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2006 <br />c�cy oe <br />��iS�� <br />Minnesota <br />Permit Application for Liquefied 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 Business Narne <br />Site Location <br />Name Sheet Address <br />Applicant (or Contractor) <br />���Y State ZipCode PhoneNumber <br />7'ank Capacity 9in gallons-water capacity, L.P. capacity, or pounds) Con[ainer Supports <br />Tank Installation <br />Protection Against Physical Damage (check all that apply): <br />❑ Manual SIZUt-Off Valve ❑ Excess Flow Valve Internal Valve <br />❑ Pressure Relief Valve ❑ Liquid Level Gauge Pressure Valve <br />Dislance from Tank to Property Line Distance from Tank to Building Distance from Tank to Fill Point <br />Piping Material (.rleel, copper, etc.) Piping Size <br />Piping <br />L.P. Gas Vaporizer Type Distance from Vaporizer to Tank Distance from Vaporizer to Building <br />L.P. Gas Installation <br />Gas/Air Mixer Dispensing Equipment Transport Unloadin�/Loading <br />Compressor Location Pumps Other <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />la. Permit fee (based on current Building Code) $ <br />] 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, lb and 2) $ <br />T_he undersigned agrees to_perform_this job in accordance with the above information, attached-plans-and speci-fications� <br />and the applicable provisions of the National Fire Protection Association Standard(s). <br />Applicant Name (Please print clearly): <br />Applicant Signature: Date: <br />