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APPLICATION FOR A FIUMBING PRENIY TY¥R: GH-BITE SEKVICRS

APPLICATION DATE:

I/We hereby make application and provide plans under the proviaions of the
pectinent Bylawa for permission to construct, repair or alter the following
building or structure and agree to comply with all the requirements of the
said Bylaws and to indeamify and keep harmless the Municipality againet all
claima, liabilities, judgements, costs and expenses of whatever kind, which
may in any way accrue againet the seid mumicipaiity in consequence of, and
incidental to, the granting of thie Permit, if issued.

BUILDING SITE ADDRESS:

PARTIAL LEGAL DESCRIPTION: Lot #

Name

Address Addrens

City City

Postal Code Telephone/Fax Postal Code Telephone/Fax

Manhole(s): Maters of Pipe
Interceptor(s) Water Main :
Catch Basin(s) Senitary Sewer RE aneriy
Lawn Drain(s) Storm Sewer Pi nee eh
Fire Hydrant(s) Lawn Drain(s)
Sandtrapa Sump(s)

Pump Chambers Trench Drain(s)
Rain Water Leader(s)

AOA AAR AAA AER RRA IRE IK
“OFFICE URE ORLY We do not plan review at the

*Permit No. counter, Incomplete dravinge may

¥ delay your permit application. Your
*Zoning 3 signature acknowledges your nner
* acceptance of thia policy. ears cette:
*Foe Paid: rn
% | ARELICARE
*Receipt s Be
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