CITY OF ROCKVILLE BUILDING PERMIT APPLICATION
P.O. Box 93 - 229 Broadway Street East - Rockville MN 56369 – Phone: 320-251-5836 – Fax: 320-240-9620
www.rockvillecity.org
– Email: cityhall@rockvillecity.org
Applicant: Property Owner Contractor Building Inspector: Inspectron Inc. 800-322-6153
Property Owner Name Property Address
Property Identification Number (PIN)
Property Owner Phone Number
Contractor’s Name Address
Contractor Phone Number
Contractor’s State License Number Expiration Date
Contractor Fax Number or Email Address
Project Description
Completed Value (includes labor and materials)
Permit Requirements:
( ) Construction Plans (2)
One 11”x17” Set PLUS
One Full Size Set
( ) Site Plan -
See Type of Construction
Project Proposed Use
( ) Residential
( ) Commercial
( ) Agricultural
( ) Industrial
( ) Multi Family (+5 )
( ) Townhouse
( ) Public
New Business
Requirement:
( ) Knox Box Installation
NOTE: Separate permit(s)
required for Mechanical &
Plumbing.
Commercial
( ) Residing
( ) Reroofing
( ) Window/Door Replacement
Contact City Hall:
Water/Sewer Connection
( ) City Water Connection
(WAC fee) GIS required
( ) City Sewer Connection
(SAC fee)
( ) Licensed Contractor with
the City of Rockville
Lake Area Sewer Connection
( ) Grinder Station & Trunk fees
NOTE: Water/Sewer
Inspections require 24-hour
notice. Contact Public Works
320-251-5836
Type of Construction - Site Plan Required:
GIS REQUIRED - City Water on New Construction
( ) Accessory Building
( ) Accessory Building (200 square feet or less)
Construction Plans Not Required/No Permit # Assigned
( ) Addition ( ) Manufactured Home
( ) Deck/Porch (
) New Construction
( ) Fence/Wall ( ) Other ______________
( ) Foundation Only (
) Relocation
( ) Garage, Attached ( ) Temporary Structure
( ) Garage, Detached ( ) Permanent Sign
( ) In Ground Pool ( ) Temporary Sign
( ) Above Ground Pool
Type of Construction - No Site Plan:
( ) Demolition - Residential Removal of 5+ Buildings, any
Commercial, Apartment(s) and Agricultural B
uildings
( ) Interior Remodel
( ) Lower Level
( ) Repair
( ) Window/Door Replacement - changing the size of the
window/door opening
(for office use)
Zoning District
( ) Rural Residential
( ) R-1 Single Family
( ) R-2 Two Family
( ) R-3 Multiple Family
( ) R-R Rural Residential
( ) B-1 Central Business
( ) B-2 General Business
( ) I-
1 Light Industrial
( ) I-2 General Industrial
( ) AG-40 Agricultural
Granted
( ) Variance No.
___________________
( ) Conditional Use Permit
No. _______________
Notice: Separate permits are required for plumbing, heating, fireplace installation, electrical work and installation of a septic system. The permit will
become null and void if work or construction authorized is not commenced within 180 days after its issuance or if the work authorized by the permit is
suspended or abandoned for a period of 180 days after the time work is commenced.
I hereby certify that I have read and examined this application and know
the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a
permit does not presume to give authority to violate or cancel the provision of any other State or Local law regulating construction or the performance of construction. This
building permit may be suspended or revoked if the permit has been issued in error or on the basis of incorrect information supplied or in violation of any ordinance or
regulation of the City of Rockville. All permit fees and other costs to review the application that are incurred by the City for professional consultants, will be paid prior to
issuance of the Building Permit. By signing below you give the City of Rockville the right to access the project address above at any given time to do water, sewer, and/or any
mitigation inspections.
Contractor Signature _____________________________________________________________ Date __________________
Property Owner Signature _________________________________________________________ Date __________________
Conditions _______________________________________________________________________________________________
Permit Approval/Zoning Administrator _________________________________________ Date _________________
Building Permit Fee/Plan Review $___________
WAC/SAC Fee $___________
Total Amount Due $___________
Water Meter Fee $___________ Check payable to: City of Rockville
SAC Fee $___________
Sewer Charge (Lake Area) $___________
Sales Tax Fee $___________
Additional Fees $___________
Surcharge $___________
Admin. Review $___________
(for office use)
Permit No. ________________
Date _____________________
Check # __________________
