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Home My WebLink About07-6981 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813)780-0020 BUILDING PERMIT 6981 Permit Number: Permit Type: Class of Work: Proposed Use: Square Feet: Est. Value: Improv. Cost: 2,400.00 Date Issued: 8/27/2007 Total Fees: 45,00 Amount Paid: 45.00 Date Paid: 8/27/2007 Phone: Work Desc: REROOF - COMMERCIAL - SHINGLES 30 YR 6981 RE-ROOF ROOF REPLACEMENT COMMERCIAL Address: 38330- 38338 5TH AVE ZEPHYRHILLS, FL. Township: Range: Book: Lot(s): Block: Section: Subdivision: CITY OF ZEPHYRHILLS Parcel Number: 11-26-21-0010-16600-0190 Name: NEWCOMBE (JOHNSON), HELEN Address: 37221 PRICE DR ZEPHYRHILLS, FL. 33542 rC!\A ~-d \ r~ !J-/I-O REINSPECTION 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 commenceme " ~ . /,/ / - ~~ ~ CONTRACTOR SIGNATURE PERMIT OFF I 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 Building Department Fax-813-780-0021 i 'e\-e ...... :S0Hfo.)S.~) Owner's Name ~ ' \ l Owner's Address 1'37 22-1 P r \. C-Q...- D C2.... 2h ~ \ \ ~ Fee Simple Titleholder Namel F" Slmpl. T,",hold" Add.... ~ ~ ~ A0e- JOB ADDRESS 1'3<63 _ 0 _ Date Received Owner Phone Number Owner Phone Number I Owner Phone Number I LOT # h~/2U PARCEL 10#1 NEW CONSTR INSTALL SFR BLOCK I B D D D D D WORK PROPOSED B PROPOSED USE D TYPE OF CONSTRUCTION D DESCRIPTION OF WORK 1 (2Q("ock'- ~hi.(\S~ .- ~O'i-r BUILDING SIZE I I sa FOOTAGE 1 HEIGHT I 111""111111"'11111111"1111"1111111"11111111111"'1111'111111""'111111""11'1'111111'111111"111111111'11111111111111111111111111'1'1111'1 ADD/AL T REPAIR COMM FRAME t\- 2~- Z-l - 6blb~ICo~' o\9b (OBTAINED FROM PROPERTY TAX NOTICE) SIGN D MOVE D DEMOLISH SUBDIVISION OTHER STEEL I D OTHER I _ )lTHER ?S SIGNATURE I Y I N FEE CURRENT Address ( e I - F<. ..335...zr License # 1I111111111I1111I1111111I11111111I11111111111111111111I11111111II111111I111111II1111I1111111111111111111111111111111111111111111I11111111111111111 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 wI Silt Fence installed. Sanitary Facilities & 1 dumpster; Site Work Permit for subdlvisions/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. Stormwater 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, D BUILDING 1$ I i:).l1 C5D, C~7.:) D ELECTRICAL 1$ I D PLUMBING 1$ I D MECHANICAL 1$ I D GAS D ROOFING D SPECIALTY D OTHER FINISHED FLOOR ELEVATIONS I I FLOOD ZONE AREA DYES DNO 1I111I11111111111111I11111111111I111111I1111111111I1111111111111111111I11111I11111111111I1111I11111111111111111I1II111I111111111111111111111111111 I I I I I I I I I I VALUATION OF TOTAL CONSTRUCTION AMP SERVICE D PROGRESS ENERGY D W,R,E,C. VALUATION OF MECHANICAL INSTALLATION COMPANY REGISTERED BUILDER SIGNATURE YI N FEE CURRENT Y/N Address License # COMPANY REGISTERED ELECTRICIAN SIGNATURE YI N FEE CURRENT Y/N Address License # PLUMBER SIGNATURE COMPANY REGISTERED Y/N FEE CURRENT Y/N Address License # MECHANICAL SIGNATURE COMPANY REGISTERED YI N FEE CURRENT Y/N Address License # Y/N COMMERCIAL SIGN PERMIT Di~~~ti~~~.: I I I . . . . . I I . . I I I I . I . . . I I . . . . I I I . . I . . . . I I . . . . I I I I I I . I I . . . . I I . I I . I . I I . I I I I I . I I . I I I I . I I I I . . . . I . I I . I I I . . . . . . . I I . I . . . I I . I I I I I I I I I I . I I I . . I I I I I 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 with notarized letter from owner authorizing same OVER THE COUNTER PERMITTING (Front of Application Only) Reroofs Sewers Service Upgrades NC Fences (Plot/Survey/Footage) 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 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" 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 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 $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 properti~s, the. ow~er 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 Installations not specifically 1n~luded.1n the application. A permit issued shall be construed to be a license to proceed 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~II.dlng Official from the~eaft~r requiring a correction of errors in plans, construction or violat~o~s a! any codes. Eve~ ~ermlt Issued. shall become. Invalid unless the work authorized by such permit is commenced within SIX months o.f permit Issu~nce, 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 mn~ty (,90) da~s 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 COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER 0 AN ATTORNEY BEFORE RECORDING YOUR TICE OF COMMENCEMENT. FLORIDA JURAT (F.S, 117, \, oJ. OWNER OR AGE T ", stscrtPed and s~m to (or affirmed) efore me t is '6 ?-<.(Lcn by eJeV"> \J 0<...1...< ~'" t-Jo 1. ,.,y~bR Who Is/are personally known to me 0 as/have produced r-::L 1)(2.0\"2- Ll c.... as Identification, ~/..... d ~ Notary Public commiS~W~J; Kar~.n ,L. Miller ~_ E CommiSSIon #I DnA0966~ Name of lei~l!9 2010 I iIiM"f_~"";;_';;~e _1919 ~~,,~~~ Notary Public Name of Notary typ , Commission No, STATE OFFLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 (850) 487-1395 MILLER, BRADLEY TLC ROOFING LLC 14138 18TH CT DADE CITY FL 33525-3603 552 - t-f 3'7 - 40-73 DETACH HERE ,.______....... I .. PASCO COUNTY BUSINESS TAX RECEIPT 2007-08 Issued pursuant and subject to Florida Statutes and Pasco County Ordinances, Issuance does not certify compliance with zoning or other laws, This receipt must be posted conspicuously in place of business, Expires September 30,_ ACCOUNT NO: 72443 SIC CODE: 1761 Mike Olson TAX COLLECTOR PASCO COUNTY FWRIDA HC ROOFING LLC TYPE OF BUSINESS: ROOFING CONTRACTOR LOCATION ADDRESS: 14138 18TH COURT DADE CITY DATE RECEIPT 07/26/07 527443 . AMOUNT 31.25 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 (850) 487-1395 TLCROOFING LLC 14138 18TH COURT DADE CITY FL 33525 DETACH HERE ";'; j~; {:~~~~:; ~'a.:J!:" 'ca:tS'~ ","'i" ,,' .....O.......""'O:~'R.. ":"'1 .:...,,:.;'.:, ".) ",,~, "'~,,\~,::~,'~L;~"';" ':'.':::.'":,',,,::;:::,,:.',:,;:\:::,'::''''.~, ',;",,'~~~~~;~~ ACOBl1. CERTIFICATE OF LIABILITY INSURANCE 1 ~ CERTlFICATE 110./ DATE 1tJ::.Oi-16000S02-S6S821 8/23/2001 1:49:S0PM ,RODUCER TtftS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rigbpoint Risk S.n'iCl88 LI.C ONLY AND CONfERS NO RIGHTS UPON THE CERTIFICATE 14160 ~1.. V&rkw.y 1500 ~ER. THIS CERTIFICATE DOES N9tr~pram OR Del.],.., B 7525& R THE BY IES BELOW. (800) 632-5096 (972) 715-0959 INSURERS AFFOItDING COVERAGE ....: 1Sl72\ &0&-&&50 "lURED: MIS l/c/f: INSURER '" Companion Property and Casualty Insurance Comp TLC ROOFING, LLC INSURER 8: 14138 18TH CT DADE CITY, FL 33525 INSURER c: (352) 521-0423 Fax: INSURERD: INSURER E: THE POUC;IIS OF IN8URANCE U8lED -..ow MAVE BEEII..-D TO 1H& INSURED NAMED AlllCNE fOR THE POUCV PPlOD IIOCATED. N01WITM8TANDlNG ANY REQUIRE_NT, ~RII OR CONDl11ONOF ANY CONTRACT OR OTHER DOCUllENTWlTHRE8PECTTOWHlCHTHIS CERT1f1CA~ MAY _ISSUED OR MAY PERTAIN, THE IM8URANCE AFPORDED '" THIi POLICIU DESCRIBED HEMIN IS 8UUCT TO ALl. THE ~RIIS. EXCLUSIONS AND CONDmoNS Of' SUCH POLICIES. AGQREGA.~ LIMRW SHOWN MAY HAW BEEN MOUCID '" PAID CLAIMS. TYPE 01' IIil8UfWlIGE l'OLICY IIUIIIIEIt GENEIW. UAIM.1l'Y COIiMiRCW.. GENERAL L.IAIIILlTY aAlMSMACEOOCCUR ~~.h~.;.1f.~ It:t \-;'J.~~..W..:t EACH OCCURRENCE FIRE DAMAGE Wrt Ono Fh) IlIED ElCP Wrt __I PeRSONAL &NN INJURY GENEftAlAGGlll!Gi'TE PRODlICTS -lXlIolPIG' AGG UMITIS $ S $ S S S C()MBINEDSlNGlELNIT {EII--.q $ IlOIlIL Y INJURY (PWper-'l s 8ODIl. Y INURY (Per -.Q $ PROPERTY DAMAGE (PW--.q AlJTO ONLy - EA ACClo&NT S OTHER lHAN EA N:.C S AUTO OIIL Y: AGO S EACH OCCURRENCE S AGGREGATE $ $ S OCCUR IlEDUCT1BLE RETENTlON $ WORKERS COIIPENIATlON AND EIIPLOYERI' LIABUTY WC77179990401 08/27/2007 04/01/2008 E.L. EACH ACCICENT E.L. DI&EASE. EA EMPI..OYEE E,L, DISEA8E - POlJCY LMT A OTHeR UMIT8 UMITS S S DESCR~ OF ClPMATIONSIl.OCA~ IIDCED...EMIORIEIIEIITII PRIMIIONS 1. This certificate remains in effect, provided the client's account is in good standing with AMS. Coverage is not provided for any employee for which the client is not reporting wages to AMS. Applies to 100\ of the employees of AMS leased to TLC ROOFING, LLC, effective 08/27/2007. 2. Insured is afforded Workers compensation & Employers liability as a co-employer under the policy for employees leased from AMS staff Leasing, Inc. CERTIFICATE IlOOlTIONAL INIUMD; ..... LET18t SttCXa.O _ OF TItI! MOVE ~ POUCIEI BE CMC!LLE'D IIEI'ClIE TItI! ~TION DAn! nEIlEOF. TItI! --..0 INIUAER WILL ENDEAVOR TO IIAII. 30 DAYS WRITTIII tlOT1C& TO lite c:ERTFlCA11! HOLJIER, NAIED TO THE LEFT. BUT F/IlIlDlE TO DO ~ IIW.L ~ NO Cl8l.lGATIONOR...-uTY OFNrf KIM) UPON THI!"-. ITIIlG1!NT11OR CITY OF ZEPHYRHILLS BUILDING DEPARTMENT ATTN: KAREN HILLER 5355 8TH STREET ZEPHYRHILLS, FL 33542 Al/THORIZEII_A'INE ACORD 25-S (7197) Parcel Information for: 11-26-21-0010-16600-0190 Card: 001 Page 1 of 1 Search Again Show MaD Generalized Building Schematic Estimate Taxes Frequently Asked Questions Other Agency Data: Tax Collector School Board Super Homestead Estimator ParcellD 11-26-21-0010-16600-0190 (Card: 001 of 001) Classification 11 - Retail Stores, One Story, All Types Mailing Address Assessment (totals) JOHNSON HELEN L Ag Land $0 PO BOX 845 Land $37,870 ZEPHYRHILLS, FL 335390845 Building $62,870 Physical Address ' Extra Features $270 38338 5TH AVE ZEPHYRHILLS, FL 33542 Total Assessment $101,010 Legal Description (First 4 Lines) Save Our Homes $0 ZH MB 1 PG 54 LOTS 19, Taxable Value $101,010 20 BLK 166 RB 728 PG 890 Land Detail (Card: 001 of 001) Line Use De . ~KOning Units Type I Price I Cond Value 1 1100 STORE 1 00C2 7,000.00 SF 5.41 1.00 $37,870 Additional Land Information Acres 0.16 Tax Area I 30ZH II Fema Code 1001 Comm Code II M5AV2AB I Building Information - Year Built 1974 USE 11 - Retail Stores (One Story) (Card: 001 of 001) Ext Wall 1 Concrete Block Stucco Ext Wall 2 None Roof Str Irregular Roof Cov Built-Up Tar and Gravel Int Wall 1 Plywood Panel Int Wall 2 None Flooring 1 Cork or Vinyl Tile Flooring 2 Carpet Fuel Electric Heat Forced Air - Ducted AC Central Baths 3,00 I Line I Description I Sq. Feet II Repl. Cost New I 1 AOF " 1,886 I $216,419 I Extra Features (Card: 001 of 001) Line ption Year I Units II Value I 1 ~SP I 1974 II 1,333 II $270 I Sales History Previous Owner N/A Year Month I Book I Page I Type Amount 1974 01 0728 I 0890 - $12,000 Search Again Show MaD Generalized BuildinQ Schematic Estimate Taxes FreQuentlv Asked Questions Other Agency Data: Tax Collector School Board Super Homestead Estimator http://appraiser.pascogov.com/search/offline _tca.asp?Sec= 11 &Twn=26&Rng=21 &Sbb=O... 8/24/2007 08/27/2007 01:25 8136627512 WORKERS CoMP CO oP PAGE 01/01 MdJJ1D.. CERTIFICATE OF LIABILITY INSURANCE t ct!"11FlC-' TE NO, IDA TI! 1IC07 -18000502-5""2 0/27/2007 12:10:18JlH PROIlUoeR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION H:l,;bpoint Rillk Sel:Y$.cea 3:.t.C ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14160 Dal1.a ~a%k~ 1500 HOLDER. THIS CERT1F1CA TE DOES NOT AMEND EXTEND OR D&11.., TX 75254 ALTER THE COVERAGE AFFORDED BY THE POUtlES BELOW. (800) 632-5095 (972) 715-0959 INSURERS AFFORDING COVERAGE Fax: '972' "04 4450 INSURED: AMS lIeN:: INSURER A: companion Property and CaS\lalty Insurance Comp TLC ROOFING, LLC IN6URER B: 14138 18111 CT ~E CITY. P'L 33525 INSURER C: (352) $2;l.-0423 Fax: INSURER 0: INSURER E: COVERAGJ:.!il 'tHe POl.lClIS OF INSURANCE LISTED 8El.OW HAVE BEEN ISSUED TO THE INSURED NAMIlD ABOVi FOA nti POLICY PERIOD INDICATED. N01WlTHSTANDlNG ANV REQUIIt....eNT. T1!RII OR CONDlTIONOF AtN C~CT OR OntER DOCUMENT WITH RESPECT TO WHICH TMl$ CERTII'ICATE MAY 8EfSSueD OR MAY PERTAIN, THE INSURANCE "f'I'ORDED BY THE POUCIES DESCRlIED HI!R&1N IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POUCIE&. AGGREGATE UMlTS SHOWN MAY HAW BEEN REDUCED BY PAID ~ ~ I m~ TVn Of' IN6\lRANCE POUCV' NU~IIR LIMns $NERAL UAElIUTV n.GI.061S9S 06/22/2007 08/22/2008 ElICH OCCURRENCE S !.. D&RClA~ GENERAL UA8ILlTY FIRE DllMAGE (Anp One "1nI) S _ CLAIMSNADE [!] OCCUR MEOElCP(I\ny__") S 5000 A - PeRSONAl. ~ AOV INJURY S - G~NEAALAGGR~~ S Ti~An LIMIT AnES P~R: PRODUCTS - COMPIOP AGG S X POLlCY I P..aQ: Lee AUTOMOBILE UAIIlUT'/' COMBINED SINGLE UNIT - (Sa .eaI.....) S - AN'/' AUTO - ALL O\MIIlltl AUTOS BODILY INJURY S SCHElUI..&O AUTOS !Per IlIrIlIII) - - HIREl AUTOS 800IL V INlIAY S NON-oWNI!D ^UTO& /Pet IICdd8ntI - - PROPERTY DAMAGe S II'ar_) ~GI!i UA8IUT'/' AUTO OIIIL Y - Ell ACCIDeNT ,. "NY AUTO OTHER 'lMAN fA ACe s AVTOONLY: AGel S EXCESS UA8IUTY El\CH OCCURRENCE S .: OCCUR DCLAlMS MADE AGGREGATE $ S OEDUCTlBl.E S I- RETI!NTlON S s WClRKEM COMPENSATION AND WC7777!19!10401 08/27/2007 04/01/2008 r,. I """""ATl'., I ION EMPLOYERS' ~IABILlTY I!.L I!ACH ^CC1D1NT . 10OOlrOO- A s 1000000 E.L DISeASe. fA EMPLOYEE e.L, OI8EA!le - POLICY LIMIT S 1000000 OTHER R J.lMlT5 S UMlTS S DESCRIPT10N OF DP!RATlONSlLOCATlOIGIIII!MICU!MlIlCLUSION8 ADElIlD 11'I' .NDOR$G~'I8PGCIAL ~$ 1. This certificate remains 1~ effect, p~ov~aea the cl1ent's account is in gooO stand~ng with AMS, coverage ~s ~ot pX'ovide4 for MY employee for which the client is not reporting wages to AMS. Applies to 100% of the employees of AMS leased to TLC ROOFXNG. LI.C. effect1ve 08/27/2007. 2. Insured is afforded Workers comp~at~on ~ ~loyer8 liability as a co~employer under the policy for employees leased from AMS Staff Leasing, Ine, CERTIFICATE HOLDER J J Al)DlllONAL INSURED: -.._lETlBI: CANCELLATION SHClUU) AN'/' ell' '!ME AIlO\IE Dl!SCItI8l!D POLICIES BE CANCELLEllIII!FOR. 1ME ~ 'r1OI't DA'lI! TIlI!RCM. TIl~ IHUINQ IN!llJRER WIll. eNlll!A~ 1'0 MAli, E P,.Y$ WIlITlEN CXTY O:f Zlni'l,nUUloLS BUJ:LPXPG DEPARTMENr NOTICE 10 'THE CI!RT1F1CA re HOLDER NAMeD 10 '!He U!FT. BU'T "AlLURE TO DO SO SMAll. Arm. KlUUlN MXLLE~ 5:3 55 8TH STREET IMPOft 1'10 OIIl.I~A"O~ OFt L1A1JlUTY OF AN'( I<INP UPON ntE! NlURI!Jt, ITS AGI!fI1$ OR ZEPHYRHILLS. PI. 33542 AU1ttOIlIZ!iD ~A11Vl! l J ..., ACORD 25.S (7/17) ~ ACORD CORPORATION 1988