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st s-7eo-oo2c City of Lephyrh ills F ire Fax 13 <br /> Permit Application <br /> Date Re��iLed �� N Phone Contact for Permit � J��� �� i� <br /> �,...,�.�g .,. �,�.. . ��"' , ` <br /> ` � � � � <br /> Owner's Name � � Owner's Phone Number ��pr <br /> Owner's Address � � � <br /> Fee Simple Tftleholder Name Titleholder Phone Number ��� <br /> Fee Simple Titleholder Address <br /> . '.�d�?.R"'1�� 3 .&•?, .. ., ,•w;.�,Y".w ,�..�pX, . .a :i � t:..• � i.�.. <br /> Job Address Lot # ' � <br /> Sub Division Parcel # <br /> c� . .. , -- � ,. .� ._ > . . . <, x = . . .. ,. .. > , . .,, , �µ <br /> � Bio-Hazard Waste Storage - ANNUAL � 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 � LP/Natural Gas-Installation <br /> � Emergency Generator > 30 kw � LPlNatural Gas-ANNUAL Sale � <br /> Fire Protection Maintenance - ANNUAL � Places of Assembly-ANNUAL r„ <br /> ry emi �n er � � ���� <br /> Sprinkler � ❑ ❑ ❑ � � Recreational Burn /� <br /> Fire Alarm � �, ❑ � � � 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 Valuation of Project <br /> � Fuel Tanks <br /> � Other� <br /> , :ai.i 4». ' 't..3:i ,e.�h. ... r.., . . .t . .� ... . r . ....o. ..�.... .. x >s ,. 'i.. <br /> Contractor Company <br /> Signature �( Registered Y/ N Fee Current Y/ N <br /> Address �f' 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 Company <br /> Signature Registered Y/ N Fee Current Y/ N <br /> Address License # <br /> �&P. .. . .H...,_.. ,., ....... _ s.... . . � ' .., ' i .. . , x. .. ....,<., . . ._ .. ' .. . .. ..... .. ... •3`��'f.� <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) <br />