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2006 <br />c;ry oe <br />1J1 <br />'� Minneaota <br />Permit Application for Liquef ed Petroleum (L.P.) Gas Installation <br />City of Roseville Fire Prevention Bureau • 2660 Civic Center Drive •Roseville, MN 55113 <br />Phone 651-792-7341 • FAX 651-765-1651 <br />Date of Application Permit Number Receipt Number <br />Application is hereby made to the Roseville Fire Prevention Bureau to: <br />❑ Install L.P. tank(s) — value exceeds $1, 000 ❑ Install L.P. gas equipment — value exceeds $1, 000 <br />❑ Install temporary L.P. gas equipment ❑ Other: <br />Address <br />Site Location <br />Applicant (or Contractor) <br />Tank Installation <br />Name <br />State <br />9in gallons-water capacity, L.P. capacity, or <br />Street <br />Zip Code <br />ContainerSupports <br />Protection Against Physical Damage (check all that apply): <br />❑ Manual Shut-Off Valve ❑ Excess Flow Valve Internal Valve <br />❑ Pressure Relief Valve <br />)istance from Tank to Property Line <br />Piping ' V <br />L.P. Gas Installation <br />Gas/Air Mixer <br />Compressor Location <br />d (.cleel, copper, etc.) <br />L.P. Gas Vaporizer Type <br />Dispensing Equipment <br />Pumps <br />❑ Liquid Level Gauge Pressure Valve <br />to Building Distance from Tank to Fill Point <br />Piping Size <br />Distance from Vaporizer to Tank Distance from Vaporizer to <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />1a. Permit fee (based on current Building Code) <br />1 b. Plan check fee (.65 times permit fee in la above) <br />2. State surcharge (.0005 times value of #1, above) <br />3. Total permit fee for installation (add la, Ib and 2) $ <br />"Cransport <br />Other <br />$ <br />$ <br />$ <br />The undersigned agrees to perform this job in accordance_with the above information,-attached plans and specifications, <br />and the applicable provisions of the National Fire Protection Association Standard(s). <br />Applicant Name (Please print clearly): <br />I Applicant Signature: Date: <br />,� <br />. <br />