HomeMy WebLinkAbout07-6754
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
6754
Permit Number:
Permit Type:
Class of Work:
Proposed Use:
Square Feet:
Est. Value:
Improv. Cost:
Date Issued:
Total Fees:
Amount Paid:
Date Paid:
Work Desc:
6754
COMMERCIAL
FIRE ALARM SYSTEM
COMMERCIAL
Address: 38530 5TH AVE
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number: 11-26-21-0010-16800-0010
1,135.74
6/06/2007
125.00
125.00
6/06/2007 Phone:
INSTALLATION OF FIRE ALARM SYSTEM
Name: SHIRTS & CAPS INC.
Address: 38530 5TH AVE
ZEPHYRHILLS, FL. 33542
E
FIRE PERMIT FEES
15.00
(0 \ ,~/c),
~~()QloeQ ~ t<6/~
I
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.
REINSPECTlON FEES: Reinspection fees will comply with Florida statute 553.80 (2)(c) when extra inspection
trips are necessary due to anyone 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 f) 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 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,
The payment of inspection fees shall be made before any further permits will be issued to the person owning same
"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."
NO OCCUPANCY BEFORE C.O.
~ I~C . ~~
CONTRACTOR SIGNA URE PERMIT OFFI
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813-780-0020
City of Zephyrhills Permit Application
Building Department
Owner Phone Number <tl~.:'l ~ ~ \l2:J
Owner Phone Number I
Owner Phone Number I
Owner's Name
s - '30 -- 0
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Date Received
Owner's Address
Fee Simple Titleholder Namel
Fee Simple Titleholder Address
JOB ADDRESS
3'~ 5 :::0
~ A0t i -Ze.ph~<\"\I'lls ~ L
I PARCELlD#1
D NEW CONSTR D ADD/ALT D
D INSTALL D REPAIR
D SFR D COMM D
D BLOCK D FRAME D
I (n~-QJ\C\.i{Dl'-.. cl ~ I r€ Q\Of (Y\. ~ ~~
I sa FOOTAGE I I HEIGHT
LOT #
SUBDIVISION
(OBTAINED FROM PROPERTY TAX NOTICE)
SIGN D MOVE D
DEMOLISH
WORK PROPOSED
PROPOSED USE
TYPE OF CONSTRUCTION
OTHER I
STEEL D
OTHER I
DESCRIPTION OF WORK
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BUILDING SIZE
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D ELECTRICAL 1$ I
D PLUMBING 1$ 1
D MECHANICAL 1$ I
D GAS D ROOFING D SPECIALTY D OTHER
FINISHED FLOOR ELEVATIONS I I FLOOD ZONE AREA DYES DNO
11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111
D
BUILDING
VALUATION OF TOTAL CONSTRUCTION
AMP SERVICE
D
PROGRESS ENERGY
D
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W.R.E.C,
VALUATION OF MECHANICAL INSTALLATION
BUILDER
SIGNATURE
COMPANY
REGISTERED
I
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License # I I
~~~1S~~:~IIG ISy~t~.J'KJ
License # I E F .. CCf:) \O~lo I
YI N
FEE CURRENT
YIN
Address
License #
ELECTRICIAN
SIGNATURE
COMPANY
REGISTERED
YIN
FEE CURRENT
YIN
Address
License #
PLUMBER
SIGNATURE
COMPANY
REGISTERED
YIN
FEE CURRENT
YIN
Address
License #
MECHANICAL
SIGNATURE
COMPANY
REGISTERED
Y I N
FEE CURRENT
YIN
OTHER
SIGNATURE
Address
COMPANY
REGISTERED
Address
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 wI Silt Fence installed,
Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisions/large projects
Attach (3) 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, Storm water Plans wI Silt Fence installed,
Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. All commercial requirements must meet compliance
Attach (2) sets of Engineered Plans.
....PROPERTY SURVEY required for all NEW construction.
DI~~~ti~~~': . . , , , , , , . , . , . , , , . , , , , , , , , , , , , . . , , , , , , . , , , , , , . , , , , , , , . , . , , , , , , , . , , , . . , , , . . , . . . , , . , . , , , . , . . . . . , , , , . , . . , . , . , , , , , , . , , . , , , . , , , . , , , . , . , , , , , , ,
Fill out application completely.
Owner & Contractor sign back of application, notarized
If over $2500. a Notice of Commencement Is required. (AlC upgrades over $5000)
Agent (for the contractor) or Power of Attorney (for the owner) would be someone wilh notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (Front of Application Only)
Reroofs SewerS Service Upgrades NC Fences (PloVSurvey/Footage)
RESIDENTIAL
COMMERCIAL
SIGN PERMIT
Driveways-Not over Counter if on public roadways..needs ROW
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 compliaQce 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" of this 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 permitting 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 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 due, will be identified at the time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to
receiving a "certificate 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 WaterlSewer 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 $2,500.00 or more, I
certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law-Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer 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 in good faith to
deliver it to the "owner" prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify that all the information in this application is accurate and that all work
will be done in compliance with all applicable laws regulating construction, 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 to meet standards of all laws regulating
construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also
certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is
my responsibility to identify what actions I must take to be in compliance. Such agencies include but are not limited to:
Department of Environmental Protection-Cypress Bayheads, Wetland Areas and Environmentally Sensitive
Lands, Water/Wastewater Treatment.
Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas, Altering
Watercourses.
Army Corps of Engineers-Seawalls, Docks, Navigable Waterways.
Department of Health & Rehabilitative Services/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 fill:
Use of fill is not allowed in Flood Zone "V" unless expressly permitted.
If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan 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 wall.
If fill 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.
If I am 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 ~hat a s.eparate perm~t may ?e requir~d for elect~ica.1 work,
plumbing, signs, wells, pools, air conditioning, gas, or other ~nstallatlons not speCifically 1n~luded.1n the application. A
permit issued shall be construed to be a license to proce~d With the work a~d not as authorl~y !o. vlol~t~, cancel, alter, or
set aside any provisions of the technical codes, nor shall Issuance of a permit prevent the B~".dlng OffiCial from the~eaft~r
requiring a correction of errors in plans, construction or violat~o~s o! any codes. Every ~ermlt Issued. shall become. invalid
unless the work authorized 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 th~ work is commenced: An extension
may be requested, in writing, from the Building Official for a period not t~ exceed n1n~ty (.90) days and Will demonstrate
justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the~ob IS conSidered abandoned.
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 LE DER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COM MEN EMENT.
FLORIDA JURAT (F.S. 1 F- 3) C"-
OWNER OR AGENT; CONTRACTOR \.J
S scrl ed and swan) to ( r affirmed) before me this SubscribEjd and sworn 0 (or a rmed) before m~ thi .. \
~D D by 1< (" \ ~* \ no fro.x'\.e. \)Q\ \ E:)/3D {O 7 by t<'c I~+' I\..ll.. Ma. ( , ~ ~ \
II k t h /h duced ~.Is/are persona.IIY known to me or has/have produced
Wbo is are persona Y nown 0 me or as ave pro
.h~ \)l2u-lZ. . U l'l as Identification. --t.- j) -R\J,'<. L..l d.... as identification.
~ ~ 2\~ Notary Public
Commission N~~'~ K . L MOlle
...," . ._.', alell . I I
.:Q; 'o.~ C .' # 0D609664
::t :*: ommlSSlon
Name of Not . rHGotuIIIer 29, 2010
, 'W:h\ __ r". ~"'"' ,_. ,." __1918
~ ~ ~~ Notary Public
Commission No. , Lo Miller
.~ Comrrission # oD609664
,
,. . ,.........., ''''' 1ClCl4Mo1018
Fire Chief Robert Hartwig
jI~~~;-" ':1
ZEPHYRHILLS FIRE DEPARTMENT
6907 Dairy Road, Zephyrhills, FL 33542
Bus (813) 780-0041 Fax (81:=) 780-0044
Occupancy No.:
Plan No.:
Business Name:
BusinessAddress:
Business Phone No.:
Business Fax No.:
Contact:
PLAN REVIEW FEES
~j Site Plan N/C
Building Plans .04 sf
RevIsion .06 sf
~,cs.. ~. M5
-~ q;
~~lSL.. ~
\Ie....
STANDPIPE SYSTEM
[J Per Riser $25
SPRINKLER SYSTEMS
[] 0 - 25 Heads $30
CSl26 plus Heads $60
FIRE PUMP
[ Per Pump $100
FIRE ALARM SYSTEM
Q 0 - 25 Devices $30
)Al. 26 plus Devices @
SUPPRESSION SYSTEMS
~ Wet $35
Dry $35
C02 $35
Other $35
GREASENENTILATlON
o Hood/Ducts $35
PLANS TOTAL rn
Comments:
INSPECTION FEES
Annual N/C
1 st Re-inspection $25
2nd Re-inspection $50
3rd Re-inspection $125
4th Re-inspection $250
5th Re-Inspection $500
, Construction $15
U Commercial $25
SPRINKLER SYSTEMS
~ Hydro Undergrounds $45
Hydrostatic System $45
Wet Acceptance $30
Dry Acceptance $45
H Hydrant Flow $25
U Hood / Booth $30
U Grease Duct $15
FIRE ALARM ~
System Acceptance
g Recall Acceptance / 50
OTHER
Fire Wall/Smoke Wall $15
LP Gas $25
Natural Gas $25
Fuel Tanks $25
Tent $15
INSPECTION TOTA~
GRAND TOTAL
Billing Phone No.: ,~?- 57~;Z-
Billing Fax No.: ~ M"
Contact: ~,-IJ? ____
,/
PERMIT FEE
SPRINKLER SYSTEMS
o Automatic $15
FALSE AL ll,RM FEE
1 st Alarm N/C
2nd Alarm N/C
3rd Alarm N/C
4th Alarm $25
5th Alarm $50
6th Alarm $75
7th Alarm $100
8th Alarm $150
9th Alarm $200
10th Alarm $250
Non Compliance $150
"Affidavit of SE'rvice/Repair"
FIRE PUMP
o Fire Pump $15
FIRE ALARM ~fM
~Detection ~
OTHER
~ LP Gas
Natural Gas
Fire Works
Fuel Tanks
$45
$45
$25
$45
GREASENENTILATION
n Hood/Ducts $15
o Kitchen Suppression $15
PERMIT TOTALaD
1/2A
I
FALSE ALAF:M [~
TOTll,L ---.J
:::'dOC. t 1~7fr ~~-fL- rA-
f
Zephyrhills Fire Rescue
6907 Dairy Road, Zephyrhills, FL 33542
Fire Marshal
Kerry Barnett
Bus (813) 780-0041
Fax (813) 780-0044
June 5, 2007
Plan Review Comments
I have reviewed and approved the plans for fire alarm located at 38530 5th Avenue under
the following conditions. My comments have been placed below. Please contact me if
you have any questions with regards to my comments,
1. Alarm system shall be code compliant .aRd Fe~OO.
2. Install smoke detection in main area of fire alarm system.
3, Install at least 2 strobe/horns in east wing.
4. East wing fire alarm shall be built out in 1 year to provide total building coverage
(per meeting w/contactor and building owner).
5. Occupant shall have an alarm log book located next to panel along with a copy of
as built plans.
Inspections required:
1. Acceptance test required for final.
NOTE: Full compliment of details and schematics needed at time offinal. This shall
include battery calcs, panel type, monitoring info, device type, etc...
Specialty E~ectronic Systems, Inc.
Post Office Box 41
Dade City, FL 33526
Invoice
Date
Invoice #
4/10/2007
205983
Bill To
Carr Construction Services, Inc
3602 Oakwood Drive
Wesley Chapel, Florida 33541
Re: New Building Fire Alarm System
~ P.O. No. Terms
~..) (:7 Due upon receipt
Item Quantity Description Rate Amount
This INVOICE is for the ROUGH IN of the Fire Alarm
in the New building and connect to the proposed new
Bosch Fire/Burg Panel Proposed at the above project.
Consisting Of:
D9127U 2 D9127U Popex II Low Current 38.00 76.00T
D461 2 Bosch 0461 Manual Station 32.3475 64.70T
BK-PC2R 3 System Sensor PC2R Ceiling Horn/Strobe Red 45.43 136.29T
BK-SR 1 System Sensor SR Strobe Only 50.00 50.ooT
329885-001 0.5 329885-00116/2 Unshielded Plenum Cable 232.90 116.45T
329885-003 0.5 329885-003 14/2 Stranded Shielded FPLP Yellow 386.00 193.ooT
Fire Alarm (Install) 0.5 Labor to Install, Program and Test 850.00 425.ooT
Terms:
500A, Upon Rough In
50% Upon Completion
Notes:
(1) Pemrit Fee NOT INCLUDED will pass cost on to
contractor.
Thank You For Your Business, Now Accepting Visa or Mastercard! Subtotal
$1,061.44
PAST DUE invoices will be subject to 1.5% interest fee. Sales Tax (7.0%)
$74.30
Total $1,135.74
~
Phone # Fax # E-Mail
352-567-5996 352-521-6085 sesalarms@yahoo.com
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Sroecialt~ Electronic S~st 352-521-6085
10. 1
!iPECIALTV
ELECTRONIC
!iV!iTEM!i.INC.
LIe. # EF0001046 35 i!-S 67 -5996'
P.o. BOX 41 - DADE CITY, FLDRIDA 33Si!6 - FAX 3Si!-Si!1-60BS
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FAX TRANS MITT AL
~ # OF PAGES (including cover)
DATE: 5- 30-07
TO Cu0j ~ ~RJJA~
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ATTENTION:
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DESCRlPTION: IP~ V~, JDeut
FAX#:
COMMENTS:
SIGNED:
A.rrF'i1iii rn~Anl - RI1Ar;1 AA AI AAM _ rmJ _ FIAF AI AAM _ I';ATF nPFAATnAIii
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GENERAL POWER OF ATTORNEY
KNOW ALL PERSONS BY lHESE PRESENTS:
I c.
. (''Principal'') maintaining an address at
tD'i fa.... {If': '(1 ',- ~. do hereby make and appoint
...k' ,.., ~nt. /'Ynrrt.. bcu I ("Agent") maintaining an address at:
'~lwlJY ;Q,'n;:,-ll/d LJ,- "bDJf cd.w l F{ my true and lawful
attorney-in-fact for me and in my nam~ and In my behalf,
My Agent shall have full power and authority to perform any act, power, duty, legal right
or obligation whatsoever that I now have or may later acquire in connection with or
relating to any person. item, transaction, thing, business, property, real or personal.
tangible or intangible, or matter whatsoever as I could do if personally present. I hereby
ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this power of attorney and the rights hereby
granted. My Agent's powers and authority shall include, but not be limited to:
1. To conduct, engage in, and transact any and alllawfuJ business ofwbateverkind
or nature, on my behalf and in my name.
2. To enter into binding contracts on my behalf and to sign, endorse and execute any
written agreement and document necessary to enter into any such conttact and/or
agreement, including but not limited to applications, assignments, bills of sale or
lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds,
security agreements, leases, mongages, notes, insurance policies, receipts, title
documents, checks, drafts, letters of credit, stock certificates, proxies, warrants,
commercial papers, withdrawal and deposit slips, certificates of deposit of, or
investments with or through banks, savings and loan, brokers, mutual fund
companies or other institutions, proofs ofloss, evidences of debts, releases, and
satisfaction of mortgages, lien, judgments, security agreements and other debts
and obligations and such other instruments in writing of whatever kind and nature
as may be.
3. To request, ask, demand, sue and take any and all legal steps necessary to recover
and collect any amount or debt owed to me.
4. To adjust, compromise and settle any claim, against me or asserted on my bebalf
against any other person or entity.
5. To receive, hold, possess and/or invest any and all sums of money, accounts,
debts, bonds, commercial papers, checks, drafts, causes of action, bequests,
deposits, notes, interests. dividends, certificates of deposit, any and all docmnents
of title and demands whatsoever, whether agreed to or disputed, now due or due
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Specialt~ Electronic S~st 352-521-6085
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in the future, owned by, due, owing payable, or belonging to, me or in which I
have or may hereafter acquire any interest, to have, or use.
6. To maintain, manage, insure, lease, rent, sell, mongage, improve, repair,
exchange, invest, reinvest and in any other manner (on such terms and at prices
my Agent may deem proper) deal with all, any pan or any interest in any real or
personal property or asset whatsoever, tangible or intangible (now owned or
acquired in the future by me) and to execute any necessary document, instrument
or deed for such transactions. This includes the right to sell or encumber any
homestead that I now own or may own in the future; the right to remove tenants
and to recover possession; and the right to ask for, demand, sue for, conect.
recover and receive all monies which may become due and owing to me by reason
of such tIansaction.
7. To apply for, purchase, maintain andlor deal with insurance and annuity contractS,
insurance policies, including life insurance upon my life or the life of any other
appropriate person and to make any elections and disclaimers under such policies.
8. To receive, deposit, hold, demand, deal with and/or sue to recover an payments I
receive from any annuity, pension, retirement benefits, retirement plans, insurance
benefits and government program including, but not limited to, Social Security
and Medicare; to prepare applications, provide information, and perform any
other reasonable request by any government or its agencies in connection with
governmental benefits (including but not limited to, medical, military and social
security benefits), and to appoint anyone, including my Agent, to act as my
"Representative Payee" for the purpose of receiving Social Security benefits.
9. To open, maintain and/or close bank. accounts, including, but not limited to,
checking accounts, savings accounts, cenificates of deposit, investment accounts,
brokerage accounts, retirement plan accounts, and other similar accounts with
fmancial institutions; to conduct any business with any banking or fmancial
institution with respect to any of my accounts, including, but not limited to,
making deposits and withdrawals, negotiating or endorsing any checks or other
instnnnents, obtaining bank statements, passbooks, drafts, warrants, money
orders, certificates, cashier checks, cash or vouchers payable to me by any person,
tJI'Dl, corporation or political entity; to perform any act necessary to deposit,
negotiate, sell or transfer any note, security, or draft of the United States of
America, including U.S. Treasury Securities.
10. To have access to any safe deposit box, vault or other storage area owned or
leased by me alone or in conjunction with any other person, including access to
their contents, and to examine, remove, keep or otherwise dispose of the contents.
11. To exercise any and all rights, including proxy rights, with respect to stocks,
bonds, debentures, commodities, options or any other investments.
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Specialt~ Electronic S~st 352-521-6085
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12. To maintain andlor operate any business that I currently own or have an interest
in or may own or have an interest in, in the future.
13. To employ any professional and/or business assistance as may be appropriate,
including but not limited to, attorneys, accountants, investment professionals,
brokers and real estate agents.
14. To prepare, or cause to be prepared, sign, and/or file any documents with any
federal, state, local or other governmental body, including, but not limited to,
federal, state, local or other income and tax returns and necessary and/or related
documents; to obtain or provide infonnation to and from any agency, including
governmental agencies, relating to tax matters and to negotiate, compromise or
settle any matter with such agency.
15. To make gifts and charitable contributions of my real, personal, tangible or
intangible property, to such persons or organizations without regard to whether
such gifts are a part of my estate planning or otherwise, and if necessary, to file
any state and federal gift tax returns and documents. Gifts to minors may be made
to the minor directly or parent, guardian or close friend of the minor or pursuant
to the Uniform Gifts to Minors Act or the Unifonn Transfers To Minors Act. Any
gifts made shall be limited to gifts that qualify for the federal gift tax annual
exclusion, shall not exceed in value the federal gift tax annual exclusion amount
in anyone calendar year, and this annual right shall be non-cumulative and shall
lapse at the end of each calendar year. However, my Agent may not, unless
specifically authorized by this document, (a) gift, appoint, assign or designate any
ofmy assets, interests or rights, directly or indirectly, to my Agent, my Agent's
estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercisc any
powers of appointment I may hold in favor of my Agent, my Agent's estate, my
Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets
to discharge any of my Agent's legal obligations, including any obligations of
support which my Agent may owe to others, excluding those whom I am legally
obligated to support.
16. To transfer any of my assets to the trustee of any revocable trust created by me. if
such trust exists at the time of such transfer.
17. To disclaim any interest (subject to other provisions of this document), which
might be transferred or distributed to me from any other person, estate, trust, or
other entity. as may be appropriate. However, Agent may not disclaim assets, to
which I would be entitled, if the result is that the disclaimed assets pass directly or
indirectly to my Agent or my Agent's estate,
This General Power of Attorney and the rights, powers, and authority of my Agent shall
become effective immediately upon execution of this instrument. The rights, powers, and
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p.5
authority of this document shall remain in full force and effect thereafter until my death
or until my disability or incapacity.
As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and
evaluate information effectively, to communicate decisions, and/or to manage my
financial resources and affairs properly.
My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a
result of carrying out any provision of this Power of Attorney. If desired, my Agent shall
also be entitled to reasonable compensation for any services provided as my Agent
If so requested by myself or any authorized personal representative or fiduciary acting on
my behalf, my Agent shall provide an accounting for all funds handled and all acts
performed as my Agem.
This Power of Attorney shall be construed broadly as a General Power of Attorney. The
listing of specific terms, rights, acts or powers are not intended to restrict or limit the
definition or scope of powers granted herein in any manner. If any part of this document
is held to be invalid, illegal or unenforceable under applicable law, then the remaining
unaffected pans of the docwnent shall still remain in full force and effect and not be
affected by any partial invalidity.
No person needs to inquire as to the reasons for the use or issuance of this power-of-
attorney or as to the disposition of any proceeds paid to my Agent based on this
document.
The powers granted to my Agent by this power-of-attorney are limited to the extent
necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any
rights or ownership with respect to any life insurance policies I may own on the life of
my Agent; and/or ( c) my assets to be subject to a general power of appointment by my
Agent.
Any third party who receives a copy of this document may act under it. Revocation of the
power of attorney is not effective as to a third party until the third party has actual
knowledge of the revocation. I agree to indemnifY the third party for any claims that arise
against tbe third party because of reliance on this power of attorney. If this General
Power of Attorney is tenninated by operation oflaw, any person relying in good faith on
the authority of this document, without notice of such tennination, shall be held harmless.
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Ma~ 30 07 01:42p
Specialt~ Electronic S~st 352-521-6085
p.6
Agent shall not be liable for losses resulting from judgment errors made in good faith.
However, Agent will be liable for breach of fiduciary duty, failure to act in good faith
and/or willful misconduct, while acting under the authority of this Power of Attorney.
I may revoke this Power of Attorney at any time by providing written notice to my
Agent.
Signed on nCDernbR ~ (date), at lY::de CltlJ.. (city),
t="lDrl do...... (state). 0 ~
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Signature of Principal
Witness Signature:
Name:
City:
State:
Witness Signature:
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tr~ was acknowledged before me this q day Df
, by (name of
ho is persona y known to me or who has produced
. '. tification.
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