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sis-�ao-oozo � City of Zephyrhills Fire Fax-813-780-0021
<br /> Permit Application
<br /> Date Received Phone Contact for Permit 813 621 1357
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<br /> owners Name FLORIDA MEDICAL CLINIC owner's Phone Number � � �
<br /> owner's Address 38135 MARKET SG�UARE DR., ZEPHYRHILLS, FL 33542
<br /> Fee Simple Titleholder Name Titleholder Phone Number �� � �
<br /> Fee Simple Titleholder Address
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<br /> Job Address 38051 MARKET SQUARE DR., ZEPHYRHILLS,'FL , ' �ot# �
<br /> sub Division CITY OF ZEPHYRHILLS Parce�# 02-26-21-0010-03900-0020
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<br /> � Bio-Hazard Waste Storage-ANNUAL � Fumigation Tent
<br /> � Comm Exhaust Kitchen HaodlDuct � Hazardous Material(Tier II or R�Facility)ANNUAL
<br /> � Controlled Bum a Hood Installation
<br /> � Emergency Generator<3D kw � LP/Nalural Gas-Installation
<br /> • � Emergency Generator>30 kw � LP/Natural Gas-ANNUAL Sale �
<br /> � Fire Protection Maintenance-ANNUAL � Places of Assembly-ANNUAL /1�
<br /> �y emi �n er �V
<br /> Sprinkler � � O ❑ � � Recreational Burn �\
<br /> Fire Alarm � ❑ ❑ � � � Sparklers
<br /> Hood Cleaning � ❑ ❑ ❑ �� ' � Sprinkler System Installations
<br /> liood Suppression � ❑ ❑ ❑ � � Standpipes(Sprinkler Sys)
<br /> � Fire Alarm Inslallalion � Torch RoofinglTar Kettle
<br /> � Fire Pumps � Waste Tire Storage ANNUAL
<br /> � Fire Works
<br /> � Flammable Application-ANNUAL $25.00 Valuation of Project
<br /> � Fuel Tariks
<br /> Q Other:
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<br /> Contractor Company
<br /> Signature Registered Y/N Fee Current Y/N
<br /> Address License#
<br /> ELECTRICIAN Company �- __
<br /> Signature Registered l�/N Fee Current Y/�I
<br /> Address License#
<br /> PLUMBER Company _ __ �
<br /> Sfgnature Registered Y/N Fee Current Y/N
<br /> Address License#
<br /> MECHANICAL Company _ �
<br /> Signature Registered Y/N Fee Current Y/IV
<br /> Address License#
<br /> OTHER JEFFERY D. BURNHAM �ompany RODAN FIRE SPRINKLERS, INC.
<br /> Sig�ature Registered Y/N Fee Current Y/N
<br /> Address E. WAY AV I A M L �icense# 8 15 10 012 6
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<br /> Directions:
<br /> Fiil out application completely.
<br /> Owner&Coniractor sign back of application,notarized(Or,copy of signed contract with owner)
<br /> If over 52500,a Notice of Commencemenl is required(Mechanical work over S5000)
<br /> Supply two(2)sets of drawings with applicable documentation
<br /> Allow 10-14 days for review after submitial date. Parcel#-obtained from PropeAy Tax Nolice(http://appraiser.pascogov.com)
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