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2006 City of 1J� —� � Nt��egota Fire Extinguisher System Permit Application City of Roseville Fire Prevention Bureau • 2660 Civic Center Drive •Roseville, MN 55113 Phone 651-792-7341 • FAX 651-765-1651 Date of Applicazion Permit Number ReceiptNumber Application is hereby made to the Roseville Fire Prevention Bureau to: ❑ Install a new automatic fire extinguisher system ❑ Modify an existing automatic fire extinguisher system Address Business Name Site Location Name Street Address Applicant (or Contractor) City State Zip Code Phone Number Type of System (Halon, Wet Chemical, etc) Type of Hazard Protected Agent Capaciry Automatic Fire Extinguisher Systems Manufacturer of Equipment Size of Area Protected Method of Automatic Acluation Location of Manual Activation Applicable NFPA Std(s) 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 1 a above) $ 2. State surcharge (.0005 times value of 1 above) $ 3. Total permit fee for installation (add la, Ib and 2) $ Information The undersigned agrees to perform this job in accordance with the above information, attached plans and specifications, and the applicable provisions of the National Fire Protection Association Standard(s). For applications involving the installation of fire protection eGuipment, the applicant agrees to submit three (3) copies of the plans and hydraulic calculations (if required) for review. The plan will show the proposed installation(s) and the location, spacing, and type of equipment to be installed. For new installations or in situations where 25% or more of the system's equipment has been moved or changed, the applicant further agrees to conduct an acceptance test in the presence of a representative of the Roseville Fire Prevention Bureau. The acceptance test must be scheduled at least 24 hours in advance. Applicant Name (Please print clearly): Applicant Signature: Date: