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2006 <br />c�ry oe <br />• ��is��� <br />Minnesota <br />Fire Sprinkler System Permit Application <br />City of Roseville Fire Prevention Bureau <br />2660 Civic Center Drive <br />Roseville, MN 55113 <br />Phone 651-792-7341 • FAX 651-765-1651 <br />Date of Applic�ion Pertnit Number ReceiptNumber <br />Application is hereby made to the Roseville Fire Prevention Bureau to: <br />❑ Install a new automatic sprinkler system <br />❑ Modify an existing automatic sprinkler system <br />Address Business Name <br />Site Location <br />Name Sheet Address <br />Applicant (or Contractor) <br />City State Zip Code Phone Number <br />Type of System Wet, Dry, Pre-Action, etc. Total Area of Coverage Total Number of Heads <br />Automatic Sprinkler System <br />Type of Sliut-Off Valve Size of Underground Size of System Riser Hazard Type (per NFPA #13) <br />Density-GPM/Sq.Ft. Temperature Rating of Heads Size of Heads K-Factor of Heads GPM Needed <br />Special Hazards to be Protected (high-piled storage, flammable liquids, etc.) Applicable NFPA Standards used <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />1 a. Permit fee (based on current Building Code) $ <br />1 b. Plan check fee (. 65 times permit fee in 1 a above) $ <br />2. State surcharge $ .SO (�r all fire sprinkler en rmit.s — do not change) <br />3. Total permit fee for installation (add la, Ib, and 2) $ <br />Please provide a brief description of work being completed and specify locations of affected sprinkler area: <br />For new installations or in situations where 25% or more of the system's equipment has been moved or changed, the <br />applicant further agrees to conduct an acceptance test in the presence of a representative of the Roseville Fire Prevention <br />Bureau. The acceptance test must be scheduled at least 24 hours in advance. <br />Applicant Name (Please print clearly): <br />Applicant Signature: Date: <br />