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2006 <br />0 <br />c;ry oc <br />�J, <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, D00 ❑ Install L.P. gas equipment — value exceeds $1, 000 <br />❑ Install temporary L.P. gas equipment ❑ Other: <br />Site Location <br />Applicant (or Contractor) <br />City <br />Tank Installation <br />Name <br />State <br />or <br />Street Address <br />Zip Code Phone Number <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 to Building Distance from Tank to Fi <br />Piping Material (s(eel, cnpper, elc.) Piping Size <br />Piping <br />L.P. Gas Vaponzer Type Distance from Vaporizer ro Tank Distance from Vapori. <br />L.P. Gas Installation <br />Gas/Air Mixer Dispensing Equipment Transport Unloading/Loading <br />Compressor Location <br />Pumps <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />la. Permit fee (based on current Building Code) $_ <br />1 b. Plan check fee (.65 tinies permit fee in 1 a above) $_ <br />2. State surcharge (.0005 times value of #1, above) $ <br />3. Total permit fee for installation (add 1a, 1b and 2) $ <br />Other <br />to <br />The undersigned_agrees to perform this job in accordance with the above information, attached-plans and specifications; <br />and the applicable provisions of the National Fire Protection Association Standard(s). <br />Applicant Name (Please print clearly): <br />Applicant Signature: <br />Date: <br />