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2006 <br />c;ry of <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 />Da[e ofApplication Permi[ Number ReceiptNumber <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, D00 <br />❑ Install temporary L.P. gas equipment ❑ Other: <br />Address <br />Site Location <br />Applicant (or Contractor) <br />c��y <br />Tank Installation <br />Name <br />Tank Capacity <br />State <br />Business <br />Zip Code <br />L.P. capacity, or pounds) � Container Supports <br />Protection Against Physical Damage (check all that apply): <br />❑ Manual Shut-Off Valve ❑ Excess Flow Valve Internal Valve <br />❑ Pressure Relief Valve <br />Distance from Tank to Property Line <br />Piping ' v <br />L.P. Gas Installation <br />Gas/Air Mixer <br />Phone <br />❑ Liquid Level Gauge Pressure Valve <br />Tank to Building Distance from Tank to Fill Poin[ <br />a� (s�ee�, copper, etc.) <br />L.P. Gas Vaporizer Type <br />Dispensing Equipment <br />Pumps <br />Permit Fee Calculation <br />1. Fair market value of job $ <br />la. Permit fee (based orr current Building Code) <br />1 b. Plan check fee (.65 times pernzit fee in la above) <br />2. State surcharge (.0005 times value of #1, above) <br />3. Total permit fee for installation (add la, Ib and 2) $ <br />$ <br />$ <br />$ <br />to Tank Distance from Vaporizer to <br />Transport Unloading/Loading <br />_The undersigned agrees_to perform_this job in accordance_with theabove informatian, attached-plans-and speci-fications� <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 />