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<br />~Qa.~ ~~~~~_ J Owner's Phone Number <br />L)~2L.\~ .~,Q~ Z ~~"^,~~~ \-L <br /> <br />F!Cp. Simple Titleholder Name r. I TItleholder Phone Number J I I I j <br /> <br />,:ee ~:Ple Titleholder Address L~ . . . . _ """"~ = ,_,""'~~ <br />",~';~m..~~-~~~~:::._~,=...,--,~,~~ ., = - <br /> <br />Job I'J:Idress I i Lot # I <br /> <br />Owrlf"r's Name <br /> <br />Owner's Address <br /> <br />Sub Division <br /> <br />Fax-813-780-oo2.1 <br /> <br />.. ,~ .~cJ. ,I __...,. _. . .I_I ,~~ <br />115~: J I (O~ <br /> <br />......~~~ <br /> <br />Parcel # <br /> <br />\ vb I hINl::'.U rKUM t-'KUt't:K I ~ I AJ\. I\IU Ill,;t:.) <br />.~~,...~ <br /> <br />[] <br /> <br />~c...t.~",<..;~~~~~~~C-JUr~-~-": <br /> <br />Bin-Hazard Waste Storage - ANNUAL <br /> <br />Fum~g?ticn Ten: <br /> <br />j"'; <br />L--J <br />D <br />D <br />D <br />~ <br /> <br />D <br />D <br />o <br />o <br />o <br />D <br /> <br />Comm Exhaust Kltchen Hood/Duct <br /> <br />o <br />o <br />D <br />o <br />o <br />D <br />o <br />D <br />o <br />o <br />D <br />D <br /> <br />Controlled Bum <br /> <br />Emergency Generator < 30 !\w <br />Emergency Generator;;> 30 IIw <br />Fire Protection Maintenance - ANNUAL <br />Sprinkler 0 <br />Fire Alam] 0 <br />Hood Clean/Suppression ~ <br />Fire Alarm Installation <br /> <br />Fire Pumps <br /> <br />Fire Works <br />Flammable Appftc3tion- ANNUAL <br /> <br />Fuel Tanks <br /> <br />Ha.."'ardous Materia! (Tier if or RQ Facility) ANNUAL <br />Hood InstaUation <br /> <br />LP!Natum! GaE-instaliaticn <br /> <br />LPINatural Ga!O-ANNUAL Sale <br />Places of Assembly-ANNUAL <br /> <br />R2creaunnai Bum <br /> <br />Sparklers <br />Sprinkler System installations <br /> <br />Smndolpes (Spinkler Sys) <br /> <br />T arch Reofing <br />Waste Tire Storage ANNUAL <br /> <br />L <br /> <br />. t Valuation of Project <br /> <br />Other: <br /> <br />Contractor <br />Signature <br />.Address <br /> <br /> <br />ELECTRICIAN <br />Signature I <br /> <br />Address ! <br /> <br /> Ccmpany <br /> REgistered <br /> Ucense '# <br />\ Compa.'1Y \ <br />Registered <br />I License '# r <br />\ Company ! <br />Registered <br />I License '# I <br />l Compan',' ! <br />Registered <br />I Ucense # ! <br />I Company I <br />I <br />Regi!;tered <br /> <br />PLUMBER <br />Signature <br /> <br />Address I <br /> <br />MECHANICAL\I <br />Signature . <br /> <br />Address I <br /> <br />OTHER <br />Signature <br /> <br />Y/N <br /> <br />YIN <br /> <br />Fee Current <br /> <br />Y!N <br /> <br />Fee Current I. Y J N <br /> <br />y / ~ Fee Current <br /> <br />YlN <br /> <br />Y/N <br /> <br />I' Fee Current <br />I <br /> <br />Y/N <br /> <br />YiN <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />~~,d~~;I~ ~_ '.~~_' . .. . .... .. ... I Ucense#l I <br />DirBctions: ~ ~ -..- "-_.~"-"'-"",",,,'. ~.~~.:-~,,-=,.~.~'....~...,"""""""'~' u>_.~""".,<,.~,..~-"""",,,,,_~~,~ -', -,-,~~---_."" ~ <br /> <br />RIl out application completely. <br />~wner & contractor. sIgn back of ap;:lication, T.otartzed (Or, copy of sigmod contra:;t with owner) <br />IT over $2500, a Notics of Commencement is required (Mechanical \\'Clrt,'er $5000) <br />Supply two (2) sets of drawings ....lith applicable documentation <br />."'.liew 1 0-14 days for review after submittal date. <br />