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2006 <br />c;ry or <br />jJ, <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 Stree[ Address <br />Applicant (or Contractor) <br />City State Zip Code Phone Number <br />Tank Capacity 9in galfons-water capacity, L.P. capacity, or pounds) Container Supports <br />Tank Installation <br />Protection Against Physical Damage (check all that apply): <br />❑ Manual Shut-0ff 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 to Building Distance from Tank ro Fill Point <br />Piping Matenal (sleel, ropper, elc.) 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/Loadin <br />B <br />Compressor Location Pumps Other <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />la. Per►nit 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, lb and 2) $ <br />The undersign�d.agcees_to_perform this j_obin accordance withxhe above_information, attacl�ed-plar�s-an-d-s�ecifcatio�s, -- <br />and the applicable provisions of the National Fire Protection Association Standard(s). <br />Appiicant Name (Please print clearly): <br />Applicant Signature: Date: <br />a <br />