Application form

Water Service Permit Application

Thursday, July 2, 20152 pages in the original

Fill in this form below, then print it. Your answers are written onto the township’s original form, ready to sign by hand and mail or drop off. They stay on your device; nothing is sent until you hand in the form.

Contents (10)

LINCOLN TOWNSHIP

WATER SERVICE PERMIT APPLICATION

Revised 7/2/15

I. Job Location

Name of Owner/Agent

Phone

Has a building permit been obtained for this project?

YesNoNot Required

Street Address & Job Location (Street No. and Name)

City/Village

Township

County

I. Contractor/Homeowner Information

Contractor or Homeowner

ContractorHomeowner

Name

License Number

Expiration Date

Street Address (Street No. and Name)

City/Village

Township

County

Telephone Number

Social Security Number

Write this on the printed form.

Federal Eamployer ID Number (or reason for exemption)

Workers Compensation Insurance Carrier (or reason for exemption)

MESC Employer Number or reason for exemption

III. Type of Job

IV. Plan Review Required

Have plans been submitted? (See below for plan review requirements before completing this section.)

YESNONOT REQUIRED

Plans are not required for the following:

1.One-and two-family dwellings containing not more than 3,500 square feet of building area.
2.Alterations and repair work determined by the plumbing official to be of a minor nature.
3.Assembly, Business, Mercantile, and Storage Buildings with a required plumbing fixture count less than 12.
4.Work completed by a governmental subdivision or state agency costing less than $15,000.00.

If work being performed is descrived above, answer Section IV. "Not required."

Plans are required for all other building types and shall be prepared by or under the direct supervision of an architect or engineer licensed pursuant to Act No, 299 of the Public Acts of 1980, as amended, and shall bear that architect's or engineer's signature and seal. PLANS MUST BE SUBMITTED BEFORE A PERMIT CAN BE ISSUED.

V. Homeowner Affidavit

I hereby certify the Plumbing work described on this permit application shall be installed by myself in my own home in which I am living or about to occupy. All work shall be installed in accordance with the Plumbing Code and shall not be enclosed, covered up, or put into operation until it has been Inspected and approved by the Plumbing Inspector. I will cooperate with the Plumbing Inspector and assume the responsibility to arrange for necessary inspections.

VI. Applicant Signature

Section 23a of the state construction code act of 1972, 1972 PA 230, MCL 125.1523A, prohibits a person from conspiring to circumvent the licensing requirements of this state relating to persons who are to perform work on a residential building or a residential structure. Violators of section 23A are subject to civil fines.

Signature of Licensee or Homeowner

(Homeowner's signature indicates compliance with Section V Homeowner Affidavit.)

Sign by hand after printing.

Date

VIIa. Fee Clarification

MOBILE HOME UNIT SITE: WHEN item is used for sewer excavations in a new park, the permit application should include the application fee plus the number of unit sites. WHEN setting a mobile home in a park, or modular home on a private property, a permit should include the application fee, a sewer or building drain, and a water service or water distrubuting pipe.

COMPLETE APPLICATION ON FOLLOWING PAGE

VII.b Fee Clarification (continued)

FIXTURES, FLOOR DRAINS, SPECIAL DRAINS, & WATER CONNECTED APPLIANCES INCLUDE:

Water Closets
Bathtub
Lavatories
Dishwasher
Water Outlet Cooler
Ice Making Machine
Water Connected Still
Connection to Sprinkler System (Irrigation)
Water connected Sterilizer
Sink (any description)
Emergency Eye Wash
Emergency Shower
Garbage Grinder
Slop Sink
Bidet
Cuspidor
Refrigerator
Autopsy
Water Connected Dental Chair
Water Connection to Filters
Drinking Fountain
Condensate Drain
Washing Machine
Acid Waste Drain
Embalming Table
Floor Drain
Roof Drain
Grease
Plaster
Shower Stall
Laundry Tray
Urinal
Starch Water Softner
Bad Pan Washer
Water Connection to Carbonated Beverage Dispenser
Water Outlet or Connection to any Make-up Water Tank
Water Outlet or Connection to Heating System

PLUS ANY OTHER FIXTURE, DRAIN, OR WATER CONNECTED APPLIANCE NOT SPECIFICALLY LISTED

VIII. Fee Chart

Enter the number of items being installed, multiply by the unit price for total fee.

Fee chart, part 1 of 2

DESCRIPTION	FEE	Number	TOTAL
Application Fee (No Refund)	$10.00	1	10.00
Water Service: Less than 2"	5.00 ea		—
2" to 6"	20.00		—
Over 6"	40.00		—

Fee chart, part 2 of 2

DESCRIPTION	FEE	Number	TOTAL
Final Inspection	10.00	1	$10.00
Total			$20.00

IX. Instructions for Completing Application

GENERAL: Plumbing work shall not be started until the application for permit has been filed. All installations shall be inconformance with the Plumbing Code. No work shall be concealed until it has been inspected. When ready for inspection, call the inspector pproviding as much advance notice as possible. The Inspector will need the hob location and permit number.

EXPIRATION OF PERMIT: A permit remains valid as long as work is progressing and Inspections are requested and conducted. A permit shall become invalid if the authorized work is not commenced within six months after issuance of the permit or if the authorized work is suspended or abandoned for a period of six months after the time of commencing the work. A PERMIT WILL BE CANCELLED WHEN NO INSPECTIONS ARE REQUESTED AND CONDUCTED WITHIN SIX MONTHS OF THE DATE OF ISSUANCE OR THE DATE OF A PREVIOUS INSPECTION. CANCELLED PERMITS CANNOT BE REFUNDED OR REINSTATED.

The Township will not discriminate against any individual or group because of race, age, religion, age, national origin, color, marital status, handicap or political beliefs.

Make Checks payable to: Lincoln Township

Mail Permits to: Greg Younk 2251 N. Eight Mile Road Sanford, MI 48657

Done? Print the completed form, sign it, and hand it in.