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Ri3-�sU-°°2e c.ity ot �epnyrnms rire �-a�e-�uu-uuz, <br /> Permit Application � <br /> Date Received Q � Phone Contact for Permit .� � <br /> F , -. <br /> Owner's Name (j �(,J � Owner's Phone Number �� ��� <br /> Owner's Address � �l � `� ��/� <br /> Fee Simple Titleholder Name Titleholder Phone Number �� � <br /> Fee Simple Titleholder Address <br /> f ' - ._ ^-x.:;.���,..�x=i:m<3yc -= d"_ _ . .,: - . _ .s ,v '*-�Sw•:$«.<.._ 'a:'�"+."f`.y3" iRF' _ _ °' _ . ,v. . 'z.4..;?' <br /> Job Address �G� �`,[, iC.� Lot # � <br /> Sub Division Parcel # <br /> r �, n =R�M*.:�_ a� ��»�:_,��� �.m .�,. . , <br /> - - - " n, ��-ae. _. _ _ _ _ ._ .: r�;r.�.a,�r«:;.�.^+�sa�<,��x.,.._� �,. �� .� . <br /> Bio-Hazard Waste Storage - ANNUAL � Fumigation Tent <br /> Comm Exhaust Kitchen Hood/Duct � Hazardous Material (Tier tl or RQ Facility) ANNUAL <br /> Controlled Burn � Hood Installation • <br /> � Emergency Generator < 30 kw � LPlNatural Gas-Installation V �� <br /> � Emergency Generator > 30 kw � LP/Natural Gas-ANNUAL Sale i ) � U��� <br /> � � �� � <br /> Fire Protection Maintenance - ANNUAL � Places of Assembly-ANNUAL <br /> r y emi �n er ��) , 1 � �,�y� -� � <br /> C✓ LC� <br /> Sprinkler � ❑ ❑ ❑ � Recreational Burn <br /> Fire Alarm � ❑ ❑ ❑ � � Sparklers <br /> Hood Cleaning � ❑ ❑ ❑ � � Sprinkler System Installations �I 2 � �v <br /> Hood Suppression � ❑ ❑ ❑ � � Standpipes (Sprinkler Sys) <br /> � Fire Alarm Instailation � Torch Roofing/Tar Kettle <br /> � Fire Pumps � Waste Tire Storage ANNUAL <br /> � Fire Works n <br /> � Flammable Application- ANNUAL Valuation of Project <br /> Fuel Tanks <br /> Q Other. ��'E" Oz �p �' y� �7 ' � <br /> R .� �� �. x..>.� �:����:�.�•� a.. ,£ � �:��T �..�._ .. <br /> � �.:r���:��-� ,w��; � . . _ : �.�:���,�;�.���;��������� ._ :_��-� w <br /> ::.�� �,,.. . <br /> Contractor Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address License # <br /> ELECTRiCIAN Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address <br /> License # <br /> PLUMBER Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address License # <br /> MECHANICAL Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address <br /> License # <br /> OTHER Company _ �f <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address <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:l/appraiser.pascogov.com) <br />