HomeMy WebLinkAboutApplication 989 7-31-19_4-4PERMIT APPLICATION��
TO CONSTRUCT -INSTALL NEW TANK (NEW FACILITY)/NEW
TANK INSTALL (EXISTING FACILITY)/MOD-MINOR MOD
Permit #
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY
(CHECK ONE ONLY) ❑ MODIFICATION OF FACILITY
. BAKERSFIELD FIRE DEPARTMENT
Prevention Services
2101 H Street
Bakersfield, CA 93301
y Phone: 661-326-3979 o Fax: 661-852-2171
Page 1 of 1
❑ NEW TANK INSTALL/ EXISTING FACILITY
U MINOR MODIFICATION OF FACILITY
STARTING DATE/
PROPOSED COMPL ION DATE
FACILITY NA E �„
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EXISTING FACILITY PERMIT #
FACILITY AD i� S
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CITY
TYPE OF BUS E
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APN #
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TANK OWNER
PHONE #
ADDRESS
CITY
ZIP CODE
CONTRACTOR
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CA LICENSE
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ICC#
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ADDRESSki
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PHONE # -.--
BAKERSFIELD CITY BUSI S .LICENSE #
CID, I 10-7 1110
WO (<MANS QOM #.�
I URER
BRIEFLY DESCRIBE THE WORK TO BE DONE:
NAME 4F TEST .-R ;; r ,i, ICC# c -%c (4q' D
THE APP.LIICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER
PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTE , ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
)ATE APPROVED APPROVED BY
FD2086 (Rev 11/2015)