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Home My WebLink About15-16355 i CITY OF ZEPHYRHILLS ' " 5335-8TH STREET (sis)�so-oozo 16 5 BUILDING PERMIT PERMIT INFORMATION LOCATION INFORMATION Permit Number: 16355 Address: 37500 LILLY BEA AVE LOT 157 Permit Type: ADDITION/ALTERATION ZEPHYRHILLS, FL. Class of Work: 434-ADD/ALT RESIDENTIAL Township: Range: Book: I Proposed Use: MOBILE HOME SUBDIVISION Lot(s):157 Block: Section: Square Feet: Subdivision: GRAND HORIZONS I Est.Value: Parcel Number: 34-25-21-0140-00000-1570 Improv. Cost: 11,300.00 OWNER INFORMATION Date Issued: 6/12/2015 Name: FISHER RONALD R& JOANN Total Fees: 195.00 Address: 37500 LILLY BEA AVE Amount Paid: 195.00 ZEPHYRHILLS, FL. 33542 Date Paid: 6/12/2015 Phone: (910)986-8131 Work Desc: INSTALL SCREEN RM/W PAN ROOF & ELECTRIC 10'X 27' CONTRACTOR S APPLICATION FEES HOMEOWNER BUILDIN FEE 135.00 ELECTRICAL FEE 60.00 / � - 13 �- �� b Ins ections Re uired FOOTER 2ND ROUGH PLUMB MISC INS TION CE IN FOOTER BOND DUCTS INSULATED ' SEWER MISC. ROUGH ELECTRIC LINTEL MISC MISC. 1ST ROUGH PLUMB PRE-METER INSULATION WALL MISC. DUCTS INSTALLED WATER MISC DRIVEWAY PRE-SLAB SHEATHING MISC. MISC. CONSTRUCTION POLE FRAME MISC. MISC. REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80 (2)(c)when extra inspection trips are necessary due to any one of the following reasons: a)wrong address b) condemned work resulting from faulty construction c) repairs or corrections not made when inspections called d)work not ready for inspection when called e) permit not posted on job site� plans not at job site g) work not accessible. NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this properly that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management, state agencies or federal agencies. "Warning to owner: Your failure to record a notice of commencement may result in your paying twice for improvements to your property. If you intend to obtain financing,consult with your lender or an attorney before recording your notice of commencement." Complete Plans,Specifications Must Accompany Application.All work shall be pertormed in accordance with Ci Codes and Ordinances. NO OCCUPANCY BEFO C.O. � CONTRA TOR SIGNATURE PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER : . O;�o � C�RitYN -:��.�� _ ��.� _ �� :� , ��. _ - ..-� City of Zephyrhills BUILDING PLAN RE�IEW CORl1NIENTS Cantractor/Horneowner: ��N �-" L S i-1 �(� Date Received: � - 2. '- � S� sxt�: 3� Soo L.r L�Y �3�,A Permit Type: 1� �' 2Z S`C-R,EEN �� vl�1 QA�'t1 ��=- Approved w/no comrnent Approved w/the belaw comments:� Denied w/the below comments: ❑ � �. 1/S� �� G� G� II� This comment sheet sha11 be kept with the permit and/ar plans. � � F � ' - ��- , Kalvin -P s Examiner Date Contracto and/or Homeowner (Required when comznents are present) a�saeo-oo20 - , - City of Zephyrhills Permit Application Fax-813-780-0021 . ' , � Bullding Department Date Recelved '_ " � " ' � Ph�one'Contact for Permittin! �- ' �� :��-, �� Owner's Name D� ��s12 � ,Owner P.hone.Number �l� �" < �� d�3/ Owner's Address � �S v� �� l f �e�' Owner Phone Number - Fee Slmple Tltleholder,Name • � Owner Phone Numb"er Fee Slmple Tltleholder Address JOB ADDRESS ��S6U [�L G ` l��" � � �G`"lJ� /— L- LOT# � SUBDIVISION l�.(�/'h''�D ��►"l z-i'iZ PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED e NEw CONSTR e �"ADD/ALT° Q SIGN Q Q DEMOLISH ' INSTALL �REPAIR PROPOSED USE Q �SFR Q COMM Q OTHER • TYPE OF CONSTRUCTION' �Q BLOCK� Q - FRAME Q STEEL Q _ � DESCRIPTION OF 1NORK f �U X o2 -�C�`°�'U/1 ('✓P't. �"r �� -V t' BUILDING SIZE !U'X 2�e � s SQ FOOTAGE ��o J� , , HEIGHT . T � -, . OBUILDING $ �/ ,9��v a , ,YALOATION'OF TOTAL CONSTRUCTION . f (/ DELECTRICAL � $ 3�O`a o AMP SERVICE 0� PROGRESS ENERGY� `Q W.R.E.C. QPLUIUIBING $ QMECHANICAL $, VALUATION OF MECHANICAL INSTALLATION ,b'SS� � QGAS Q ROOFING .Q SP.ECIALTY 0 OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA QYES NO BUILDER � 2 �COMPANY � SIGNATURE J REGISTERED Y/ N FEE CURRE� Y/N o �S Address ��s ✓��-�• ✓�"✓z- z � �'� License# �C�,�° ��-� ' �1 �� I , ELECTRICIAN. �� U COM PANY f' a Vyl 'L Q I.J i'l-�^ SIGNATURE REGISTERED Y/ N FEE CURRE� Y/N Address Llcense#� � PLUMBER . �j/�-„ COMPANY SIGNATURE l REGISTERED. Y/ N - FEE CURREK', Y/;N Address >License# MECHANICAL �//�- � COMPANY s SIGNATURE l � � ' REGISTERED Y/ N . FEE CURRE�, Y/N� Address' • � � ' License#. OTHER " - COMPANY � SIGNATURE " � � REGISTERED Y/ N FEE CURRE� Y/N, Address . - � �. ^ - - � � '�'C'icense# � RE5IDENTIAL- Attach(2)^PIot,Plans;,(2):,sets�of�Building;Plans;(:1).sef of Energy�Forms;R-0=WPermit for new construction, � Minlmum ten,(,10)�working day_s�,after;submlttal,d"ate:,Required on§ite,._Constrtictiori`Plans;Stortnwater Plans w/S(It Fence installed, Sanitary FaoillUes•&;1:dumpster SIte;VUork�Permit<,for,;subdivislonsllarge projects ; �;_ ° COMMERCIAL Attach(3)complete�sets=of�Building-Plans plusa Llfe''Safety'Page;`(1)set of Energy Fomis.R-O-VV Permit for new constructfon. � Minlmum ten(10)working days'after submlttal date. Requlred onslte,Constructlon Plans,Stormwater Plans w/Silt Fence Installed, Sanitary Facilltles 8 1 dumpster.Site Work Pertnit for all new:projectsr-All,commercial requlrements must meet campliance 51GN PERMIT Attach�(2)sets of Engineered.Plans.,� . .. - � , . • "'"PROPERTY SURVEY required for�all NEW construction.� _ , _ .. _ -,� • � . - ....... _._.__ ... ..,_._ . ,_ )lrectlons: � : ' I Fill'.out application completely. Owner 8 Contractor slgn back of applfcaUon,notarized ' If over 52500,a Notice of Commencement is required. (AIC upgrades over�T500) " Agent(for the contractor)'or Power of-Attomey(forthe�owner.)'would be sortieone wiith notarized letter from owner authorizing same �VER THE COUNTER PERMITTING.,. _. .,(Front of ApplicaUon_Only). . ` �eroofs if shingles Sewers Service Upgrades A/C Fences(PIoUSurvey/Footage) Driveways-Not over Counter if on publlc roadways':ne'eds ROW� � NOTIGE O�DEED RESTRICTIONS: The undersigned under.�tands that this.p�rm(t.may be subJect to"deed"r�stNctlons" which may be_moce�estrictive than Gourity�eguiat{ons. T#ie unders�gned assumes responslblftty for compllance with any applicable deed restrictions. UNLlCENSED CONTRACTORS ANL?- CQN7RACTOR RESPONSlBlLITIES: If the owne� has hired a corttractor or contractors to undertake work, #hey may be re�quired.to be;licensed fn accardanae.with state and•local reguiatians. If the cont�actor is not licensed as required by law, both tfie owne� and contractor may be cited for a misdemeanor violation under stafe law. If the ouvner or Intended contr,actor are uncerta#n as to what licenstng.requtrements may appty.�for #he intended wark, they are �dvised to contact the.Pasco County Building Inspection Division—L.Pcensing Sec#ion at 727-647- SU09. FurthermoreT !f the owner has hired a contractor or contractors� he is advlsed ta have the cantraetar(s) sign portions of the "contrac#or Biack" of fhis appi6ca#ton for which they witt be responsible. if yau, as.the owner sign as the contractor, that may be an indication that he is not.praperly licensed and is not entitled to permitting privileges in Pasco Courtty. TRANSPORTATION�IMPACTIUTILITIES IMPACT ANp RESCIURCE RECOVERY•FEES: The undersigned uriderstands lhat Trarespartakfon Impact Fees and Recaurse Recove.ry Fess may�:appiy-to tha construction of new buildfngs, ahange of use in existing buildings, or.expansion.ofi�existirig`buildings, as specfified in Pasco Caunty Ordinance number 89-OT and 90-07, as amended. The undersigned also understands,.that.such fees,�.as:may�be�due,;wlll be identtfied at the time of permltting. 1# Is turther undersfoozf tha#Transpottation Impact Fees and Resource Recauety�"Fees must be paid prtar to receiving a °certificate of occupancy" or fina{ �ower.release. :If the;projec#,,does not Involve a certificate af occupancy or finat power retease, the fees musE.be pald prior to permft issuance. Fu�thermo�e;��f Pasco County iNaterlSewer Impact -------- fees-are-due,'they:must be=paid-prior�to�permit`issuance�in`accardance witti appiicatile`Pasco`�County o�dinances:� CONSTRUCTION LlEN L.AW(Chaptar 713� Florlda Statutes,as amended): If valuatlon of work Is$2�50Q.00 ar more, ! certify that t, #he appllcant, have been probfided wi#h a copy-of �the "Florida Constructian_Lien. Law:Homeowner's Proteckion Guide" prepared by the Flarida Department of Agrlculture and ConsumerAffairs.: If the appNcant is someane other#han the"owner", t certlfjr that 1 ttave.cibtaEned a copy.of.the above descrlbed document and promise in,g�od falth to deliver it to the"owner"�prior to�commencement: � CONTRACTOR'S/OWNER'3 AFFIQAYIT: I ce�tify;that a9l,the informatfor►In•this appltaatton is accurate and th�t a!1 work w�li�be done in corr�pliance with all applicabte laws regutating cvnstruction, zoning antl land-development. Applicatian is hereby made to obtain .a perrnit,ta do woric..and installation as (nd(cated. L.certffy that no work or tnstallation has commenced prtar to [ssuance o€'a permit and tha#.aEl work w311 be performed to meet standards of all taws regulating- construction, County and City codes, zoning regulations, and land development regulattons-tn the jurisdiction. I al'so certify that ( understand that the ceguiattvns of othe�government agencles may apply�ta the inEended work, and that it is my responsibitiry#o identify what.actions I must take to be�ln.corilpliance: S,uch agencles-Include-but are.not limited ta: - Department of Env(ronmental Protection-Cypress'Bayheacls, Wetland Areas and Environmentally Sensitive �ands,lNater/Wastewater Trea#men#. - Southwest Florida Water Management .District-Wells, Cypress. Bay,heads, Wetland. Areas, Altering Wate�courses. - Army Corps of Engtneers-Seawalls, Docks, Navtgab�e Waterways. - Depa�tment of Health & Rehab!litative,Servlcas/Environment'at Heatth Unit Well.s,_Wastevu�ater Treatment, Septi+c�Tanks. � _ . - US Environmental Proteation Agency-Asbestos abatement. - Federal.Av6atlon Authority-Runways. - I understand that the fopawing�restrictions apply to the use of flll:� - Use of fN is not ailowed in F#ood Z�ne"'V"untess expressly permftted. - if the filt material is to be used in.-Flood Zone °A°, it. is understaod that a drainage pian addressing a ucompensating valume" will be sub�itted at time �af permitting which is prepared by a professfonal engineer licensed by the State of Flqrida. - If the fill material is`to be used in Flood Zane "A" in�connec#ion�with.a permitted building using �tem wall � construction, l ce�ti that fiil will:b.e-used ont ta.fill the area wi#hln.the s#em walt. � ` ',� - if fill materlal ts t�be used in any°area, 1 certify tha# use. af such"fill wiil. �at adverse y:a.ffect adjacent properties. If uss af flN is found to aduersely affect adJacent properties, the owner may be c�ted for vlofating the conditions af fhe building.permit i"ssued�under the attacfied perrriit applicatian, for-�lots less.tha� one (1) acrE which are elevated byflll, a�englneered drainage.pla�is required. , If 1 am the AGENT FOR THE QWNER, I,rpromise,in good falfh to inform�the�owner af_the.perm{tting candi#I4ns set forth In this affidavit prior #o commencing constructtori. I understand that a separate permit may be required for electrical work, plumbing, signs, wells, poolsr, alr condittonfng, gas,.ar,,other„!`nstall�itf`ons^nat.speci�icaity tncluded-in the appli�ation. .A permit issued shail be construed:to be�a�iicense#o�proceed with the,work and nqt as._authority�.to:violate,,cancel, alter, or . set aside any provisions of the�technlcal codes; nar shall Issuance�af a permit prevent the Build[rig Official from thereafter reguiring a cor.rection a�f errors.in-plans;constcuction,or vlalations of`any-codes.-Eve-ry-permit issued sFiall�bectirrie invalid unless the.work authorized by such permit,�ls.commenced�witliin sUc;months of permit issuance, or if work authvrized by Ehe pertn{t is.suspended.or abandoned•#or:a-period-of:s�C.(6)�months.affer.:the tlme the�work ls commenced. An e�cfensia� may be requested, in writing; from ttie Building,Official for�a perlodrnot to exceed nineiy�(90) days�°and�will�demonstrate justifiable cause for the�extension. If work ceases,for ninety(90)consecutive days,_.the job�is cansidered abandoned. WARNING TO .OWNER:` YOUR..FAI,L,URE.TO,RECORD A,NOTICE.OF.�COMMENCEMENT-MAY°RESULT IIN YOUR PAYING,TWICEsFQR�IMPROVEMENTS T;O YOl1R�PROPERTY. tF YOU�INTEND`TQwOBTA1N�FtNANCING,C(JNSUlT WITH'�DUR LENDER OR AN A�TORNEY BEFORE��R�CORDING XOU �NOT�CE:O�COMMENCEIIffENT: FLORIDA'JURAT{F.S;11T_:U3) . . . , . � . � -� � � , � , . . OWNER'OR ACiENT � �°�CONTRACTOR" ' - � ' ' ' .. , , : Subscribed and swom ta r a e befgre me this Subscrlbed and'swom .{or aflimt dj e�re'me this' ' :r°Z�1� by �trh.� �l�I.i�' .S�-Z.�'�'!r ,�yy. 6�� .�ri!'Ifv,t..;: _. Who Is/a�re perso all kn to�,me,or. as/Fiav@:produced., . Who:ls/ere.per�,or al�y known:.o� e or hasmave produaed:•• � � ,_;FLD/_., ,�Zi' - `�= �� as`Identlecadon. a�l G'G .S `frS-- �"�": X �_as EdenU�catfon. �,.�`��'—"' Natery Publta . ` Natary Public Cammissbn No. ��: ..: ' Commisslon.Nv. ��7��5 CHRISTOPHER DEL COTTO �;,��IS�OPHER DEL-CO1T0 ' Nam ��I�tOd��t Name of Notary d adat q�p�t,.,�r, . .�RY pt+:,, CHRIS3'OPIiER DEl CdT70 , - •�SP °Q ��tY Pl� . �� CHR1STdRHER DEl COTT4 �;z°n�.`�"'s_ Natary Public-State of Florida •osP�' �et;•. ` '�- " ' � « :•_ My Camm.Expires Jul 17.2017 ;r*�*�'-;, Notary Public-State of Florida ="* ""' Commission#FF 0370A5 = . .•� MY Gamm.Expires dui ST.2017, 4: i #`tfi • ,9l �= =N. o, Commission#FF d37d45 ��'��°�� Bonded Through National Nolary Assn. �'%;�'or-F�°�`` , , ��,,,,�� Bonded Through National Notary Assn. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII � ��cpt:1689364 Rec: 10.00 I�I DS: 0.00 IT: 0.00 06/12/2015 B. M. , Dpty Clerk 2015093175 'PRULR 5 0'NEIL,Ph D PASCO CiERKOf�1�'�PTROLLER 06/12/201��"' P� �� OR BK Permit No. Parcel ID No .��/" as 4�� YO-00000- �cS70 � / NOTICE OF COMMENCEMENT State of '— G V r�� County of � �� THE UNDERSIGNED hereby gives notice that improvement will be made to certain real property, and in accordance with Chapter 713,Florida Statutes, the following information is provided in this Notice of Commencement� 1 Description of Property: Parcel Identification No. Street Address: J ��v � �� ` `' ��C`' 2. General Description of Improvement �� x � 7 � G�'��1/� ��-�yv�_ 3. Owner Information or Lessee information if tfie Lessee contracted for the improvement: �o n t�- I o( f�- f s h-�/` Name -� h �( t^�J 37s� Lr ll� Ge� Address -- T City St� Interest in Property� ��r Name oi Fee Simple Titleholder (If different from Owner listed above) Address C Ciry State 4 Contractor �Y� d J I ��y�J Name r��,,_, � � rc �`f`i �IS �L, �JS� � 3� 1 � S ti'v � '� State � Address City Contractor's Telephone No. r�D�-'-.��-� �s3 5. Surety: Name Address City State Amount of Bond: $ Telephone No.. 6: Lender: Name Address City State Lender's Telephone No. 7, Persons within the State of Florida designated by the owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)(7), Florida Statutes: Name Address City State Telephone Number of Designated Pe[son: 8. In addition to himself,the owner designates of to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes. Telephone Number of Person or Entity Desig�ated by Owner• g Expiration date of Notice of Commencement (the expiration date may not be before the completion of construction and final payment to the contractor,but will be one year from the date oi recording unless a different date is specified): WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNOER CHAPTER 713, PART 1, SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION, IF YOU INTEND TO OBTAIN FINANCING,CONSUIT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Under penalty of perjury,i declare that I have read the foregoing notice of commencement and that the facts stated therein are true to the best of my knowledge and belief STATE OF FLORIOA COUNTY OF PASCO Signature of Owne"r or Lessee,or Owner's or Lessee's Authorized ��, Officer/Director/PartnerlManager va�'Pu � ,�`� �ATRiCIA L.JOHNSON ��„��d \I\'COi4�tISSION N FF135847 Signatory's Title/Office '��ApP EXP:RES.'December28.2018 �,�� .,�;��:m�,�, �. � y 7lM Su�crv�N The foregoing instrumen Hi`as ac�Cnowledge��efo�ri'ie this �o� day of 3JNE ,20�,b as (type of authority,e.g.,officer,trustee,attorney in facf)for (name of party on behalf of whom instrument was executed). Personally Known 0 OR Produced Identification(� Notary SignatUre OG�— v' ��" (,. Name Print f'i1TFlfG/L� L• �'ONn1.fOA/ Type of Identification Produced /�• � � wpd atalbcsln oti cecomm e n cem en t_pc053048 r . . June 1, 2015 To whom it may concern; I Ronald R Fisher authorize Tim Sullivan to submitt and pickup building permetts in the city of � Zephyrhills,Fl. � p7�G�i�✓ Ronald R. Fisher 37500 Lilly Bea Ave. ,,,N�N,;,,,, IRIS IVANAC Zephyrhills, FI. 33541 ;r: :°�=': Notary Public-State ot Floridi 813 788 2973 : :•` My Comm.Expires Jun 2,2o�e =;,• •�: Commission N FF 128460 ''%%°��i,`•°p',, BondedThroughNalionall�taryAssti. � � � DISCLOSIIRE STATEI�SNT FOR OWIdSR CITY OF ZEPHYRIiILLS BIIILDING DSPARTN�N'P 8 / .� 2, / /��(/��/� �� i�j�/"� have read and fully uaderstand aad agree to the provisioas of this instrument. The undersigned states and affirms that he or she ie desirous of constructiag, reaovating, addiag to or reroofiag his or her own domicile, that he or �he actually occupies, ox��:--eee�gg-� said domicile, aad same is not for , rent, lease or sale. That he or she shall comply with the following conditions: 1. That the owaer and he or she aloae shall act as the builder for all phasea of conatruction. 2. That the owner will comply with all provisioas of the City of Zephyrhills ordinances aad codes pertinent to the buildiag. 3. That ia the event various phases of coastruction are subcontracted, he will � engage only properly licensed subcoatractors and will persoaally supervise such work. 4. That ia the event the Buildiag Inspector shall require corrections to be made, the owaer will assume full respoasibility to iasure they are made, aad upon completion will call for a reinspection before proceediag with the building. 5. That the oaiaer shall assume full respoasibility for the constructioa and will aot expect supervision of his work from the City of Zephyrhills Buildiag Departmeat. 6. That prior to fiaal inspectioa any additional fees, iacluding reinspection , fees, must be paid in full. A writtea request from this office shall constitute an official aotice to pay additional fees. 7o That the ownes shall comply with all City, State aad Federal laws in regard to social security, workman's compensation, lien laws, etc. , where applicable. 8. That the owner shall comply with all the safety codes issued by the Florida Industrial Commissioa. 9. State law requires conetructioa to be doae by liceased contractors. You have applied for a permit under aa exemption to that law. The exemptioa allows you, as the owaer of your property, to act as your owa coatractor with certaia restrictions evem though you do aot have a license. You must provide direct oasite supervision of the coastruction yourself. You may build or improve a one-family or two-family resideace or a farm outbuildiag. You may also build or improve a commercial buildiag, provided your coats do aot exceed $75,000. The buildiag or residence must be for your own use or occupaacy. It may aot be built or substaatially improved for sale or lease. If you sell or lease a buildiag you have built or substaatially improved yourself within 1 year after the coaetruction is complete, the law will presume that you built or substaatially improved if for sale or lease, which is a violatioa of this exemption. You may not hire an unlicensed persoa to act as your contractor or to supervise people workiag oa your buildiag. It is your respoasibility to make sure that people employed by you have liceases required by state law aad by couaty or municipal licenaing ordiaances. You may not delegate the respoasibility for supervising work to a liceased coatractor who is aot licensed to perform the work being done. Any person workiag on your buildiag who is aot liceaeed must work under your direct supervisioa aad muat be employed by you, which meaas that you must deduct F.I.C.A. and withholdiag tax and provide workers' compensation for that employee, all as prescribed by law. Your constructioa muet comply with all applicable laws, ordinances, buildiag codea, and zoning regulations. � OWNER'S SIGNATURE A DATE � ,. / �. � ADDRBSS ✓ PHONS y"j � . ' ' ��..r WITN�.'SS !�-rv.� � � PSRMIT # ; 1�!1 j 100% �`iUF'�2��y �T�. S; ?e. q 't�n` ,��'+m..�'• � JEfF ATWATQ2 ' CHIEFFlNANCIALOFFlCEA STATE OF FLORIDA � DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW** CONSTRUCTION INDUSTRY EXE�APTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVEDATE: 4/1/2015 EXPIRATIONDATE: 3/31/2017 PERSON: SULLIVAN TIMOTHY H FEIN: 473516942 BUSINESS NAME AND ADDRESS: SULLIVAN REMODELING AND SMALL JOBS LLC 35145 ADA AVE. ZEPHYRHILLS FL 33541 SCOPES OF BUSINESS OR TRADE: CARPENTRY INSTALLATION OFCA Pursu ant to Chapter 440.05(14),F.S,an o flicv of a corporatian who elects exemption from this chapter by filing a certificate o(eleaion und cr this section may notrecaverbenefitsorcompensationundvthisdiaprer.PUrsuanttoCh�tv440.05(12),F.S,Certdiptesofe6ea�ontobeexcmpt. applyonty with in the scope of the busin ess or trade listed o n the notice of election to be exempt.Pursuan t to Chapter A 40.05(13),F.S.,Notices ol Mection to he r,�cmv��dcMiliwtesoleleaiontobe�empt shaAbesubjetttorevowtionif,atanytimeaftertheli6ngoftAenoticeortheisuanceolthecertificat0 th e person named on thc notrce or artNicate no longer mcets the requiremcnts of this seaia n lor issum ce of a cenifinte.The department shatl«voke a DFS-F2-0WC•252 CEFiTI FICATE OF ELECTION TO BE EXEMPT REVIS m OS-13 QUESTIONS?(B50)413�7609 _� , PASCO COUNTY BUILDINGGQFlS7RUCTION�ERVtCES DEPT. =CONTRACTOR LICENSING � CERTIFICATE OF COMPETENCY I.D.#0 2649 � C.C.#LCC-8826 Firsf/Last Name Timothv Sullivan Contractor Type: Carpentry Contractor Sullivan Remodeling&�Sr��ItF;fobs LLC a-, ,,..-._.,c.-s X�. �._,� �-.,G T..i .. 3 a,; '��._1 ..._ ;. HAVING MET THE COIVt��T��IEY REQUIREMENT FOR THE LICENSE TERM' �PIRING 9-30-16 ��G+iv�u-(� �./� SIGNATURE