:: Residential Plumbing Application ::
:: Construction Code Authority ::
1075 Suncrest Dr, Ste A, Lapeer, MI 48446
Phone:810-667-0420~Fax: 810-667-2952
RESIDENTIAL PLUMBING JOB LOCATION

Job Address:                                            City:                                Zip:                                       Municipality:
Job Between What Roads?                                                                                Side of Road Job is On
APPLICANT/HOMEOWNER INFORMATION
Contractor Name:                                                Licensee:                                        DOB/DL #:
Address:                        City:                Zip:                        Phone:                                Fax:
State Lic #                                                                  Fed ID #                                                  MESC#
Workman's Carrier:                                                                Contractor's Email:
Homeowner Name                                                 Phone:                                                Fax:
Address:                City:                        Zip:                          DOB/Dr.L #
Homeowner Email:
Section 23a of the State Construction Code Act of 1972, Act No. 230 of the Public Acts of 1972, being
Section 125, 1523a of the Michigan Compiled Laws, 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.

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

By entering your name, you electronically acknowledge that you have read and accept this permit
application.

Contractor/Homeowner Signature:                               Application Date:
JOB INFORMATION- Fill in all the appropriate information for your job below.
2 Insp.-Rough/Final or Service/Final      $162.00


3 Insp.- Service, Rough & Final              $243.00
(Plus enter items to be installed below at no extra charge.)


FOR ANY OTHER WORK AND ALTERATION JOBS-BASE FEE OF $81.00
(Plus add cost of items to be installed)
ENTER NUMBER OF ITEMS TO BE INSTALLED BELOW
Water Connected Fixtures                              Sump Pumps/Ejectors


Water Line Connections                                  Subsoil Floor Drains


Sewer/Septic Connection                                          Stacks or Vents


Water Softener System                                            Outside Faucets


Reverse Osmosis                                                 Backflow Preventer


OUTDOOR LINES .25 per ft- round off to nearest dollar.


Waterline Footage                                         Sanitary Line Footage


Storm Sewer Line Footage

Code Compliance Inspection-Additional-Reinspection $81.00


Yearly License Administartive Fee $15.00


Installation started without permit being obtained $100.00 Administrative Fee


TOTAL DUE:


Make Checks payable to C.C.A. or Construction Code Authority                    
For Credit Card Payments, Contact C.C.A. 810-667-0420                            
Surcharge Fee of 3.5% will be applied to Credit Cards                               


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