES/PAYMENT

    Please make check payable to      Fairbury Light & Water

29. REQUIRED FEES:

    1. PLUMBING INSPECTION: $5.00
    2. PLUMBING PERMIT: $10.00
    3. CERTIFICATE FOR PLUMBERS REGISTRATION/1YR (work on business): $50.00
    4. RIGHT-OF-WAY PERMIT (work done in City ROW): $10.00
31. SEWER CONNECTION FEE:

    1. 4" TAP: $35.00
    2. 6" TAP: $45.00
32. WATER CONNECTION FEES:

    1. 5/8", 3/4" OR 1" TAP: $25.00
    2. 1 1/2" TAP: $35.00
    3. 2" TAP: $45.00
    4. 4" TAP: $100.00

    1. 6" TAP: $125.00
    2. 8" TAP: $150.00
    3. 10" TAP: $200.00
    4. 12" TAP: $250.00
34. TOTAL DUE
35. AMOUNT PAID
36. PAID WITH:

    1. CASH
    2. CHECK
37. CHECK #:
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