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5 3-�sao�1� c,iry ot �ephyrnms rire Fax-ttl,i-/8U-UU'L1 <br /> Permit Application <br /> Date Received 6 � Phone Contact for Permit �� � <br /> r _ . , , , -. . . <br /> Owner's Name �,� �/ S � �!J /�.1( Owner's Phone Number �' � e � Z L �v � <br /> Owner's Address � G� G.-J G�(. � '� � 3`� � <br /> Fee Simple Titlehoider Name Titleholder Phone Number �� � <br /> Fee Simple Titleholder Address <br /> E S.te"-1 'f:-`>' - '�b'�'?fi�",=�3'-"a�:-_ ��, -. �.t.�... = r#�t�+''- '°�r^''"'°"' - :.;�t�31°st°; .' � �#"i __ __ . "' - <br /> Job Address h y�� �� (%� /�� V�7� � 3 �i � y� � <br /> Lot # <br /> Sub Division Parcel # <br /> y •.=n � ,n_ ... _s -a;� ;rM'!,s��*'*.>,- - - � -, �A��s,°:,.a': - .:�:w�,+�::r�s: -�.�r'aa�:..�#��::���,�f-. s�: s <br /> _. vw-.n��.k,C',. sa�.� ^ t,.a z:lu`:xn .., ,: ��:s�e�'«, <br /> � Bio-Hazard Waste Storage - ANNUAL � Fumigation Tent <br /> a Comm Exhaust Kitchen Hood/Duct � Hazardous Material (Tier II or RQ Facility) ANNUAL <br /> � Controlled Burn � Hood Installation - <br /> � Emergency Generator < 30 kw � LP/Natural Gas-Installation <br /> � Emergency Generator> 30 kw a LP/Natural Gas-ANNUAL Sale /� ��,�(� <br /> � Fire Protection Maintenance - ANNUAL � Places of Assembly-ANNUAL `� /"c� � <br /> �y em� �n er � <br /> Sprinkler � ❑ ❑ O � � Recreational Bum <br /> Fire Alarm � ❑ ❑ ❑ � � Sparklers <br /> Hood Cleaning �`� ❑ O� � Sprinkler System Installations <br /> Hood Suppression ❑ ❑ ❑ � � Standpipes (Sprinkler Sys) <br /> � Fire Alarm Installation � Torch Roofing/Tar Kettle <br /> � Fire Pumps � Waste Tire Storage ANNUAL <br /> � Fire Works <br /> � Flammable Application- ANNUAL Valuation of Project <br /> Fuel 7anks <br /> Q Other: <br /> M `af.7i;� x. _;��a Y.:. "S'l�:Cbx�$3.�E:.�.• . ;Nt��34;.;�;. , ix;>.,"�a . � „ '^ryg,',a�s^szx4:maJrxn-.�,,.i"=z . - . ` ' .:^'�-#�"z�'p�y�:,..,`,�+?,: -„ tv - x - :�:FS'*•-:#+r�..� , uay=v.$ ..;--r,ks <br /> Contractor / Compa�y <br /> Signature fi� C� !) L � i C iZ Registered Y N Fee Current Y/ N <br /> Address License # <br /> ELECTRICIAN Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address 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 License # <br /> OTHER <br /> Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address 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:/lappraiser.pascogov.com) <br />