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2009 ��,�r/,,,, COMMUNITY DEVELOPMENT DEPARTMENT • PHONE: 651-792-7080 • FAX: 651-792-7070 2660 CIVIC CENTER DR. � ROSEVILLE, MN 55113 PLUMBING PERMIT APPLICATION 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 to the City of Roseville to perforni the work as herein described. The undersigned further states, under penalty of law, that the �aork will be performed in accordance with the Minnesota State Building Code, this application, and any approved plans and/or specifications. Print Name: Signature ❑ Contractor ❑ Owner ❑ Other: Phone: Date: E-Mail Address: Fee Calculation: Plus: Plumbing Permit Fee $55.00 Each Fixture/Opening $ 9J5 State Surcharge $�5� Backflow Prevention Verification $24.50 Miscellaneous Plumbing Work: 1.25% 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 Department (651-792-7051). All outside remote water meter registers are to be installed in front of houses, to�mhomes, or condos or located with othet "'ity meters. Meter base must be prewired by plumb'"��ontractor. Wire and spacers will be furnished by the City of Roseville.