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<br />813-780-0020 <br /> <br />Date Received <br /> <br />Owner's Name <br /> <br />Owner's Address <br /> <br />Fax-813-780-0021 <br /> <br /> <br /> <br />Phone Contact for Pennit <br /> <br />Owner's Phone Number <br /> <br />"I <br /> <br />II I I <br />I I I I <br /> n :r!1llW" <br /> Lot # I I <br /> I <br /> TrwT.i.'f nlill.~W <br /> <br />Fee Simple Titleholder Name <br /> <br />I Titleholder Phone Number <br /> <br />I <br /> <br />Fee Simple Titleholder Address I <br />r~IH -_~ ~".' l___%m~~,.,~ <br /> <br />135.;150.A <br /> <br />Job Address <br /> <br />Sub Division <br />ilIIi.6. ,\ !i/i <br /> <br />D <br />D <br />D <br />D <br />D <br />D <br /> <br />Contractor <br />Signature <br />Address <br /> <br />ELECTRICIANI <br />Signature , <br /> <br />Address I <br /> <br />PLUMBER I <br /> <br />Signature <br />Address I <br />MECHANICALI <br />Signature <br />Address I <br /> <br />-,><II'" <br /> <br />Zevh~llIs I FL. <br /> <br />~ Parcel # <br /> <br />tilLl niT li <br /> <br />A'If.. . <br /> <br />~~,1Tm k JIT~WiiJl:l <br /> <br />lilll'iI1Il1X~ 1M! <br /> <br />rrfv.;:nl1llp'" ,j <br /> <br /> <br />Bio-Hazard Waste Storage - ANNUAL <br />Comm Exhaust Kitchen Hood/Duct <br />Controlled Bum <br />Emergency Generator < 30 kw <br />Emergency Generator> 30 kw <br />Fire Protection Maintenance - ANNUAL <br />~. y ~~~ <br />Sprinkler l:{J.J'.. 0 0 L-J <br /> <br />Fire Alann D 0 0 0 C:=J <br /> <br />Hood Cleaning D 0 0 0 C:=J <br /> <br />Hood Suppression D 0 0 0 C:=J <br /> <br />Fire Alann Installation <br />Fire Pumps <br />Fire Works <br />Flammable Application- ANNUAL <br /> <br />Fuel Tanks <br />Other: <br /> <br /> <br />OTHER <br />Signature <br />Address l, ., ,. ..... . , _ M .,.,._ <br />Directions: <br /> <br />~.'t'n>t;i;l(";l'lTtHI'I'li<i1' Ii':! <br /> <br />,~-, <br /> <br />v"~ <br /> <br />33SL/1 <br />I <br /> <br />D Fumigation Tent <br /> <br />D Hazardous Material (Tier II or RQ Facility) ANNUAL <br /> <br />D Hood Installation <br /> <br />D LP/Natural Gas-Installation <br />D LP/Natural Gas-ANNUAL Sal <br /> <br />D Places of Assembly-ANNU <br /> <br />D Recreational Bum <br /> <br />D Sparklers <br /> <br />D Sprinkler System Installations <br /> <br />D Standpipes (Sprinkler Sys) <br /> <br />D Torch RoofinglTar Kettle <br />D Waste Tire Storage ANNUAL <br /> <br /> <br />Valuation of Project <br /> <br />Company <br />Registered <br /> <br />License # <br /> <br />5,,.,...,pl-o, ~ <br />Y/N I Fee Current Y/N <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 />Fee Current <br /> <br />Y/N <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 />wJ <br /> <br />Company <br />Registered <br /> <br />License # <br /> <br />--~A~:'~~O~l"~~J <br /> <br />Y/N <br /> <br />Fee Current <br /> <br />Y/N <br /> <br />I <br />.s'l}:;' .r...->....-~..ll~r~.'. ""''''''- <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. Parcel # - obtained from Property Tax Notice (http://appraiser.pascogov.com) <br />