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OFFICIAL USE ONLY Date: Fee: Agent: App. No.: Certificate of Inspection Application Commercial with Public Assembly Space (Please attach a copy of Inspection Report from licensed inspector.) Address of Premises Inspected: Parcel No.: Applicant Information: Name of Applicant: Address of Applicant: Telephone Number of Applicant: Cell Phone Number: Email Address: (NOW REQUIRED) Name of Business/Entity: Tax ID Number of Business/Entity: Inspection Information: Date Initial Inspection Occurred: Other Insp. Dates: Name of Licensed Company Performing Inspection: Name of Inspector: Violations Correction Date: Verification of Correction Date: Name of Inspector Verifying Correction: Application Fee: $50.00 Method of Payment: Credit Card or Check (circle one) Credit Card Number: Expiration Date: 3 Digit Code: I , duly authorized to act on behalf of , verify that all information provided in the governmental document is complete. Further, I verify that all necessary inspections and corrections of any violations have occurred at the premises known as , and that I have no knowledge of any fire safety, property maintenance of any other code violations in existence at the same premises. Signature of Applicant