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Home My WebLink About08-8250 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813) 780-0020 ANNUAL FIRE PROTECTION MAINTENANCE 8250 Permit Number: 8250 Permit Type: FIRE PROTECTION MAINTENANC Class of Work: FIRE-PROTECTION MAINTENAN E Proposed Use: COMMERCIAL Square Feet: Est. Value: Improv. Cost: Date Issued: Total Fees: Amount Paid: Date Paid: Work Desc: Address: 38250 A AVE ZEPHYRHILLS, FL. Township: Range: Book: Lot(s}: Block: Section: Subdivision: CITY OF ZEPHYRHILLS Parcel Number: 14-26-21-0010-01300-0010 8/25/2008 25.00 25.00 8/25/2008 Phone: FPM-SPRINKLER QUARTERLY FOR ZEPHYR HAVEN NURSING HOME Name: ZEPHYR HAVEN NURSING HOME Address: 38250 A AVE ZEPHYRHILLS, FL. 33542 V::rJ q-f ?Or: 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 INSPECTION CALL FOR INSPECTION - 8 HOUR NOnCE REQUIRED ZEPHYRHILLS FIRE RESCUE DEPT -.Fire Marshal Office - 813-780-0041 813-780-0020 Date Received Owner's Name Owner's Address Fax-813-780-0021 Phone Contact for Pennit Owner's Phone Number "I II I I I I I I n :r!1llW" Lot # I I I TrwT.i.'f nlill.~W Fee Simple Titleholder Name I Titleholder Phone Number I Fee Simple Titleholder Address I r~IH -_~ ~".' l___%m~~,.,~ 135.;150.A Job Address Sub Division ilIIi.6. ,\ !i/i D D D D D D Contractor Signature Address ELECTRICIANI Signature , Address I PLUMBER I Signature Address I MECHANICALI Signature Address I -,><II'" Zevh~llIs I FL. ~ Parcel # tilLl niT li A'If.. . ~~,1Tm k JIT~WiiJl:l lilll'iI1Il1X~ 1M! rrfv.;:nl1llp'" ,j Bio-Hazard Waste Storage - ANNUAL Comm Exhaust Kitchen Hood/Duct Controlled Bum Emergency Generator < 30 kw Emergency Generator> 30 kw Fire Protection Maintenance - ANNUAL ~. y ~~~ Sprinkler l:{J.J'.. 0 0 L-J Fire Alann D 0 0 0 C:=J Hood Cleaning D 0 0 0 C:=J Hood Suppression D 0 0 0 C:=J Fire Alann Installation Fire Pumps Fire Works Flammable Application- ANNUAL Fuel Tanks Other: OTHER Signature Address l, ., ,. ..... . , _ M .,.,._ Directions: ~.'t'n>t;i;l(";l'lTtHI'I'li<i1' Ii':! ,~-, v"~ 33SL/1 I D Fumigation Tent D Hazardous Material (Tier II or RQ Facility) ANNUAL D Hood Installation D LP/Natural Gas-Installation D LP/Natural Gas-ANNUAL Sal D Places of Assembly-ANNU D Recreational Bum D Sparklers D Sprinkler System Installations D Standpipes (Sprinkler Sys) D Torch RoofinglTar Kettle D Waste Tire Storage ANNUAL Valuation of Project Company Registered License # 5,,.,...,pl-o, ~ Y/N I Fee Current Y/N Company Registered License # Y/N Fee Current Y/N Company Registered Y/N Fee Current Y/N License # Company Registered License # Y/N Fee Current Y/N wJ Company Registered License # --~A~:'~~O~l"~~J Y/N Fee Current Y/N I .s'l}:;' .r...->....-~..ll~r~.'. ""''''''- Fill out application completely. Owner & Contractor sign back of application. notarized (Or, copy of signed contract with owner) If over $2500, a Notice of Commencement is required (Mechanical work over $5000) Supply two (2) sets of drawings with applicable documentation Allow 10-14 days for review after submittal date. Parcel # - obtained from Property Tax Notice (http://appraiser.pascogov.com) 'NOTICE OF :DEEDRESTRICTIONS: The undersigned understands that this permit may,besubjectto."deed"xestrictions" which may be more restrictive than County regulations. The.undersigned assumes responsibility for :complial7lce'with any applicable deed restrictions. UNLICENSED CONTRACTORS AND . CONTRACTOR RESPONSIBILITIES: If the owner has -hired:a-'contractor or contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the contractor is not licensed as required by law, both the owner and contractor may be cited -fora misdemeanor violation under state law. If the owner or intended contractor are uncertain as to what licensing 'requirements may apply for the intended work, they are advised to contact the Pasco County Building Inspection Division-Licensing Section at 727-847- 8009. Furthermore, if the owner 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 that he is not properly licensed and is not entitled'to permitting privileges in Pasco County . CONSTRUCTION LIEN LAW (Chapter 713, Florida Statutes, as amended): If valuation of work is $2;500.00 or more, I certify that I. the applicant, have been provided with a copy of the "Florida Construction Lien Law-Homeowner's Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is 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 it to the "owner" prior to commencement. CONTRACTOR'S/OWNER'SAFFIDAVIT: I certify that all the information in this application is accurate 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 permit to do work and installation as indicated. I certify that no work or installation has commenced prior to issuance of a permit and that all work will be performed to meet standards of all laws regulating construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is my responsibility to identify what actions I must take to be in compliance. If I am the AGENT FOR'THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work, plumbing, signs, wells, pools, air conditioning, gas, or other installations. not specifically included in the application. A permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension may be request~d. in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBT IN FINANCING, CONSULT WITH YOUR LENDER OR AN A NEY BEFORE RECORDING YOUR NOTIC C MEN CEMENT. FLORIDA JURAT (F.S. 117.0 OWNER OR AGE Subscribed and sworn to (0 by Who is/are personally known to me or has/have produced as identification. CONTRACTOR Subscribed and sworn by Who is/are personally known to me or has/have produced as identification. Notary Public Notary Public Commission No. Commission No. Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped DETACH BEFORE DEPOSITING No. 3028552 .. INVOICE DATE NUMBER DISCOUNT AMOUNT 08212008 PERMIT082108 0 .00 25 .00 056313 0.00 25 .00 District : 292 Technician Work Report Miguel A Rivera Date of Work: Not Scheduled Technician Owner Christopher R Brackett 15258348 Task Number Scheduled Start Service Request Service Request Customer Acct Customer Name Site Name Contact Name Site Address City State BillTo Name BillTo Address: City State In Planning Time Type Number 213 90 Zephyr Haven Nursing Home Inspection-Auto Gen 10398184 Payment Terms: Immediate Neal Frasier Phone 813 -7825508 38250 A Ave, Zephyrhills FL Zip 33541-5759 Zephyr Haven Nursing Home 38250 A Ave, Zephyrhills FL Zip 33541-5759 Contract Number: 139394 Inspections: Feb 2008, May 2008, Aug 2008, Nov 2008 Service Plan: SP-TESTjINSP Task Type Task Name Problem System Summary Notes 1 Person Inspection SP-Aug 2008 Priority Medium Current Inspection: Aug 2008 Inspection SYSTEM-SP-WET SPRINKLER Wet Sprinkler System Aug 2008 Created BY AutoGen Serial: LEGACY CUSTOMER NUMBER - 01142858 INSPECTION - 1-100% Inspection In January, Smoke Detector Cleaning As Needed, Ahca Inspection In July 100% Sensitivity Testing Required Every Even Year SERVICE - Inspection Comments - KITCHEN PART - 360d FUSIBLE LINKS Quantity: 2 -- Interval: Semi-Annually do not charge service call, $85 plus parts 125.00 a hood cleaning no service call "tl./C:O Fire & Security SiIDple.Grinnell SimplexGrinnell LP 50 Technology Drive Westminster, MA 01441 (978) 731-2500 AP FAX: (978) 731-7756 Payment Requisition Form This form is to be used onlvwhen payment is required and an invoice is not available ( i.e. permits, drawings, bids). If an invoice is available please go through the standard payment procedures for submitting invoices to accounts payable. Please provide a detailed reason for payment and attach any available back up when submitting request. Please supply vendor number. If not available, send an email tosg.apinquiry@tycoint.com. Please fill in "Request for vendor number" in the subject line. Reference the full remit-to address in the body of the email. You will receive either a response with the current vendor number or information on how to have the new vendor setup. This payment will be made per system payment terms. Exceptions will require additional approval. (RM < $25k or VP > $25k) Note: Signature cards must be on file with Accounts Payable for all approvers stating their approved dollar limit. 08/21 /08 Request Date: Requestor: Email Address: Chris Brackett cbrackett@simolexQrinnell Vendor Number: 056313 Pay-to Vendor Name: Remit-to Address Line 1 : Remit-to Address Line 2: City / State / Zip: City of Zephyrhills 5335 8th Street Zephyrhills, fI 33542 Payment Amount: $25.00 Need by Date: 07/02/08 Checks will be cut on Tuesdays & Thursdays Reason for Payment: Permits for sprinkler inspection at Zephyr Haven Nursing Home in Zephyrhills, FL. Delivery Method: U.S. Mail U FEDEX 0 o Deliver to District District Number: 292 FedEx Contact: Scott Brackett Permanent /1 Per District U Deliver to Vendor Vendor Name: Contact: Mail-to Address Line 1: Mail-to Address Line 2: City / State / Zip: Teleohone: Approver (Print Name): Title: Signature: Date: Cost Distribution L- PO Num $Amt a.l 'E #1 1/ 0 a.l #2 Ul ltl #3 .!: ~ #4 ::l a. #5 Subtotal $ - ...... Proj Num Ctrl Dist $Amt Ul 0 #1 () .0 #2 0 ...., #3 ...... () ~ #4 i:5 #5 Subtotal $ - c. Acct Num Dept Dist $Amt x #1 62477 652 292 $ 25.00 w 'C #2 ltl a.l #3 .!: L- a.l #4 > 0 #5 Subtotal $ 25.00 Grand Total $ 25.00 Cost Distribution in balance. Additional Approvals (when applicable) Print Name: Title: Signature: Date: Print Name: Title: Signature: Date: