HomeMy WebLinkAbout16-17869 .
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� CITY OF ZEPHYRHILLS
5335-8TN STREEf
(813)780-0020 � $�9
� BUILDING PERMIT ,
I ' PERMIT INFORMATION L.00ATION INFORMATION� /
Perrrtit Number: 17869 Address: 5906 AVQCAQU ST '
Perrrt�it Type: RE-ROOF ZEPHYRHILLS, FL.
Class c�f Work: RQOF REPLACEMENT Township: Range: Book:
Proposed Use: NOT APPLiCABLE Lot(s): Btock: Section:
Square Feet: Subdivision: COLONY HElGHTS
Es�. Value: Parcel Number: 12-26-2'i-0260-00400-0250
Impr �v. Cost: 9,959.86 OWNER INFORMATIQN
Date Issued: 1110912016 Name; RAMOS MOISES
Tot I Fees: 85.00 Address: 5906 AVOCADO ST
Amo nt Paid: 85.04 ZEPHYRHILLS FL 33542-3843
D te Paid: 11/09/2016 Phone: 813-715-2516
Wo k Desc: REROOF 5HlNGLE
CONTRACTOR S APPLICATION FEES
ROOFM CORP REROOF RESIDENTIAL 85.00
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Ins ections Re uired
DRY IN R F IN
TAPE JOINTS RC?OF INSP
FINAL I I c�- /. /(�r
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REINS�ECTION FEES: (c)With respect to Reinspection fees will comply with Florida Statufie 553.80 (2)(c)#he
local overnment shall impase a fee of four times the amaunt of the fee imposed far the initial inspection or
� first reinspection,whichever is greater,far each such subsequent reinspection.
NOTIC�: In addition to the requirements of this permit, there maybe additiona! restrictions applicable to this property that
may b�found in the public records af this caunty, and there may be additianal permits required from other governmenta(
entities such as water management, state agencies or federal agencies.
"Wa n�ng to owner: Yaur failure ta record a notice of cammencement may resutt in yaur paying twice far
impr�►vements ta your property. If you intend to obtain financing,consult with your lender ar an attorney
before recording your natice of commencement.°
Compt te Plans,Specifications Must Accompany Applica#ion. All wark shall be pertormed in accordance with
Ci Codes and Ordinances. NO OCCUPANCY BEFORE C,O.
NQ OCCUPANCY BEFORE C.O.
a ��n� �����
CONTRACTOR SIGNATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MCINTHS 1NITHCiUT APPR4VED INSPECTION
CALL FOR INSPECTTON - 8 HOUR NOTICE REQUIRED
PR4TECT CARD FROM 1NEATHER
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From:Ashtin Be�ve Fax:(877)265-18r'1 To.+18137800021 Fax: +1813i800021 Page 3 of 4 10128l2018 12:25 PM
e��-�eo�oozo i Ciiy of Zephyrhiils Permit Application Fax-87�78D-0021
iBuilding Deparlmenl i
Dala Racalved �
'(`�'t'i-1"I'I-1 ! PhonB Contact For Permittfng� _
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Owner's Nama �GLfNI� Ownar Phone Numbur
Owner'e Addrens S��IO � � ST' OvmerPhona Numbe� ��J" 1 I�
Foo Slmple TIIlehoidor Namo � Owner Phone Num6or � I
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Fae Slmple Tlllahnldor Mdross f �
J06ADDRES9 �!� �V��O VT ���� L JJJ-1Z LOTtF G.�
SUBDNISION I H � ti'4-5 PARCEL IAJi !t—zb�ZJ—n'z.(�_oypd—�,�0
(09TAlHED FROM PRDPERTY YA%NOTICE)
WORKPROPOSEC e N�[ONSTR ADDlAI.T Q $IGN Q Q DEMOUSH
INSTALI � REPAIR
PROPOSED US� Q SFJR Q COMM � OTHER
TYPE OF CONSTRl1CTION Q BLOCK Q FRAME Q STEEL �,
DESCRIPTIOkOFWORK 1"� ! FQ^ ` _�• Y�L.L�p ,1
t tn
6UII,DING SQ$ I SQ FOOTAGE � HEIGNT 1(�
QBUILBING a .� VALUA710N OF 70TAL CONSTRl/CTI�N //_��
�ELECTRICAL S � AMP SERV�CE Q PRpGRESSENERGY Q W,RE.C. �/�"{"
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�PLUMBING S i � �
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QMECHAhfICAL g � VALUATION OF MECHANICAt INSTAlLAT30N �l � r�`
QOAS ROOFINo SPECIAtTY o7HER � � �/ n ��
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FINISHEDFLQOR ELEVATlON� ; FLOODZONEAREA []YES NO � '�
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BUIL�ER � COMPANY
SIGNA7URH aEGSStEaEn Y/ N FEEGUaaEn Y/N
Addross � License 7!
i
ELECTRICIAN � COMPANY
SIGNATURE I n6GistEaEn YI N r�ewru�n Y/N
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aaa�eza i u�a�a
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PLUMBFA I COMPANY
SIGNATURE � REG�S7EAED Y f N FEE CURREn Y J N
Addross � License B
MECt1ANIGAI. � GOMPANY
SIGNATURE i aeGiSieaEo Y! N FEEcuxRen Y/N
Addross � • Licenso#
OTHER � COAAPMtY � CO
SIl3NATLIR� REOISTEREn Y!N FEECURRE� Yf N
Addresa 2� �i is8 y• License8 � � �
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AESIOENTlAL Atlach 2 Plot Pkns; �
( ) {2}agts of 8utlding Plaas;{1�set of Energy Forms;R-O-W Permlt far new canstruclbn,
Minimum taf(1�)warking bays afler suhmitlal date. Required onsite,Coru Wction Plans,Stormwatat Plans w/5ift Fonco installad,
Sanitary Facilities 81 dumpater,Site Work Permit forsubdivlsiansRarge pro�acts
COMMERCIAL Ariach(2)complete sels of;8uilding Plans plus a Lifo Safaty Pago;(1)se!of Enorgy Fo�rns,ft-O-W Permit for new conslructlon.
Mlnimum ten{70)working days ettef submidal dnte.Required onslle,CanstnicUan Plar�,Stormwafer pfans w!Silt Fence instaUed,
Sanitary PaGllues d 1 dumpater.Slle W ork Permil tor all now projeets.All�ommerciai mquirements must mect compiianec
SiGN PERMIT Attach(2)sets ot Englnesrgd Plans,
••••PROPERIY SURVEY raquirad for all NEW construpion.
� .�.
Directions:' , • • • • • • • • � i
FlII out appllcatlon campletety.
Owncr 8 Conlractor slgn baak of appGcatiDn,notarized
If over SR500,a Nopco ot Commenceminl Is reqvlred. (A/C upgradae over f7500j
" Agant(!or the coniractor)or Power nf Atln�mey(for the owner)would be someona wilh noterized letler from awner eulhorizl�g seme
OVERTHECOUNTERPEitMtTT]NG (copyo(wnVactrequirod)
Reroptslfshingtos Sewers Serviee�Upprados A/C FeneesjPlat/5urvaylFootaga)
Drlvaways-Nol ovar Counter if on public i dways..needs ROW
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From:Ashtin Be ae Fax:(8i7)265-1871 To:+18137840021 Fax: +18137800021 Page 4 of 4 10J28/201812:25 PM
NOTICE OF DEED RESTRlCriO S: The undetsl�ed undorslands thal this permit may be subJed to'deed'restr(cUons'
whlch may be more restri�tive th Cnunly regulatlons. 11i0 undo�BigRBd BSsumCS fespcnsibffRy for�vmp(lencu wilt►any
apAficable clCed tesMdions.
UNLICEKSED CONTRACTORS AND GONYRACTOR RESPONStB1LITIES: II tt�e owner hos nrred a contracfar o►
contractors to undertake wortc, y may be requtred to ba Acensed In accordance with sWlQ and local neguiattons. It Ihe
conVer�ot fs not t[cansed as req Ired by iaw,bath Ihe owner and conUador may be cited for a misdemeenoC viofatlon
undar state law. If the owner or ntended conGector arq uneertaln as�n whet ficensing repufrements may apply 1or the
intanded work,they are advised t wnlaet�he Pasco Counly BuQding Inspeclion Division--Licensing Section at r27-847-
8009, Furthertnore,fE the own has hirad a eonVaetar or oontractore.he!s advised to heve fhe contrac�or(s)slgn
por'3ons a(1he'contractot 6balc'of ttils appliration far which they wi�he respor��fe. !f yov,as ths cwner sign as Ihe
c0AV2CI0;11�ei may be an indica ion that Fre!s not properiy licensed and Es nol entiUed to petmilBrn�pmnleges in Pasw
County.
TRANSPORTATION IMPACt LlT7E5(MPACT IiND RESOUfiCE RECOVERY FEES: 'i1iB utKlersigned understands
that T��nsponation lmpact Fees nd Recuurse 13ecevery Fees may apply to ti�e aonst�uction of new buadh�gs.change of
uso in exisling buddings,or exp� lon oi existing huildings,as speeifiad In Pasco Coanty Qrdinance number 89-fl7 and
90-07,es emandcd. Thn undets ned also understend5,that seuh fses,as may ba due,wID be Identified ai ihe time af
permilUng. It Is�urther underst that Transportallon Impact Fees and Resource Recovory Fees must be pald yrior to
recetving a'cerGficate ot ocwpa cy.'or fmal pawer releese. I!!he proJect does not Lsvolve a cerfii'kate of oocups�cy or
Cu�a!pawer release,t3ie�ees m t be patd prlar to permit tssuancx�, Furtharmore�if Pasco Caunty WaterlSewer lmpact
fees ora due,they riwst be paid p r to partrrlt Fssuance In accnrdartoa with appllcable Pasco County ordinances.
CONSTRUCTiDN LlEN I.AW(C ptar 793,FloNda Stalufes,as amended): !f valuatlan of wcrk is 52.500.00 or more,I
cadi[y Ihat 1, the applicant, hav been provfded wilh a copy af Ihe "Ftoride CertsWclion Llen Lew--HomeownQ�'s
Protection Guide'ptepared by th�orfda�epartment of Agdarlture and Consume�Aifefrs. !f the applicerR fs someana
olhnr thon thC'ownOY'�I txtrdfy th t f ha�abtained a copy ot the abovo desuibad documant and promise in good tailh lv
deIiver itio Ihe'awne�'prlor to co �sncement. � �
CONTRACTOR'3lOWN8R'S AF IDAVIT: !certify that aII Ihe informatfon tr►tti�s appticauen ts accutate snd that atl work
wiU be dvne in wmp[iance with t eppiicebtc lews tegufating tanstrttt�ien,toni�and land developrnent. ApplicaUon Is
hereby made to obtain a pemti to do wortc and instat[ali��as in�cated. !certity thai no worh w�staAalton has
cammenced prlar ta issimnae�t a permit m�d that sll work wi1S bo pedormed to meet standards oi dll(a�ws regufating
canatructian,County and Cftyr es,zoning�egutaUons,and land developmen!repufntions 6�the jur�dicl'ron. f also
cerHty that t undersiand lhal 1he �gulattoru of othez government agencies mey epply lo the Inlonded wark,and that it is
my resportsi6ility to identi(ywhat �t"ibns I rrwst take lo be In comp�nce. Sach agent7es irtctude but are noi nmited i�:
- Deparimant of Envi nmentaf Protectlon-Cypress Boyheed4,Woflnrnl Arasa and Environmo��ally Sonsilive
Lsnds.WaledlNasl ater Trealment
- SouU�west Flwi6a ater Managemen� Dislrkl-�Nclls, Cypress Hayheads, Wetland Areas, Altering
Wateroou�ses.
- Army Corps of Engi ezs�-seawae�s,Aors�a,NavrgabVevoaten�ray,s.
- Deparfinertl of Heell & RcheblGtat(ve Serv(oes/Envlroomenlal lieallh Unit-Wdls. Waslewater Treaanertt,
5eptic Tartks.
- US Environmentat P Iectlon Agencyr-Asbesios ahatemen�
- Federa[Avladnn Au rlly-Rumvays.
I undorstarxl thal tho fotlowtng res euons appty ta!he use of fill:
- UsQ of RI ls notaQo d fn Flood Zone'V'unlesa expre�sly permitted.
- IE the fdl mqtedal is lo be uaed tn Fiaod Zana 'A', !t Es understood that e dreirtage plan addressing a
compensaf[ng volum 'will ba suhmlttad a1 tlme ef petmltting wht�fs preparnd by a professiona!artgineer
l(ce�5ed try tha StacB f Frurida.
- IF riie fiQ meterial is t be used(n Flood Zone`A'in connec6on with a permitted 6uifding usfng slem vrd11
conslruetlon,l cerlify t f�1 will be used onty to tig the erea wilhin the stflm vrd�l.
- It fi� mnlariel 1s to b used in eny area, 1 cedi[y that asa of audi fili w11) not ndvprsaty eNQct adJacent
psoperlies. If uss of I is found!o adversely effect adacent propertfes,Ihe ewner may be i+ted for violating
Ihe condNions of Ihe uDding pemllt issued under thp atlached permft appllqtipn,for lots tass than ons(1) •
aaa whlch are deval byfli I,an engineered drainage plan Is required.
l!I em the AGENT FOR THE OW ER,1 promisH in good faHF�to Intorm the owner of the permittlrrg condilions setlorth in
Ihis atfidavit priot to commencing aonslcucdon. !understend lhel o seflarate pomtit may ba requlred for e]edriral wark,
plumbt�,aigns,we1b,poats,air cond�lian'rng.9as.ar o15�et inslailatioam no1 specifieaSly lnetuded in 1he appCica{iotti. A
pertnit tssued shall be conswed be a licen�ta proceed wifh fhe work ar►d not as suthorily la violate,cencel,aller,or
set aalda arry prov�sfons of!he t fcai oodes.nor shatl lssuaneo of a pem�tt prever�t tho BuAding Otficlal frorte tharaaftar
requtring a cotreCi�on of errors fn lans,oonsUuctton or vlolallnns of any codas. Every pormlt L�sued shatl bQcome Invalld
unlass ths work au�harlaed by su h pemilt is commenced wtitiin stx months of permlt Issuance,or If work authortzed by
the permit is suspended or aband ed for a period aF six(6)moelhs aker Ihe time Ihe woric is cammencad. An exiension
may he requesled,ln writing,fr the Building Oflicial tor a pedod nof!o exceed ninely(90)days and wi�d�men6trata
Justifiable cause Tor lha extenslon. If wark ceases for nlnery(90)consewBve day6,ihe job Is cansidared aaartdaned.
WARNlNG TO OWNER; Y011R AItllRE 70 ftEC012E�A N0Y10E OF COMMFlVCEMEN7 MAY RESl1L't!N YbUR
PAYING 71NkC�FOR IMPRO E1�1'�5 TO YQllR PROPE[�TY. 1F YOU 1t�1TEND TO DH�A1N flNANCtl1G,COtiSlfLT
H YdU L�NDER O AN TTORNEY BEFORE RECORDING YO11R N07iCE OF CO ENCEMENT.
FLORIDAJURqT(F,S,17T. i
!
OWHER OR�l6 CaNTRACTOR
1 O,Sub vibad an� ( o�mca)Deto e ma tnb �� d ond s tf ioro mr s
�f tslar pelse nfY luimvn tq n+e he ave Prod�+ecd t perteealy a nas+hava Produaa
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�bp.�5 i i[fw,SL �den' we,. astamtr
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' f Hnlary PuDUc i�� pqry p�prp
' Camm�s:�ee Na ssbn wa ZZ
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N o N e Namo o!t�bhry typo Antotl or s �n�.�
���mq• ��wr'U�y LOiiA KNOPf �
=jo •°�e���' HOLLY MCCART R :+° °�'n•
_ ..= Notary Publlc-St�te o Florlaa � • - notary Public•State of Florida
Commieslon�r FF 9 945o s� � Cammisslpn�k FF 947226
=� �,,,,o«..' My Comm.fxplras Dec 30,2079
'•�o�� ,�� My Comm_Explres dun 7.2020 �
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From:AshGn 8e ue Fax:(87�265-1971 To:+18137800021 Fax: +18137800021 Pege B of 7910282016 1:32 PM
EXTENSION OF INFORMATION PAGE WC 00 00 01 A- ITEM 1
ARRIER: Bridgefield Employers Insurance Company AGENCY: Greene-Hazel Associates, Inc. - 2432
P.O. 8ox 988 10739 DEERWOOD PK $LVD STE 204
Lakeland, FL 33802-0988 JACKSONVILLE, FL 32256
(863f 665-6060 (9Q4)398-1234
NSURED: Raofmax Corp POLICY NUMBER: 830 - 55130
DBA: pOLICY PERIOD: 01/18/16 - Q1118/17
4237 Salisbury Rd # 125
Jacksonville, FL 32218-8029
Other workplaces
Roofmax Corp
4237 Salisbury Rd # 125
Jacksonville, FL 32216-8p29
FEDERAL ID#46-3551093
� CORPORATION
�
Date Prepared:01/25/16
WC 00 Od 01 A - ITEM 1 Page 1
From:Ashtin Bi gue Fax:(87�265-1971 To:+18137800021 Fax: +1 81 378 00021 Pege 3 of 7910282016 1:32 PM
K� STATE OF FL�RIDA �
�- � ��-= � DEPARTMENT OF BUSINESS AND PRQFES�IONAL REGULATION �
� � �� �_ � '
�,.E' CONSTRUCTION INDUSTRY LlCENS1NG B�ARD (850) 487-1395 '�
�`��,;;`�� 260� BLAIR STQNE ROAD G ',
TALLAHASSEE FL 32399-0783 �I
IFFT, BARBARAJEAlV
ROOFMAX CORP '
2545 SOUTH ATLA�ITIC AVENUE#404
' DAYTONA BEACH SHORES FL 32118
�•R`�i1h�n�T va>�+'.1 �yv..,;��. :C'•r� x .r,•.;�T,��>. �:a"' :.�:. T\r
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Congrat lations! With this license you become one of ea y �=- � , �-� � •- .
one million Floridians licensed by ihe Department of Business and �> • _ � . `;`=
Professional Regulation. Our professionals and businesses range ?�'� - �, � .� �STAI"E�OF FLORIDA .... ��:
from arc'�itects to yacht brokers,from boxers to barbeque t�� � � �." DEPART[1A����z,:.,��;;�USINESS AND ;;��
�, restaura�nts and the kee Florida's econom stron ::-:• Y` s ���.C.ULATION - • .
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Every d y we work to improve the way we do business in order :��` 'GCC132651.7..;���.�:'W�;�:�^ '�lf�i;��08./02/2�16 i
to senre ou better. For information ahout our services, lease {'�; �•• ' '`��'������` � ` y�x��' � �� .. � �� �
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log onta vuww.myfioridalicense.com. There you can find more ih:' -QERTIFi�b R�;.�� �'.�`r�_ ; ;�`;fi���.,t.��. .,;. � . �'
f. ���: "'�^ �� -�'>t
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informat on about our divisions anci the regulations that impact 1�.�=g/aRgA � ,_;,%�:r<_y%,�•:`�,�:',n:> '. �:�
you,su scribe to de artment newsletters and learn more abouf .'��.��.'.a: �`•�`���z���`�" ���'�'fs'�'' •� �- � •• �� �"�
P �. _`ROS�fJUIIAX::GO F�.zr�:�:�, t�-������:< -,
#he Dep �tmenYs initiatives. r.,:• � .. , f�,��`=� �• � �'s'�`::.:;, . , . �L=:
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OurmisS�ion atthe Department is:License Efficiently, Regulate ���=`'--�"; '. �� ~<';�:�u::�Y;"�°` ••� '.. ,
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Fairly. e constantly strive to seroe you better so that you can �. • � ��� ••- � -� � •..' .. �:;
serve y ur customers. Thank you for doing business in Florida, �:. '`�S ��ERTIFIE.D•ut�derikie�.,pfoy.isivhs,p,f..d.h.qs.s:.Fs. ���•• ..:�:�:
;z:^ "��tiaR:flqts� AU1G 3,7,�09.�.:� ... ... -L1608020001'�60
and con ratulations on yaur new Iicense! _:.��..�,�L`.aT��4�_+:+'�;.�%>•��.:��' :51.`_ i^3r�':_\`� �3':�\ti: ' �ti=_�•M:.�•,}\'rvvt:�
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' �-D€�'ACH EtERE-_. ... _. _ ._.
� RIC SCQTT'GOVERNOR � ` � " ��. "����", � " '� • ` ' . '.. " ' KEN LAWSON, SECREfARl'
. . . , .. � `� • . ��TA�E OF FLORIDA � � • , . .. ' � . ,
� � ' � . � �� �•D.EPARTMENT OF BUSINESS AND RROFES510NAL REGULATIQN � k 4
' `� ' CONSTi�UCTIO�i INI]USTRY'LI.CENSlNG BOARD ' , .
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The R r.OFING CO�TRACTQR:. ...... ... ::��;�s�;"��`,����."rwc.,,. , • : �� .. . � , � ' , ;�;, -
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IssuED: o8�oti2o�s DISPLAYAS REQUIf2ED BY LAW SEQ# L16D802000116�
irom:Ashtin Be�ue _Fax:(87�265-1971 _To:+18137800021 _Fax:_+18137800021 Page_79of-7910C2612016 1:32 PM---..--..---------
1 AC�� na�(Mnvoomrr�
� � CERTiFlCATE OF LIABILITY INSURANCE 10/28/2016
j THIS CERTtFICAT@ I5 ISSUED AS A MA7TER OF INFORMATION ONLY AND CONFHRS NO RIGHTS UPON 7HE CERTIFICAT�HOL�ER. 7HIS
; CER FICATE DOES NOT APFiRMA71VELY OR NEGATIVELY AMEND, F.XTEND OR AtTER TE[E COVERAGE AFFORDED BY THE POLlCIES
j BELO . 7HlS CERTIFICATE OF INSURANCE OQES AlOT CONSTITUTE A CONTRQCT BETWEflN THE ISSUlNG lNSURER(S), AUTHORIZED
� REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
i IiU1PORTANT: If the certificate holder Is en ADDITIONAL INSURED,the policy(les)must be endorsed. If S UBROGATtON IS 1NAIVED,subJatt to
tbe te�ms aod cond(ttons of the poltcy,certaln pollcles may requfre an endorsement. A statement on this certificate does not confer rights#o the '
certlflcate holder In Ileu of such endorsement s,
rRoouce "Ta
HAME:
Greene= azel Insurance Group� Hub Intemationaf PHONE _ _ FAX
NC Ne:
10739 eerwood Park elvd S 240 E.n�a,�
Jackso� ille FL 32256 ADDR s ' '
iNSURERS AFFORDINOCOVERA6E NAICl1
�NSURER A•
� INSURED ROOFCOR-01 rt�sur�R e:
i RMX C nstruction,Inc. �esur�Rc:
! RooTma Corp iMsuRee o:
j 4600 7duchton Road E.Ste. 1150
1 JacEcsor�ville FL 32246 INSl1RER E:
I iksur�R F:
� COVERAGES CERTIFfCATE NUMBER:276845440 R�1/ISION NllMBER:
� THIS IS TO C�RTIFY THAT THE POLICIES OF INSURANCE LIS7E�BELOW HAVE BEEN ISSUEO TO TNE tNSURED NAMEP ABOVE FOR THE POLICY PER10D
INDICA'fED. NOTWITHS7AtVDING ANY REQUIRFJNEN7,7ERM OR CONDITION 0�ANY�ON7RACT OR O7H�R DOCUMENT WITH RESPECT TO VNilCH THlS
CEftTI�ICATE MAY BE i55UED OR MAY PERTAIN,THE tNSURANCE AFFORDEO BY THE POLICIES �ESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AMD CONDi1i0N5 OF SUCH POLICIES.LIMiITS SHOWN tNAY HAVE BEEN REDUCED BY PAID CLAIMS.
iNSR TypE Of INSURANCE POLICY EFF POLICY EXP
L R WSR WVD POLICYNUMBER MMlDO MM/D� uM1T3
8 GENERALLIABfLITY CBC200013049U0 4/75/2076 4/15l2017 EqCHOCCURRENCE 51,00O,OOD
X COMMERCWL6ENERALLIA&LITY
PftEMISES Ea Occurrer�ce 5'100,000
CLAIMS•MA�fi a OCCUR MED EXP orre erson 510 000
PERSONALBADVINJURY 51,000,000
GEraERaLaGGREGATE 52,000,000
GENLAGQREGA7ELiMITAPPLIESPER: PRODL1CTb-COMPIOPAGCi 52,000,000
x POLICY PRO• L� S
AU OM081LEUABILITY
Ee acddent
ANYAUTO 60DILY INJURY(PerpenonJ 5
� AUiO�3�E� AuiOSu�D BpDILYlNJURY(Pereeddent) S
NON-0WNED RO E TY DAMA E S
� HIRE�AUTOS AUTOS PetacUdent
S
uMBRELLAt1Ae OCCUR EACHOCCURRENCE S
EXCESSUAB �q�MS.MADE AGGREGRTE S
' �ED RETEN710N5 S
S p WORxERSCOMPENSAT1pN OB3055130 1f18I2016 7lS812017 X �SiATu- OTH-
; ANb EMPLOYERS'LIABILITY Y 1 N
i ANY PROPRIETOR/PARTNER/EXEGUT{VE❑ N IA E.L EACH ACpD�M 51 OOO O00
OFFlCEWMEMBER FJCCLUOED7
� (M�ndetOry In NH) E.L.DISEASE-EA EMPLOYE St,�00,000
IIY s.descnb9untl0r
DESCRIPTIOfJ OF OPERATIONS below E.L.DISEASE-POLICY UMIT 51,0OO,ODO
s
�
i
OESCRIP ON OF pPERAt10N5 I LOCA710N51 VEHICLE9(Atla ch ACORD 707,Addlllonai Remarks Scbadulo,If more space b requlrad)
I
CERTI�ICATE HOLDER CANCELLATION
SHOULD ANY OF 7HE ABQVE DESCRIBED POLICIES BE CANCHLLE�BEFORE
Ciry of Zephyrhills Building Deparlment THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
� 5335 8th Street ACCORDANCE WITH THE PBLICY PROVISIONS,
; zephyrhills FL 33542
� AUTHORIZE�REPRESENTA77VE �
� �+r�
i l�
1
�1988-20'{0 ACORD CORPORATION. All rights reserved.
ACOR 25(2010105) The ACORD name and togo are regtstered marks of ACORD
, I
i
From:Ashtin Begoe Fax:(87�26''r1971 To:+18137800021 Fax: +18137800021 Pege 33of 79102820161:32 PM
,
'dge,f�eld �inploye�s
Insuranee Campany�
A Member af Great American Insurance Group
A Stock Insurer•PO.Box 988•Lakeland,FL 33802-0988
WOR ERS COMPENSATION AND EMPLOYERS LIABILfTY INSURANCE POLICY INFORMATION PAGE
Carrier de 31267 Policy number 830-55130
Item 1. Insured
, R�sK�.o. o00000000
Nam
an Roofmax Corp Indiv�dua� X Corporation
, Mailin 4237 Salisbury Rd # 125 Partnership Subchapter"S"
Addres Jacksonville, FL 32216-8029 ` —
�ther
Other orkplaces not shown ebove: FEIN 46-3551093
SEE EXTENSION OF INFORMATION PAGE ITEM 1
Item 2. Policy period
From 07/18/16 to 0���8�17 12:01 a.m.standard time at the address of the insured as stated herein.
Item 3. Ccverage
A. Worlcers Corripensetion Insurance: Part One of tite palicy applies to the Workers Compensetion Law of the states listed here:
Florida
B Employers Lfabifity Insuranoe: Part Two of the policy applies to work in each state listed in Item 3.A.The limits of our liability
under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident
Bodlly Injury by Disease $ 1,000,000 each employes
Bodily Injury by Disease $ 1,�OO,U00 policy limit
C. Ofher States Insurance: Part Three of the policy applies to the states, if any, iisted here:
Alabama Arkansas Georgia lndiana Kentucky Louisiana�Mississippi North Carolina South Carolina
Tennessee Texas
D. This policy includes these endarsements and schedules:
SEE EXTENSION OF INFORMATION PAGE ITEM 3.D
Item 4' Premium
The premium far this palicy will be determined by our Manuals of Rules, Classiflcations, Rates and Reting Plans.All informafian
req Ired below is subject to�erification and change by audft.
Glassifications Premlum Basis: Rate Per y100 of Es6mated
Code No. Total FsUmated Remuneration Annual Pr+emlum
Annual Remunefatlon -
SEE XTENSION OF INFORMATION PAGE ITEM 4
i Total Estimated Annual Premium $ 47.���•�
Min mumPremium$ 1,200.00 Expense Constant $ 200.00
Cou tersigned by w� Date �1/2511fi I�
2432 Greene-Hazel Associates, Inc.
jk Date Prepared:01/25116
WC 00 01 A {Ob/86l I�ludes copyright matedalof the Natlonal Councfl on Campensation Insurance.Used wlth Ite pertnfaeion.
�1887 Natlonal Councll on ComPensetlon Insurance
From:Ashbn Be ue Fax:(87�265-1971 To:+18137800021 Fax: +18137800021 Page 9 of 7910282Di 61:32 PM 'i
EX7ENSION OF INFORMATION PAGE WC 00 00 01 A- ITEM 3.D
CARRIER: Bridgefield Employers Insuranae Company AGEI1lCY: Greene-Hazel Associates, Inc, - 2432
� P.O. Box 988 90739 QEERWO�D PK BLVQ STE Z00
Lakeland, FL 33802-0988 JACKSONVILLE, FL 32256
i863?665-6060 (904)388-1234 ��
I INSURED: Roofmax Corp POLICY NUMBER: 830 - 55130
, DBA: E OD• / - 817
POLlCY P Rl . �1198 16 0111 !
4237 Salisbury Rd # 125
Jacksonville, FL 32216-8029
Schedule of Endorsements
Form Number: Edition: Description:
� WC 00 03 08 0484 Partners. Officers and Others Exciusion Endt
WC 00 03 10 d484 Sole Proprietors, Partners, Officers, Others Cover
WC 00 04 04 04-84 Pending Rate Change Endt
WC 00 04 06 A 0$-95 Premium Discount Endt
WC 00 04 14 07-9U Noti�cation of Change in Ownership Endt
WC OU 04 19 01-01 Premium Due Date Endt
WC 09 04 01 06-87 FL Contracting Classification Premium Adjustment E
WC 09 �4 02 10-88 FL Experience Rating Modification Factor Endt
WC 09 �4 03 B 01-15 FL Terrorism Risk Ins. ProBrem Reauthorization Act
WC 09 04 07 07-13 FL Non-Cooperation with Premium Audit Endt '
WC 09 06 06 1 Q-98 FL Employment and Wage Information Release Endt
WC 99 03 03 1 1-1 1 Employers Liability Coverage Endt
WC 99 06 01 05-06 FL Legal Action/Collection Endt
WC 99 06 06 10-10 Florida Participating Endt
I
�
Date i'repared: 01/25/16
WC 00 �0 01 A - ITEM 3.D Page 1
Fram:Ashtin Be`de Fex:(87�265-1971 To:+18137800021 Fex: +18137800021 Page 78of 79101282016 1:32 PM
2015-2016 BUSINESS TAX RECEIPT
MICHAEL CORRIGAN, DUVAL COUNTY TAX CO�.LECTOR
231 E.FORSY7H S7REE1'.SUI7E130,JACKSONVILLE,FL 32202-3370
Phone:(904)630-1916,opti0n 3; Fax:(904)630-1432
Websile:www.coj.neUtc;Email:taxcolleclor@coj.net
ote--A penalty is imposed for failure to keep tiiis receipt exhibited conspicuous{y at your place of business.
This business tax receipt is furnished pursuant to Municipal Ordinance Code, Chapters 770-772, for the period
Uctober 1, 20'i 5 through September 30,2016.
RMX CONSTRUCTION INC DBA ROOFMAX
ROBERT ROBLES -
4237 SALISBURY ROAD
STE 145 �
JACKSONVILLE, F�32216
AC OUfVT NUMBER: 287323
LO ATION ADDRESS: 4237 SALISBURY ROAD STE 145
JACKSONVILLE, FL 32216 —"
..
DE CRIPTION: CON7RAC70R-ALL TYPES STATE LIC�NS�NO.: CCC7326517/CRC057962
CO NTY RECEIPT DESC: CONTl�ACTOR-ALL TYPES COUNTY TAX: 5.63
MU ICIPAL RECEIPT�ESC: MC 772.309 MUNICIPA!TAX: 23.13
TOTAL TAX�PAID: 28.76
VALED UNTIL September 30,2016
'�'�*ATTENTION***
THIS RECEIPT IS FOR BUSINESS TAX-RECEIPT ONLY.
CERTAIN BUSINESSES MAY REQUIRE ADDITEONAL STATE LICENSING.
This is a business tax receipt only. It does not permit the receipt holder to violate any existing regulatory or zoning laws of
the County or City. It does not exempt#he receipt holder from any other license or permit required by law. This is not a
certifi'cation of the receipt holder's qualifrcations.
�' —.�'�'���'.,'�
' TAX COLLECTOR
THIS BECOMES A RECEIPT AFTER VALIDA710N.
PAID--300026.00D2-0002 A19 05/04/2016 28.76
From:Ashtin Bel �e Fax:(87�26rr1971 To:+18137800021 Fax: +18137800021 Pege 7 of 7910fL82016 1:32 PM
idgefield Emplaye�s
Insu�ance Compa�ay�
I A Member of Great American Insurance Group
A Stocic Insurer•P.O.Box 988•Lakeland, FL 33802-0988
WOR ERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE
Carrier de 31267 Policy number 830-55130
Item 1. lnsured RISK I.D. OOQ000000
Nam
an Roofmax Corp Individual X Corporation
rwai�in 4237 Salisbury Rd # 125 Partnership �Subchapter°S"
Addres Jacksonville, FL 32216-8029 Other �
Other orkplaces not shown ab�ve: FEIN 46-3551093
SEE EXTENSION OF INFORMATION PAGE ITEM 1
Item 2. Policy period
From 01/18/16 to 07/18/17 12:01 a.m.standard time atthe address ofthe insured as stated herein.
Item 3. Coverage ��
A. Workers Compensation Insurance: Patt One of the policy epplies to the Workers Compensation Law of the states listed here:
Florida ' �I
B. Employars Liability Insurance: Part Twa of the palicy applies to wark in each srate listed in item 3.A.The limits of our liability
under Part Two are. Bodily Injury by Accident $ 1,000,�00 each accident
Bodily Injury by Disease $ 1,000,000 each employee �
8odily Injury by disease $ i,000,Od0 policy limit �
C. Other States Insurance: Part Three of the policy applies to the states, if any,iisted here.
Alabama Arkansas Georgia lndiana Kentucky Louisiana Mississippi North Carolina South Carolina !
Tennessee Texas '
D This policy includes these endorsements and schedules:
S�E EXTENSION OF INFORMATION PAGE I7EM 3.D
Item 4 Premium
The prernium for this policy will be determined by our Manuals of Rules, Classifioations, Rates end Ra6ng Plans.All information
req ired below is subject ta vedflca�on and change by audft.
Premlum Basls: �te Per 5180 of Egtimated
I Classifications Code No. Total Eetlmated Remuneration Annual Premium
Annual Remuneratlon
, SEE XTENSIDN OF INFORMATION PAGE ITEM 4
Total Estimated Annual Premium $ 47,171,40
Min mumPremium$ 1..200.00 Expense Constant $ 200.00
Cou terslgned by ��� —~� Date 01125/16
2432 Greene-Hazel Associates, Inc.
jk Date Prepared;01/25/16
WC 0 00 01 A (05/88l InGutlee copyrfgM materiel of lhe National Council on Compensatlan Insurance.Usetl wilh Its perm�sioa
O 1987 Natlanal Caundl on ComDensatlon Ir�surance
From:Ashtln B y�e Fax:(8i7)265-1971 To:+18137800021 Fax: +1813i800021 Page 2 of 4 10128/2018 12:25 PM
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