HomeMy WebLinkAbout91-1511
STATE OF FLORIDA
City of Zephyrhills
/v/,./tfD38
Type of Permit
PASCO COUNTY
BUILDING DEPARTMENT
1-813-788-6611
Permit:N'~
1511t::,
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Properly Owners Name: :i;;. 7- ~r~
Job Address: "" -
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Legal Description:
Sub.Div,
Zoning CI:
Description of Work
C~R'e.f'6k/,:&L
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Date-s!:) -/ ~ -/1
M~'
Lot Blk,
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Energy Code Readout:
((/'-- .. ILL. S-- 2/-'1 I t:5~
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Complete Plans, Specifications and Fee Must Accompany Application
(~ ~J.V1rd~ITJt~~
( - ELECTRIC ".,. MECHANICAL_,
Tp,Serv,
Rough In
Meter Can
Const. Pole
Pool
Pre-Meter
Final
Estimated Cost: ,;/l-
All work shal! be performed in accordance
with the above and all City Codes
and Ordinances,
OCCUPATIONAL LICENSE #
/7$c/U.
aL: ;:~
BlJlLDtNG
PLU~
----
SLB
Tub Set
Water
Sewer
Final
Ftr.
Pre SLB
Lintel
FRM,
Insul.CL
WL
Driveway
/- $Cd
Fee: /,0.' ,0--
SIGNATUREI./~~-z2~- .*~?-
COMPANY
ADDRESS
TELEPHONE #
Breakers
Ducts Insl.
Compressor
Final
Relnspectlons: When extra inspection trips are necessary due to anyone of the following reasons, a charge of ten ($10,00)
dollars shall be made for each trip,
(a) Wrong Address
(b) Condemned work resulting from faulty construction
(c) Repairs or corrections not made when inspection called for
(d) Work not ready for inspection when called,
The payment of reinspection fees shall be made before any further permits will be issued to the person owning same,
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49 05 61
POLICY :--00.
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LIBER1Yfe
MUTUALW
. Liberty ':\ lutuallnsurance GroupfBoston
LIBERTY MUTUAL INSURANCE COMPANY 15628
SALES OFFICE' CODE SALES REPRESE:--OTATIVE
Workers Compensation and
Employers Liability Policy
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ISSUING OFFICE 570
INFORMATION PAGE
TO,CO
CODE :-.;
1ST YEAR
CI-351-490561-01091/9TAMPA 555 ASSIGNED
I~m 1,~ameofCARLYLE R. HUFFMAN DOING BUSINESS AS
Insured CARL YLE ELECTR I C
P.O. BOX 251
Addre~ CRYSTAL SPRINGS, FL 33524
000 2 89
FEIN 592792170
Status
INDIVIDUAL
Other workplaces not shown above: S E P H Y R H ILL S :
38300 11TH AVENUE
Item 2, Policy Period: From
\'
Mo, DIY V..,
05 30 90
12:01 AM
to ~5 ~"~ ;ei ---~)
..standai.itrtme:,at=~f the insured as' stated hcrein,
Item 3, Coverage
A, Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: '
FL
B. Employers Liability Insurance: Part Two of the policy applies to work in each state li~ted in item ),A. The limits
of our liability under Part Two are: ' " ,
Bodily Injury by Accident $ 100 ,000 each accident
Bodily Injury by Disease $ 500 , 000 policy IJmit
Bodily Injury by Disease $ 100 , 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPT THOSE LISTED IN ITEM 3A AND THE STATES OF
NV NO OH WA WV WY AK
D, This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4, Premium - The premium for this policy will be dctennined by our Manuals of Rules. Classifications. Rates
and Rating Plans, AU information required below is subject to verification and change by audit.
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P,emium Basir Rates L1:'\E 1 1
Estimated Per 5100 E~tlm'ted
, Code TOIlI Annuli or Re' "nnual
Classifications , :-;0, Remuntrltion muneruion l'r~mtums
SEE EXTENSION OF INFORMATION PAGE
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\linimum Premium $ 550
( FL>
Total Fstirnated Annual Premium $
1,013
Interim nlljustment or premium shall be made: ^ N N U A L ~ V
*N*9NOO*
.. ,
ARC
Deposit Premium $
81
1 ,013
This policy, including all endorsements isslIed therewith. is hereby cOllntersigned by
.\uthlln;pd Rtple~Phl.'u\.'e
1 lale II: II~ '111
PRODUCER OF RECORD
INSURANCE MART
37606 CtRt S4 Wt
ZEPHVRHILLS, Fl ,34249
I.oc, C;,,'I Term. Ope" TN
1 2/02/90
RENEWAL OF
WC1-351-490561-019
I:
GPO JOJO RI
\IT 00 00 01 ,\
COPYright 1987 National CounCil on Comr~n~atlon Insurance
, ~~ ~~T~:ti)" ":"~T-ii'r'~C-'''
Item 4, Index of Classifications
CLASSIFlCATIO:'\ OF OPERATIO:'\S
ELECTRICAL WIRING - WITHIN
BUILDINGS & 0
FLAT CHARGE
...
Polk)' \'0, we 1- 351- 4 90561- 0 10
GPO 2924
~:j.' -~
CODE :'\0,
4
900
190
038
~
Page \'0,
1
wcnOOOOI,\
, '~ib'~LA
"nn. ti .
QLA 3....46 21
~NEWAl OF NUMBER
522 85
i;f AMERICAN SOUTHERN INSURANCE CO.
ATLANTA. GEORGIA
GENERAL L1ABllITY.AUTOMOBILE
~
'100.00 MINIMUM RETAtNaD PRBNIUM
DECLARATIONS
1t11ll1. NI"" Jns.,,' and Address: (No" street, Town or City, County, Stlh)
RUfl'MAN, CARLTL!
'.0. BOX 251-RADM,U PLACK
CRYSTAL 'POS, PASCO, n. 33524
It,.. 2. Policy Period: (Mo. D.y Yr ,)
From 10-09-'0 to' 10-09-'1
]2:0] A,M.. standard time at the address of the nlmed InsDred as stated herein,
The Ill"" Ins.,,' Is:
[]Clndlvldual D Partnership
Builness of Ihe n....d Insured is: [RNT... ..LOW)
aLP.CTRICIAN
o Corporation
D Joint Venture D Other:
Audit pe'r'iod: Annual, unless otherwise stated, (...n.. ..LOW)
It.m 3, The insurance afforded is only with respect to the Coverage Part(s) indicated below by specific premium charge(s) and allached to and forming a part of
this policy,
~
AdYlnce Ctymae Cover'le P.rtls) Adv.nce Cmr'ae Coverall Partls)
Premiums Part Ntis). Premiums Part Nols),
S Automobile Medical Payments Insurance $ Hospital Professional liability Insurance
$ Automobile Physical Damage Insurance $ Manufacturers' and Contractors' liability
(Dealers) 291.00 [,6<<10 Insurance
$ Automobile Physica' Damage Insurance $ Owner's and Contractor's Protective liability
(Fleet Automalic) Insurance
$ Automobile Phrical Damage Insurance S - Owners', Landlords' and Tenants' liability
(Non,Fleet Insurance
$ Basic Automobile liability Insurance $ Personal Injury liability Insurance
$ Completed Operations and Products liability $ Physicians', Surgeons' and Dentists' Professional
Insurance liability Insurance
$ Comprehensive Automobile liability Insurance S Premises Medical Payments Insurance
S Comprehensive General liability Insurance S Spec ial Protect ive and H ighw3yliability Insurance
S Comprehensive Personal Insurance New York Department of Transportation
$ Conlractualliabilily Insurance S Storekeeper's Insurance
$ Druggists' Liability Insurance $ Uninsured Motorists Insurance
S Elevltor Collision IMurlnce S
$ Farm Employers'liabilily and Farm Ef1lllloym'
Medi,cal Payments Insurance S
$ Farmer's Comprehensive Personal Insurance
$ Farmer's Medical Payments Insurance S
$ Garage Insurance
t,..611)-A $100.00 DEDUCTIBLe ml P.o. au 271 6/85 Form numbers 01 endorsements,
other than thos. entered on
$ Cover'le Pulls), .llach.d .t issue
S 291 .. I) OTolI1 Advanco Premium f.r this polley, I AS 304 U/89 )
10/90
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· II the Policy Period Is more than one year and the premium is to be paid in installments, premium is payable on:
Effective Date 1st Anniversary 2nd Anniversary'
$ $ $
Item 4, During the past three years no insurer has cancelled insurance, issued to the named Insured, similar to that afforded hereunder, unless otherwise stated herein:
lSIUID POle 090S!-e IN!UlANe! ~L\RT-Z~pnRYRtLLS
Count.Fllillldl 10/0l/DO
~~rHY'Rl{t ~L$
INot 'Plllluble'n Tem
CDL8300(O)X-G
(1-1-73'
By IDGA, INC. .4199 ,J
Ptd, 'n U,S,A, Authorized Represenlalive
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COVERAGE PART MANUFACTURERS' AND CONTRACTORS' LIABILITY INSURANCE
C(l\I~RAGE FOR PREMISES AND FOR OPERA nONS IN PROGRESS INCLUDING OPERATIONS OF INDEPENDENT CONTRACTORS
..,
~ ..
Fa; altaCh~ent to Policy No, OLJ\ 5 22 e S
L 84tO'
(Ed. 1.73)
. to complete said policy,
AODITIONAL DECLARA TrONS
Location ~&emlses owned by. rented to or controlled by t~e named Ins~red "NT" ......... .. ..... LOC'TION., 'ODU.. '''OWN'N .u.. '0. OOCL..."ON.:
,
Interest of nlmed Insured in such premises 'C"OCK ULOW,
~ OWNI''' 0 OIlNl'ftAL LII..... 0
"J.'~
'.
TENANT
D Other
Parl occupied by nlmed Insured ,ONT.. ULOWI
ENTIRE
SCHEDULE
The Insurance afforded Is only with respect to such of the following Coverages as are indicated by specific premium charge or charges. The limit of the company's
liability against each such Coverage shall be as stated herein, subject to all the terms of this policy having reference thereto,
A Bodily Injury liability
B-Properly Damage liability
Form numbers of endorsements attached at Issue
$
$
$
" $
AdYlnce
Premiums
Total AdYlnce Premium
General liability Hazards
Advance Premiums
Bedily Injury Property Dlm"e
Rates
B.I. P,O,
Premium Bases
110.00
130.00
.661
.781 C
1()700
23.00
28.00
COYerale.
Code
No,
Description of Hazards
Premises, Operations
17315 ELECTRICAL WIRHG
WITHIN BUILDINGS,
INCLUDING INSTALLATION
OR REPAIR OF FIXTURES
OR APPLIANCES.
SURCHARGE
I
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...;: , f
t\ y' ~ , , I
(a) Per 100 Sq, FI. 01 Are8
(bl Per lInear Foot
(c Per $100 of Remun"a!lr, ,
(d) Pe' $100 of R""eir" '
fel Per Unil
Per tanding
- _l___
(a) Are. (Sq, 't,)
(h) rront,'~e
(el R''l1unCI3tlon
(d) r,"ftiot5
(e) Units
Numb"-' Illsurtd
E~I' a!;,:nrs ("umbryr al Preml~~~)
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<'-~._._..--c;;;;----- '!'\"~ren-!et1' e~~traetors
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T.t-' .~Y~"r. 'I' '"~ " ;; ~~, _! ;::-.:-., T ----~-- --
-:....':..._._--...:"'~,___ _" I
'" {.~
s 133.00 s
158.00
When used as a premium basis:
1. "cosl" means the lotal cosl fa the "~"1r.~ i'~tlr~1 VJi:h ""r-' , >',
contractors of all work let or sub,lct in cr~:1ccli0n wi::, ,,'
or delivered for use in the execulicn of sl1ch \'I~r~, VI!' 00,
commissions made. paid or due;
._. f, "1 ,f I... !t,.~ ... '"1"
.. ~ Ih~ po' icy rcriarl hy inder~ndcnl
',' : lah Jnd r.quiprnent lurnishr.d, l1sp.d
c';r'S~n f~~Sr ni!o\":':~,;r.'i, !JOllUSCS or
2, "reeelph" met". th. IIr",. amnunl nl Inn",,, th"~MII...' .'", ""' '. ~, "y ..!I'e" dllrlng t~e ",,"ey "erlnd
as are rated on a receipts basi,. other Ih,:l1icC-'-' , , "', oL'or t~:: laxc":ich th:' "~med
Insured collects as a separate item ~n" ::':;:~ ":'"." ,:, ".. "'''''1
3. "fCmuIlZfltlDiI" m~ails Ik~ enUre reiliUMralion earned during the policy period by proprieto' ~nd by all employees of the named Insured, other than
chauffeurs (except operators of mobile equipment) ,n,l "",," .:'" 'lIots, su~ ' "~ime earnings or limitalion of relllul1crati~n rule
applicable in accordance with the manuals in use ~;
(cv~r)
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