HomeMy WebLinkAbout15-16628 • CITY OF ZEPHYRHILLS
� �� 5335-8th Street
(813)780-0020 16628
ELECTRICAL PERMIT
_� PERMIT INFORMATION -� � - LOCATION INFORMATION
Permit#:16628 Issued: 9/30/2015 Address: 4850 16TH ST
Permit Type: ELECTRICAL MISC ZEPHYRHILLS, FL.
Class of Work: ELECTRICAL MISC Township: Range:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Sq. Feet: Est. Value: Book: Page:
Cost: 500.00 Total Fees: 40.00 Subdivision: CITY OF ZEPHYRHILLS
Amount Paid: 40.00 Date Paid: 9/30/2015 Parcel Number: 14-26-21-0010-02100-0150
� CONTRACTOR INFORMATION � - OWNER INFORMATION �
Name: ON-LINE ELECTRIC ' Name: KFP 4850 16TH ST LLC
Addr: P.O. BOX 921 Address: 5465 SADDLEBROOK WAY
VALRICO, FL 33595 WESLEY CHAPEL FL 33543-4338
Phone: (813)662-0362 Lic: Phone:
Work Desc: SAFETY INSPECTION /NEW SERVICE LINE/JUNCTION BOX LINES TO PANEL BOX
� APPLICATION_FEES � �
ELECTRICAL FEE 40.00
� � � INSPECTIONS RE UIRED �
ROUGH ELECTRIC
CONSTRUCTION POLE
PRE-METER � '��
FINAL �-�
REINSPECTION FEES:(c)With respect to Reinspection fees will comply with Florida Statute 553.80(2)(c)the
local government shall impose a fee of four times the amount of the fee imposed for the initial inspection or
first reinspection,whichever is greater;for each such subsequent reinspection.
NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property 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 and Fee Must Accompany Application. All work shall be pertormed in accordance with City
Codes and Ordinances.
CONTRACTOR PER OFFI
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
�
� , 8��-��� Ciiy of Zephyfiills Permit Application Fax-813-780-0a21
Building DepaMieni
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date Received �
Pho�re Contact for Permlttin
Wu�iedsNama / l0 S� I OwnerphoneNumber
SA �
Uvinet's Addross � i Owner Phone Number
Fee Simpin TiUeholder Hame , Owner Phone NambBr _ i_�
Fee 5imple TiNeholderAddress '
.�oaanoeess I(o�^ S-F�. t� ✓h.�t IS LOT# 0
SUBUMSIDN ,p PARCE�(OtF i
toarnweo FRO�t rreorenn-raz Nonc�
WORK PROPOSE� e xEw CON57R 8 ADDlA�T d SIGN 0 Q �EhAOLtSH
1NSTHLL REPAIR �
PROPOSEO USE Q SFl2 Q COMM � OTHEf7
7YPE OF CONSTRUCTiON Q BLOCK Q FRAME Q 57"EEL Q
d��t,n�+2. )Gt�w�� s _,'l.2,W S�"tk w,� t�t��r�n�v rnd����'�J'vs,v?•t.,.�
DESCRiPT10N Of lNORK flI[.� ' J f �X- p� E X ��,�`.
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BUIL0ING SIZE SQ FOOTAGE�� HEIGHT � w`��S�d,hy. �aYtZJC
fl
OBUILDING S � � VALUATIDN OF TOTnL CONSTRUC710N
I �ELECTRICAL $�� �� MAP SERVICE � Q PROGRESS ENERGY [� W.R.E.C.
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I QPLUMBING $ �/_� �
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i QMECHANICAL $ VAl.UATION OF MECHANICAL INSTALLATION � I
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' QGAS Q ROOFING Q SPECIALTY�� OTNER
FINISHED FL0012 ELEVATlONS � FLOOD'LONEhRFA �YES NO
BUILDER COMPAtdY
St6NATURE REG3STFiiED Y!N �cuaaEn Y/N
' pd� License#
ELECTRICIAN . � COMPANY ��"�-'�'+-'�- ��C�L
SiGNA7URE �c�srcam Y/N rce cuwun Y!N
adare�s It�6 ��• .sY,rh sr. T w, er F2... ur.e�se# i,C s�co t �'
P�ume� co�wP�wv
SIGNATURE REGISTERF� Y!N �E c0�ar�. Y!N
Ad�ess license��
MECHANICAL COMPANY
SIGNATURE REGI37EHf� Y 1 N Fce c+taHSn Y!N
Add+ess Lic[:nse!!
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On{� COMPAHY
SIGNATURE r+ECls�ieo Y 1 N F�cuaR�.� V f N
Address � Liccnse Sf
II/IIIIIIOIf1111111I191t11L1111i11t11111t1111111i11111Y1I1i11/ 11111
RESIDEN7IAL. Attad�(2)Piot Plans;(2)sets of Bulding PWm;(1}set of Erieegy Fortns:R-O-W Pertnit far new consWction.
� Minimum ten(10)working days afler submitlai Jate. Reyuired orcyite,Ctmsbuclian Plans,Stomixrater Plans w/Si1t Fence inshatted.
Sanftary Fau7lties 81 dumpster,Stte Work Permit Tor subdivistonsfiarge proJects
COMMERCfAL AttacFi(2}comptele,seFs uf Building Plans plus a LHe Ss(xty�Paga;(1)set of Energy Fom�s.R-O-W Permit For newconshuctian.
Minimum ten(70)working days after suDmlHa1 date. Required onsite,ConsWction Plans.Stortnvratar Ptans w/Sdt Fence insialted.
Sanitary Fecilities&1 dumpstet.Site WoAs PermN for a�d naw pmjects.Au cammercial requ"vuments mus!meet compGance
SIGN PERIAIT Attach(2)seLS ot Engineered Plans.
"'••PROPERTY SURVEY re�uired ior ali NEW con.ahuc?ion.
Dlrodions: 'I* �
F7�out�dicatian completety. ' �
Owner&ContractoT slgn back of applicadon,notar(zed �
U over s2500,a Hotiee o(Commencement ls required, (A/C upgrades over$7S00j
"' ftqent(for tAe cantractor)or Power of Altomey(fo�the bwner)would be someone wrih notarized letter imm uwner authorizing same
OVERTHE,COUN'YER PERMI'fTiN6 (COpy of cnntract required)
RarooFs It shfngles 8ev�ers Servioe Upgrades AIC Fences(PlotlSurveylGootago}
Drlveways-Not overCaunter if on pub�c,roadways..needs ROW �
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I CONTRACTOR
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� State.of Florida � �
County of f,15�/1D � '
; The foregoing in rument was acknawledged before me this 23 day of�,��'
20 �S , by Rd�Q �,2 � �� who is personally known to me or has produced
�---,
as identification. , ,,----� �
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D4NOVAN Ri:ED �
(SE �i'�i p� Na��`Pubiic,State of Florida j ; r
Comm�ssion#FF 1d2472 ;
Niyoorom:expiresoec:lo,�OtB � � (�otary Public{Signature)
*x�*m**�a*�*******�*****x�****�*****x�*x�**�xx�*********�*****�***�**�**�*******���a�*x�****
OIMNER
, State of Flori a
County of �t SC O
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The foregoing in, strt�ment was acknowledged before me#his�_day of�C l
T�'
20 ,by Glncd- 1�.}�.;.�-)-c� .who is personally known to me or has produced
, 'Qr��rs (�C.�nSf as identification. �
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(SEAIj '
' i Notary Public(Signatu
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f��'pY`"A���:. TABATHA N WRIGHT -
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t+,�, Q� MY COMMISSION#FF33490 ,
11'�.........!p f ,
•„FOF r�o,,.• EXPIRES July 4.2017
(d07)398-0153 FloridallotaryService.com �
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� LIMffED POWERi OF ATf�RNEY
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Date �
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; I heceby appoint �Y� k ��� � to be my tawful attorney-in-fact to pull a
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; permit and sign for any pertinent documents as they relate to the following address with�ty of
Zephyrhilis: .
.,
4850¢6�'St.
• Zephyrhills,FL '
. �
EG 130�t �'S�j
License Number
��or5.�- �3�(Jr�r 1 5�iG
Name of Contractor
�.-..�,.�.
' Signature
*�x��***�**�****�*�**�***�*:�x�**�*�***�*��*��****��*��**��**��x***��**�*�**��*x�*�
State of Florida
County of l,LrS�Bc��tt h�- ,
The foregoing ins rument was acknowledged bifore me this_��day of �`!t �
20_[�,by QO�ZLI K �who is,personaHv known to me or has produced
as identi�cation. �
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F
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� DONOVAN REED i I
z� �� Notary Public,State ot Florida.
Commission#FF 182472 �
,� My comm.e�@ues Dec.1 Q,2018 � .
� Notary Public(Signature)
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_.--_.._...___.. -.---...._.. _. __.._._...__.._..__.__.__. ._. .�__._- .---- - _- --__.___.__._.._------- --_.._�
- ----._���.._.. _.__...._.. _
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� � � _ ,-__ - - ._��_� DATE(MMIDDIYYYY)
A�° CERTIFICATE OF LIABILITY INSURANCE - -�--09/30/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTAC
A.KILBRIDE INSURANCE INC. NaME:
�ao�w.eusch a�vd. P"o"E , g13-931-7467 aC No: 813-932-7336
Tampa,FI 33612 A o"R'ESS: certificate akilbride.com
813.931.7467 Phone
813.932.7336 Fax INSURER S AFFORDING COVERAGE NAIC#
INSURERA:At�dlltlC Casualt Insurance
INSURED INSURER B:
Luper,Amos dba On-Line Electric
210 West Powhatan Avenue iNSU�R c:
Tampa, FL 33604 INSURER D:
INSURER E:
INSURER F.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE'BEEN REDUCED BY PAID CLAIMS.
INSR TypE OF INSURANCE ADDL SUBR pOLICY NUMBER M�LDDY� MM/LDDY� LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ Z,OOO,OOO
✓ COMMERCIAL GENERAL LIABILITY PR M SES EaEoccu ence $ �OO,OOO
A CLAIMS-MADE �oCCUR L0300034224 9/12/15 09/12/16 MED EXP(My one person) $ 5,000
PERSONAL&ADV INJURY $ 2,000,000
GENERALAGGREGATE $ 2,000,000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2,000,000
� POLICY PR� LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident
ANYAUTO BODILY INJURY(Per person) $
ALLOWNED SCHEDULED BODILYINJURY(Peraccident) $
AUTOS NONAWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESSLIAB CWMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N�A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 107,Additlonal Remarks Schedule,if more space Is requlred)
Electrical Contractor#EC13001753
License Qualifier: Horst Odparlik
CERTIFICATE HOLDER CANCELLATION
City of Zephyrhills
rJ33rJ$th St. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Ze h rhills, FL 33542 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
P Y ACCORDANCE WITH THE POLICY PROVISIONS.
derek.phs@gmail.com �
Fax(813)780-0021 AUTHORIZED REPRESENTATIVE
O - 010 ACORD CORPORATION. All rig s reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD