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<br />. 813-780-0020 <br /> <br /> <br />Date Received <br />w;'l:i~i'RR~~~'W.~~~~~' <br /> <br />I LItS2..Lf} ,ffOnVA-TJ-I <br />I 'PO Bo.X q'73~ IIfI1PfrR 33647 <br />I <br />I <br /> <br />~_m.~~ U~~"'i!ffii.!i!iii_-=Ii"~~~Of~~-~ .~ <br /> <br />I GOLDEN fAND4 <br />I <br /> <br />Owner's Name <br /> <br />Owner's Address <br /> <br />Fee Simple Titleholder Name <br /> <br />Fee Simple Titleholder Address <br /> <br />Job Address <br /> <br />Sub Division <br /> <br />Fax-813-780-0021 <br /> <br />I Owner's Phone Number <br /> <br /> <br />lJ <br />...~ii.>i~~;U'io>,';';;","~'~~;,w'IMf;;.;q\!i";4.j,:," <br /> <br />/I <br /> <br />I Titleholder Phone Number <br /> <br />II <br /> <br />II <br /> <br />1ltV' -Wl'i <br /> <br />.e1......,-1=!:.lIlIimt <br /> <br />'!II ~_"19i",_____ <br /> <br />I Lot# <br /> <br />37Q/S -t:.:ILftNJJ BLVD <br /> <br /> <br />I Parcel # I <br /> <br />~- <br /> <br />~ <br /> <br />~""""...... <br /> <br />~~~~~'_~~''''''''''~~;~~!ml1i~'~~' iff <br /> <br />Bio-Hazard Waste Storage - ANNUAL <br /> <br />D <br />D <br />D <br />D <br />D <br />o <br /> <br />D <br />D <br />D <br />D <br />D <br />D <br /> <br />:l!.. <br /> <br />Contractor <br />Signature <br /> <br />Address I <br /> <br />ELECTRICIAN <br />Signature I <br /> <br />Address I <br /> <br />PLUMBER <br /> <br />Signature <br /> <br />Address I <br /> <br />MECHANICALI <br />Signature . <br /> <br />Address I <br /> <br />OTHER <br />Signature <br /> <br />Comm Exhaust Kitchen Hood/Duct <br /> <br />Controlled Bum <br /> <br />Emergency Generator < 30 kw <br />Emergency Generator> 30 kw <br />Fire Protection Maintenance - ANNU~ <br />Sprinkler D UP~~ <br />--- <br />Fire Alarm D <br />Hood Clean/Suppression D <br />Fire Alarm Installation <br /> <br /> <br />Fire Pumps <br />Fire Works <br />Flammable Application- ANNUAL <br /> <br />Fuel Tanks <br /> <br />~,!m!i[" <br /> <br />tUb' AII"t::U t-KUIVI t"'KUt"'t::K I r I AA ,"U 11\..t::) <br />-,........- t:li' T -:- .>==~iT i!lIilit'~~f~~~h- Ii" Ii'T!*'...."""'u <br /> <br />~~ <br /> <br />D <br />o <br />D <br />D <br />D <br /> <br />Fumigation Tent " <br />Hazardous Material (Tier II or RQ Facility) ~~.NtIAL :; b <br />Hood Installation / ;fl\ 11 <br /> <br />LP/Natural Gas-Installation <br /> <br /> <br />7 fe I" fl <br />--r e . ~tw'- ,S <br />"1) /11 "2. tAj ./ <br />. t1 j... . <br />1't,.;~J <br />Sparklers ~ <br />Sprinkler System InstallatiOns--.p~ ,. ~ - 0 <j <br />Standpipes (Sprinkler Sys) <br /> <br />LP/Natural Gas-ANNUAL Sale <br /> <br />Places of Assembly-ANNUAL <br /> <br />Recreational Bum <br /> <br />Torch Roofing <br />Waste Tire Storage ANNUAL <br /> <br />5'l/r~ <br />gl7"~3sl <br /> <br />Other: <br /> <br /> <br /> <br />~~ <br /> <br />Company <br />Registered <br /> <br />UiVl1l..6I(S'€ :S..EI(V7c.cs <br />Y I N I Fee Current I Y I N I <br />I <br /> <br />Y I N I Fee Current Y I N I <br />I <br /> <br />License # <br /> <br />Company <br />Registered <br /> <br />License # <br /> <br />Company <br />Registered <br /> <br />Y/N <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />License # <br /> <br />Company <br />Registered <br /> <br />License # <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />Y/N <br /> <br />Company <br />Registered <br /> <br />Y/N <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />License # <br /> <br />Fill out application completely. <br />Owner & Contractor sign back of application, notarized (Or, copy of signed contract with owner) <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 />