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si3-��°-°°1° Lity ot Lepnymms rire <br /> hax-81 d-/SU-UO'L1 <br /> Permit Application <br /> Date Received — ' �' <br /> ` ,.,.. Phone Contact for Permit , Q a <br /> Owner's Name .� � l 3-- �� 1�� <br /> '� Owner's Phone Number <br /> Owner's Address 5 3 y <br /> Fee Simple Titlehoider Name � � �� <br /> Titleholder Phone Number <br /> Fee Simple TitieholderAddress <br /> k <br /> ' - .F" - i.'�&�c' s.::L;. -:.:JL:is'+L:.� i�.���1ti.ni � _ ..c. i�.i'i.'L:���.:�m;.b¢i:.�..,2x��.'°..�'4°� <br /> Job Address °,��d�ar�:--�-�.._r._ x _..$�� .� <br /> �s.° .�.� <br /> Lot # � <br /> Sub Division <br /> F Parcel # <br /> :r _s-R,F ._€ ,d u-:k . <br /> - _ _ ' :c+���, y i'�"�'FY°�:R.Ss:a��.e-r.. .Iqt. ." 3 ' _ M'�r i- ' <br /> � - _..�,iS'�.. _ _ 4Mh[� _ _ _ _ __ ' - , .; .4r�& �°q;✓,�n21'-.� <br /> Bio-Hazard Waste Storage - ANNUAL � <br /> a Fumigation Tent <br /> Comm Exhaust Kitchen Hood/Duct � Hazardous Material (Tier II or RQ Facility) ANNUAL <br /> � Controlled Burn Hood Installation <br /> � Emergency Generator < 30 kw � <br /> � LP/Natural Gas-instailation <br /> Emergency Generator > 30 kw � LP/Natural Gas-ANNUAL Sale <br /> � Fire Protection Maintenance - ANNUAL � <br /> Places of Assembly-ANNUAL <br /> ❑ � emi � er ❑ <br /> Sprinkler ❑ ❑ ❑ Recreational Bum <br /> Fire Alarm � ❑ ❑ ❑ C] � Sparklers <br /> Hood Cleaning �� ❑ ❑� � 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 <br /> a Valuation of Project <br /> Fuel Tanks <br /> Q Other: <br /> e .�r�r::�, > �., .a.. , „ -... _ ,n�,;�, ; . <br /> 'i*�6":..� xT ` 2 �.'Y' 6 &'F" 5 u' .. . 3 tl� ° .:� 3 a2r�'€f"444Nd"fi'.%.?f-.F:b : � .:".b&�t�,.p.... R:]sv'i�...-,. <br /> d3 <br /> Contractor - , .,,�.:,. :�:ti.��:.,- . .�, <br /> Signature Company ¢ � . <br /> Registered Y/ N Fee urtent Y <br /> Address <br /> License # <br /> ELECTRICIAN <br /> Signature Company <br /> Registered Y/ N Fee Cument Y/ N <br /> Address <br /> License # <br /> PLUMBER <br /> Signature Company <br /> Registered Y/ N Fee Current Y/ N <br /> Address <br /> License # <br /> NECHANICAL <br /> iignature Company <br /> Registered Y/ N Fee Current Y/ N <br /> Address <br /> License # <br /> )THER <br /> �ignature Company <br /> Registered Y/ N Fee Current Y/ N <br /> Address <br /> iirections: License # <br /> Fill out application completely <br /> Owner & Contractor sign back of application, �otarized (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 htt //a <br /> � P� Ppraiser.pascogov.com) <br />