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Type of <br /> <br />Address: <br /> <br />Owner: <br /> <br />· Tax·Lot No: · <br /> <br />Plbg, Installer <br /> <br /> '~NO?OF~ITEMS4~ %~'F£E,.ON EACH ,TO, L T <br /> Base Price , ' ......,: , . . $10~00 <br /> Residential ' ' r ~ a ~h : . , - <br /> N~ Construction (~ch flxtu~) ~ ,. bath. ~ ~n~" , ~ ~,~ ~ ~ 5()~~: <br /> Alteratl~n~ (each fl~ure) ' ~'~ s'to&ls "' ~.~0~ ...... ' : <br /> Sewer Se~ice Line : .......... <br />: Pr vate- Sba be charged per 100'. or[tact on there&r' ~ ~ ........ '~ ......... ZO. 00~ '"' <br />New ~n~ru~ on (each f xture):" · · ; <br />Ateralons(each'f xture) ' ' '*, .: ~' ~ ~ · : <br /> <br /> TO andJnCluding each protect vedev ce~ .,,: .... ~ ...... "" '"- ' 5.00 <br /> Please return comp ete app ~t on ' ,. · , }z. ~u~ ~ ..... _ <br /> <br />exPressly war- :;, <br /> <br /> <br />