HomeMy WebLinkAbout10-10123 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813) 780 -0020 10123
ANNUAL FIRE PROTECTION MAINTENANCE
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Permit Number: 10123 Address: 7050 GALL BLVD
Permit Type: FIRE PROTECTION MAINTENANCE ZEPHYRHILLS, FL.
Class of Work: FIRE - PROTECTION MAINTENANCE Township: Range: Book:
Proposed Use: MEDICAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 30- 26 -20- 0000 - 00200 -0010
Improv. Cost:
Date Issued: 2/11/2010 Name: FL HOSPITAL OF ZEPHYRHILLS
Total Fees: 25.007 Se e ('vccff1 Address: 7050 GALL BLVD
Amount Paid: 25.00 j t (Ak ZEPHYRHILLS, FL. 33542
Date Paid: 2/11/2010 Phone:
Work Desc: FPM - SUPPRESSION SEMI- FLORIDA HOSPITAL -CRDT PRMT 9735 SCH WK OF 15TH
FIREMA ER FIR PERMIT FEE 25.00
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FIRE AC PTAN E Final IN/
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 $100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMNT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE
OF COMMENCEMENT." _
P �• IT OFFICER
PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813- 780 -0041
813- 780 -0020 City of Zephyrhills Fire. Z 3 Fax -813- 780-0021
Permit Application 3
Date Received I p 2 -/J e /O
Phone Contact for Permit =NM if 7S--
Owner's Name I I Owner's Phone Number I I I
Owner's Address
Fee Simple Titleholder Name Titleholder Phone Number
Fee Simple Titleholder Address I
Job Address rOrt L /c= 7' 7 6) s� 6 z-di (3/+-'d
Lot #
Sub Division Parcel #
n Bio- Hazard Waste Storage - ANNUAL n Fumigation Tent
n Comm Exhaust Kitchen Hood /Duct n Hazardous Material (Tier II or RQ Facility) ANNUAL
El Controlled Bum n Hood Installation
El Emergency Generator < 30 kw n LP /Natural Gas - Installation
I I Emergency Generator > 30 kw n LP /Natural Gas - ANNUAL Sale
n Fire Protection Maintenance - ANNUAL n Places of Assembly- ANNUAL r ,..V.....
fowl ISemiJ Other
i t
Sprinkler n ❑ ❑ ❑ n Recreational Bum C �- � l
Fire Alarm n ❑ ❑ ❑ I I n Sparklers '�Q, O p 5 7
Hood Cleaning IT ❑ ❑ ❑ I I I I Sprinkler System Installations `
•
Hood Suppression 1I ❑ S ❑ I I n Standpipes (Sprinkler Sys)
n Fire Alarm Installation n Torch Roofing/Tar Kettle
n Fire Pumps n Waste Tire Storage ANNUAL
I I � Fire Works
r� Flammable Application- ANNUAL
1 I Valuation of Project
I Fuel Tanks
n Other: I
'r..�✓+,-s:< .FSi3'Y.>5ffi31 3/t'$",.`w ^..te - ;• §,.'4.33334/ 'dE,`!E �',VF � /�I� � 2':� 7 34 «'w:R S: 'i::.'; ...31.4"x...' e,. .m .. e<.:. .�_,°rY -sr...:&`. ..z.:. ._n °Sa. S_. :, ,. '"."t's, : ...,7 :. 6.:re. .r k <. c:.ff .t.s.err , x'444 .. ... a.., -s ,., r »,. r:_ . .
Contractor �7.2 Company m ac - pt..54- - er pcvi -c - 1-er— I
Signature
Registered Y/ N I Fee Current I Y/ N I
Address I L17ci Dc 1 r j - I lv - - 7G _ ‘ I License #
ELECTRICIAN Company
Signature Registered Y/ N I Fee Current I Y/ N I
Address I I License # I
PLUMBER Company
Signature Registered Y/ N I Fee Current I Y/ N,I
Address I I License # I
MECHANICAL Company I
Signature Registered Y/ N I Fee Current I Y/ N J
Address I I License #
OTHER Company
Signature Registered Y/ N j Fee Current I Y/ N I
Address
License #
Directions:
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 DEED RESTRICTIONS: The undersigned understands that this permit may subjectto "deed °:restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for:compliante -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 for a 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 (Chapter713, Florida Statutes, as amended): If valuation of work is $2,500.00 or more,
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'SIOWNER'S AFFIDAVIT: 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 requested, 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 OBTAIN FINANCIN , CONSULT
WITH YOUR LENDER OR AN TT • RNEY BEFORE RECORDING YOUR NOTICE OF
FLORIDA JURAT (F.S. 117.0
OWNER OR AGENT ; /.h. CONTRACTOR
Subscribed and sworn to (or a "T ed) before m - his Subscribed and swom to (' affirmed) before me this
by by
Who is/are personally known to me y Who is/are personally known to me or has/have produced
i d enUfic a vi on. produced as identification.
as ientificti
Notary Public
Notary Public
Commission No.
Commission No.
Name of Notary typed, printed rinted or stamped Name of Notary typed, printed or stamped
FEB -08 -2810 10 :19 From: 2398961695 2398961695 To:919787314671
Pa9e:1 2
Fire & SimplexGrinnell LP
security 50 Technology Drive
SlinplexGrinnel/ Westminster, MA 01441
(978) 731 -2500
AP FAX: (978) 731 -7756
Payment Requisition Form I
This form is to be used g_nly when payment is required and an invoice is= 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 to sg.apinquirygtycoint.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. (AM a $25k or VP . $25k)
Noto: Signature cards must be on file with Accounts Payable for all approvers stating their approved dollar limit.
Request Date: 02/08/10
Cost Distribution
Requester: Mike Snyder Pro' Num Ctrl Dist $ Amt
Email Address: misnyderOsim rJlexarinnell.com r
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Fax ������� }�t'���4;y'Fi!��'�' }.4 i1 {StiGi: '�!� {�5. '1i1 ri5��51!45 X5 ' ! 54 ; � } 5 { {{ ii'�ii5 ^� :j
ax Number: 813 -1731
Acct Num � � � >;., ,,,;i ;I .�'���ii #� €'w��, � "�'',:'�,,, 5
���� fi5'!i'1�:i ii4.�A .l i.L { �, � '� hA� iii }1 i
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Vendor Number: 056313 ti14; 4 „ 51010 ,� Dept
KH510 f Dist 709 25.00
.L'.', }''I��(ti;Ri� {ti1'y��'ii' ?a'ri'l �'S1 {�ii� }'�� �5r” 17;S�til'pi� $ Amt
�� ?� "';'';'q'a r'x���.
}fi�,� ;�,; },. i, ;kdfi'ivl,�' ?s''R' Si,U� y l i /'rrr wr 4,'41d ?I4 ?yr,'n 1i
Pay -to Vendor Name: City of Zephyrhills PO Num $Amt
Remit Address Line 1: 5335 8th Street ---,-------
Remit Address Line 2:
City / State / Zip: Zephyrhills, FL 33542 Q Multiple line distribution,
See next page for breakdown.
Payment Amount: $ 25.00
Reason for Payment:
Need by Date: 02/11/10 Inspection Permit For Zephyrhills Hosp.
Checks will be cut on Tuesdays & Thursdays
"ASAP" will default to Wednesday or Friday delivery.
Please Note: Purchases of non- inventory items of $500 or Approval
Tess should be charged to the Purchasing Card. See Print Name: Mary Vogt
Purchasing Card Manual found at the link below for details. Title: Office Manager
http:// sirnplexorinnell- ia/ Cor0Services /CreditCardPrograms /CardCon Signature: f /
tent /Purchsingcard Man ual.pdf �
Date: 0210811 P 1 -
Delivery Method: U.S. Mail ❑ FEDEX Additional Approvals (when applicable)
IN Deliver to District
District Number: 709 / SG 292 Print : Name;
FedEx Contact: Mike Snyder Titlee
Permanent / 1 Per District Signature:
O Deliver to Vendor
Vendor Name: Date:
Contact:
Print Name:
Mail-to Address Line 1:
Mail -to Address Line 2: Title:
City / State / Zip:
Telephone: Signature:
Date: