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a�s-�eo-oozo City ofZephyrhtlls Fire Fax-813-780-0021 <br /> .� Permit Application <br /> Date Received 2/6/2013 Phone Contact for Permit 813 313 1611 <br /> Owner's Name Ze h r Haven Nursin Home Owner's Phone Number �� � <br /> Owner's Address 38250 A AVE ZEPHYRHILL FL 33542-5759 <br /> Fee Simple Titleholder Name Titleholder Phone Number �� � <br /> Fee Simple Titleholder Address <br /> Job Address � <br /> Lot# <br /> Sub Drvision Parcel# <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 � <br /> LPlNatural Gas-ANNUAL Sale <br /> Fire Protection Maintenance-ANNUAL � Places of Assembly-ANNUAL <br /> Sprinkler ����� � Recreational Bum �{i/ ,3�/ <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 r--� Valuation of Project <br /> ❑ Fuel Tanks <br /> x❑ Other Backflow <br /> Contractor Wanda Paradis Comp Sim lex Grinnell <br /> Signature Regist Y/N Fee Cu Y/N <br /> Address 4701 Oak Fair Blvd,Tam a FL 33610 License# <br /> ELECTRICIAN Compan <br /> Signature � Regist Y/N Fee Cw Y/N <br /> Address <br /> License# <br /> PLUMBER <br /> Compan <br /> Signature Regist Y/N Fee Cu Y/N <br /> Address <br /> License# <br /> MECHANICAL Company <br /> Signature � Registd_Y/N Fee Cu Y 1 N <br /> Address — <br /> License# <br /> OTHER Company <br /> Signature Regist�_ Y/N Fee Cu Y/N <br /> Address — <br /> License# <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 applicab�e documentation <br /> Allow 10-14 days for review after submittal date. Parcel#-obtained from Property Tax Notice(http://appraiser.pascogov.com) <br />