HomeMy WebLinkAbout08-8024
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813) 780-0020
ANNUAL FIRE PROTECTION MAINTENANCE
8024
ermit Number:
Permit Type:
Class of Work:
Proposed Use:
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
8024
FIRE PROTECTION MAINTENANC
FIRE-PROTECTION MAINTENAN E
COMMERCIAL
Address: 5935 GALL BLVD
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s}: Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number:
6/30/2008
25.00
25.00
6/30/2008 Phone:
FPM-ANNUAL FIRE ALARM-BARGIN WAREHOUSE
Name: AIN WA
Address: 5935 GALL BLVD
ZEPHYRHILLS, FL. 33542
~0~jb
Qr l\:<'
Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire
prevention and protection related activities such as inspections, plan review, administrative fees, and other
costs related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMNT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE
OF COMMENCEMENT.'.
-...
P IT OFFICER
PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPEcnON
CALL FOR INSPEcnON - 8 HOUR NOnCE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813-780-0041
JUN/26/2007/TUE jl:09 PM ZEPHYRHILLS BUILDING
FAX No, 813-780-0021
p, 002
'~,i .~.RecejV8d . '/
Owner's HeIne ~ T
Owf\8r's Address .5 OJ 3 ~5
City of Zephyrhllls'Fire.: '. .
Permit Appicatlon
. :.' ': -., . :Pt;;):~for Permit ~
~. ~8 Phone Number .1
1l.x..813-780-0021
813-7SD-0020
. ~~
~.~
I.
PaRl8l*
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J Lotti
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Fee Simpls T1l1eholder Nam.
Fes Slm..'lllIehoIdsr Ad.4I1lH r
:= I ~~E-
"T\tI~~ PII~ Number .I
o Bio-Hu8rd Wa&1e StarSllS ..ANNUAL :D Fumlglllion Tent .'
D' Comm Exheu&t Ki~" HoodIDuct . '0 Hazafdau& Materiel (TIer II or RQ FadIlly) ANNUAl...
o CQntralled Bum . D Hood instillatiOn
D Emergerq Genendor ~ 30 kw . 0 LP~\UI'al cm-InSlalldon
~ 'Emergency Gener*r > 30 kw. . D lP/NatWa! Gas-ANM~AL Sa.
. Fir~ ProMIellon MsinlItnance. NI~ I!!!!!J ~rm" '. . D . Places of Assembl)'-ANNUAL
Spflnkler '. ~. . ~ , ..0 '. D ~8um
Fire Alarm 0 0 .' D Spartdef's
Hood Cleaning 0 1:1 0 0 Spl1nkler Sy&18m In8IIlIIiIllons .
Hood Suppmeion. 0 o. 0 0 . D standplpss (Sprlnld&r Sys)
Fire AIann Inftllllslion '8 1'orch RoolIngITllI' KeltIe
Fire Pump9 Waste TiI'8 ~1I ANNUAL
FII1I Works.
F\ammIIble Applimian- ANNUAL. ) -J Valuation o~ Project
Fuellenka .
other:
co~r v . ~ny ., c.~..z:-~L~~/c.. 5eCu&ITY
Signa1U'e ^ c." . . . R8g1stered'. (Y>iNI Fee ClImlnI . ~ 1-' sY.5~.
EL=~'110 ;J. J.WIg. r~ I.kc:!1tt// :::r~.=:-1*E ~ta20':l4: : f..dC'
Signature L . -----=-.:.... RsgIslol1ld trrN _ Fee CuI!1ll1t _ Y I N _ .
AddnIIi& I r' Licsn&ef I l
= I 1 .= I Y/N r=.ec:unent LY/N I ~
Address I I UClInIe" l I
==CAL! I :~ Iv I N I Fee CumIftt 1 Y'I N I
Addfe8a I I .licsnse , c::. I
:::.. I ~~ r YJN l'eeeun.nt V/N
AddAlA j I Ucen&8 fI ~
Di~OI'\I:
F1I"outlllJlllllll:8tjon ~.
Owner & Connclor sign b80k at lIPPIicIItion. noIartzed (Or. cap)' of sIgnsd con1l'aCt IIVIlh 0WIl8r)
If over $2600. . Nab at CarnmencelY1lri "lWqUIred.(~I_rk _16000) .
Supply two (2) .... of dnIwing& with applicable daculMnlatlon .
Allow 10.14 da)'& for review.,. Bubmlllal d8le. P81'C9!i#.- obtained from PropenyTax Noitce (h1lp:/IappraIser.pucagov.com)
JUNIZ8/2007/TUr 01 : 13 V1l ZEPHYRHI LLS BUI LIJING
FAX No. 8IJ-7~IT-rrIT21
P,003
'NOTICE C)F :DEEO 'RESTRICTIONS: The .un~erslQned~u!1de~~nds .that this permit mqy be;subjeotito'.!'d-*i~w~r.Ictions-' .
, .which may' be more ~trictive thEm County. regulations. .' The',utidersigned ,assumes responsibility Jor :t:Qmp'ia~'with any."
_applicable deechestrictlons.. . ".,
'UNLlCENSED ~CONTRACTORS AND 'CONTRACTOR Rf:SPONSIBlJ.;lTItS: ,.If"the. owner has -hlred':a~contractot 'or"... .
contractors 10 undertake work, they mllY be reqwired 10 be licensed in accordance with state and local" r~ulatlons. If the
contractor is not licensed as required by law, bOth the owner and 'contractor may be cited "for a "misdemeanor violation
under state law. If :t)le owner or Intended contractor are uncertain ,as'to what licensing TeqUirement8 may;apply for the
intended wor1(,1hey are advisec:l"to contact the;Pasco County Budding Inspection'Olvlsion-Licensing Section...~ 727:.s47-
8009. Furthermore. 'if the 'pwner has hired -a contractor. or .contractors, he is advised.to.have"the contractor(s) sign
, portions of.the *contractor . Block- of this application 'for which -they will be responsible. If you, as'the owner 'sign 'as the
contractor.. that may be an indication .tha1 he is 'not property licensed and.is ~t entitled'to 'pennJttlng..priVileges in .Pasco
County.. . ' .
CONaTRUCTION .uEN,LAW (Chapter713. 'Florida Statutes,:as :amended): 11 valuation of work.ls '$2;500.00 or mOre, I
certIfY that 1. 1he applicant, have been provided wcth a copy of -the "Flortde Construc:tiOn 4en .Lew-Homeowner's
.Protection Gulde-.prepared by1he Florida Department of Agrlcuhuf8 and Consumer A~lrs. If the applicant ~ 'someone
other than the '''owner'', I certify that I have obtained a copy of the above described document and promise in good. faith to
deliver if to the.~ prior to commencement .. '
'CONTRACTOR'SlPWNER~S.AFFIDAvrr: .1 ~ that all ,the infonnatlon in this application' is aoourate and
that all work will be done In Compliance with all applicable laws regulating construction, zoning and land
development. Application is hereby made to obtain a ~it to do work and Installatlon.as. indica~. I certify
that no work or installation has comme~ prior"to Issuance o"a permit and-that all work will be perlormed to
meet standards of all laws regulating construction, County and ~ity codes. .zoning regulations, and land
development ragulation~ In ft:1e Jurisdiction. I also certIfY that I' undel'6tand that the regula~ons of other
. government agenaies .may aPPly'~ the:intsnded'lNDrk. and that it is my responsibility to identify what actions I
must take' to be In compllanoe. - " '
If I am the AGeNT 'FOR 'THE OWNER, I promise In good faith to Inform the .owner of .the pennltting conditions set forth in
this. affidavit prior to commencing constructJon: .1 understand that a 8epara~ permit may be required for electrical work,
plumbing, signs, wells. pools. air conditioning, gas. or other installatione not spectflCally included in the -application. A
permit issued shall be construed to.be a licenee to proceed with the work and not as authority to violate. cancel, ~lter. or
set aside any provisions of the ~chnlcal oode8, nor shall issuance of a permit prevent the ~uilding OffICial from thereafter
requirlnta.correctlon of errors in plans, cOn$truction or violations of any codes. Every permit issued shall bec:ome invalid
unless the work autho~ by such permit Is cOmmenced within six months of permit Jasuance. or If work authori;zed by
the .permit is suspended or abandoned for a per10d of six (6) months after the time the WO{k Is commenced. An extension
may be llIquested, In writing, from the Building QfJicl8t for a period not to exceed ninety (90) days and will demonstrate
justifrabte c:auset~ the extenSion. 11 work ceases for ninety (90) C?Onsecutive days. the job Is considered' abandoned.
'WARNING TO OWNER: -YOUR 'FAlLURE TO ReCORD A 'NOTICE "OF 'COMMENCEMENT
PAYING .TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN
Y R OR N AT1"ORNEY RE DING Y, F
FLORIDA JURAT (F.S. 117.03)
OWNER OR AGENT .
, SubeafbedllflCf $Mlm to (or alinned) before me this
py
W10 lalare pereonaIIy known lID me or I1as/hlWe ~
. 8!l idenlltlcation. .
ESUL T IN 'YOUR
lNG, CONSULT
NoI8ry PubPc
Notary Public
Commission No.
~mmission No.
Name of Notmy~. printed or s1Bmped
Name of NoI8ry typed; printIId or s1Bmp8d
.'
Jun 30 08 08:51 a ESSI
(813) 931-4048
p.1
E.S.S.I.
Phone:(813) 935-7487
Fax: (813) 931-4048
FAX TRANSMISSION COVER SHEET
RECIPIENT: Bobbie or Jackie
COMPANY: City of Zephryhills
FAX NO.: 780-0021
SENDER: Roger Estrada
COMMENTS: Thank you
ELECTRONIC SECURITY SYSTEMS, INC
8910 N. DALE MABRY HWY #11
TAMPA, FL. 33614
Date: June 30, 2008
Jun 30 08 08:51 a
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From Carey Roberts At: Brown & Brown FaxID: To: Building Dept
Date: 613012008 08:57 AM Page: 1 of 3
ACORD... . CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYYYYI
6/30/2008
PRODUCER Phone: 941-205-2040 Fax: 941-205-2048 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Brown & Brown of Charlotte County ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
126 E Olympia Ave Suite 200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Punta Garda FL 33950
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Owners Insurance Co. 12700
A Window Pro Contracting, Inc INSURERB:
Richard Leonard
28230 Pasadena Dr. INSURERC:
Punta Garda FL 33955 INSURERD:
INSURERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~:: ~DD'L POlICY NUMBER P~,i~:~~8,W.E pg...Lfl,=,WlN LIMITS
NSR
A ~NERAL LIABILITY 20588793 6/21/2008 6/21/2009 EACH OCCURRENCE $See Attachec
X- 3MERCIAL GENERAL LIABILITY PREMISES iFa occur""ce) $See At tachec
- CLAIMS MADE Ii] OCCUR MED EXP (Anyone person) $See Attache
PERSONAL & HJV INJURY $See Attache(
-
GENERAL AGGREGATE $ Sep ll.r tache!
~'LAGG~n LIMIT 7lPER: PRODUCTS - COMPIOP AGG $Spe ll.trache
X POLICY ~rc?T LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Eaaccid""t)
-
- ALL OWNED AUTOS BODILY INJURY
(per person) $
SCHEDULED AUTOS
f--
f-- HIRED AUTOS BODILY INJURY
(per accident) $
f-- NON-OWNED AUTOS
f-- PROPERTY DAMAGE $
(per accident)
~GE LIABILITY AUTO ONLY - EA ACCIOENT $
mv AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
~ESSI\JMBRELlAlIABlurY EACH OCCURRENCE $
OCCUR 0 CLAIMS MADE AGGREGATE $
$
:=j ,DEDUCTiBlE $
RETENTION $ $
WORKERS COMPENSATION AND I WCSTATU- I IOJ~-
EMPLOYERS' lIABILITY
ANY PROPRIETORIPARTNERlEXECUTIVE E.L. EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
II yes. deSC~be under
SPECIAl PROVISIONS bel"'" E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE S I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
:;lass, Door and Window Installation - Refer to attached for General Liability limits of coverage
ontractor: Richard Leonard
CERTIFICATE HOLDER
City of Zephyrhills - Building Dept
5335 8th Street
Zephyrhills FL 33542
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUI' FAILURE TO DO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
ACORD 25 (2001108)
From: Carey Roberts At: Brown & Brown FaxID: To: Building Dept
Date: 613012008 08:57 AM Page: 2 of 3
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
From: Carey Roberts At: Brown & Brown FaxlD To: Building Dept
Date: 613012008 08:57 AM Page: 3 of 3
Owners
Page
55040 (11/87)
Issued 05-06-2008
TAILORED PROTECTION POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING. MI 48917-3999
AGEtICY BROWN & BROWN OF FLORIDA INC
12-0124-00 MKT TERR 068
INSURED A WINDOW PRO CONTRACTING INC
(866) 727-0908
Renewal Effective 06-21-2008
POLICY NUMBER 002312-20588793-08
ADDRESS 28230 PASADENA DR
PUNTA GORDA, FL 33955-2451
Company POLICY TERM
Bill 12:01 a.m. 12:01 a.m.
06-21-2008 to 06-21-2009
In consideration of payment of the premium shown below, this policy Is renewed. Please attach Ihis
Declarations and attachments to your policy, I f you have any questions. please consult with your agent.
COMMERCIAL GENERAL LIABILITY COVERAGE
LIMITS OF INSURANCE
Bodily Injury General Aggregate
Property Damage General Aggregate
Bodily njury Products/Completed Operations
Aggregate
Property Damage Products/Completed Operations
Aggregate
Personal Injury And Advertising Injury
Bodily Injury
Property Damage
Damage to Premises Rented to You (Fire Damage)
Medical Payments
$300,000
300.000
300,000
300,000
300,000
300.000 Each Occurrence
300,000 Each Occurrence
50,000 Any One Premises
5,000 Any One Person
Twice the "General Aggregate Limit", shown above, Is provided at no additional
charge for each 12 month period in accordance with form 55300.
AUDIT TYPE: Annual Audit
FORMS THAT APPLY TO THIS COVERAGE: 59350 (01-08) 55068 (08-89) IL0021 (11-85)
CG0220 (07-92) IL0017 (11-85) 55146 (06-04) 55188 (09-04) 55238 (06-04)
55296 (07-05) 55300 (07-05) 55051 (12-04) 55202 (12-04)
06/30/2008 08:10
8132078906
POSEN CONSTRUCTION
PAGE 01/01
HILLSBOROUGH COUNTY BUSINESS TAX RENEWAL INSTRUCTIONS
Chapter 205.0535 (5) Florida Statutes requires one of the fol/owing:
FEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER
1. SIGN and return entire form in enclosed envelope. Your validated Business Tax receipt will be returned to you.
2, Business Tax receipts expire midnight. September 30th, Failure to display a valid Business Tax receipt after
September 30th is a violation of Hillsborough County Ordinance 95-4, as amended by 02-5,
MAKE CHECK PAYABLE TO:
DOUG BELDEN, TAX COLLECTOR
POBox 172920
TAMPA, FL 33672-0920
2007-2008 HILLSBOROUGH COUNTY BUSINESS TAX RECeiPT
L(cIU'IIOf~*CI-II~ES cilllm"OU$ --.-.'o['Fll"---or r~LO'I'EES.- -'..1'[ I
EXPIRES 9-30-2008 ~OLIO NO.
. rr- - 189020
H.VVASTE TAX
SURCHAMe
40.00 18.00
ace. CODE
090.010
BUSINESS 1YF'~
GENERAL CONTRACTOR (ROOFING)
BUSINESS
LOCATION
2501 BORDEAUX WAY
I:.UTZ335S9. .....' f. .
PERKINS JAMEY L. . . . .,',): I'
ALt~TECk" BUILbf:RS , ALL:itCH ROOFING' INC" ,.. -
2501 BORDl:AUXWAY
LUTZ FL. 33559
HAS HPeDY PAID A .-R1II1l.!Gl! fA)! TO ENQAc;:f;
IN BUStNESG. PRCFE!I..'tION. O~ OCC\JPAT1ON SPl!COPll!D HEREON.
DOUG BELDEN. TAX COLLECTOR
8'~5200 .
THIS BECOMES A TAl( RECElPTWIEI\l VALIDATED.
Bu 50 .Tot.1 k Ht:'\za.r d J..Jq st ~
[lr,:.l.'~ Be Il! ~~n.' Hill St. or c\u3h Coon t ~ T me (: 1)
HlJc::h;:: 19nn OO~. rutl.:cwsl~
TrClrr'; ::-~2J. F'~C""Pt. ;;; (116~~3
A.:d.~ .U~7'/.r)r.1 PO!l C:od!2: ,no.!!
06/271100B NTOI 2~OB '72.50
03~;''! SUf'.:htlJ'!:l!:::
C'351 Hu~inI;r5~ ru.'"!
Cash fqndp.r'!?lj:
Chcln.9€ Tl:!r.i.1€1'(?(I:
:Ii 50 ;JO
$22 c:C,
$1UO.:]0
~$27.5(1i
NAME
MAIUNG
^DD~ESS
BUSINESS TAX
4206 18902000001 000018002 000040006
\
f-h-fo'l:> Uwll"1
ZEPHYRHILLS FIRE DEPARTMENT
6907 Dairy Road, Zephyrhills, FL 33542
Bus (813)780-0041 Fax (813)780-0044
Fire Chief Keith Williams
FIRE SERVICE USER FEES
Occupancy No.:
Plan No.: 08 - OS-W ~
Business Name: 'vi ~ n --:f--e
Business Address: . t5. ~
Business Phone No.:
Business Fax No.:
Contact:
PLAN REVIEW FEES
B Site Plan N/C
Multi-Family/Commercial .06 sf
(Minimum Charge $25.00
o Plan Revisions . DBl
INSPECTION FEES
NlC
N/C
$100
$250
$500
$100
Annual
1 st Re-/nspection
2nd Re-/nspection
3rd Re-/nspection
4th Re-Inspection
(Business closed until
violations corrected)
SPRINKLER SYSTEMS
~ Hydro Undergrounds $45
Hydrostatic Test $65
Acceptance Test $45
Hydrant Flow $75
$15 perwaJl
$25 pertank
$25 per system
$50 ~ Tent 1 0'x1 0' or g/"l!l!lter
Fire Pump
$50 . Fire Suppression
$5O)lL System Acceptance
$50 B EXhaust HoodIDuct $30
$50 Re-/nspection DBl
(other than annual)
$50 0 Inspection scheduled DBl
and cancelled less than
24 hours
B Construction Insp. N/C
Emergency, Vehicle ACt $50
PLANS TOTALCI:IDJ INSPECTION TOTALc=J
SPRINKLER SYSTEMS
a 0 - 25 Heads $50
. 26 plus Heads $100
STANDPIPE SYSTEM
o Per Riser $50
FIRE PUMP
o Per Pump
FIRE ALARM SYSTEM
B 0 - 25 Devices $50
26 plus Devices $100
SUPPRESSION SYSTEMS
B:: E
a Other $50
KITCHEN EXHAUST
o HoodIOucts
OTHER
o LPlnstallalion per tank
l.)( Fuel Tank Installation
(Per Tank)
o Natural Gas Installation
(Per System)
o Spray Booth
Comments:
ARE ALARM SYSTEM
B System Acceptance $50
Recall Acceptance $50
OTHER
~ Fire WalllSmoke Wall
lP Gas
Natural Gas
GRAND TOTAL
$15
$45
$30
contraclor.~ll(.~ R~..,(e....
Billing Address: ~~-:;:--h{~ I ~
Billing Phone No.: ;
Billing Fax No.:
Contact:
per system
per system
PERMIT FEE FALSE ALARM FEE
Sprinkler $50 1 st Alarm NlC
Standpipes $50 2nd Alarm N/C
Fire Pump $50 3rd Alarm N/C
Hoods $50 4th Alarm $100
Fire Alarm $50 5th Alarm $150
lP Gas $50 6th Alarm $200
Natural Gas ~ NON COMPLIANCE $150
F~ITanks- pertank. $50 Z-
Sparklers
Fire Works $500
CampFire $25
Controlled Bum $100
Hood/Duct $50
Place of Assembly $50 Annual
.Fire Protection $25
Flammable Application $50 Annual
Waste Tire storage $50 Annual
Generator < KW $100
Generator>3Q KW 150
Bic-Hazard Waste $100 Annual
Fumigation Tenting $50
Torch Pot/Applied $50
Haz. Materials $100 Annual
perlllnt
B
r/TM, FALSE ALARM
PERMITTOTAL~- TOTAL)
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Date:
Ins~ctor: ~
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