CITY OF HILLIARD, OHIO
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Department of Public Safety
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APPLICATION FOR POLICE/FIRE ALARM SYSTEM PERMIT
Lisc. No.:
FEE:
$5.00
Issued:
Exp. -
IMPORTANT: FALSE OR INCORRECT STATEMENT(S) MADE IN THIS APPLICATION OR FAILURE TO CONFORM TO APPLICABLE
RULES/REGULATIONS, LAWS, AND/OR ORDINANCES WILL BE CONSIDERED CAUSE FOR THE DENIAL OR REVOCATION OF THE
PERMIT. ALL FEES PAID NON-REFUNDABLE.
PREMISES WHERE ALARM
WILL BE LOCATED
Address. zip code, telephone number
"I,
printed (or typed) name of applicant. address. zip code. telephone number
DBA
name of business (it applicable). address. rip code, telephone number
HEREBY APPLY
TO
THE CHIEF OF POLICE FOR A
PERMIT
TO INSTALL/MAINTAIN A POLICE/FIRE ALARM
Of.
THE PREMISES
INDICATED ABOVE AND AGREE TO CONFORM TO AND ABIDE BY ALL RULES/REGULATIONS, AND ORDINANCES OF THE CITY OF
HILLIARD AND/OR OTHER APPLICABLE STATE OR FEDERAL LAWS GOVERNING SUCH PERMIT."
SIGNATURE OF
DATE SIGNED:
APPLICANT
CLASSIFICATION
OF
ALARM:
POLICE
FIRE
BOTH
OTHER
TYPE OF ALARM:
LOCAL (AUDIBLE ONLY)
DIRECT CONNECT
TO
POLICE/FIRE DEPT.
DIRECT CONNECT TO
CENTRAL STATION
TELEPHONE DIALER
OTHER
WILL ALARM RESET ITSELF AUTOMATICALLY?
YES
NO
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TYPE AND LOCATION: SENSORS AND/
OR SPECIAL FEATURES OF ALARM SYSTEM:
ALARM SYSTEM
(TO BE)
INSTALLED BY
DATE
MANUFACTURER OF ALARM
SYSTEM:
NOTE:
SECTION 98.04, HILLIARD CITY CODE. ''EQUIPMENT MAINTENANCE AND INSPECTION OF ALARM SYSTEMS''. STATES
(in part: (a) All equipment used in. installations far which a permit in required shall meet the applicable
standards of the Underwriter's Laboratory of the United States and of Canada, Factory Mutual. or other recognized
industry standard. Applicant my be required to submit evidence of the reliability of the equipment to be installed.
EMERGENCY NOTIFICATION:
LIST AT LEAST TWO INDIVIDUALS (YOU MAY INCLUDE YOURSELF, IF APPLICABLE) TO BE
CONTACTED BY POLICE/FIRE IF THE ALARM ACTIVATES
(Note: it is extremely important for the Police or fire Depts. to
be
able to contact someone if the alarm should be activated.)
NAME, ADDRESS. TELEPHONE NUMBER
NAME. ADDRESS. TELEPHONE NUMBER
SENIOR CITIZEN'S EXEMPTION
AFFIDAVIT
I HEREBY CLAIM EXEMPTION FROM THE COLLECTION OF THE PERMIT FEE BY REASON THAT I AM AT LEAST SIXTY-FIVE
YEARS OF AGE AND I FURTHER CERTIFY THAT THE PERMIT BEING APPLIED FOR IS FOR AN ALARM SYSTEM (TO BE)
INSTALLED/MAINTAINED IN My PERSONAL RESIDENCE.'
DATE OF
SOC. SEC.
SIGNED:
BIRTH :
NUMBER :