Forms • McCook, NE • CivicEngage

Job Address:*

PROPERTY OWNER INFORMATION

Name*

Address*

City/State/Zip*

Phone*

Email

Date*

CONTRACTOR INFORMATION

Business name

Address

City/State/Zip

Phone

Email

Date

Is the Contractor licensed?

Yes

No

Type of Work*

	New Construction
	Demolition

	Add./alt./replacement
	Other:

Category of Construction*

	1 & 2 Family dwelling
	Accessory building
	Commercial/Industrial

	Multifamily
	Other

Description of Work
(example: upstairs bath remodel)*

TOTAL COST OF JOB*

Fee Schedule - Use Checklist

$25 Min. plus $3.00 per item over 6 items

Description of item

Quantity

Water Closet (toilet)

Bathtub

Lavatory (wash basin)

Shower

Kitchen sink and disposal

Dishwasher

Laundry tray

Clothes washer

Urinal

Drinking fountain

Floor-sink/roof drain/floor drain

Floor Drain

Roof Drain

Sewer line

Water heater

Waste interceptor

Water piping & treating equipment

Water softener

Vents

Cleanouts

Emergency eye wash

Trench drains

Sand & oil interceptor/grease trap

TOTAL # OF ITEMS

* indicates required fields.

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