PLUMBING PERMIT APPLICATION
CITY OF LAKEVILLE
BUILDING INSPECTIONS DEPARTMENT
20195 HOLYOKE AVENUE
LAKEVILLE, MN 55044
952-985-4440
Office Use Only
___________________
Permit Number
___________________
Received By
___________________
Date Received
___________________________
Permit Fee
DATE YOUR E-MAIL ADDRESS
SITE ADDRESS
TENANT SUITE NO.
THE APPLICANT IS: RESIDENT OWNER CONTRACTOR
RESIDENT OWNER
NAME________________________________________________________________________
ADDRESS_____________________________________________________________________
CITY _____________________________ STATE_____________ ZIP _____________________
DAYTIME PHONE # WHERE YOU CAN BE REACHED ______________________________
CONTRACTOR
Company name must be as
appears on State License
COMPANY NAME______________________________________LICENSE #______________
ADDRESS_____________________________________________________________________
CITY _____________________________ STATE_____________ ZIP _____________________
OFFICE PHONE # ________________________ FAX # _______________________________
CONTACT NAME______________________________________ PHONE__________________
RESIDENTIAL
LAWN SPRINKLER
WATER SOFTENER
WATER HEATER
ONLY
INSIDE PLBG
CONVERSION
ADDN/REPAIR
MISC (fill description)
PERMIT TYPE
COMMERCIAL ONLY
COMM PLMBG SYSTEM
COMM/MULTI-FAMILY
LAWN SPRINKLER
FIRE SPRINKLER
BACKFLOW
INSTALLATION
Residential Permits Available on-line
TYPE OF WORK
ADDITION
REPLACE
ALTER / REMODEL
DEMOLITION
JOB DESCRIPTION
RESIDENTIAL FEES:
Repairs/Remodel, Water Heater or Water Softener + State Surcharge ($1.00)
COMMERCIAL FEES:
JOB COST:
$
Example: $12,000 Job Cost
1-1/2% of contract cost up to $10,000
$10,000.00 x 1.5% =
$150.00
1% of cost above $10,000 plus surcharge
+
$ 2,000.00 x 1% =
+ 20.00
(Surcharge = Contract Cost x .0005)
+
$12,000 x.0005 =
+ 6.00
TOTAL
=
= $176.00
Minimum of + State Surcharge
NO. OF METERS
SIZE OF METER
LOCATION OF METER
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Lakeville and with the Minnesota Plumbing Codes; that I understand this is not a
permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the approved plan
in the case of all work which requires review and approval of plans.
NAME OF APPLICANT (Please Print)
Date
SIGNATURE OF APPLICANT:
PLEASE NOTE: SEPARATE PERMITS ARE REQUIRED FOR ANY BUILDING, MECHANICAL & ELECTRICAL WORK
www.lakevillemn.gov
$40.00
($1.00)
$40.00
$0.00
0.00
PLUMBING PERMIT APPLICATION PAGE 2
OFFICE USE
SYSTEM TYPE:
REQUIRED INSPECTION:
NEW
COMBUSTION AIR
ADDITION
FINAL
REPLACE
OTHER
ALTER/REMODEL
ROUGH IN
REPAIR
BACKFLOW TEST REPORT
DEMOLITION
UNDERGROUND
PERMIT FEE
PERMIT FEE:
$
SURCHARGE:
$
METER:
$
REDUCING VALVE:
$
MXU:
$
OTHER:
$
TOTAL:
$
ISSUED BY:
DATE:
0.00
COMMENTS:
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