Permits - 2433 Black Lake Road - 5/28/2021d, LITY OF SPRING PARK
P. O. BOX 452 APPLICATION FOR PLUMBING
SPRING PARK, MN 55384 P E R M I T
General Information
1. You may apply for plumbing permits by mail or in person at the City offices.
2. Mailed in application are subject to the postage and handling fees shown below. Permit Cards will
be sent by return mail the same day the application is received.
3. Permits are not valid until you receive a permit card.
4. Mork must not begin until tho permit card is posted on the job site.
S. Plumbing permits may be issued to state -licensed plumbers or to homeowner/occupants who intend to
actually perform their own work in their home.
6. When any new construction or remodeling in involved, a separate building permit must be obtained.
7. All work must be done in accordance with the State Building Code Requirements.'
S. All work must be inspected before it is covered. Call for inspections 24 hours in advance 1
(473-7357).
Instructions. Complete all items on this application. Compute the permit fee. Sign and date thel
certification. Incomplete applications will not be processed. If you have any questions, call.
473-7357. 1
WALX-IN PERMITS --Apply at City Offices, 4349 Warren Ave.
MAIL -IN PERMITS--Encloae Fee --Nail toi P. U. Box 452, Spring Park, MN 55384
JOB SITE ADDRESS (7
Occupancy Type: Residential _ Commercial
Work to be Performed by: Licensed Contractor Owner/Occupant
a
OWNER'S NAME � �� -c Telephone No.
Mailing Address
PLUMBER'S COMPANY
Mailing Address
iness o. D �d
Master Plumber's State License No. 14VIV City Cert. No.
PLUMBING FIXTURE SCHEDULE
(Show Number of Fixtures of Each Type on Each Floor)
FIXTURE TYPE
8SMT.
lot floor
2nd Floor
Other Floors
FIXTURE TYPE
BSFfr.
lot Floor
2nd Floor
Other Floor
Water Closet
/
Laundry Tray/
Lavatory
Washer
Bathtub
Water Heater
Shower
-_
Water Softnec
I
Kitchen Sink
Disposal
Misc. Fixtures:
(List)
Dishwasher
Wet Bar
Sillcock■
Floor Drains
Sump Pump
I
Or FIXTURES
Sewe[ L actor
I
I
PERMIT FEE CALCULATION
1. Fixture Fee. The minimum permit,,fee is $25.00.
Compute number of fixtures x $4/fixture cro
2. State Surcharge $ .50
3. Postage and Handling (Only for Mail -in applications) $ -
4. TOTAL Permit Fee (Add lines 1-3 above)
The undersigned hereby applies to the City of Orono for issuance of a PLUMBING PSRMIT, agrees to do all
work in strict accordance with the ordinances of the City and the regulations of the Minnesota aeaco '
Building Code, and certifies that all statements made on this application are complete, true and
correct.
MINNESOTA STATE DEPARTMENT OF HEALTH
BONDING AND INSURANCE CERTIFICATE
This isito certi fy that KENNETH R. BOUTIN Master Plumber License No. PM00317:1
.'Represent'ing Ken Boutin Plumbing
has filed a.`: $20000 bond with the Secretary of State on December.20, 199%nd provided evidence of Public Liability
Insurance, including Products Liability Insurance of at least $50,000 per person and $100.000 per occurance and Property
Damage Insurance of at least $10,000 for the year of 1994 in accordance with the provisions of Minnesota
Statutes 9326.40, (1978)
BOND N0. 5747005 POLICY NO. 934606 08522492 00 93
934606 08522492 00 94
.,Western Surety Company Owners Insurance Company
Sioux Falls, South Dakota Wallace C. Johnson, Minnesota Agent
If)94 HE-01135-02
White Bear Lake, Minnesota
.Director, Division of Environmental Health
Mary Jo O'Brien, Commissioner
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fflinnezota BOX pepartment 59040 of 30ealtb
PLUMBING UNIT,
925 SE DELAWARE ST., MINNEAPOLIS , MN
Master plumber License
LICENSE NO 003171PI4
Kenneth R. Boutin
EXPIRATION DATE
EFFECTIVE DATE 12/31/94
01/01/94