Application For Fire Protection Or Hazardous Materials System Permit Form

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PERMIT #___________________

DEPARTMENT OF DEVELOPMENT AND PERMITS

Code Compliance Division

Tel. (757) 382-6018

P. O. Box 15225

Fax (757) 382-8448

Inspection Request:

Chesapeake, VA 23328

(757) 382-2489

Date:___________________

APPLICATION FOR FIRE PROTECTION or HAZARDOUS MATERIALS SYSTEM PERMIT

A permit is hereby requested to install the following fire protection or hazardous materials system at:

Project Name___________________________________Builder/Owner/Occupant_________________________________

Address__________________________________________________________________ Suite #____________________

Installing Co. Name________________________________________________ State Reg. #_______________________ A B C

Owner/Master Tradesman

Signature_______________________________________ Phone_______________ Fax________________ Other______________

PRINT Signature Name_____________________________________________ Ches. Bus. License #________________________

Business Address____________________________________________________________________________________________

System will be: ___New, ___Addition/Alteration to existing, ___Relocated, ____Removed, ____Abandoned in place (undergrnd. tanks only)

Structure use: ___Commercial/Industrial

Describe facility type/use____________________________________

Code Used: ____Inter. Mech. Code (IMC) ____Inter. Building Code (IBC) ____Inter. Fire Code (IFC) ____Other Ref. Standard (__________)

FIRE PROTECTION AND OTHER SYSTEMS TO BE INSTALLED OR ALTERED

Scope of work: ________________________________________________________________________________________________________

I. Automatic Fire Suppression System:

1. ____Automatic Sprinkler System: ____Wet, ____Dry, ____Pre-Action, ____Deluge, ____Comb. Dry Pipe/Pre-Action, ____Anti-freeze, ____Limited Area

2. ____Standpipe System: ____Wet

____Dry

3. ____Alternate Fire Protection Systems: ____Commercial Hood, ____Spray Paint Booth/Room, ____FM 200, ____Other______________________________

Extinguishing Agent to be used: ____Wet Chemical. ____Dry Chemical, ____Clean Agent, ____C02, ____Foam, ____Halogenated, ____Other________

II. Fire Alarm/DetectionSystem: ____Manual, ____Automatic

Describe type and purpose:______________________________________________________

III. Water supply: ____Fire Pump (____Elec./____Other fuel type-list___________), ____Back Flow Prev., ____UG Fire Main, ____Tank storage,

____Private Fire Hydrant (____Dry Hyrant,____Wet supplied by Municipal Water,____Wet supplied by on site private system)

IV. Hazardous Materials Storage Tanks and Dispensing Systems: ____AGST, ____UGST, ____Petroleum Dispensing System, ____Propane Exchange Rack

Further Describe: Product type, container/tank volume & how many of each, and fuel dispensing system__________________________________________

___________________________________________________________________________________________________________________________________

V. Other System Type not Listed Above: _______________________________________________________________________________________________

Make/Model No. of System(s) to be installed as indicated in I-V above: ______________________________________________________________________

MINIMUM PERMIT FEE $40.00

Contract Value $ ________________

Permit Fee $_________________________

How to calculate permit fee

(Ex: contract value 0-1000 = 46.00; 46.00 x 2.0% state levy (.92) = 46.92 + 5.00 (technology fee) = permit fee

$51.92)

FIRE PREVENTION APPROVAL (see Fire Dept. review letter for additional comments or contingencies)

Plans Approved By:_________________________________________________ Date:______________________

Fire Official Plan Reviewer

The Fire Code Official shall be notified when the system installation reaches a pertinent stage of completion for an inspection. The permit holder shall assure that the

inspections have been conducted and approved by the Fire Code Official when applicable. A certificate of occupancy, indicating completion of the work for which a

permit was issued, shall be obtained from the Building Code Official prior to any occupancy. By signing above, I understand that the permit is granted for the work

shown and described in this application. Any falsification, misrepresentation or misleading information given VOIDS the permit. Inspections for Fire Protection

Systems will be performed by Fire Prevention Office. Inspections for Fire Protection Systems will be performed by the Fire Prevention Office. Please call 382-CITY

(382-2489) or go to

(Customer Contact Center) to request your inspection. Please allow at least two business days to schedule your

inspection. The inspection is not confirmed until the Inspector calls you back. Also, the fire permit # must be obtained and provided at the time of the inspection

request before your inspection is confirmed.