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oio-ro�-v��v l.11y OI L6FJflyff11115 rlf@ r2X-tSl3-/tSU-UUYI <br /> Permit Application <br /> Date Raceived * � Phone Contact for Permit � � � <br /> r i . r. . . <br /> Owner's Name ��-'S L��d � — �Li._ Owner's Phone Number � � � <br /> Owner's Address 3�2Zc1 �nr t2 �!�°�— Z (�� '�j �S Y� <br /> Fee Simple Titleholder Name Titleholder Phone Number � � � <br /> Fee Simple Titleholder Address <br /> e { _ Y, . ,,._ - � _ � - -.r-- .. - . � < _ <br /> Job Address `'' ���� Lot# � <br /> Sub Division Parcel# <br /> r __ r ; .,,_ � _ �. � _ .., . , ,_ —:_, � .. > �.�� „_ <br /> � Bio-Hazard Waste Storage-ANNUA� � Fumigation Tent <br /> � Comm Exhaust Kitchen Hood/Duct � Hazardous Material(Tier 11 or RQ Facility)ANNUAL <br /> � Controlled Burn � Hood Installation <br /> � Emergency Generator<30 kw � LP/Natural Gas-Installaiion <br /> � Emergency Generator>30 kw � LP/Natural Gas-ANNUAL Sale <br /> � Fire Protection Maintenance-ANNUAL � Places of Assembly-ANNUAL ��� (�� <br /> I �� <br /> �y emi �n er �' <br /> Sprinkler � ❑ ❑ ❑ � � Recreational Bum <br /> Fire Alarm � ❑ ❑ ❑ � � Sparklers �I"� <br /> Hood Cleaning � ❑ ❑ ❑ � � Sprinkler System Installations <br /> Hood Suppression ]X � ❑ �/ ❑ � � Standpipes(Sprinkler Sys) <br /> � ��r 0 <br /> Fire Alarm Installation Torch Roofing/Tar Kettle <br /> � Fire Pumps � Waste Tire Storage ANNUAL <br /> � Fire Works <br /> aFlammable Application-ANNUAL Valuation of Project <br /> Fuel Tanks <br /> Other: <br /> 4 �. _ � . _ , ,.. � <br /> - � - .._� . �.�-,--. .... ,-�,...�-_ -_�:�: _ <br /> Contractor C \' Company vr��� K�. �F- �il�c-f ' �,� <br /> Signature �� Registered Y N Fee Current Y/N <br /> Address f; �jC-F Lice�se# <br /> ELECTRICIAN Company <br /> Signature Registered Y/N Fee CuRent Y/N <br /> Address License# <br /> PLUMBER 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 Current Y/N <br /> Address 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 applicable documentation <br /> Allow 10-14 days for review after submittal date. Parcel#-obtained from Property Tax Notice(http:/lappraiser.pascogov.com) <br />