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zoox 1��, J♦- COMMUNITY DEVELOPMENT DEPARTMENT • PHONE: 651-792-7080 • FAX: 651-792-7070 2660 CIVIC CENTER DR. • ROSEVILLE, MN 55113 PL UMBING PERMIT APPLICA TION PERMIT NUMBER: WORK PROPOSED: ❑ New ❑ Alteration ❑ R.P.Z. PROPERTY TYPE: ❑ Commercial (2 sets of plans required) ❑ Residential APPLICATION DATE: SITE : Address: APPLICANT: Name: Phone: Address: OWNER: Name: Phone: Address: CONTRACTOR: Name: Phone: Address: WORK DESCRIPTION: Water Closet: Bath Tub: Kitchen Sink: Urinal: Shower: Wash Basin: Gas Stove: Water Heater: Dish Washer: Laundry Trays (2): Disposal: Fountains: Floor Drain: Catch Basin: Wet Bar: RPZ: Slop Sink: Storm Sewer: Other: TOTAL NUMBER OF FIXTURES: Acknowledgement and Signature: The undersigned hereby makes application ro the City of Roseville to perform the work as herein described. The undersigned further s[ates, under penalty of law, that the work will be performed in accordance with the Minnesota State Building Code, this application, and any approved plans and/or specifrcations. Print Name: Signature ❑ Contractor ❑ Owner ❑ Other: Phone: Date: E-Mai] Address: Fee Calculation: Plus: Plumbing Pennit Fee $52.00 Each Fixture/Opening $ 9.25 State Surcharge $ .50 Miscellaneous Plumbing Work: 125% of estimated job cost Fees: Permit $ Contractor's License $ State Surcharge $ Other: $ Approvals: Total Fees: $ Plan Reviewer Date Receipt #: _ Receipt Date: Note: Meters are installed by the Utility Depart ent (65 ]-792-7051). All outside remote water mrt�i rr��i>t�rs are to be installed in front of houses, townhomes, or condos or located with other � meters. Meter base must be prewired by pluml�ii�itractor. Wire and spacers will be furnished by the City of Roseville.