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sis-�ao-oo2o City of 7_ephyrhilis Fire Fax-B13-780-0021 <br /> Permit Application <br /> Date RP��rved '_ �--1 Phone_ContactfOr�ermd �,?�} 9"i Q (q Q3 <br /> Owner's Name /f� � � � �C,e, /yJ/}WGILC/�'�C�i Owner's Phone Number C� � � <br /> Owner's Address �� �Q y �/!�/ i <br /> Fee S�mpie Titiehoider Name Titleholder Phone Number C� � � <br /> Fee S�mple Titleholder Address <br /> Job Address b,�aj� _ �AI,�Y �/'�/ - - - -_ - �� <br /> � Lot# <br /> Sub Division Parcel# T I <br /> � Bio-Hazard Waste Storage-ANNUAL � Hazardous Material(Tier II or RQ Facility)ANNUAL <br /> � Comm Exhaust Kitchen Hood/Duct � Hood Instailation <br /> � Controlled Burn Q LP/Natural Gas-Installation ��( ���� <br /> � Emergency Generator<30 kw � LP/Natural Gas-ANNUAL Sale <br /> � Emergency Generator>30 kw � Places ofAssembly-ANNUAL <br /> � �ire Profection Maintenance-ANNUAL � Recreational Burn <br /> try emi � er <br /> Sprinkler � ❑ p ❑ 5y� � Sparklers <br /> Fire Alarm � O ❑ ❑ � � Sprinkler System Installations <br /> Hood Cleaning � ❑ ❑ ❑ �� � Standpipes(Sprinkler Sys) <br /> Hood Suppression � ❑ O ❑ C� � Torch Roofing/Tar Kettle <br /> QFire Alarm Installation � Waste Tire Storage ANNUAL <br /> � Fire Pumps <br /> � Ffre Works <br /> � Flammable Application-ANNUAL �� Valuation of Project <br /> � Fuel Tanks <br /> � Other <br /> - -� <br /> Gontractor - - -- .,-�_.,_ _. . _._. ; _ _ <br /> Company —�-- � <br /> S�gnature Registered Y/N Fee Current Y/N <br /> aaaress 3�j,3� � }on �icense# Q � g �� z <br /> ELECTRICIAN <br /> Company <br /> Signature Registered Y/N Fee Current Y/N <br /> Address License# C � <br /> P�UMBER Company � <br /> S�gnature Kegistered Y/P� Fee Current Y/N <br /> Address License# � <br /> MECHANICAL Company � � <br /> S�gnature Registered Y/N Fee Current Y/N <br /> Address license# �— � <br /> vTHER � � Company <br /> _igr,a'.ur� <br /> Registered Y/(�J Fee Currerit Y/N <br /> Address _ ' � ` _ � <br /> License# <br /> Cirec;ions: - - <br /> Fill out application completety <br /> Owner&COntractor sign back of appiication,notarized(Or,copy of signetl contract with uwner) <br /> If over 32500,a Notice of Commencement is required(Mechanical work over$SOOU) <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 comj <br />