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���y v LGF/IIr111111J� ��c raX-tS1,S-780-0021 <br /> Permit Application <br /> Date Received — - 3 t 7� - <br /> c <br /> � ? Phone Contact for Pertnit ! 1 �� <br /> -�:-.>�:;...n.� .. . � . <br /> Owners Name Owners Phone Number <br /> Owners Address �� �� � <br /> Fee Simple Titleholder Name Titleholder Phone Number [� �� �� <br /> Fee Simple Titleholder Address —� <br /> =�`� �` -=�s....:aci-. ,P��y_D^"��r�'-'r:t++'�-":^�'a�E3`�?��s <br /> / .w'c:�-s�`�"•c,.-:.c:',:� .�a. <br /> Job Address �� /� �- ��,,� �a� � �vc��``� Lot# <br /> Sub Drvision �� <br /> Parcei# � <br /> � ..u.�z���°.Y°.�°�.-�'�.��.-�-___.....__.��� - - - <br /> �.;,,.��:--- .�.�...,.,,,,� .��.:_�.�..?��s��;�.^., ��.�. <br /> a Bio-Hazard Waste Storage-ANNUAL � � Fumigation Te�t m <br /> aComm Exhaust Kitchen Hood/Duct a Hazardous Matenal(Tier II or RQ Facility)qNNUAL <br /> aControlled Bum a Hood Installation <br /> aEmergency Generator<30 kw � LP/Natural Gas-Installation <br /> a Emergency Gene�ator>30 kw � LPlNatural Gas-ANNUAL Sale <br /> aFire Protection Maintenance-ANNUAL a Places of Assembly-ANNUAL <br /> ❑� emi �n er � <br /> Sprinkler ❑ ❑ ❑ Recreational Bum � � � j <br /> Fire Alarm � ❑ ❑ ❑ � � Spariclers �� <br /> Hood Cleaning � ❑ p p �� a Sprinkler System Installations <br /> Hood Suppression � r ❑ � ❑ � � Standpipes(Sprinkier Sys) <br /> a Fire Alarm Installatio� � Torch Roofing/Tar Ketlle <br /> a Fire Pumps a Waste Tire Storage ANNUAL <br /> aFire Works <br /> aFlammable Application-ANNUAL � <br /> � Valuation of Project <br /> Fuel Tanks <br /> � Other: <br /> Contractor �- <br /> Com an <br /> Signature P Y � � - � �"'����/�'�4--� <br /> Registered Y/N Fee Current Y/N <br /> Address y��( �`�G �«� �4_ _ T <br /> ELECTRICIAN � License# � fY�3.�z1 �oe�f��o�� <br /> Company <br /> Signature Registered Y/1� Fee Current Y 1 N <br /> Address <br /> License# <br /> PLUMBER <br /> Signature <br /> Company <br /> Registered �'/(v Fee Current Y/(� <br /> Address <br /> License# <br /> MECHANICAL <br /> Signature <br /> Company <br /> Registered Y/N Fee Current Y/N <br /> Address - <br /> License# <br /> OTHER � <br /> Signature <br /> Company <br /> Registered Y/N Fee Current Y/N <br /> Address <br /> n <br /> License# <br /> uu ca,uv�u. .._- <br /> Fiil out applicaGon completely <br /> Owner&Co�tractor sign back of application,notarized(Or,copy of signed contract with owner) <br /> H 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 h J/a <br /> i ( ttp' ppraaser.pascogov.com) <br />