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2009 l�� 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: PROPERTY TYPE: APPLICATION DATE: SITE : Address: APPLICANT: Name: Address: OWNER: Name: ❑ New ❑ Alteration ❑ R.P.Z. ❑ Commercial (2 sets of plans required) ❑ Residential CONTRACTOR: � Name: WORK DESCRIPTION: Phone: Phone: 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 to the City of Roseville to perform the work as herein described. The undersigned further states, under penalty of laN, that the work will be performed in accordance �vith the Minnesota State Building Code, this application, and any approved plans and/or specifications. Print Name: ❑ Contractor ❑ Owner ❑ Other: Phone: Date: • • Fee Calculation: Plumbing Pennit Fee $55.00 State Surcharge $ .50 Miscellaneous Plumbing Work: 1.25% of estimated job cost Fees: Permit State Surcharge $ $ Signature E-Mail Address: Plus: Each Fixture/Opening Backflow Prevention Verification Contractor's License $ Other: $ $ 9.75 $24.50 Approvals: Total Fees: $ Plan Reviewer Date Receipt #: Receipt Date: Note: Meters are installed by the Utiliry Department (651-792-7051). All outside remote water meter registers are to be installed in front of houses, townhomes, or condos or located with othe �'ity meters. Meter base must be prewired by plumh ^.ontractor. Wire and spacers will be furnished "y the City of Roseville.