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8'13-78U-OUZO c;ity or cepnyrnuis rire rax-a�a-iau-wn <br /> Permit Application <br /> Date Received � � '� Q���,/�� Phone Contact for Permit I s�f� G�j� <br /> : _ <br /> Owner's Name L�.SZL.O f�{��C�/f}T.�� Owner's Phone Number Qr3 S� ��-'_� <br /> Owner'sAddress ��.;�� 9��8 %�/��� �-� ��6��s <br /> Fee Simple Titleholder Name Titleholder Phone Number � � � <br /> Fee Simple Titleholder Address <br /> � • �=r�s.:�r�e- _ .._� , F <br /> >,�'�'^,�.�u=-� , .°:,�.��s•��.-�r�::.: ���:%u�sa��ax,a�,« �.�.- «,�*�;��� <br /> Job Address G1�/�7� ��'1(�f( 7i�iJCy �LL ;g1�"L7, ��'Pfi/y,,t�/LLS �L Lot# � <br /> Sub Division Parcel# <br /> � .,x _, � iY�^'.�t.'��eVi'��5-"`!-tk`rF�4 r�a�S . .. _ WY'::.WKti,Tq•.i,e _..:- .w ._ ,�-�a.:tdf".�n'> -�Y_>E�t+�'.s+.5v..•i24i.°M����`°�'!��1F'�""3I'�H'^�'9`•F .°r;!'=--±^�'�.:AY}..:m e""J^.n§x�e.MSfiY*e_. <br /> � Bio-Hazard Waste Storage-ANNUAL � Fumigation Tent <br /> � Comm Exhaust Kitchen HoodlDuct � Hazardous Material(Tier II or RQ Facility)ANNUAL <br /> � Controlled Burn a Hood Installation <br /> � Emergency Generator<30 kw � LP/Natural Gas-Installation <br /> � Emergency Generator>30 kw � LP/Natural Gas-ANNUAL Sale � ' � <br /> � Fire Protection Maintenance-ANNUAL � Places of Assembly-ANNUAL <br /> �y emi �n er ❑ / <br /> i� ✓ <br /> Sprinkler � ❑ ❑ ❑ Recreational Burn ' � <br /> Fire Alarm � ❑ ❑ ❑ � � Sparklers � � � ; <br /> Hood Cleaning ❑ ❑ <br /> (�' ,_,/ / ��/ � <br /> I� I b•d � � Sprinkler System Installation � ,Z} �l ' <br /> Hood Suppression � ❑ ❑ ❑ � � Standpipes(Sprinkler Sys) <br /> 1' <br /> � Fire Alarm installation � Torch Roofing/Tar Kettle <br /> � Fire Pumps � Waste Tire Storage ANNUAL . <br /> ❑ ` � � <br /> Fire Works <br /> � Flammable Application-ANNUAL Valuation of Project <br /> Fuel Tanks <br /> Q Other: <br /> P .,�.,rX.+�a'�.".� ,-�q's', . . �.._ i�LK$:d ,S�i€'3,�!. ,:rx'+F�`�E�P.�h'�:-'b?._';�-A`,'�a:"3�aa.�;�.y,,s°f._�.. ,.... v. _.r "' "4,iS:ki....-:4.!Gv'"'r"�$`�.°-F^'.�U��-"Yi3�!+t✓t�.Y"d°236=KNr`..,�....�,-ti44'K:a..,�. -.`�4�.'�:"__.� <br /> Contractor /�� Company �,/�1/J�./� �� � <br /> Signature r1� 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 /> _.......�.. I . .,..__ Company <br /> Signature Registered Y/N Fee Current Y/N <br /> Address <br /> License# <br /> MECHANICAL Company <br /> Signature Registered Y/N Fee Curtent Y/N <br /> Address <br /> License# <br /> OTHER <br /> Company <br /> Signature Registered Y/N Fee GuRent Y/N <br /> Address <br /> License# <br />� <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 />