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813 - 780 -0020 City of.Ze P h y rhills Fire i 0 (C4 Fax -813- 780 -0021
<br /> Permit Application
<br /> Date Received 1 2.-j [e, Phone Contact for Perrnit 1 g (3 ( FIST 1/3G I
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<br /> Owner's Name I P 1 L4 tv � Al..' 7 4114 1 144C '' '�/ Owner's Phone Number
<br /> Owner's Address . 78%45 641 aiti r> . 1 "eP
<br /> Fee Simple Titleholder Name Titleholder Phone Number
<br /> Fee Simple Titleholder Address 1 ; I
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<br /> Job Address 72- 4,8 G 9r� r3 ( V ~ ' — i ' `, D 1 y Lot #
<br /> Sub Division 'be4? 01 !l" 60 M"40 NS Parcel #
<br /> ..:" :? .sue•.. arMa.dsga'am o .. .. v , , :m... , ;: ,, -: 9:v ; , M. ,::& f+P ..ue i i „'. v. s am r r ,, 2 ,.r mt 6a£ «,'?r r`: x:&-& ,......are na m1«. f ...«..v . ...t..i:a 'i
<br /> n Bio -Hazard Waste Storage - ANNUAL n Fumigation Tent
<br /> n Comm Exhaust Kitchen Hood /Duct n Hazardous Material (Tier II or RQ Facility) ANNUAL
<br /> El Controlled Bum n Hood Installation
<br /> Emergency Generator < 30 kw n LP /Natural Gas - Installation
<br /> n Emergency Generator> 30 kw n LP /Natural Gas - ANNUAL Sale
<br /> n Fire Protection Maintenance - ANNUAL n Places of Assembly- ANNUAL
<br /> IQtriyl 1Semil p Other
<br /> Sprinkler El ❑ ❑ ❑ f 1 n Recreational Bum
<br /> Fire Alarm n ❑ ❑ ❑ L 1 1 1 Sparklers
<br /> Hood Cleaning n ❑ ❑ ❑ 1 1 Er Sprinkler System Installations
<br /> Hood Suppression 0 ❑ ❑ ❑ I 1 n Standpipes (Sprinkler Sys)
<br /> n Fire Alarm Installation n Torch Roofing/Tar Kettle
<br /> I Fire Pumps n Waste Tire Storage ANNUAL
<br /> El Fire Works
<br /> I Flammable Application- ANNUAL 1 1 I Valuation of Project
<br /> n Fuel Tanks
<br /> n Other: I 1
<br /> AC amm ° eA,. i.ut l4 4r:: sg . N...a4 r .. m ig,, m* °',,:, ..Z. RgleVaL ,.> A ,s ,? .: i ° wXHaaa t :r. : AUSS:
<br /> Contractor 1 �. ,,, off / _ Company C'*25 Go .".4 t] V C 'It-LQ J „PVC.
<br /> Signature �, 1 Registered CSP/ N I Fee Current I 1E7 N
<br /> Address $`3,o C V. "PO Co,tA444 C.Q P41Lie QGVD I License # I Pfe'4g$o ate/ ZCO'
<br /> ELECTRICIAN Company I
<br /> Signature I Registered Y/ N I Fee Current 1 Y/ N
<br /> Address I License # (
<br /> PLUMBER Company I
<br /> Signature Registered Y/ N 1 Fee Current I Y/ N
<br /> Address 1 1 License # I I
<br /> MECHANICAL Company 1
<br /> Signature Registered Y/ N I Fee Current I Y/ N
<br /> Address I 1 License # (
<br /> OTHER Company I
<br /> Signature Registered Y/ N 1 Fee Current I Y/ N
<br /> Address I .. . ,,, .
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<br /> License #
<br /> Directions:
<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)
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