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<br />o <br /> <br />Date RG' W' 'lid <br /> <br />OWner's Name <br /> <br />owner's Address <br /> <br />!,'AX <br />.0 <br /> <br />v!tY or .Lepnyrnms rlre <br />Permit Application <br /> <br />~OOl <br />nlx-o lv-fOU-W":: I <br /> <br />.~ <br />I <br /> <br />.~~ <br />I . <br /> <br />~/ <br />" <br /> <br />Phnnp.. ~~r.t tnr flermit <br /> <br />~:.. ~ .11.;1 t!' <br />1'1' /,1 <br /> <br />Owner's Phone Number <br /> <br />TiUeholder Phone Number I <br /> <br />I <br />'/ <br />173 s-o <br /> <br />/.1 <br /> <br />Ie <br /> <br />Fee Simple Titleholder Name <br /> <br />Fee Simple Titleholder Address <br /> <br />Job Address <br /> <br />Sub .Division <br /> <br />,fl. 'Z>qi'1 <br /> <br />~.I ~~(~il'J. f~u.::.~.~c:t:,AX"U~ <br /> <br />P'uIIIIYdti!J1I T ..Ill <br /> <br /> <br />~ <br />D <br />o <br />D <br />o <br />,0 <br /> <br />o <br />o <br />,0 <br />D <br />o <br />o <br /> <br />EI' <br />D <br />o <br />o <br />o <br />D <br />o <br />D <br />D <br />D <br />o <br />D <br /> <br />Sparklers <br />Sprinkler System InstaUaUons <br />StandpipeS (Sprinkler S15) <br />Torch Roofing <br />Waste Tire Storage ANNUAl <br /> <br />ttlo-riazara vvaSl8 6wrage - ANNUAL <br /> <br />Coinm Exhaust KItd1en Hood/Duct <br />ConlrcU8d Bum <br />, Emergency Generator < 30 kw <br />Emergency Generator> 30 kw <br />Fire Protection Maintenance - ANNUAL <br /> <br />Hazardous Material (Tier II or RQ Facility) ANNUAL <br />Hood Installation <br />LP/Natural Gas-lnstaUation <br />LP/Natural Gas-ANNUAL Sale <br />Places of Assemb/y-ANNUAL <br /> <br />.2S:I G".. -\-t' \'\ <br />D <br />D <br /> <br />Sprinkler <br />Fire Alarm <br />Hood CleanlSuppression <br />Fire Alarm Installation <br />Fire Pumps <br />Fire Works <br />, Flammable Application- ANNUAL . <br /> <br />Recreational Bum . <br /> <br />FUel Tanks <br /> <br />. J <br /> <br />'l Valuation of Project <br /> <br />Other: <br /> <br />ContnlclDr <br />Signature, , . <br />AddfSSS I J.f7CJ( ~k.. rr-r -{ft.- ~ ~ .,"",.. <br />ELECTRICIAN I <br />Signature I ' <br />, Address I 'I <br /> <br />~~:~ I ,/ <br /> <br />~~I I <br />.' ~ECHAN'C4 I <br />SIgnature ' <br />~~!I <br /> <br />~~ 1 I <br />Signature <br />~ress' I <br />Directions: <br /> <br />, , . Cc:'mpany I <br />' Registered , <br /> <br />License # I <br /> <br />~mpany I <br />Registered <br /> <br />License # I <br /> <br />Company ',I <br />Registered . <br /> <br />License # ., <br /> <br />=:e:d I <br /> <br />License # I <br /> <br />==~d , <br /> <br />Licer1$e # J <br /> <br />Qj m-Jl /.tv Gr-. n 'Ii <br />Y/N. r ~eeCummt rY/N I <br />I <br /> <br />Y I N ~ Current ./ Y I N I <br />I <br /> <br />Y/N Fee Current Y/N I <br />I <br /> <br />Y IN I FeeCurrent Y I N I <br />I <br /> <br />Y/N I FeeCummt Y/N I <br />I <br /> <br />Fill out appIlc:a1lon completely. <br />" --,- '-- '........ --. --0'Wi"iei"3-asntnierorSl~rnnfClnjf'BPPllditiOn. 'notariZealm;-copyonjgneacomraefWltff~WN!l'} <br />If over $2500. a Notice of Commencement Is required (Mechanical work over $5000) <br />, Supply two (2) sets of drawings wllh appficable documentation <br />Allow 10-14 days for review after submittal date. <br />