Free Fire Department Permit Survey Form - Nevada

CLARK COUNTY FIRE PERMIT SURVEY FORM
PROJECT ADDRESS (BUSINESS LOCATION) ______________________________________________________________ PROJECT NAME (BUSINESS NAME) CONTACT PERSON INITIATING AGENCY: AIR QUALITY BUILDING DIVISION ____________________________________ DATE ____________________ ASSESSOR'S PARCEL NUMBER(S) _______________________________________________________________________ __________________________________________ PHONE # ___________________________

(Check Box, Agency Application/Permit #, and Agency Signature Required below) BUSINESS LICENSE CURRENT PLANNING FIRE DEPARTMENT HEALTH DISTRICT

INITIATING AGENCY APPLICATION # or PERMIT # ________________________________________________________ INITIATING AGENCY SIGNATURE __________________________________________________ CHECK "Yes" or "No" for each item below that your building/business/project includes. YES NO £ Water supplied by a well or private water system 1. £ £ Propane tank(s) 2. £ £ Aboveground or underground flammable/combustible liquid tank(s) 3. £ £ High-piled storage* (see definition below) 4. £ £ Spray paint booths 5. £ £ Medical Gas Systems 6. £ £ Combustible Dust Producing Operations 7. £ £ Chemicals ­ Storage, Manufacture, or Use ** £ 8. Fire Dept. Review/Comments Signature is only required for any "Yes" response.
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Fire Dep t. Rev iew/Co mmen ts

Sig n atu re

Date

A "Yes" response to any of the above conditions may require the applicant to obtain a permit from the Clark County Fire Department (CCFD). CONTACT CCFD PLANSCHECK AT (455-7100) IMMEDIATELY for permit requirements. v A "Yes" response to conditions #7 and #8 also requires Signature of Building Division below and may require approval of a Special Use Permit through the Current Planning Division. NOTE: Title 30, Section 30.04.160, provides for the revocation of any land use approval not in compliance with Codes. PRINT NAME CIRCLE ONE: ATTENTION: _______________________________ Property, Building, or Business Owner SIGNATURE ___________________________________________ ~ Responsible Party

~ Occupant's Legal Representative

FAX COMPLETED FORM TO CLARK COUNTY FIRE DEPARTMENT AT (702) 735-0775

* High-Piled Storage is storage of combustible materials in closely packed piles or combustible materials on pallets, in racks or on shelves, where the top of storage is greater than 12 feet (3658 mm) in height. High-piled combustible storage also includes certain high-hazard commodities, such as rubber tires, Group A plastics, flammable liquids, idle pallets and similar commodities, where the top of storage is greater than 6 feet in height. ** Refer to the Clark County Fire Department's "Hazardous Materials Systems" Guideline. For Development Services ­ Building Division Use Only Hazardous Occupancy Required? YES______ NO______ If YES, then Special Use Permit Required.

Building Division Signature ___________________________________________ New Construction Addition Remodel PAC Process Walk-thru Commercial Residential

~ DISTRIBUTION ~ CUSTOMER AIR QUALITY MANAGEMENT BUSINESS LICENSE DEPARTMENT FIRE DEPARTMENT HEALTH DISTRICT DEVELOPMENT SERVICES: BUILDING PLANS EXAMINATION ZONING PLANSCHECK CURRENT PLANNING
Revised 1/10/06