<br />d'i.j-(I;iV-UU.c:LI
<br />
<br />J
<br />Date ReceJved i
<br />r';"-';~~?1:r~~~~V'~' ,
<br />
<br />Ovvners Name
<br />
<br />Owner's Address
<br />
<br />'-.....j _.~--,.. .~.
<br />
<br />Permit f\p~lic2itio:-1
<br />I Phone Contact for Permit 'I
<br />~~~ll7&.~~~~~~'j~~~~~~.c:~--:7.~;.~.",",T-.;.
<br />
<br />If 1[---
<br />,_'''~''''''_',"v __" _" ....~ __ ....~""""~...""
<br />
<br />B\~ I"~,:il~ ,~~
<br />
<br />"-'~""'_.''''''''''''''-.-';,..~-Il. jJ ~. -.,.;
<br />
<br />r\,:0 ~ <b (OC"-.~l\ ,",Oil.
<br />~'._'-
<br />
<br />LV27lO\. \jo.~~~. ~~.
<br />I
<br />j
<br />
<br />I O..vner's Phone Number
<br />
<br />Fee Simple Titleholder Name
<br />
<br />Fee Simple TiUeholder Address
<br />
<br />Z #~'^,\\':,'\ \=L
<br />
<br />j TItlehotder Phone Number
<br />
<br />f
<br />
<br />Job Address
<br />
<br />,,,,=~,l>:;::;~~;e~l'___,~_~~~.",,,,?__~~~~~~~
<br />I
<br />I Lot#
<br />
<br />Sub Division
<br />
<br />Parcel #:
<br />
<br />lUt:llf'.lNl;;L..' rKUIV! jJKUt-'t:KI r L-'\X NU IICt:)
<br />~~..,....~~~~~~
<br />
<br />D
<br />
<br />E-i(:~-:~R~~~-"'>~~"""~~' ~~.-
<br />
<br />BiD-Hazard Waste Storage - ANNUAL
<br />
<br />Fumj;~;tjon Ten:
<br />
<br />
<br />,---,
<br />L.J
<br />D
<br />D
<br />I i
<br />~
<br />
<br />o
<br />D
<br />D
<br />o
<br />D
<br />o
<br />
<br />Contractor
<br />Signature
<br />Address
<br />
<br />ELECTRiCIAN
<br />Signature 1
<br />
<br />Address I
<br />
<br />Comm Exhaust Kltci1811 HoodlDuct
<br />
<br />Controlled Bum
<br />
<br />Emergency Generator < 3C KW
<br />
<br />Emergency Generator:> 30 !('N
<br />
<br />Fire Protection Maintenance - ANNUAL
<br />Sprinkler 0
<br />Fire Alarm I \
<br />Hood Clean/Suppression 12SI
<br />Fire Alarm Installation
<br />
<br />Fire Pumps
<br />
<br />Fire Works
<br />Flammable Applicatbn- ANNUAL
<br />
<br />Fuel Tanks
<br />
<br />Other:
<br />
<br />PLUMBER
<br />Signature '
<br />
<br />Address f
<br />
<br />MECHANICALI
<br />. Signature I
<br />
<br />Address j
<br />
<br />OTHER
<br />Signature
<br />
<br />Address J
<br />~~--"'"")j;:',,,,,,,,,,,
<br />Directions:
<br />
<br />Flli ou: application completely.
<br />
<br />2\'JTler &? Con~cv::. s~gnpack of ap;;licalio~,nota~':::ed (O~J c;:.py of signEd contra:;! wit!', owner)
<br />~ over $_500, " Nvuc; 0, Commencemen: IS req:.;;red (Mechanics.i warr. '~ $.5000',
<br />;:;,~ppjy two (2) sets or dralNings with applicable documentation '
<br />:;,.',cW 1 lJ-14 {Jays reI' revIew after SUDmitta' OcfS
<br />
<br />o
<br />rl
<br />L-J
<br />o
<br />o
<br />D
<br />D
<br />o
<br />D
<br />o
<br />D
<br />o
<br />f" I
<br />
<br />Hazardous Material (Tier II or RQ Facility) ANNUAL
<br />
<br />Hood Installation
<br />
<br />LP1Natuml C-as-:nstBliauon
<br />
<br />LP/Natl1!al Gas-ANNUAL Sale
<br />
<br />Places of Assembly-ANNUAL
<br />
<br />Recmalior.2: Bem
<br />
<br />Sparklers
<br />Sprinkler System installations
<br />
<br />Standpipes (Spr:nklEr Sys)
<br />
<br />Torch Roofing
<br />
<br />Waste TIre Storage ANNUAL
<br />
<br />, , Valuation of Project
<br />
<br />.
<br />
<br />Company
<br />Regisiered
<br />
<br />
<br />
<br />Ucense #.
<br />
<br />I
<br />I
<br />I
<br />
<br />Ccmp3ny I
<br />Registered
<br />
<br />J
<br />I
<br />1
<br />I
<br />I
<br />I
<br />
<br />Y1N
<br />
<br />Fee Current
<br />
<br />Y/N
<br />
<br />Ucense #
<br />
<br />Company
<br />Registered
<br />
<br />Y/N
<br />
<br />Fee Current
<br />
<br />YfN
<br />
<br />License #-
<br />
<br />Company
<br />Registered
<br />
<br />I' Fee Current
<br />
<br />Y/N
<br />
<br />YiN
<br />
<br />License '#
<br />
<br />Company
<br />Registered Y I N Fee Current
<br />
<br />.~ ,,~J>.__'" "c.~t""""""...~:;,~~....."L ~~". ..,."..,~,.=~.~, .'. ~>".~
<br />
<br />.~-";';...J",,"-''''''''''''. ..... --~ ".< "--""""ia<''':L';'-Wt;>~~<--.,.;...,.,
<br />
<br />YiN
<br />
<br />-~-~=~~
<br />
|