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Home My WebLink About22-50255335 Eighth Street Zephyrhills, FL 33542 Phone: (813) 780-0020 Fax: (813) 780-0021 [ MORRIM BAC-005025-2022 Issue Date: 11/07/2022 . I 1'/'T I -d7) , ) J, de., 'fi> AV 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 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 permit required from other governmental entities such as water management, state agencies or federal agencies. t M, r # 11111i!llil 1 1111111117 1 ill i 1 111111111111 M Complete Plans, Specifications add fee Must Accompany Application. All work shall be performed in accordance with City Codes and Ordinances. NO OCCUPANCY BEFORE C.O. NO OCCUPANCY BEFORE C.O. 65K-TRACTOR SIGNATURE PE IT OFFICElf) PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 813-780-0020 City of Zephyrhills Permit Application Fax-813-710,0121 Building Department Date Received Phone �Contact Contact Permitting pPrOwner'smrmriunOitlenmie.r Coy Healthcare Owner P Number 2-521-570Name Owner's Address , FL 2�25 37912 Church AvenUe, Dade City` Owner Phone Number C_ 3 �5 Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address JOB ADDRESS E37:8�4LO Mledical Arts Center, Zephyrhills, FL 33541 LOT # SUBDIVISION PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED e NEW CONITR ADD/ALT SIGN DEMOLISH INSTALL REPAIR PROPOSED USE SFR COMM OTHER TYPE OF CONSTRUCTION BLOCK FRAME STEEL DESCRIPTION OF WORK Remodel of pharmacy 34'q BUILDING SIZE SQFOOTAGE HEIGHT =5,- =BUILDING VALUATION OF TOTAL CONSTRUCTION =ELECTRICAL AMP SERVICE -ell PROGRESS ENERGY 0 W.R.E,C =PLUMBING 101,200,00 1 =MECHANICAL VALUATION OF MECHANICAL INSTALLATION OTHER ]GAS ROOFING SPECIALTY 0 FINISHED FLOOR ELEVATIONS BUILDER I / ( Vv COMPANY SIGNATURE f 4 (IV I REGISTERED Address PO Box 1869 Dade ,Fl_ 33526 ELECTRICIANC-_ COMPANY SIGNATURE: EGISTERED R =YES NO Borregard ConStrl,Xtion, Inc. Y/N FEE CURREN Y/N License# 1 CGCO26850 Alston Electric `�Y / �N FEE CURREN Address 15103 D gin Road', Dade City, FL 33525 Lic,rielt EC13009620 PLUMBER 2 COMPANY Chris Bahr Plurribinq TE Y/N FEE CURREN SIGNATURE REGISTERED =Y C142682 Address 5729 Ga Ivd-, Zephyrhills, FL 33542 License # CF4 REGISTERED / ��_ 1 FEE CURREN YIN MECHANICAL COMPANY SIGNATURE License # Address OTHER COMPANY SIGNATURE REGISTERED L�=Y_/ �NFEE CURREN Address License # RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction, Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence inst,.Oed, Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisions/large projects COMMERCIAL Attach (2) complete sets of Building Plans plus a Life Safety Page, (1) set of Energy Forms, R-O-W Permit for new construction. Minimum ten (10) working days after Submittal date. Required onsite, Construction Plans, St to;Tnwater Plans w/ Silt Fence installed, Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet compliance SIGN PERMIT Attach (2) sets of Engineered Plans. ****PROPERTY SURVEY required for all NEW constriction. 4*44-4FA Directions: Fill out application completely. Owner & Contractor sign back of application, notarized If over $2500, a Notice of Commencement is required. (A/C upgrades over $7560) — Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (copy of contract required) Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage) Driveways -Not over Counter if on public roadways needs ROW 813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions" which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any applicable deed restrictions. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation under state law. If the owner or intended contractor are uncertain as to what licensing requirements may apply for the intended work, they are advised to contact the Pasco County Building Inspection Division —Licensing Section at 727-847- 8009. Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign portions of the "contractor Block" ofthis application for which they will be responsible. If you, as the owner sign as the contractor, that may be an indication that he is not properly licensed and is not entitled to p-.,mitting privileges in Pasco County. TRANSPORTATION IMPACT/UTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of use in existing buildings, or 'fied ordinance number 89-07 and 90-07, as amended. The undersigned also understands, that tin• buildin•s ass•ed i in Pasco Count it • low" Il0-0111l. commencing construction. I understand that a separate permit may e required for electrical work, plumbing, s gns, wells, pools, air con•I other installations not specifically included in the application, A permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid unless the work authorizer, by such permit is commenced within six months of permit issuance, or if work authorized by the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned. 1101 A I J, W 11161TA4 J, 1:4 a Vill KIRK0111:4 &I M41 : I i W Who is/are personally known to me or has/have produced as identification, •mission No.TTT I -U Xmilap go,4 as identification. 813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department [?ate Received € P 't i . " " ';7 Phone Contact for Permitting 2 , 8 15 r f Owner's Hama ly7'erlllCr CyorYtYYlutliiV Helltht'.c`x.t`c Owner Phone Number ,"'� J 1 'a2f}QQ.. owner's Address P-0 IioX n32 L�r`�{ e C`Ltya } �.., JJ: ?- } Owner Phone Number J Pee Simple Titleholder [dame j Owner Phone Number Pea+ Simple Titleholder Address 37840 Me, cat Arts Court Ze harhills. FL ;33541 JOB ADDRESS� Ig "� LOT SUBDIVISION PARCEL ID# ( '4-34-25-21-Q080-00000-003 1 m . L _ IOBTAINE6 FROM PROPERTY TAX NOTICE.) WORK PROPOSED ' Nrrk ON -STIR �� SIGN � � DEMOLISH .-.......� `NST, L REPAIR PROPOSEDUSE SFR COMM OTHER TYPE OF CONSTRUCTION BLOCK FRAME STEEL DESCRIPTION OF WORK Priv°ate I'rovid r Iteration (Remodel/Renovation) BUILDING slzE r, �.�_----_� $ct roaTAG HEIGHT �----- MBUILDING $ #� VALUA flN OF TOTAL CONSTRUCTION t J1EJ-EcTR1CAL 5 AMP SI_.PVI, E 0 PRO . ESs ENFRGv =PLUMBING $ =MEC f-IANJCAL T .- � VALUATIONS OF ME, ANICAL I. ALLATION GAS ROOFING 0 SPECIALTY t__-__..D OTHER FINISHED FLOOR ELEVA11ON5 --„„ - ] FLOOD ZONE AIR -. =YGS NC BED SIGNATURE Address ET. 0 .i ELECTRICIAN l.n El SIGNATURE Address PLUMBER �.,r Llt SIGNATURE Address MECHANICAL } I l IGNA TURE SIGNATURE SIGNA II�� Address T OTHER SIGNATURE arl -7- t• C catr bU1.'1i0I1 ______ _.( cone ANvRK' -rEREDCCUREiW vC=, i <x i E3 I_;ses# COMPANY M. GIST--- E.G COMPANY R GISIFFIEL COMPANY REGISTERED COMPANY RFcISTFRE^ 3URIEN y " N _J if wee A�' Lice - URftE4 LIcEnSB ^�,� CURREN Address I I_____ i License # _ RESIDENTIAL ,attach (2) Plot Plans, (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Pe,m t for new construction, Minimum ten (10) working days after submittal date. Required onsets, Construction Plans, Storinruater Plans wf Silt F ce installed. Sanitary Facilities & 1 dumpster; Site, Work Permit for suodivisionsJial�e projects COMMERCIAL Attach (2) complete sets or Building Plans plus a Life Safety Page;,') set of Energy Forms, ;R-O-uV Permit for new con ructon, Minimum tarn (10) working days after submittal date. Required onsite, Construction Plans, Strinnrwater Plans w! Silt Fenc lnstaked, Sanitary Facilities & 1 dumpstei. Site ?Mork Permit for all new projects. All commercial requirentG�nts must meet oompl anc SIGN PERMIT' Attach (2) sets of Engineerrxa Plans, —PROPERTY SURVEY required for all NEW construction, Directions: Fill out application completely. Owner & Contiactor sign back of application notarized It over $2500, a Notice of Commencement is required. (A/C upgrades over $7500) Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letfai Forn owner authorizing same OVER THE COUNTER PERMITTING (copy of contract required) Remark if shingles Sewers Service Upgrades A/C Fences (PloUsurveyfFoatage ) Driveways No! Caer Counter if on public ioadways-neiros I;OW 813-780-0020 City of Zephyrhills Permit Application ;=ax-eta-Tao-cut2n Building Department NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to -deed' restrictionswhich may be more restrictive than County regulations. The undersigned assumes responsibility fear compliance with any applicable deed restrictions. UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: It the owner has hired a contractor or contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the contractor is not licensed as required by law, both the owner and contractor may be cited for a rtisdeirneanor violation under state law. If the owner or intended contractor are uncertain as to .chat licensing requirements may apply for the intended work. they are advised to contact the Pasco County Building Inspection Division --Licensing Sectior at 727-847- 8009. Furthermore, if tine owner has hired a contractor or contractors, he is advised to have the contractor(s) sign portions of the 'contractor Block" of this application for which they will be responsible. If you, as the owner sign as the contractor, that may bean indication that he is not properly licensed and is not entitled to permitting privileges in Pasco County, TRANSPORTATION IMPACTIUTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of use +n exsting buildings. or expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and 90-07, as amended. The undersigned also understands, that such fees, as may be one, Mine identified at the time of permitt rip. it is further understand that Transportation Impact Fees and Resource Recovery Fees must be paid prior to receiving a'certifcate of occupancy' or final power release. If the project does not involve a certificate of occupancy or final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water'Sewer impact fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances, CONSTRUCTION LIEN LAW (Chapter 713, Florida Statutes, as amended). if valuation of work is $Z500.00 or more. I certify that 1, the applicant, have been provided with a copy of the "Florida Construction Lien Law--Homec,wner's Protection Guide" prepared by the Florida Department of Agriculture and Consurnor Affairs. if the applicant is someone other than the "owner", I certify that I have obtained a copy of the above described document and promise i , good faith to deliver it to the `owner" prier to comniencennent. CONTRACTOR'SIOWNER'S AFFIDAVIT: I certify trial all the information in this application is curate and that all work will be done in compliance with all applicable laws regulating constriction, zoning and land development, Application is hereby made to obtain a permit to do work and installation as indicated. I certify that no work or installation has commenced prior to issuance of a permit and that all work will be performed In meet standards of ail laws regulating construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. 1 also certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is my responsibflity to identify what actions I must take to be in compliance. Such agencies include but are not limited to: Department of Environmental Protection -Cypress Eayireads, Wetland Areas and Environmentally Sensitive Lands, WaterA'Vastewater Treatment. Southwest Florida Water Management District -Wells, Cypress Bayheads, Welland .Areas, Altering Watercourses. Army Corps of Engineers -Seawalls, hocks, Navigable Waterways. Department of Health & Rehabilitative Servicesr/Environmental Health Unit -wells, Wastewater Treatment, Septic Tanks. US Environmental Protection Agency -Asbestos abatement. Federal Aviation Authority. -Runways. I understand that the following restrictions apply to the use of III: Use of fill is not allowed in Flood Zone "V' unless expressly permitted. If the fill material is to be used in Flood `Lone "A it is understood that a drainage ;clan addressing a "compensating volume' will be submitted at time of permitting which is prepared by a professional engineer licensed by the State of Florida. If the fill material is to be used in Flood Zone "A' in connection with a permitted building using stem wall construction, I certify that fill will be used only to fill the area within the stem wail. I; fit] material is to be used in any area, I certify that use of such fill will not adversely affect adjacent properties. If use of fill is found to adversely affect adjacent properties, the owner may be cited for violating the conditions of the building permit issued under the attached permit application, for lots less than one (1) acre which are elevated by fill, an engineered drainage plan is required. !f I an, the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical :work, plumbing, signs, wells, pools; air conditioning, gas, or other installations not specifically included in the application. A permit issued shag be construed to be a license to proceed with the work and not as authorffy to violate, cancel, alter, o; set aside any provisions of the technical cedes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans., construction or violations stony codes. Every permit Issued shall oecome Invalid unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized oy the permit Is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned, WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COS CEMENT flM1A RESULT IN YOUR PAYING ICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEN TI OBTAIN ANCING, CONSULT FLORIDA JURAT (F.S. 117,03) OWNER OR AGENT CONTRACTOR Subscribed and sworn to for affirmed) before me this S Inscribed and sworn) to at riled) be e by---------..... who istare personally known to me or hasmave produced 11h is/are personally known to mr to has aye produced as identification. a identification. y- Notay Public Public _ .—_Notary (� r Commission No. _ ----------- - Commission Nor._ Na^te of Notary typed, printed or stamped Name of Notary typed, printed or stamped :'dip ' w 0 M 21 September 20, 2022 Zephyrhills Building Department 5335 81h Street Zephyrhills, FL 33542 Sent Via Fed -Ex REFERENCE: Premier Community HealthCare Pharmacy- Zephyrhills SEI Project No.: 2022-16 SUBJECT: Building Alteration Application Approval To Whom It May Concern, On behalf of our client, Spring Engineering, Inc. has enclosed the following information for a building alteration permit approval for the Premier Community HealthCare Pharmacy- Zephyrhills project: 1. Permit Application (2 Sheets at 8.5 " x I I") 2. Private Provider Documentation (5 Sheets at 8.5 " x I I") 3. One (1) Affidavit to Authorize Agent (I Sheet at 8.5" x I I") 4. (1) Set of signed and sealed Architectural & Electrical Plans (10 Sheets at 42" x 30") 5. (1) Set of digitally signed and sealed Architectural & Electrical Plans (Thumb Drive) Please review this information and issue your approval as soon as possible questions or need additional information, please call our office. Very truly yours, SPRING ENGINEERING, INC. Derek Ray Senior Project Manager DRImrlky Enclosures cc: Aaron Brandt (Sent Via Email) Cheryl Henwood, SEI ]�aMpa'ga. 3014 US Highway 19 Holiday, FL 34691 Tel: 727-938-1516 sei@springengineeringinc,com Fax, 727-942-4174 WVVW'.5,pnNeD lineeringinc,com If you have any Atl? 1320 Ellsworth Industria' Suite Atlanta, r Tel: (40,4 DocuStgn Envelope V: 2907C346-BABB-4287-A900-7BD8FE5F5A9C Geotechnicai Engineering [BUNIVERSAL Construction Materiais Testing & Inspection ENGINEERING SCIENCES l3witcling Code Compliance Occupational Health & Safety Environmental GI-OUnded in Excellence Buittling Envet.pe Private Provider Plans Compliance Affidavit Private Provider Firm: Universal Engineering Sciences Private Provider: George W. Dixon, BCA Address: 9802 Palm River Road Tampa, FL 33619-4438 Phone, 813 740 8506 Fax: 813 740 8706 Email: Tam MgLn�o iaJnlversalEn iteerin :.com Project Name: Premier Community Healthcare Pharmacy— 37840 Medical Arts Court, Zephyrhills FL Sheets: Architectural — 9 pages Electrical — 1 page code compliance, V*cuSign*4 by: Signature: ShMVA, Date: 8/31/2022 Plans Examiner, Bldg Doc Signed by: Gary Viarass, PX3589 Signature: I Vt " S Date: 8/31/2022 Plans Examiner, Elec /—DocuSioned by: 11 Timothy Henline, PX4134 -Signature:[,., Plans Examiner, Plum Geq!gtffl. Dixon BU1097 Signature: Private Provider State of Florida, County of Hillsborough, SWORN AND SUBSCRIBED 2022 by George W. Dixon a�nd bei WMEEM ZME;Wm�� -141 #GG 289722 nc 0 V, dJ S TAA Printed Name Form # 9W3.053-2002-01 Use of Private Provider Effective January 20,2003 Project Name: Parcel Tax ID: 34-25-21-0080-00000-aal 0 03 1 Services to be provided: Plans Review X Inspections 116161 Section 553 .791(2) Florida Statute. the fee owner, affirm I have entered into a contract with the Private Provider indicated below to conduct the services indicated above. Universal Engineering Sciences Private Provider Firm-- Mark K Hardy Private Provider- 9802 Palm River Road, Tampa, FL 33619 Telephone:, 813-740-8506 Fax: 813-740-8606 Email Address (Optional): TampaBIDScheduifng@UniversalEngineering.com Florida License, Registration or Certificate #; 57233 &r.x#1 MKO An W SO 010 &IN I Via 001% Will"11160 10 1 Instead, plans review and/or required building inspections will be performed by licensed or certified personnel identified in the application. The law requires minimum insurance requirements for such personnel, but I understand that I may reouire more insurance tR irotict mi interests. Bv iiet t and am satisfied that my interests are adequately protected. I agree to indemnify, defend, and hold harmless the local government, the local building official, and their building code enforcement personnel from any and all claims arising from my use of these licensed or certified personnel to perform building code inspection services with respect to the building that is the subject of the enclosed permit application. I understand the Building Official retains authority to review plans, make required inspections, and enforce the applicable codes within his or her charge pursuant to the standards established by s. 553,791, Florida Statutes. If I make any changes to the listed private providers or the services to be provided by those private providers, I shall, within I business day after any change, update this notice to reflect such changes. The building plans review and/or inspection services provided by the private provider is limited to building code compliance and does not include review for fire code, land use, environmental or other codes, W-a� zzrf,, 2. Proof of insurance for professional and comprehensive fiability in the amount of $1 Ilion per of 5 years subsequent to the performance of building code inspection services. (signature) Print Name: Address: Telephone No.: Please use appropriate notary block. STATE OF C J, COUNTY OF Individual Before me, this day of ll pemmally appeared ing instrument, whocxccu ihetiXikeici - and acknowledged before me that same was executed for the purposes therein expressed. Partnership Print"Corporation Name Print Partnership Name Bv By: iaatrre (signature) Print Print Name: Name: Its: Address, V Address - Telephone Telephone No. No.: corporation Partnership Before me, dais day of Before me, fais day of 20 personally appeared personally alp fmared partner/agent on behalf of torpors", on behalf oftho state corporation, who a partnersh ip, who executed the executed the foregoing instrument and foregoing iustrument and acknowledged before me that same was acknowledged before me that same executed for the purposes therein was executed for the purposes therein expressed. expressed. I Personally known/ or Produced identification Type of identification produced 4 Signaturcof Print Name - - - ----- -- Notary Pdblic State of Florida Jennifer M Maffetl orn MYHCH 3M61648i" Notary Public: NOTARY,41W010W E .,.yid 1 Exp. 111612025 My commission expires: Geotechnicai Engineering gUNIVERSAL Construction Materials Testing & Inspecti ElNiCHNEERING SCIENCES Building Code Compliance Occupational HPatth & Safety Environmentat Grounded in Excellence BUilding Envelope Alternative Inspection Services Agreement Project: Premier Community Healthcare Pharmacy - 37840 Medical Arts Court, Zephyrhills FL Private Provider Firm: Universal Engineering Sciences Private Provider Name: George W. Dixon, BU1097 Address: 9802 Palm River Road, Tampa, FL 33619 Phone: 813-740-8506 Fax: 813-740-8706 Names, License/Certificate Numbers, and License description of provider and duly authorized agents who will be providing services for this project. License/Certificate No.: Licenseidert 11 c I at 11 e "I'll, y I p I- e -1 : 1-1-1 57233 QW,11 WW WW BN6-6 "8-OxS�b'� J1 Standard inspector& Plans Examiner Kenneth Scheitler BN2552,PX2340 tandard Inspector & Plans Examiner oger yers BN6695 Standard Inspector Steve Lee Standard Inspector ------------ Frank Ross- BN4330, PX2269 Standard Inspector & Plans Examiner Robert Mason- BN4490, PX4174 Standard Inspector & Plans Examiner - bell BN6679, PX3600 Standard Inspector & Plans Examiner Standard inspector & Plans Examiner 069, FiX4134 Standard Inspector & er Steven Spangler BN8281, PX4761 Standard Inspector & Plans Examine-r ko-gerAusburn ctor & Plans Examiner Michael Mullis Printed Name of Alternative Provider: George W. Dixon, BU1097 Si�nZat�ure* ��F 0 -qfmta of Florida, County of Hillsborough, '00, , V, 0 0 * * 4 a 0 * 1- "N 17( SW rn to (or affirmed) and subscribed before me, by means physical presence or 8.�Lj:� day of t, to 2022, b� OqvhW. Dixon, wh is personally known to me, 0%\�vy,,�Y, Vkq�M',Xkz Kim Y. WhiLe v, Printed Name of Notary Signature of 4Noy Notary Public Stamp: 01 -gig 30, 28972? Zl� U , this DATE (MMfl)WVYVYI •' ' 'CERTIFICATE OF LIABILITY INSURANCE 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 BOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the polldy(ies) must have ADDITIONAL INSURED provisions or 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 r" his to the certificate holder in lints of aiech endvrsemen s . PRODUCED Beecher Carlson Insurance Services... ; Nimh nI-Iuc1,gins_ .... Bart of Brown & Brown Inc;. PHONII FAX 6 Concourse Parkway, Suite 2300 � �� . _., _..... .. to ., Atlanta, GA 30328 A ?R € vrhfleU tr 2 h ; arc l f rs Graf www.bbirisuranco.com IN E A,, EVON t Dti011ar'I Saran or by INSURED iNsvR Ra Everest Pivrviw, inn„ALiP'anc Company Universal Engineering Sciences, LLC 20 Vineland Road, Suite L1 It�suNER St�rStrar7,� Specialty i=a osatt Company � 44776 Orlando FL 32811 f s R t o AXIS surplus Insurance Company 26620 INSURER F ; Landmark American Irsl�� 33 t 3 COVERAGES CERTIFICATE NUMBER; 7I[a' REVISIOf NIiNiGER; THIS IS TO CERTIFY THAT THE POLICIES OF ENSURANICE LISrEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD, INDIC.ATE0 N')T-.MTHSTANOING ANY FtEQUiRE.NIEN T . TERM OR 'CONDITION OF A. -NY (,ONTRACt OR OTHER l0-',.SJ%AFNT 'AdTH €J SP± IGT To v:'Hr(f *i TH;S CERTIPI CA' E NIAY BE ISSUED CIR MA PERT,A'N THE INSURANCE "AF= - TRDED BY THE PO ICa ES DESCRIBED HEREIN iS SUBJECT TO ALI l`HE TERMS. FX,,t! (,SIr`,NS A? I! C's,HrAT!Q ``E GF 5 ii, H PI:)i..lk IFS 7l J,1, 1410,°tN IMA's" F+'1-t'Y FFFN tA.;=DUCFD BY PAW -CI AiNI5 a{5N: AUD�a�tiafz, POLICY FFF Poticytxp , T: Y"-PE tJ61td°uU FaCi i3E.t#:�PtUir�`dF,fi:.. ' Fit t h434�+ IPRE€a A ` cea R is o � e Lam sal F r.1SC>L k 5 2 �i t 112,)'22 1 a L,121 1. 31,000,000 "I, a.�th u dt , �... u—=.a; 3'UC.i,()0fT �I V i OX1 4 , �15 ,:r.: � .: T2 004?,000 PRO u Erb, iCno L3unofit5 i cnao,00a A I RM5CA00056,221 1,1,2022 k;2 % r, tl. ibi5t irLIAPT 13. QC Oft Ati III _ _1Q, t M)IVS " Nt WPM i kEf'I'ii':3 fifP#i.'✓IIWIqCINd Y ,-=f•_cr u.. rl; @E I R UM5RE(LACIAE7 LF:A }sC7E7 EXCESS L ae j WORKERS COMPENSATION RF,15b5'C00084 221 (Af)SI 1fy �Lu®2... 1;1'2323 6 T r Fy hP7PSEMPki3YER4 t)ABbIIFY f 3 R?,, -,W(.,'L'?E�t.8 5 221 (Fi,N J, VrEi # ;202`? , i :", 23 k K t F 1 7040,0=10 VE, ! A 6- .. C Exces4 C � Pr,�I 07), t :1 x y,it;,1' !?1i1"rL E'<? L' y£> t t ?,0 3 J !P,JJT I1( t"t,t�t)t} CI e :=:i s ku?D ! = h,3 Cy' i; Ely # : t ,'` t P-kill 00 7691 „D-G ! v r" I y 3 LAIIT L i?) t iT 01,iP'aCW PTION Uf- OPERA @S (ACORO 101, Add lI.€ ;41 Ro—rk. S.:NM—In nay ha xrfarraar$ tf mtare zpai:a 1� [rim r. �, Pf3 is -err e, r :T;rru. ik y Heai'r Gar F. Evil?t'F ,_f? Ine:.iti'ti.E ELLED halt § c ff e I`1yrhiIIS Bull°Mng Division THEE LD EXPIRATION DATE ANY OF THE AVTH REOF, NOTICE DESCRIBED i WILL FS OF f�BE CDEL I €LED, RIN tt1'9" ACCORDANCE WIT66 THE POLICY PROV)SiON3 aUt*IcrRt�UsalrN�sr=>I:a;ratS .r.$ec�.��cC'rsaf.rc�rr fir.=asxeess,°e,Sarrc-s�c=,.�',C""�' .on Ir raiic,ctr .-L,'- : 1989-2015 ACORD CORPORATION- All rights reserved. ACORD 25 (201&03; The ACORD nartae and logo are rDrgister d marks of ACORD mmamm "INN RTT 6860/6862 Medical Lane, Zophyrhills, FL 33542 within in: 02-26-21-0290-00000-0030 and 02- 26-21-0290-00000-0050. Best Regards, Title STATEOF t ", COUNTY OF " LA, S- - ------------------- The foregoing instrument was acknowledged before me this Not?HH State Of Florida je Moffett My Comm838 salon 193 EXp, 11/612025 Type of Identification Produced Personally Known day SuiteA-1800 Atlanta, GA 30318 Tel: (404) 881-8370