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2006 <br />c;ry ae <br />�J, <br />� <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 />Da[e 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 Name <br />Site Location <br />Name Sireet Address <br />Applicant (or Contractor) <br />City State Zip Code Phone Number <br />Tank Capacity 9in gallons-water capaciry, L.P. capacity, or pounds) Container Supports <br />Tank Installation <br />Protection Against Physical Damage (check all that apply): <br />❑ Manual Shut-Off Valve ❑ Excess Flow Valve Internal Valve <br />❑ Pressure Relief Valve ❑ Liquid Level Gauge Pressure Valve <br />Distance from Tank to Property Line Distance from Tank ro Building Dis[ance from Tank to Fill Point <br />Piping Material (sleel, 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 Unloading/Loading <br />Compressor Location Pumps Other <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />1 a. Permit fee (based on current Building Code) $ <br />l b. Plan check fee (.65 times permit fee in la above) $ <br />2. State surcharge (. 0005 tinzes value of #1, above) $ <br />3. Total permit fee for installation (add la, Ib and 2) $ <br />The undersign�d_agcees to perform_this j_o_b_inaccordance_with_the above_inf�rmation, attached plans-and�pecifcations, -- <br />and the applicable provisions of the National Fire Protection Association Standard(s). <br />Applicant Name (Please print clearly): <br />Applicant Signature: Date: <br />� <br />