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I11• City oF =,%, �� M;nc,eeoca Permit Application for Liquefied Petroleum (L.P.) Gas Installation City of Roseville Fire Prevention Bureau • 2660 Civic Center Drive •Roseville, MN 55113 Phone 651-792-7341 • FAX 651-765-1651 Date of Application Permit Number Receipt Number Application is hereby made to the Roseville Fire Prevention Bureau to: ❑ Install L.P. tank(s) — value exceeds $1, 000 ❑ Install L.P. gas equipment — value exceeds $1, 000 ❑ Install temporary L.P. gas equipment ❑ Other: Address Business Name Site Location Name Street Address Applicant (or Contractor) ��Y State Zip Code Phone Number Tank Capacity 9in gallons-water capacity, L.P. capacity, or pounds) Container Supports Tank Installation Protection Against Physical Damage (check all that apply): ❑ Manual Shut-Off Valve ❑ Excess Flow Valve Internal Valve ❑ Pressure Relief Valve ❑ Liquid Level Gauge Pressure Valve Distance from Tank ro Property Line Distance from Tank to Building Distance from Tank to Fill Point Piping Material (sreel, copper, e�c.) Piping Size Piping L.P. Gas Vaporizer Type Distance from Vaporizer to Tank Distance from Vaporizer to Building L.P. Gas Installation Gas/Air Mixer Dispensing Equipment Transport Unloading/Loadin 8 Compressor Location Pumps Other Permit Fee Calculation 1. Fair market value of job $ 1 a. Permit fee (based on current Building Code) $ 1 b. Plan check fee (.65 times permit fee in la above) $ 2. State surcharge (.0005 times value of #1, above) $ 3. Total permit fee for installation (add la, Ib and 2) $ The undersigned agrees to.perform this job in accordance with the above information,-attached plans-and�pecificatio�s; -- and the applicable provisions of the National Fire Protection Association Standard(s). Applicant Name (Please print clearly): Applicant Signature: Date: 1