HomeMy WebLinkAbout126 Main St - CofO (20)L
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SUPPLEMENTAL INFORMATION-
1
BUSINESS ADDRESS 12 (0 M
2.
Person to contact in case of emergency- A41r%nn Pa;
Telephone number: -17V-XI-Vi
3.
-,Does the building in question have electricity?
❑ Yes
GrNo
(a) If No, are you requesting .hat the electricity be
l3"Yes
turned on?
❑ No
4.
The building is sprinklered? _-
Q—Yes
ry
0 No.
;
5.
Operationswill produce dust/wood shavings or similar`
material?
❑ Yes ,
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o
6.
Operations Will involve the-, repair, - or replacement of
Ch Yes
:automobile parts? _ _._
allo
If Yes
- :
(a) Describe the components repaired or replaced .
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(b) Does the operation involve the use of an -open flame.?'.
- _ . ❑ Yes
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7.�
The business is drinking, dining or assembly • use that will
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result An an, occupant _load, of more than 0 persons.
0-Yes
0'No
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8.
The following best describes my, operation;
Office Only
ail Sales
�.
Ware Ouse
Manufacturing / Distribution (describe process and end product)^-
Restaurant/Take Out Food
:
Medical / Dental
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Other .(describe)
SUPPLEMENTAL INFORMATION
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SUPPLEMENTAL INFORMATION,
(Continued)
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Does the a_peratiari 'involve- any==of th6 `€ollowirig materials?
O Yes
I"No
If
Yes, indicate .quantities " k
Material � �" Quantity
1.
Flammable liquids
Class I -A
Class 1-B
:Class l-C
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2.
Combustible liquids
4
Class I!
Class, III -A
3.
Combination flarpapabie• liquids ' _
_ . ,'•
,
4.
`J Flammablegases
5.
Liquefied flammable gases
_
6.
Flammable _ fib �.rs -loose
r r
7.
.. Flammable fibers - baled
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8.
Flammable solids
~ 9.
Unstable materials,,,,,,,,
10.
Corrosive liquids
T....,
.. -.Oxidizing material - gases
12..___.._.0xidizing. material - liquids --
;
13
,Oxidizffig.- ~raterial. - solids- "'
1.4.
'"-; `"Organic peroxides
15
Nitrometliane (unstable materials)
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4
16
, :,Ammonium nitrate
.
17.
Ammonium nitrate compound mixtures
containing more than 60% nitrate,°a`
by . weight
18.
Highly toxic material and
poisonQ,gs gas, d.
19_
_ ._Smokeless -powder..
_ 20.
Black sporiing powder
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he...ab.ove. -information is true ':and:: correct
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Prt:
Signature ,
Date
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