Laserfiche WebLink
<br />06/13/2008 14:53 FAX <br />811-780-0020 <br /> <br />~ Receil'ed <br /> <br />OWner's Name <br /> <br />Owners Address <br /> <br />~006 <br />rax-tl1i1-7BO-0021 <br /> <br />I !/! ~~ <br />./ <br />I <br /> <br />...// <br /> <br />City otLeptlymms t-Ire <br />Permit Application <br /> <br />Phon.. r:nI'ltRQ mr Permit "' ~3 <br /> <br />Owner's Phone Number I <br /> <br />JJ: '.<< 5_2JJ~_~f ( <br />11"'.[== <br /> <br />I <br />'1 <br /> <br />Fee Simple TiUehoJder Name <br />Fee Simple Titleholder Address <br /> <br />I TItleholder Phone Number <br /> <br />Ie <br /> <br />,./ <br /> <br />Job Address <br /> <br />Sub Division <br /> <br />I 7:No -0.,"'1 ~4_ <br /> <br />Zt.lhy'illb ( rL <br />I Parcel # <br /> <br />3sS'c.to I Lot# C <br />'1 <br /> <br />lUtllAINt;LI r~UIVl I"'KUI"'CK IT \I\A NU 11l.'t:) <br /> <br />flUllliYdtlUIl T ..,.1 <br /> <br />~ <br />o <br />D <br />o <br />D <br />D <br /> <br />.. '",,, <br /> <br />'0 <br />o <br />.0 <br />o <br />D <br />,0 <br /> <br />tslo-Mazard vYasle Storage - ANNUAL <br /> <br />Co~m Exhaust KItchen Hood/Duct <br />Controll8cl Bum <br />. Emergency Generator < 30 kw <br />Emergency Generator> 30 kw <br />Fire Protection Maintenance - ANNUAL <br />Sprinkler D <br />Fire Alann ~ <br />Hood C1ean/S....ppression D <br />Fire Alann Installation <br />Fire Pumps <br />Fire Works <br />Flammable Application,. ANNUAL . <br />Fuel Tanks <br />Other: <br /> <br />Con1ractor <br />Signature. . <br /> <br />Address I <br /> <br /> <br />ELECTRICIAN <br />Signature I <br /> <br />. Address I <br /> <br />PLUMBER I <br />SlgnaluRl <br /> <br />Address I <br /> <br />. MECHANIC4 <br />Signature . <br />Address I <br /> <br />OTHER I <br />Signature <br />Address I <br />Directions: <br /> <br />J.f7~( ~k.. ..Fr-r .,t. ~ · fZI.-. '",q <br />, <br />./ <br />I <br />I <br />I <br />I <br />I <br />, <br /> <br />Hazardous Material (Tier" or RQ Facility) ANNUAL <br />HdOd Installation <br />LP/Natural Gas-lnstallation <br />LPlNatural Gas-ANNUAL Sale <br />Places of Assembly-ANNUAL <br />Recreational Bum <br /> <br />Sparklers <br />Sprinkler System Installations <br />StandpipeS (Sprinkler Sys) <br />Torch Roofing <br />Waste rue storage ANNUAL <br /> <br />. f Valuation of Project <br /> <br />.. Company I <br />. Registered <br />License # I <br />Company I <br />Registered <br />License # I <br />Company j <br />Registered <br />License # ., <br />Company I <br />Registered <br />License # I <br />Company I <br />Registered <br />license # '- <br /> <br />Qj m-((J~ Gt-.n 'Ii <br />Y IN,. T Fee Current ry I N I <br />. ' . <br />I <br />I <br />I <br /> <br />. . 'to <br /> <br />Fee Current' I <br /> <br />Y/N <br /> <br />Y/N <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />Y/N <br /> <br />Y/N ,. <br /> <br />Fee Current <br /> <br />Y/N <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />Y/N I <br />L <br /> <br />- <br /> <br />All oul application completely. <br />'-'UWI'1l!"~'CotinClOr s'gnoadK-mappJicaliOil,"'nomnzecl TOi';-copy-6f'si9fjeaCOiifFcicfWftti 0WI'It!rJ <br />If over $2500, a Notice of Commencement is required (Mechanical wor1I: over $5000) <br />Supply two (2) sets of drawings with applicable documentation <br />Allow 10-14 clays for review after submittal date. <br />