Plumbing Permit

2. Application for Plumbing Permit
   203 S. Arkansas Ave.<br> Russellville, AR 72801<br> Ph: 479-968-1002<br> Fx: 479-968-4327

   203 S. Arkansas Ave.
   Russellville, AR 72801
   Ph: 479-968-1002
   Fx: 479-968-4327

4. Date*
   Date

6. Name of Applicant*

   Name of plumber, contractor or home owner.

7. License Number*

9. Applicant's Address*

11. City*

12. State*

13. Zip*

15. Address*

17. City*

18. State*

19. Zip*

21. Number of Water Closets*

22. $2 per Water Closet Equals*

24. Number of Lavatories*

25. $2 per Lavatory Equals*

27. Number of Sinks*

    (Other Than Lavatories)

28. $2 per Sink Equals*

30. Number of Showers*

31. $2 per Shower Equals*

33. Number of Bath Tubs*

34. $2 per Bath Tub Equals*

36. Number of Washing Machines*

37. $2 per Washing Machine Equals*

39. Number of Dishwashers*

40. $2 per Dishwasher Equals*

42. Number of Water Heaters*

43. $2 per Water Heater Equals*

45. Number of Water*

46. $2 per Water Equals*

48. Number of Gas*

49. $10 per Gas*

51. Number of Floor Drains*

52. $2 per Floor Drain Equals*

54. Number of Urinals*

55. $2 per Urinal Equals*

57. Number of Inspections*

    3 are required,

58. $4 per Inspection*

60. Total Permit*

62. If permit is granted, I agree to do all work above in strict compliance with city and state regulations.

64. Signature*

    Signed by licensed plumber or homeowner.

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field