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2009 1J, COMMUNITY DEVELOPMENT DEPARTMENT � PHONE: 651-792-7080 • FAX: 651-792-7070 2660 C1V1C CENTER DR. • ROSEVILLE, MN SSll3 PL UMBING PERMI T APPLICA TION PERMIT NUMBER: WORK PROPOSED: ❑ New ❑ Alteration ❑ R.P.Z. PROPERTY TYPE: APPLICATION DATE: SITE : Address: APPLICANT: Name: Address: OWNER: Name: ❑ Commercial (2 sets of plans required) ❑ Residential CONTRACTOR: � Name: WORK DESCRIPTION: one: 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: �Z' 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 law, that the work will be performed in accordance with the Minnesota State Building Code, this application, and any approved plans and/or specifications. Print Name: ❑ Contractor ❑ Owner Phone: Fee Calculation: Plumbing Permit Fee State Surcharge Miscellaneous Plumbing Work: Fees: Permit State Surcharge Approvals: Plan Reviewer ❑ Other: Date: Signature E-Mail Address: Plus: $55.00 Each Fixture/Opening $ .50 Backflow Prevention Verification 1.25% of estimated job cost $ $ Contractor's License Other: Total Fees: $ Date Receipt #: Re � t D $ $ $ 9.75 $24.50 ceip ate. � ��lote: Meters are installed by the Utility Department (651-792-7051). All outside remote water meter registers are to be installed in fronr ofho�ses, �� ,n��nhomes, or condos or located with other�'ty meters. Meter base must be prewired by pl�,»b'^ �„ir��ror. Wire and spacers will be furn;shed � the City of Roseville.