City of Hartford

CITY OF HARTFORD
FIRE ALARM MASTER BOX REGISTRATION

 MASTER BOX #_______________(Do Not Fill Out)

PERMIT #___________ (Do Not Fill Out)

       PLEASE PRINT

____________________________________  PREMISES NAME  ___________________________________
 NAME OF RESPONSIBLE PARTY
____________________________________        __________________________________
PREMISES ADDRESS                                                                             DAYTIME  PHONE NUMBER
____________________________________________________________
TYPE OF PREMISES (for example, RESIDENCE, OFFICE, FACTORY, WAREHOUSE, APARTMENT, CONDO, RESTAURANT)
_____________________________________   
NAME OF CONTRACTED SERVICE COMPANY		 ___________________________________
CONTRACTED SERVICE COMPANY PHONE #
____________________________________  FIRE ALARM CONTROL PANEL MANUFACTURER _____________________
MODEL #  

TYPE OF DISCONNECT:            ZONED Check Box                    ADDRESSABLECheck Box                  GLOBALCheck Box

NUMBER OF DEVICES:

PULL STATIONS:__________

SMOKE DETECTORS: IONIZATION:___________ PHOTOCELL____________ DUCT DETECTORS________
HEAT DETECTORS:________
SPRINKLER FLOW SWITCHES:    WET_______________ DRY_________________

EMERGENCY CONTACTS:  Full Names and complete home addresses must be filled in; no alarm companies


_________________________________________________________________________
NAME of Emergency Contact #1                      Complete Home Address                  Pager Number & Phone Number

_________________________________________________________________________
NAME of Emergency Contact #2                      Complete Home Address                  Pager Number & Phone Number

_________________________________________________________________________
NAME of Emergency Contact #3                      Complete Home Address                 Pager Number & Phone Number

*  A COPY OF A SIGNED SERVICE CONTRACT FOR THE YEAR COVERED BY THIS PERMIT APPLICATION MUST BE ATTACHED, AS WELL AS A COPY OF THE SYSTEM TEST REPORT FOR THE PRIOR YEAR.

*  I HAVE RECEIVED A COPY OF THE ALARM DEFINITIONS AND REGULATIONS.

_________________________________               _________________________
Signature                                                       Date

Print this form and mail it to:  
Hartford Police Department
Attn: Alarm Registration Unit,
50 Jennings Road, Hartford, CT 06120