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<br />06/13/2008 14:54 FAX <br />813-780-0020 <br /> <br />gate 1'l8l:9i"lld <br /> <br />OWner's Name <br /> <br />owners Address <br /> <br />City of Lephyrnms t-Ire <br />Permit Application <br />Phon.. r.nptj;lclfnr pAI'QJit 1 ~J3~~.;:.~ if I. <br /> <br />OWner's Phone Number I . II.. I .I <br /> <br />J .h3{~JT <br />I <br />I <br /> <br />:J'" <br /> <br />.. ,. <br /> <br />~007 <br />rJX-o I"-'OU-UU~I <br /> <br />I <br />'I <br /> <br />. Fee Simple Titleholder Name <br />Fee Simple Titleholder Address <br /> <br />Job Address <br /> <br />Sub Division <br /> <br />Titleholder Phone Number <br /> <br />II <br /> <br />IC <br /> <br />t:)lo-Maiard haste Storage - ANNUAL <br />Cornm Exhaust K1tGhen HoodlDuct <br /> <br />'3BZo3 Minr <br /> <br /> <br />F L- I is'&{o Lot # C <br />'1 <br />\ut:) I ~Nt;U t"I"IUM t"~Ut't;~ I Y , PIA I\lU 11I..t;} <br /> <br />fiiiUIII;!::fCIli~" T Clll <br /> <br />~ <br />o <br />D <br />.D <br />o <br />D <br /> <br />D <br />o <br />.0 <br />o <br />o <br />.0 <br /> <br />l>r. <br /> <br />2. <br /> <br />ControllEid Bum <br />. Emergency Generator < 30 kw <br />Emergency Generator> 30 kw <br />Fire Protection Maintenance - ANNUAL <br />Sprinkler 0 <br />Fire Alarm ~ <br />Hood Clean/Suppression 0 <br />Fire Alarm Installation <br />Fire Pumps <br />Fire Works <br />Flammable Application- ANNUAL . <br /> <br />Fuel Tanks <br /> <br /> <br />Other: <br /> <br />Contractor <br />Signature . <br />Address I Lf7t)( eJtiI.~ h-r .J!'- ~ JZI.... .,"', <br />ELECTRICIAN <br />Signature <br />. Address <br /> <br />PLUMBER <br />Signature . <br /> <br />Address <br /> <br />, MECHANIC4 <br />Signature . <br /> <br />Address I <br /> <br />OTHER I <br />Signature <br /> <br />Address I <br />Directions: <br /> <br />Hazardous Material (Tier II or RQ FadHty) ANNUAL <br />Hood Installation <br />LPlNatural Gas-Installation <br />LPlN'atural Gas-ANNUAL Sale <br />Places of Assemb~-ANNUAL <br />Recreational Bum . <br />Sparklers <br />Sprinkler System Installations <br />StandpipeS (Sprinkler Sys) <br />Torch Roofing <br />Waste Tire Storage ANNUAL <br /> <br />'1 Valuation of Project <br /> <br />.,.Cl?mpany I t5Jrl"~t.v Gr-.nC'Ji <br />'. Registered Y IN,. ... ~eeCmentY IN <br />Ucense # I <br />Company I .. , , <br />Registered Y/N Fee' Current' I Y/N <br />Ucense # I <br />Company J <br />Registered Y/N Fee Current Y/N <br />Ucense # '1 <br />Company I <br />Registered . Y/N. I Fee Current Y/N <br />Ucense # I <br />Company I <br />Registered Y/N I Fee CurTant I Y/N <br />Uc:ense # <br /> <br />I <br />I <br />I <br />I. <br />I <br />I <br />I <br />I <br />I <br />I <br /> <br />All out application completely. <br />'--owner'5'ClJImictoniaff6acKlifappllcatiOii', 'n6fif'riZiil1Or. copy of'ii9fj<<rconfiCtiNittlOWf18i'} <br />If over $2500. a Notice of Commencement is required (Mechanical work over $5000) <br />Supply two (2) sets of drawings with applicable documentation <br />Allow 10-14 days for review after submittal date, <br />