HomeMy WebLinkAbout07-7253
CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780-0020
BUILDING PERMIT
7253
Permit Number: 7253
Permit Type: SPECIAL EVENT
Class of Work: SPECIAL EVENT
Proposed Use: MEDICAL
Square Feet:
Est. Value:
Improv, Cost:
Date Issued:
Total Fees: 500.00
Amount Paid: 500.00
Date Paid: 11/29/2007
Work Desc: FIRE WORKS DISPLAY 12-2-07
Address: 7050 GALL BLVD
ZEPHYRHILLS, FL.
Township: Range: Book:
Lot(s): Block: Section:
Subdivision: CITY OF ZEPHYRHILLS
Parcel Number: 35-25-21-0010-10500-0000
Name: FL HOSPITAL OF ZEPHYRHILLS
Address: 7050 GALL BLVD
ZEPHYRHILLS, FL. 33542
Phone:
c:}~\ 1\
(\~~ "P
~~
1Y
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
befo rding your noti of commencement,"
RACT R SIGN U E PERMIT OFFI
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
NOV/l~/2007/THU 04:59 PM
ZEPHYRHILLS BUILDING
FAX No, 813-780-0021
p, 002
Cer( ~#'
.-----.,
. /r'H Ct/'Yv~ ,
,U'l~,
6-~
(,.:.i
''rempo~ar:y 'Sale.s iChecklist
, ',City of ~hytbil1s
'5335 SDI Street
, .ZephyrhUls, Fl. 93542 , ,
,Pl!one:' 813~780..o020 IFu: 813~780-0021
REQUIREMENTS
~ ,Plot Plan showing s~tup oflocation.
Notarized letter from property owner stating their approval.
. Afl.am.eTetardailt certificate is 'required 'IF a tent is 'involved. Inspecti9n i~ required once tent ,
is erected and,prior to opening for b~in~ss, '
Approved certified me extinguis~ ,per NFP A lO.
, _' ,No SmQking signs must be placed outside e.ntr~es"
IF thereis a wiie :fence or chain. link fencing ,must have at least '5 Ft setback from tent 8nd at least
2 exits.
IE te~t has sides. the sides shall be in the up position unless there' is incl~t weather,
then. 2 sides must be,in the up ~osition. ,
FIREWORK. REQUIREMENTS ":"'" an. addition 1:0 the above)
Proof of State License.
Pr~of of Liability insurance.
List of items 'to be sold at site.
Copy ofDrivel"s License and Social Security Nm;nber of all personnel dealing
with the sale of fireworks at the tent location. '
FEEs
'$ 30,00 -;' City Registration (If Regulated ,by,DBPR - fee is Wai-ved)
...4- $500.00 -'Fir~works fee - Fire Department fee
$ 5.pO -'Temporary Sales Fee for l:sttwo days ", '
$ 1'.00 - Temporax)' Sales Fee 'per day for each consecutive day thereafter, not to ,
: exceed duration of 30 consecutive days arid no more than one oCCUlTence '
per calendal" year pel" Ordinance #408,
$' 50.00.- Tent Fee (35.00IBD, 15.00*/FD) -{*S15.00 waived for Fireworks)
$ 35,~0-ElectricalFee (if applicable) ,
Property Owner:
Applicant:
Phone' Contact:
Address Site:
Date of Sale:
. Florida Hospital ZephyrhillR
Pyr'otecnico
Marsha LeFebvre - 800-8,4-470,
7050 Gall Blvd. Ze~hyrhillR. FL 11~ul'
l1/J:L/u/ ,2-Z-bl
Ordinance No. 408 dated 1/26/1981 (for additional requirements) ,
NOV!2712007/TUE 02:22 PM
ZEPHYRHILLS BUILD!I~C
FAX No. 813-780-0021
P. 002
--_._--~-
City of.7.ephyrhi\lS'Perrnit Applicallon '..
. BuUdirlll Deper\ment
FBX..$13-18o.00'n.
:<.tx.1;~5!J
813.180-oo2Q
OeRa ReceIved
OWner.stfsmo Florida Hos,...ital. Ze h rhills... ownerPhon8N\IllIb~; 813-235-3150.
_"'M"'" [7DSO Gall nvd.zephyrhiIls.,(iJ 3~,__,LE~13-235~3150'
fee SJml>le THfoholdsr Hamcr . ~ Ownsf phone Number -
fee Slmpl,.rrt1eholder Addr~s [ i
.loso Gall
JOP APDRES9
B1Vd..zePhyrhillsc=:
J PARCEl. lOti
33541
..
:);
l..
L01'-##
'L
j
~
l
~
-;"
1:
(OOTAIIII:D FROM TP!RTY TAX ~OTlcll
WORK'RO'O'''' E3 ~~.m B =:'T O' ~... 0 ~""'E 0 . """"".H
PfmPOSED lISlO . 0 SFfl Cl coMM D'. .OTHER r- f;<. I
rrPE OF CQOI$TRU""",, d 'u"" c::J "'^"" 0 .- 0 ~ ornER L . -. i
. O",,",,,,,OR 0"."'" [ Fi r ewo r ks 'Ii J
Er,~;:::.:F':, '~.., .,' ..,.. '~:0~r~~~~~'~F~2~::f:";>
. ',~.
. 0 ELEG'TRICAL E J ~ SERVICE . 0 PR0(3~~S5 ENERGY
o PI.UMBINa [$ J. I;
CJ MECHANICAL. ~ .l VALU^TtON of MECHANlCAllNSTAUAT10.~.
D GAS 0 ROOFING c::J SPECIALTY D. . OTHER '~Jt:
. ." J.
"",,"'0 MOR _A~OR"~ . '. . 1 ""'.oDWRe AREA. t::]'OS . pRO .
-t11111111111111111111111111111111 11111111111111111111, II11 ~ iii! ~ 11111111111111 III ~1111111111I111111.~~1111111 t 1111111 \111111111111(11 S
:'~'i':RE f" - I = . "'- '" . ~
. Addr9$~ [= 'J J u~ L
ELECTRICIAN COIWAN'I' @,.<l.
,iGNAT""" t -' ,
,,= [: 'OMP~~ [ ij,r-
......"'.. ~ l _...... '1M I ~ L:0Ll
Addre6$ II 1 '. U~n&:~;(~ L
MIOCHANICAL' .. .J coMPANY C . ~~.
,_TORE .t _ - -. I Vi" --"I'""
Ad..... ~ . ':J"-, J
.~~~~~ Yll(LUljULO<~f~J
! . (! . Frill)
SUBDIVISION
-.J
If I 'If" rrr n,
Ifli~
o
W.R.~c.
Addr&$.!l
u:.L!!-J
J
SIGN pl!RMIT
Anach '(2) Plol plans; (2) ,S15 of BuIlding Plan&; (1) sol of Ener~ Forms: R-O-V( pennll Jor n
Mlolmum Isn (10) WOf1lIIIlI days a\1Sl' 5\lllITIIl~ dale. Roqulred D~e. constl\lCllon plaM. SIo
Senll8lY Pl\clllU..e & 1 dUmplJlar; Slle Work PlII1IIll ror 5\J~",rgs ptolll\lt8 : .
At19ill1 (31 ~,,18 of Building PtwlB: (1) 88t of Enorgy F(JfIII5, R..()..W!1"lIffl\lt tor new cornJ1ruclIOn:.
M1n\lJ\um ten 110) working lil:Iya Bfter submlll;d "'"c. Required QI18ilo, C~lruoUon Plans, sliJim wI.SUt knee \n6lst\ed.
SaollalY FsclUUes ,. 1 dumpS..... Site WOIl< pennlt for lIlI naw ptoJaa\8. All commerchol requltame,jjg m "ilt m6EIt cOO1Illlance
Allaoh (Z) $8lIJ of englno<<8d prem;. '. . :
'...PRoPER1Y SURVEY reqUIred 'lOr all Ni:OW con,l/1lcUgn. . . i.niL in.
RESIDENllAL
COMMI!RCI.AL.
NOV/27/2007/TUE 02:22 PM
ZEPHYRHILLS BUILDING
.FAX No. 813-780-0021
i
, I
"NOTICE OF:DEED' RESTRICTIONS: The undersigned undenl\ands lhat this permit may 'be'subJect to "deed", restrictlonll'
whIch may be more restrictive than County regulations; The undersigned assumes' responsibility for compliance with any
, applicable deed re&tricUon&.' .. , ' ' "
'UNLlCENSEll-CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: 'If-the owner haS hired a contr~ctor or
conlraotOrll to undertake work; they may be required to 'be licensed In accordance with state and local regulations. ' If the
contraotor Is nol.llce~ed a!! required by law, both the owner and contraetor may' be cited for a misdemeanor vIolation'
: uncler,stat'illaw. If the owner or In,lended ,contractor are uncertaln,ael~:rwhat 1I0enslng requlremenle'may apply for the
Inlended work,they are advised to conlaQt the'Pasco County BuD!ilng IIlSPeotlon,Dlvielon--Llcensing Section at'7:27-847.
'8009. ,,:Furthermore, If the owner,haS hIred a <<x>nlr\1lctor or contraQtors.. he Isadvieed to have the caniraclor(e)"slgn
portlorw of the "oonlraclor alook. of this application for whIch they wUI be responsible. If you, as the 'owner sign as the
contractor, lhat may be an lndl~tfon that he Is not properlY Ilceneed and i9not e~titled to permlltlng prIvileges In PeSco
CoUnty. ' ,,' ','" ',', " ,
'TRANSPORTATION IMPACTJUTILlTIES IMPACT AND RESOURCE ~ECOVERYFEE5: The underelgned understands
thaI Transportatton'lmpact Fees and Recouree .Re~OV'ery,Feee may apply to the construction of new, buildings, change of
uea In e~B\lng bulldlnge. or expansion, of exlsUng buildings, as specil'led In Pasco County O1'dinancEi nUl'\'1ber 89-01 and
00-07, as amended.' The ,underGlgned a160 understands, that8uoh fells, as may be dua, wUl be Identified, at the tIme of"
permitting. It \$'further understood that TraneportQlIon ImpacfFees'ar,d RasolJfCe Recovery FeeS must be plilld PrIor tci
reoervlng "...certlflcate of occupanoy' or final power release. If the, project doee not-Involve 'a certificate of occupancy or
final power raJeaee, the fees must ~e paid prior to permit i6Suanoe. Furthermore. If Pasco county Water/Sewer Impact
:fe&S are, due, they musl be paid prior to pennlt lsSl.!ance in accordanoe!wllh applicable Pasco County ,ordinances. .
'CONSTRUCTION l-IEN LAW (Cl1apter'713, Florftla'Statl.lt9s, e& arnondod): If\laluallon of work Is $2.600.00 or more, I
certifY' thet I, the applicant. hav9 been provl~ea with a copy ~f the 'FlorIda Construction Uen ,Law-Homeowner's
Pl'Qlectton GuIde" prepared by the Florida Department of Agriculture !ind, Consumer Affair&~ If the applloant Is eomeone
oth~r than the .owner", I certify that I hal/e obtained EI copy of the abova described document and prom Is!, in good faith to,
delll/er It to the "owner" prior to cominencemGnl.' ,', '..' ' ,:' " ,
CONTAACTOR'8/0WNER'~ AFFIDAVIT: I oertllY that ell the Informatlon'ln this application Is aeaLi,rate and that all work
wl\1.be done In oompllance with all applloable laws ragulallng oonstructlon, Z9nlng and land development. Appllcallon Is
h,ereby made to obtain a permit to do work and Installation 'as Indicated, I certify that no' work or Installation has
commenced prior IQ Issuance 'of a permit and t"at all work will be performed to meet standards of all laws regUlating
conslrUo\ion, Count)' and City codes, :mnlng regulations; ,and'lana deve!opmenl regulations In the jurisdlclion. I aleo
, certify that I understand that the regulallone .of other govemment agencies may apply w the Intended work, and that It Is
my responsibility to IdentIfy what aellons I must take to be In compliance. Such agencies Include but are not limited to:
Department of Enviro~ml;lntel Protectlon-Cypress Bayheads, Wetland Areas and environmentally Sensitive
Lends, WaterlWastewater Treatment. ' '
'southwest Florida Water Manage!1lent Dislrlct-Wells; Cypress Bayheads, Wetland Areas, Altering
Watercourses,' " '
Army Corps of Engineers-seawalls, Dock~, Navigable Wat9lWSYS. . ' ,
pepartmant of Health '& RehabilitatiVe serviceslEnvirQhmental Heal\h Unit-Wells, Wa5tewater Treatment,
Septla Tanks. ' ' ,," '
US Environmental Proteotion Agency-AEIbe9tos abatement.
:. Feaer,1 Aviation Authority-Runways. ,
I understan~ that the following re5trlctiQris iapply to the use of fill;', '
Uee of 111115 not allowed In Flood ,Zone 'V" unless expreesfy permitted. ,.'
, If the 'flil material Ie 10' be: USeQ In Flood Zone "A", It III understood thai a dralnege plan addreslOlng a
, ' '"compensating voluma" will be submitted at time of permItting which Is prepared by a profe9s1'onal engineer
licensed by lhe ~\ateof FIQrlda, , .... ' ': " ':,
If the flllm~terlaf Is to be used In' FIQod la,tle "A" In connedion with a permitted bullo\og using slemwell
constr.uction, 1 ce;rtlfy thaI nil will be used onry 10' fill the ar9B within the stem wall. '
If, fill matertal Is ,to be used in any area, I certify lhat use of such flll will not adversely alfect adJacenl
, pr~partleEi. If uS!3 of r.lls found to adversely affect adJacent 'prc~rtles, the owner may be cited for vIolatIng
the conditione of ,I he building p&'mlt 15$ued under the attached permit applicaUon,,{or lots lellS than one (1)
acre which are elevaled by fill. al'l engIneered drainage jJlan Is required. ' .
If I ilm the AGENt FOR THE OWNi::R, I promIse In good faith to In~orm,the owner of the parmlltlng conditions eet forth In
thIs effldavlt pr10r to commencing construotion. I underetand lhat a liieparate permIt may be rsql.ll,re~ for' electrloal work.
plul'T)bl,ng, signs, welle. poolS, air conditioning, gas, or olher Installations not speolfically Included In the application. 'A
perml\ I,,!sued shall be coristrued 10 be a'license 10 proceed with the work, and not ae authority to, vlolete, cancel, slter, or
sel astde any proitlsiol1S of the technical codes. nor shall Issuance of a permit prevent the BuDding Official from .thareafter
requiring a correction of errore In plane. construction or violation,S of any codes. Every permillssued shall become Invalid
unlee&'lhe work authorized by such permit Is c~mmenC8d within siX months of permit 'i~susnoe. or If work aUthorized by ,
the permllls suspended or abandoned for a period of siX (6) monlhs after the time the WQrk Is cQmmence~, An extensIon
may be,requBstfi;ld; In wrIting, from the BuildIng OfficIal for a perlod'not to exceed ninety (90),days and will demonstrate'
~o"'.~. ,."'" fa< ... .""MIon' .If _k """'" f".I"'~. (oo,"'.,,""',. doyo, ","!"b ~ ""..- .',:.d..... .
WARNING TO OWl'lER:' yoUR FAILURE-rO RECORO A NOTICE OF COMMENCEMeNT MAY RE1.SULT IN YOUR
PAYING -MICE FOR IMPROVEMENTS TO YOUR PROPf:RlY.' if yoU INTE':ND TO OBTAIN FiNANCING, CONSUl. T '
lyE' E "'N 11 y E 0 c 0 'G 0' R OT E F a C Nl ' T '
FLOR10AJURAT(F,S,111.03) "
oWNER OR AGENt
SUbsl;lllbe<;lsnd;(" to (or "Ilirrned) baiera me thl$ ,
j)' '
Wl\Q Islarll pe1llona11y known '10 m. or hile/lIBYa,produced
, ' as ldenUIk;8 n,
!
i
I
I
I
. \
\
J
,I
\
, CONTRACTOR '
subs~b9d,sfld sworn' 10 (or alfim1ed) befc,e ",e !hig,'
, by , , ,', '
Who tslaropersonallyl<rICWKl \0 mil or hee/hllVe IlrodlJced
8$ Idenllliealloll,
Nol;ory PIJIlUC
Iary public '
f;ommi.8Ion,l'lo.
ANIA
. ~m~ 01 Nol8ry lYPed. printed or atan1ped
.... ,.~-_.._-,..._---
. ..~~ .
P. 003
. Nov. 27,2007 11 :.38AM
Pyrotecnico".- .
No. 96r7P. 4'
.Headq\\arters
u.s. l,ocations
fa.u.ll.
inf09pyrotecnlco.com
Allanu. GA
la5 veDiS, NY
Manlgom!ty. AL
New Orleans, LA
T.mp.. fL
871.924.0\02
eoo; 956. 7976
BOO. 255. \199
400. 7B3.'2513
8BB. 352. 7976
P.O. Box 149
New Castle, PA \6103
fAA'
724. 652. 1288
YITAU fAMILY F1REWa~U' ".~
O~flC!
724. 652. 9555
800. 854.4105
wu
" www.pyro\ecnica.com
November 27,2007
City of Zephyrhills
. 5335 8th Street .
Zephyrhills, FL 33542
Dear Sirs:
This is a letter of authorization for Jerry Sterner of Florida Hospital ZephYl'hills
to pick up the permit for the December 2. 2007 show.
Sincerely,
PYl'otecnico
W}~~
Marsha LeFebvre
Fire Chief Keith Williams
ZEPHYRHILLS FIRE DEPARTMENT
6907 Dairy Road, Zephyrhills, FL 33542
Bus (813)780-0041 Fax (813)780-0044
Occupancy No.:
PI.nNo.: 67-It'ti ~
Bus!ness Name: . ~~~ .... . .
Business Address: ,
Business Phone No.:
Business Fax'No.:
Contact:
FIRE SERVICE USER FEES
Contractor. 4 rJ +em; (' LJ
Billing Address:
Billing Phone NO~/.If1~~7"
Billing Fax No.:
Contact:
PLAN REVIEW FEES
B Site Plan NlC
MuIti-FamiIy/Co';'mercial .06 sf
(Minimum Charge $25.00
o Plan Revisions. DBL
SPRINKLER SYSTEMS
B 0 - 25 Heads $50
26 plus Heads $100
STANDPIPE SYSTEM
o Per Riser $50
FIRE PUMP
o Per Pump
FIRE ALARM SYSTEM
B 0 - 25 Devices $50
26 plus Devices $100
SUPPRESSION SYSTEMS
B~ :
B~ $50
KITCHEN EXHAUST
o HoodIOucts
OTHER
B LP Installation per tank
Fuel Tank Installation
(Per Tank)
o Natural Gas Installation
(Per System)
o Spray Booth
PLANS TOTALc=J
Comments:
INSPECTION FEES
NlC
NlC
$100
$250
$500
$100
Annual
1 st Re-inspection
2nd Re-inspection
3rd Re-inspection
4th Re-Inspection
(Business closed until
violations corrected)
SPRINKLER SYSTEMS
~ Hydro Undergrounds $45
Hydrostatic Test $65
Acceptance Test $45
Hydrant Flow $75
per system
per system
per wall
per tank
per system
pet IBnl
PERMIT FEE
$50
$50
$50
$50
$50
$50
$50
$50
e
FALSE ALARM FEE
1 st AIann NlC
2nd Alann N/C
3rd Alann N/C
4th Alann $100
5th A1ann $150
6th A1ann $200
NON COMPUANCE $150
FIRE ALARM SYSTEM
B System Acceptance $50
Recall Acceptance $50
OTHER
~. Fire WalVSmoke Wall $15
LP Gas $25
Natural Gas $25
$50
~ Tent 10'x10' or g/'!illlter
Fire Pump
Fire Suppression
System Acceptance
B Exhaust HoodIOuct
Re-inspection
(other than annual)
o Inspection scheduled DBL
and cancelled less than
24 hours
B Construction Insp. NlC
Emergency Vehicle ACl $50
INSPECTION TOTALc=J
Sprinkler
Standpipes
Fire Pump
Hoods
Fire Alann
LP Gas
Natural Gas
F~lTanks- petlank
I Fire Works
Camp Fire
Controlled Bum
Hood/Duct
Place of Assembly
Fire Protection
Flammable Application
Waste Tire Storage
Generator < KIN
Generator >30 KIN
Bio-Hazard Waste
Fumigation Tenting
Torch Pot/Applied
Haz. Materials
$100
$50
$50 Annual
$25
$50 Annual
$50 Annual
$100
150
$100 Annual
$50
$50
$100 Annual
$15
$45
$30
$50
$50
$50
$50
$30
DBL
B
l
~- FALSEALARM
PERMIT TOTAL~ TOTAL I
'- -)2b~
$50
GRAND TOTAL
'l~f41Ikr4~
Date:
Ins~ctor.
"
Zephyrhills Fire Rescue
6907 Dairy Road, Zephyrhills, FL 33542
Fire Marshal
Kerry Barnett
Bus (813) 780-0041
Fax (813) 780-0044
FIREWORKS DISPLAY REQUIREMENTS
}l- During the firing of display, all personnel in the discharge area shall have proper
protection: head, eye, hearing, long sleeved & long legged clothing that is wool,
cotton or similarly flame resistant.
}l- Monitors shall be positioned around discharge site to prevent spectators or any
other unauthorized persons from entering.
}l- No ignition sources shall be within 50' of any fireworks or pyrotechnic material
}l- Inspection of site area prior to operator setting up to ensure it is acceptable.
(included in permit fee) This will be done around 12:00 PM time. No one has to
be there. Site should be clear by that time.
}l- All distances (set back, fallout, etc...) for 2 W' shells and cakes shall be in
accordance with the tables in NFP A 1123.
}l- Inspection of discharge area and fallout once setup and prior to discharge. 1 hour
needed for inspection. (included in permit fee) This will be started at 4:00 PM.
}l- Fire Marshal and engine company will be on site at time of discharge. (included
in permit fee) They will be there ~ hr before shoot., approximately 6:00 PM
}l- Inspection of fallout area immediately after the display and at first light by
persons acceptable to the AID. (included in permit fee)
NOTE: All requirements ofNFP A 1123 shall be followed, this includes proper labeling
of fireworks, salute shell limits, inspections of shells and mortars, fuses (if manually
ignited), time delays, chain fusing, minimum site sizes for the type of firework
discharged.
Fire Marshal's contact number: 813- 714-6326
Nov.17. 100711 :38AM
"Nov 3004 ~~Jsap
Pyrotecnico
pulelU.a Re"loat.i'ons
No.9617 P. 3
e:1 s-7aS~En os p,G
:SITElNFOllMATiON FOR:FlREWORKS DISPLAY
Org8ruzadon sponsoring event: Florida Hosllita:l Ze.nhvrhillss ,050 Gall Blvd. J
Zephyrhills,FL 33541 - Jerry Sterner 813-235-3150
oarenndtimoo~production:"December 2, 2007 - 6:30PM
Location of production: Florida Hospital Zephyr hills
Nlmle ofmainop<<m11or: Chris Reitano
"Number and ages ofal1uslstBJllS:
Ryan Pedraza - 22 yr~, nlrl
Confirmation of License held by operator~ See attached
E1rldence ofpcnnitec's insurance cerrier: See attached
Number" and types ofpyroteclmic device!! and mll1crialS to be
used: Spp attal"hprl
. MSDS forpy.rc1echnJcsuaed:~~eatt.a..ched
Bxtinsuisbere on she (ptesmiz.ed water - at least 2): 2
Diagfam of where production to be.conducted (to include point of firing. fall OU~ radius,
aana\ldience location)~ See attached
Piring safepuds in place:
. c~uit testers no more than 2S roA
. power for firing sources be restricted to batteries or isolated power supplie9
. firing systems ensures against accidental firing (2-step interlock)
. not to be left lIll8ttcnc:1cxl
. llmoking pro~ibi1ed within 2S' of the firing;handUng aroa .4. ,~\) .~~
. QPPUJ}I1.. iale distance from audience (not 10sI tban twice the iI110ut ndiu() "'l ~.,~ ~~~ .
· all~~arcblookod.fflnto~.... -g~~ ~o\~~~"I . 1
"o~<tj<f>o\ (<;ff''l. . ~e~~ #~~ i\\,v4 ()
~ cdS ~~rJ .~~ 1\ ~~ "'~~ \
. .~&,\~90 S ~\.c~\\.~\."o~ ~'I(;<":1~~ ~ vo~
~~\: e, 'b.~~ e'4e 0\ 1$' ~~ ..
~ '\i\.'\.e ~ c:~~
A r,~o.~ Q"f.;s.e
,,\.~~ 0-'
......, Nov, 27, 200711:39AM Pyrotecnico
\I ~: .('~ ,or C (\\ I /' ! i
I ~', ! . , .. ~ ; 'I lj
, k ~ it ~J
SPECIAl ENTERTAINMENT PRESENTATION
EAST PASCO MfDlCAl CfNTfR
"HOliDAY TREE liGHTING')
IEPHYRHlllS~ RURIOA
DECEMBER 2, 2007
82,500,00* lOW lEVEl RmAP
.Permit fees not included,
BODY
50 - Two and One Half Inch Shells
lOW lEVH PRESENTATION
1 - 1 00 Shot Cake
2 - 1 SO Shot Cakes
1 - 300 Shot Cake
1 - 600 Shot Cake
2 - 2", 50 Shot Brocade Crown Display Boxes
2 - 2 Vi I., 36 Shot Display Boxes
GRAND FINAl[
70 - Two and One Half Inch Shells
Pyrotecnico 1111312007
EPMC-htI12121/07 $2.500. Pg.416
No, 9617 P. 10
....,
No:y~~::1.:2 007 l1: -3 8 AM
Pyrotecnico
"' -"~N~:v2.~.'
No. 9617
P. 9
'-:"':;';':::':':-:'::;':':':':':::':':::]:::::'i ::::: '.t
. "-.....................~..... .. If
. ........... H.......'.._..$...., '''.
.... :::.X.:.:.:.: .:.:.:.:.:.:.:.:.:.: ~.:.:.:.: ~':':':l':-:':': -:.:. l
. ~::}:~::::~::::::::::::::::::::::::::::::::::::::::::~::f~:::: .::: i (
..:..:.::::::::::::V:::::::::::::::::::::::~::::::::~;:::~:::::::: :::: ~}
~
l:::lfE
~Cl
....~
Q:
~t::;
e:~
~81
~
~ ~--;==~=--
;HTERY 1m~n
, Nov. 17: :'20"07:1"1-38 AM
Pyrolecnico
'~),jlS:~f1:":" -".. No. 9617
P. 8
DIRECT ATF
OORREBPONOENOE
TO
'DEPARTMENT OFTHE TREASURY. BUReAU OF ALCOHOL.iOBACCO AND FIREARMS
,LICENSE/PERMIT (18 U.S,C. CHAPTEA40,~EXPLOSJVES)
In accordance with Ihe provisions orin'e XI, Orgsnized Crime Contro\fAcl.of'1970.'Bnd the rlglllallons IRued thereunder (27
CFA Part 655)vou may Ingaga In the aotl\llly specUled In this license/permit wllhln Ihe limItations of Chapler 40. TItle 18, United
Stsles Code and the regulations Issued thereunder. until the explrallon date shown. See .WARNING" and "NOTICES" on back.
....
~
. The IlcenseeJpsrmillee namedheretn lJi1e11
Ilcense/permil 10 asslsl e lransleror of ellflloelveG
and slalus of Ihe IiceneeB/perll\illee se provided I" ,
. The signature on each reproduclion must be sn ORIGINAL e
ATF F 6400.1<115400.15, ParI 1 (8188)
~ov. 27. .2007 11: 38AM
P y r otecni co
No. 9617". ,Po 5
.A CORD.M :CERTI FICAtI1E iOF :LIABII.JJY;lNSWRANCE
. DATE IMMJDDIYYYY)
1.127 2007
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
AtTERTHE COVERAGE AFFORDED BY'THEPOL.lCIES BELOW.
PRODUCER phone; .440-248-4711 Fsx: .440-248-5406
Britton-Gallagher and Associates, ~nc,
6240 SOMCenter Rd.
Cleveland OR 44139
INSURERS AFFORDING COVERAGE
NAIC#
l~eIlRED
pyrotecnico ofFlorida,LLC
P,O. Box .3~0
New Castle PA 16103
INSURER 0:
INSURER E:Axi S S
THE POLICIES OF INSURANCE LISTBD BELOW HAVE BEEN. ISSUED TO THE INSURED NAMED ABOVE FOR 'mE POLICY PER.IOD INDICATED.
NOTWITHSTANDING ~ REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTXFlCATE MAY BE ISSOED OR MAY PER~AIN, THE 'INSORANCEAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITSSYOWN M1Y HAVE BEEN REDUCED BY PAID CLAIMS.
~~: ~~~ POLlCVNUMIlER P~i~~:~~~g.wr P~lfl ~J;~~N L'/oIIT3
A _~NERAL LIABILITY 6990164 1/14/2007 1/14/2008 eACH OCCuRRENCE 51 000 000
.L COMMERCIAL GEN EAAL LIABILITY PREMISES lEa oec:ut8nce\ sSO 000
=:=J ClAIMS MADE IiJ OCCUR MEO exp IAnY ontP8Iton) S
- PERSONAL.& AOV INJURY 51 000 000
-- GENERALAGGREGAlE 52 000.000
~'LAGG~E~ILIMIT APn PER: PRODUCr8-COM~OPAGO S :2 ,.Q..QJL..Q...Q.Q-
POliCY P,~ LOC
B ~ ~TOMOBILE L1ABIL":" CA3B09096~ ~/14/,2007 1/14/2008 COMBIHEOSINGLE LIMI'r
~ ANY MITO IEucelaenl) 51,000,000
I-- ALL OWNED AUTOS . 800lL Y INJURY
5
SCHEDULED AUTOS IPet perl on)
-
x... loilREOAuYOS &ODILY.INJUAY
A- IP8I acctdeAl) 5
1I0N.ow~EOAUTOS
-...-' .~ PROPERTY DAMAGE 5
(Per accIaenl)
=JRAOE LIABlulY AUTO ONLY - EAACCIDENT S
ANY IUiTO OTHER THAN EAACC 5
AUTO DN\. Y: AOO S
C ijES&/UrGRELLA LIAIlILITV IuLPOO1l761 1/H/2007 1/~4/2008 EACH OCCURRENCE. $4 000 000
X OCCU~ 0 CLAIMS MADE AGGREGATE 54 000 000
5
~ DEDuCTIBLE: 5
X Rl<TEI'ITION S10 000 S
D WORKEfllII CO"PEN8ATION AND 2826C707 6/22/2007 6/22/2008 ~ l.Y;!~T~T~D I 1OJ~-
EMPLOYERS'LIABlLny 000 000
"NY PROPRIETORIPAATNERiEXECUTIVE E.L. EACH ACCIOENT Sl
OFFICER/IoAEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE 11 000 000
~~ec~;:o~:S:ONS belOW E.L. DISEASE - POLICY UMlT 11 000 Don
E oltll!A. EAU723 112 1/14/2007 1/14/2008 ss ;000,000 Each Occurrence
Excess' Liab. $5,000,000 Aggregate
DI!6CRIPTIO" OF OPERATIONS ILOCATIONS 'VEHIClESl EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
f'irewcrks Display Dats: Decembel; 2. 2007 . .
Location; Florida H03pit&1 zephyrhills
dditicnal Insured, City of Zephyrhille, PL; Plorida Hospital Zephyrhil18
COVERAGES
Florida Hospital Zephyrhills
7050 Gall Boulevard
Zephyrhills FL 33541
CANCELLATION
SHOULD ANY OF THE ABOVE DESCR.IBED POLICIES BE CANCELLED
BEPORE THB EXPIRATION DAT~ TH~REOF, T~ ISSUrNG rNSURER
WILL ENDEAVOR TO Ml\.IL 30 DAYS WRITTEN NOTICE 'to TilE
cEaTIFlCATE HOLDER NAMED ~O THE LEFT, BUT FAILURE TO DO SO
SHALL IMPOSB NO OBLIGATION OR LIABILI~r OF ANY KIND OPON
THE rNSURER. ITS AGENTS OR REPRESENTATIVES.
CERTIFICATE HOLDER
AUTHOR~DREPftESEHTAnVE
t2J:/tsJr:=.
@ACORD CORPORATION 1988
ACORD 25 (2001/08)
Nov. 27. 2007 2: 40PM
Pyrotecnico
No. 9626 P. 2
VITALI FAMILY FltfWQM($. ,.ti
The show on .Decelllber .2, 2007 will be shot .manually..
Thank you,
Marsha Le.Fe.bvre
'Nov. 27. 200711: 38AM
'p y rote'c-n i co
:N6.~96l'l :~p, 6
U.S. Department oLLalilor'
'OccuplltlonaISafetY,'8nd Health Admlnls1~tlon
(Noo'-Mrtndatorv For.m:) ,
Form Approved
OMB No, 1'2"8-0072
Material Safety Data sheet
MilY ,be' used to oomply with
OSHA',8: HBlsrd 'Communlcallot,l' Sl~rtdlntl,
'Rb CFR,f910.120Q, SUtndard'musl be
,consul\~d lor-' SpllclnC, r.equlremenls,
\RENTI1YcAt ,iJseiJ, on,i;ab~/.ncl Us~'
, P1:r,ewark,s: ":1..3 UN Q3~5- PG"Il
Se-c.tlain 'I
Mlinu/il"lure"f,ll NlIme ' , .. Emelgency Telephonil Nirmb'llt ", ' _' .', ,
'$. Vi:t:6.ta"P.Yr.Q.tQehn1c: In~. _ .loc .dl~la"P:yroBc,n-1'co , 8-SPM 8,00--6,54-4,705 5-BAM 1-800....2.65-3.9.2;1-
Al1dte.II11 ~mbif, SItHl, cJIty;'Stlll1. and, ZIP ~ri) , ' Tflll!l!hone NlImb)lr-k?r InlClirnalltir.l ;
~O~ 'WHsliJn Rd 'N!'!w eastle.. pA 16101 eOO-BS.4...47'0.5 800..,2;5'5..3924
OllIe Prepared '
. A,pri 1 .1998
:Slgnlllura 01 P~patlr' (6pIloIli'O .
~~
,W
No/a;, tJ.~k $/llee,$',tI"'no/,:p'rmrn~d. 1t.."y"'1n &.~f'ipP~tJI";Of.'1iJ
Inlotmll'/o/J:l(Hr~flilsbJ8, Ihe spICe .mus/:b" trlirk.d,1O IIltJlilatlllhlll.
"
Sactlon:1I ,-"Hazardous ingredlentslldentlty l"torml1'tJon
. . , . -~ .
, .
HIl%8'tdo\Jll'Oomp;;'nen18 (Spaclilc;OhllmlcalldenUly;. Comrium N,m*)) OSHA PEL.
Speotal. d:1sPl flY f'\.r~\'Iorks c;onhj n e~Jlos'1v~llnd
p'y.ro.te~hn1-c :aompos:Ui.ohS'7 'lind' are' c:las-s1f1:ed:. '
as firewo,r.Rs',L3G" Otr aS35j p'Q :U by the U ~S ~
Oep:a,-tm~n~ of Triln~.portatiotl.. 'No: .chemlc.a1 .
o~m~'osit;1on hi eXpo'sed durin'g. :ncir~~' hand:' lf19
and storage.,
ACQIH nv'
Othe;: Umlle
Rlll:Ommendlld ' tA, (tNJllOillllj
p ,:-,.'
. ,
..v
, .'
Section III ""'"" PhysicaliC::hemlcal Characleristlcs
~~.
"
,
Bbl~"11 P.Qlnt /;lpll.clno $..~ty.O~aO" 1) ,
., nln nfa
VlIPOf P,elllUnl (mm HQ!1 . nfa . M81111\11 polnl'
n-la.., .
Veptfr DenSity (Alii Cl 1) , 'EYBpor.n RAI. .
-n/a . (Butyl l\C.ClIA\e .. 1) '0/9-
"
, "
'Bo(ublllty .111, Wlllllr
. S.l i g,ti1r
App'.....nq.e artd Odlif . '., '
.... . All ch'emtc.al camposit 100' 15 cohtaliled 1 n c'ardbdard o~ pI astta cas1 n9 '
- . . . . .. .
S:ectll'-h IV - FIre sOd axploslon Hazard. Data
.F.lBllI). POInr(MBlbl'.~FIJsel;IJ n le. Flammable Uinlla' . UEL.., n l a
Exfl!'!T~ti~lnu. M~ , ' . .
, 0:0 ho.t attempt to, f1:yht 'f'~lr.e 'in v'i.c,1nlty of 1.3S Fir.l!work-s UN 0335'" Ev,acuate. area
'Special F!t~ Filihllng f'Loced.ur811 '. : ' .. . . , .
,[vacuate ftre ,'area 1mmed}a,tely, and -~eek she~te.r.' ro~lo\Y estab"ished emergency a~t;on plan.
.... -
Unuautll ArB and Explilslon Heurds
,Unusual ftrewo'rks may ,mass e~pl[)de in a fire situ.at1on
, ,
.slyle, 'C,U~FPl '74 Lab-elmastet, Olv, of Alll'llrlcan lab.elmark Go. Inc. 60.a46
~
OSt:iA .t1<4, Sept. 1905,
9.
!
j
i
!
i
I
. ~
,
!-
. '
j
i
1
,
.
,
I
i
.,
. . Nov. 27. 2007"Pb:3-WAM'::" Py-rot ecn i co
, '.~"', -N '96'17
.. ~ .!.. ~ .....",.,. "...,,. - '0-
. ,_. _.t:.uli~,_ .
- .
'P. 7
S&.QtlOrl V - ReactIvity 'Data
Sl11blllty . UIJ.I.bls . CQNdJiloi\9.1o AV~~' . . Vicinity of s-tored
o ripen ,ames., smok1h.9 or mo1starei n
Slable. X f1r~works. Avo1 d frict10n and impact..
~
Incp.mpa~lbIllW (M.a/etlaIB ID A'iofd).
)
H;Ul!lQ~stJeCOnlPDsllloh: or Byproducls
"+a'%IUc!OIl3 MllY OCcUr . cOlldlUons lo,'Ayolil .
'.
PoIY~'le"ll~\Ion
WI'Nol OCCIlI X. .. . .
. ..
Do ilot.nl1ow,f'ireworks. to g'et s.oaking wet.
D.ev1aes. \'11'11 aip'1odein f'i:r,e s:ltuation'...
Sl!otlcm VI.- Health- Ht1~ard Oala
~R'oiilo(s)~' ~ii~' lritlalallol)? NO
. HOallfi'Hlilarda. (AaUl...enl1 ChlDnloJ.
..... Sldn"jf
NO
IngUlIiQI'l?
f. 'I
NO'
there: is no, ~~p:Qs,ed chem1~'i11 .compoSi~ion,
'. -
,,'
. ,
. Qetolnog.nlOllyl.
NTP?'
NO
. . I/\RG 'MililOoraph3'l
-riO.
OSHA 'Aligllll\tlKl?
NO
SIgns und Symp:IDm~ 01 exposuro
NI-A
, '
"':'
MBdlcil Conditio/>> ·
ca~ll~r~ly. ;4g9r~val8d :by I;:)cpoSUfll
.
NJA
,. \.,
, .
Emet~nc;y..1lIIdFftS\ Ald..p,~edmes
NlA
h.... . . ..
Section VII....... Precautlon~f for Safe H.ndllng'snd Use
'SIBP~ roo Be lQken In 'CaN Ma\.OtlBlle Released c)('s~ii'eil .. ,... '. . .
o _ ___ _ __'7.C~ut'io.uslY poi-ok upsp".l16d .dE!-V1ces'and _p-laqe.in c~~dboa!d
....:cart'Qns. . Ab.liQlut-e.'y no smo~1ng :open t].:ame~J o'r '.:Ipark'1:ng metaltoo's,1"nvi~1ni.:t~ of ',sPi1'l~d
f1'reWbrk.s',' .' ".
Wt\9\il;Olsp'on(Melhod . . . . .. . .' ~. ~'(.,~.
. ..' . ... . S:Qak 'any 8*'P }sed chemi c'1l1 compasi't.1'o.n w1th water:: sW'eep. .up w1th a.. mlture.~ ...
. .t1'ber brus~ .amf tfi$PQ.se Of'~Y' burn1'ng ,compl'iahce's ~/-ith :state and,q.cic'al 'regulat1 nos.
PnK;aOllllils. to ijll' TaKen In Handling BO'd Giortng . .. . .. . .
.. . 'K~ep ffreYfor"s cool and dry, Avoi'd impact with sH~'p1n9
. cll)"tQns. Absolutely no .smoking in vi c.in1'tyof any special fireworks..
.Qlher'PrllCllI.iIlDttIl N.. . . '
. '. ..' one.
.,
. SectlQn~11I ~. ~cmtrOl MQ8SUr.~lJ.. , '
'RilsplralDlY P(O\8OIIl:lri'.(~~) , , ..
. . - None t'eaui-red wh'en 'h-andltn
Vllnllhillon LoaQ\. ~1l4S1
NlA
M~han!Cat(G;m~/'lJQ N/ A
Pr~'\vo .GIoVIl!f
fi'n i s'hed fi rew.orks.
SpecIal "N/A
C9lhel
N/A
,1. Ey,e Pro.'lecuon,
I. NlA
,. :
t
I
" I
~/A ,.
Other Proleellver ,CIOIhlno: or Equlpmenl
. WorWliiY~lenlo Pr_GIlCl~~ ..
'N[A.
Ab.solutel X no smokinQ near an,Y f1.rewor~5
Page :to
.. 1U.G:I';D""'-H\-~~'/4"'~
Pyrotecnico
No v: 27. 2007 11: 39AM
Chris .Reitano has shot the folloYing shoy:
11/9/07
11/10/07
11116/07
11/17/07
11/23/07
Pirates Week in Grand Cayman, Cayman Islands
Pirates Week in Grand Cayman
Great Explorations in St, Petersburg, FL
Lakeland Margarita Society in Lakeland, FL
Rochester Resorts in Sanibel, FL
No.9617
P. 11
55 tt~fo7-(p3-3~77
You can call John Feigert at 770-842-3977 for confirmation,
. N~v. 27. 2007 11: 39AM
.Py~r:ote:c'n:i >C.O
; CPR Pro
For1ha prol.nionBI ".seber
;
. nil .......'.11 ...pI,lod .nd ._.,.",tt """~lid lilt
reqta;".""DW1ld.. an4,UI Q~lItlvel'f)f. CQ"~' ~
AdlU ~RAllI 01111 erRAtD In/.., CPR
/Il......dt/. .0' stju... ...'s",.;( <,~,,.. /111I do..)
Nntrt,,~ ItItlY' ",llIh "'llilllll
1A.....,..aI.."o~sa~ttilWU:r...~1
(8
Baslt First Aid ~
For Firal Aid Provid.~
r """"...., w..?'~ .
'.h r/~l-oli~r f {!/ /oA6
h.. ..cu..,.....'.'"olf>"',,~ .., con.,..ltftW p.tl.tmad 01.
.tqIlMI" knov-t...ndlt...tlab,HI,"" I.t I Gouflein'
~"IIIIt. F;...Al. A'~~ filiI Ai. U.-......ll1n1 AId
/tt.,..vlH"~" diJI..'.......d,( ...."".d... 060../
"",,nc.n Weir' ""l1n "I'.".
M';smIa.oclll.:'rnwIU.let1N~"'uellan
.
No: 96n"!"~R.c -12
ASH! APPROVED CERTIFICATION CARD
,WHATELEY.B
A.flIrill4l.lItua........ "-l
/'
~.r.$t"""
0710 9
Rct'oONJ''''
OtIfClllTPt:.d
'362-628-9538
C,E.C.
'.."""_lW_.... '''~OM,,_
_l""....~~-..... a"'_........,~e4w;o1odpo....... '*"""........~...
. Ill. ..lIIadeAo'''~ --.0.......... _M~ .....DI_... .....""'........
...;..., 1f............._,..."Qlt'll_it ..oo_.....~.I.'.
W~llorCl'll... CeCI~CIIIllI&J ,......"'""..~..........""-"'"
11010 11IIo lDIIIM "....II-..illntlililt."'.. co, lIIOlIl2AG41Ol.
ASHi APPROVED CERTIFICATION CARD
07 I 0 9
AlMw~ 01111
C::35'~ t,2f\-QS3H Q. .C.G
Tn IQ tu~.ND . -,="'""'(;pW....
SOoeoUlol""","",.................."" ....~~tM oliIob:od_ II"" -_...
....IlI%diooo....ASIt .__doI 11.........__ ...,-....."""'. ..............
...1Ifh 11I10 t""'*"'........ """_ _ s tcq, _ ,"*".lIftlIaI......1 ,ho 2W6",""'"
F~M_A6AlvotlolM Ic..ao.CIdll5/...- ._.._---.dIl.'n.
_11......,..._ .I_..........,..~'" Ofcd(lOCl124'4"l
. P/28/2007 11: 135
18137156697
NUTRICIAN
~~ FLORIDA HOSPITAL
II~ Zephyrhills
November 28, 2007
City of Zephyrhills
5335 8th Street
Zephyrhills, FL 33542
Dear SirlMadam:
This lctter is to acknowledge that Florida Hospital Zephyrhills has contracted
Pyrotecnieo of Florida, LLC, P. O. Box 310, New Castle, PA 16103, telephone
724-652-9555 to perform a special aerial display of ilreworks, approx" an eight
(8) minute show at south end of the hospital following the Lighting of the Trees
& Hospital. This fireworks display will take place between 6:30-6:45pm.
Florida Hospital Zephyrhills appreciat~ the City of Zephyrhills approval of this
exciting element at the end of our 23rd Annual Christmas Tree Decorating &
Lighting Ceremony.
SiDcerely ,
~ Ste":er, CMSR, Director,
MarketinglPubJic RelationsfPhysician Recruitment
Volunteer Services
s
Adventist H(alth System
7050 Gall Boulevard · Zephyrhills, Florida 33541-1399 · (813) 788-0411 · Fax (813) 783-6198
TDD - Tclccommttn.lC<ltion Device For The Dcaf (813) 783~1242
PAGE 132/03
'11/28/2007 11:05
18137156697
NUTRICIAN
PAGE 03/03
CERTIFICATE 01<' CO",7EMGE Tssue Date: 06/0Jl2oo7
Adventist Haith System This certificate is issued as a IlIlltter of il1formBtioll nn Iy and confers nO ri ghLS
Dept. of Risk M:l'lagcmcul &. J,n~urancc: llpon thc Certificate Holder. This =tifieale c10cs I1011lmcnd. extend or alter the
111 North Orllllldo Avenue C(\vcrage lIfforded by the self in~un:d tr\Ist or any insurance policies listed below.
Winter Park, FL 32789 407-975.1420
Named PlIrticlpBDt: COMPANIES AFFORDING COVERAGE
cmiiiiiI", .Letter A: MIS 1.iabllTIV Selr 1n,,!1IftCC TNs!
COIll1l...... Letla' B. ADHcallll-lI!.ncI\11'111ce
Cft_m Leuer Co ADHc>>lII (A\Red World AmJr:mCC C""'....nvl
Comn~- Letter 1); ADH~Is..;u~)
" CmnDll1lY Letter E: LibertY MUll110l Fire 1nJ~ CO....IIIIV
Florida Hospital Zephyrhills. Inc. eem.DT J..eUer 1: PlQricb HMftI..' SCIr.Fundod Worlccr's CanIIlelISlllion I'IG""''''
0.-:1,", J.,r.IIer G. ASS SeIr.fuDded Worka's Ccm1lellJlltlcm Premm
7050 Gall Boulevard CmIlDlm,. J~lltr H: Ml~,I>_""'-'
Com""- T..eUer x: Unlll:ll WdcClllPn 1fts\InIIcc CariiII:lIl,.
Zephyrhills, FL 33541 Ca......",. Lettu' I. cmraBIElo;c=atiYc lUsk l.......il'l
Co_Ill' Leder X' ?;arieh Amerton 1IWI\'lIDCe ~
Co.....81l. Lctrr.r J.: ZlIricb Amo:ric2II W\Ir1Ifla: C"""'_
o._DY LdJer III: wlli",(WIIDs_l:anmoIw
CM-:l....I,dkrN: UIW.l',c>fLcllldon
-CtmID:IMJ",,_ 0. AJch ~~lV ln5nnmco ComallJl'l
cOiii1ii",. J,etta'1': l.lIndmri AIIIerlcom In:uruce Co........"
eo_ LeUH' Q: ^DRc:llLb
COVer81!eS
'Pus is to certify t.!I:It eovcnl:l' d(Clmcnts lJ$lCd below 1I:I,.c been iJS')C(l1O lhc Named P/lI'IIelpllDI Ji~led above (or thc Dmo period indiC2lted. Nll<<Wit/lst:\lldlng any reIlUlrclllCD1, lcrm or condition of
:\llY eonttact or other doc:mncDt "';111 I'I:SpCC:I 10 wbich tl!i~ c:cnlfiCllII: JIlI)Y 110 lUlled or rray pertain. tlle lnsurnncc ~ffordcd by !he polidc$ described m:re;nls subjccI10 all the tcm\<, excluJiClft$, :IIId
condltiom of sud\ ~llclcs. Limir.~ ,<IIown lJlIIV have been relIllc:cd bv mid clnims.
Co rol\cJ Bll\diyt Pole, Explnt11nD T..inlilS
Ltr ~'otJ_rIlllCl! I'ftII....N"mbe.. Dlolr. Dnte
A X Hosp, ProfJCamprCIICllJlw 0C:\ICfIl1 Unbility A Jlbnp 85?-3.:2007 ()4IlI1120ll7 DilIOl/2008 BRch OClODnalCC $15.000.000
CIrc bro'l< &. OlIli!llonl'
B " lJ"'JI. PlOr./ConlJlrellcnSiI/C Gcnernl Li~lIlty IlL M.....p1 oo7047~-005 ool101nll1/7 04l0l/?llOB A~""'ll"le $2.S.00o,(Illll
c.n. Bn-ars &. OmlJPlcms
C X H~ l'rOf.lComJm:ht1lSl.... G:ner:d UMlli", & MlI"tCd ClIll:zs6~J004 04/0112007 ~IOII2OllS AIW"lP1e S2S,Ooo,OllO
0= ElftlrS &; OmimOllS
p X 'If""" 1'rDr~:i.." C'..cnctnI UabllllY IlL MlInaBCd MHJlt98.2 (1410112007 O'lIOlanDS A!!Jt!C~nte 51S.000,OOlI
c;.n, ~ &. Oml~an.~
NBlCIO " I ClSIII!I MLNlc (HP1. & M"""p CIrc Emm;)
AlSICIO X I ();cnneneC (CGJ~ Only)
"F.! X All\O"",lnlc Li:lbUlty. /l.n vahiclCi AS2-6.S1-28G53S,Ol"7 0110 112007 OI/O\/2DllB Combined Slow" Limil $\ ,000,000
~llCi:l;:'~jwy &J'mpcny
DlI1I1l'
P X Worker' J CmapetI::ulOD l'1odda Irasp'''' - Oriftllllo F1iWC07 otIIO lFJUJ7 O6IOlI?OOR Stan'l(lY}' Limits $1.000.000
ond .._I-sl,.iAbilil'\l 1'na1iti~
G X Warter's Cocnpc:c.:uillll l"lorid~ DMJlon AltSWCOi OfilDll2OO7 06lO11200~ Sumltory Limic 51.000.000
:md l!IftpIoycr' s J..lAbiliLy PllCili~ 3Ild all Olbcr I
SlDtCS Bll""'" Tcx:ll:
H X War1="s CoIlIpelISIIGlI1l CO. Pf_ GA. n. KS. KY. EWCOO7923 oGlO ll2007 06Jll112Oll8 iilOtllllllY Umlts $1.000,000
3IIdi;"",lavcr'. LilIblUtv NC. TN
JJ X WlJlkl:r'8 CcmpaIsallD'l Tc:nDeSIlCC ^JW1'!l"lC EWCOO75!1t1 0610112007 06101/2008 SlIllll1my Limits
:wi !IllDIm/cr'. LiabilllV
I X Work1:r'~ ~tll'I' ChippewA :HDlIJ'it.>l 04DOllGZ'I!l~ 1 l/O~1200G lIJ04I1.1lO7 S'"b1Iory LiDU
anti"Bm.;lo.....'. Li:lbiU",
"""""'" 8t omem:
J X PrimAty Plllicy &161-94?5 O6IDII2OOG 09101J1Ql17 Sl S,OOll,DOll
X " &ccs:; I'DIicy S2391Z'1.01 0610112006 091011.llI07 $10.00lI.DOD
J X PkIc1Jty B167-9438 OfilDI12OO6 0'J01J?OO7 :>IO.Ol1O.DOll
J X F1duclnry 8167.940\0 06ID 11.llI06 0910112007 $10.000,0l\ll
Propeny nncl ~~:
Priaury Polley (QuO'" Sb.....)
L X ~1riclI ZMD 370565605 0110]12007 01101I2OOB }
M X l..c:ltIlJJ!fGJI 16062!18 01/0112007 OIIOI/2lIlIR :;'7511,000.000
N X Lloyd" ofLatldOll 0l'SS0607 01 Jtlll2DD7 0110112008
0 X Atcb SpeciAl", 1tt<UrnIICC C"""'''''>' PRl'OOI9SR6-00 0110112007 01/0\12008
6 X I'll':( Exec.. Loyer L"RO~SD233 OllOl12DD7 01/0112008 USO.DOll,OOO
X SeellIId :Ell....... L/ntcr AIJS2II07.o1 01/0\ I2Oll7 0110\/21108 51.700.000.000
Descrlption Or OperationtllLoc:ation$IVebldeslSpeclalltems:
All opcraIiOllS subjea to the tcnnS a'Od conditions ofthc Trus1 orinsuDnce policies listed above,
Coverage -prollided is;l per oeeurrencc aggregate and is no1 iJlcreased by the number ofn:uncd participants or c:Jaimants illvOlVI:I!.
C<<'lftcalt Hllldl!l' Omozll:s\llln
Sbot.)d "DY of tile ;Illove described rollclcs be QlJleelled before !be lCOfllr:nion dla: 11lerc:01. llIc jS$1liDI
company wlll coliCIn/or lD mail wrillCft notice lO !he Ctttincall: Boltler IIllmcd 10 !be lcoft., !nit mill'''' 10
Florida Hospital Zephyr-hills m:liJ ,..cl'l nollec sbAII impose no oblif!l'tion at lIabilil)' <,If ~ny Idnd IIpOII t.hc CDmpllny, il$ ~RCIIb ar
Yelll'C!CDrntiVd or cnmJo"""",,
7050 Gall Boulevard ^.thorjad~tlllll~~
Zephyrhil1s, FL 33541 p~~ ~-
D:Itt: 06lO1IlOll7