To the Village of Millstadt:
A. THE UNDERSIGNED, being the (Owner, Owner's Agent) of the property located at (Number) (Street)
DOES HEREBY REQUEST a permit to install and connect a building to serve the (Residence, Store, Plant, etc.) at said location.
1. The following indicated fixtures will be connected to the proposed building sewer:
Number | Fixtures | Number | Fixtures |
Kitchen Sinks | Water Closets | ||
Lavatories | Bath Tubs | ||
Laundry Tubs | Showers | ||
Urinals | Garbage Grinders |
Specify other fixtures
2. The maximum number of persons who will use the above fixtures is .
3. The name and address of the person or firm who will perform the proposed work is .
4. Plans and specifications for the proposed building sewer are attached hereunto as Exhibit “A”.
B. In consideration of the granting of this permit, THE UNDERSIGNED AGREES:
1. To accept and abide by all provisions of the Village Code of the Village of Millstadt and of all pertinent ordinances or regulations that may be adopted in the future.
2. To maintain the building sewer at no expense to the Village.
3. To notify the Village when the building sewer is ready for inspection and connection to the public seer, but before any portion of the work is covered.
DATE: SIGNED: (Applicant)
(Address of Applicant)
(Certification by Village Treasurer)
$ connection fee paid.
$ inspection fee paid.
Application approved and permit issued:
DATE: SIGNED: (Approving Authority)