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Home My WebLink About08-8055 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813) 780-0020 ANNUAL FIRE PROTECTION MAINTENANCE 8055 Permit Number: 8055 Permit Type: FIRE PROTECTION MAINTENANC Class of Work: FIRE-PROTECTION MAINTENAN E Proposed Use: COMMERCIAL Square Feet: Est. Value: Improv. Cost: Date Issued: Total Fees: Amount Paid: Date Paid: Work Desc: 7/08/2008 25.00 25.00 7/08/2008 Phone: FPM-FIRE ALARM SEMI ANNUAL-ZEPHYR HAVEN NURSING Address: 38250 A AVE ZEPHYRHILLS, FL. Township: Range: Book: Lot{s): Block: Section: Subdivision: CITY OF ZEPHYRHILLS Parcel Number: 14-26-21-0010-01300-0010 Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire prevention and protection related activities such as inspections, plan review, administrative fees, and other costs related to the aforementioned. Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All work shall be performed in accordance with City Codes and Ordinances. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMNT 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." -.. P IT OFFICER PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813-780-0041 813-780-0020 Date Received ~l. ~ Owner's Name Owner's Address City ofZephyrhills Fjr,e. Permit Application II ,j:~~?1tL() ~ r I I Ui18~ tf eD~~ Fax-813-780-0021 Phone Contact for Pe.rmit j ~... "I ~\~~__H_! ~~"U -?J.91 J II /'/ I I I I .'lIlIiIlf' I I Owner's Phone Number Fee Simple Titleholder Name II I I ~8aSD Titleholder Phone Number II Fee Simple Titleholder Address ~ Job Address Sub Division IUIILIL D D D D D D Contractor Signature Address ELECTRICIANI Signature . Address I PLUMBER I Z .(.\'Y'\,-\( ~\\ ~ \ ~ 1.- 1 Parcel # D D D Hood Installation D D D D Recreational Bum D Sparklers D Sprinkler System Installations D Standpipes (Sprinkler Sys) D D A A"t... lilIZU - Bic-Hazard Waste Storage - ANNUAL Comm Exhaust Kitchen Hood/Duct Controlled Bum Emergency Generator < 30 kw Emergency Generator> 30 kw Fire Protection Maintenance - ANNUAL . ~~~~ Sprinkler 0 0 0 0 L-J o 0 ]I.... 0 c=J Ooooc=J Doooc=J Fire Alarm Hood Cleaning Hood SuppreSSion Fire Alarm Installation Fire Pumps Fire Works Flammable Application- ANNUAL Fuel Tanks Other: Signature Address I MECHANICALI Signature Address I OTHER Signature Address! Directions: illl!:J:lI. --- 3~SYl I " Lot # -~-'~ ~;r liT ~_ ~i Fumigation Tent Hazardous Material (Tier II or RQ Facility) ANNUAL LP/Natural Gas-Installation LP/Natural Gas-ANNUAL Sale Places of Assembly-ANNUAL Torch RoofingfTar Kettle Waste Tire Storage ANNUAL Valuation of Project Company Registered License # Company Registered License # Company Registered License # Company Registered License # Company Registered License # 51"""p,/~ ~ Y/N I Fee Current Y/N Y/N Fee Current Y/N Y/N Fee Current Y/N Y IN I Y/N Fee Current Y/N Y/N Fee Current L- ,_ d ~~~. Fill out application completely, Owner & Contractor sign back of application, notarized (Or, copy of signed contract with owner) If over $2500, a Notice of Commencement is required (Mechanical work over $5000) Supply two (2) sets of drawings with applicable documentation Allow 10-14 days for review after submittal date, Parcel # - obtained from Property Tax Notice (htlp://appraiser,pascogov,com) 'NOTICE OF:DEEDRESTRICTIONS: The undersigned understands that this permit may_besubjectto-"deed"rre-stridions" which may be more restrictive than County regulations. The.undersigned assumes responsibility for :complial<lce\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 -fora 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. CONSTRUCTION LIEN LAW (Chapter713, Florida Statutes,-asamended): 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'SAFFIDAVIT: 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. 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 that a separate permit may be required for electrical work, plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid unless the work 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 the work is commenced. An extension may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned. WARNING TO OWNER: YOUR FAILURE TO RECORD A 'NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBT IN FINANCING, CONSULT WITH YOUR LENDER OR AN A NEY BEFORE RECORDING YOUR NOTIC C MENCEMENT. FLORIDA JURAT (F.S. 117.0 OWNER OR AGEN Subscribed and sworn to (0 by Who is/are personally known to me or has/have produced as identification. CONTRACTOR Subscribed and sworn -ry - 'is - b"t) by Who is/are person..Uy Imo--l to me or has/have produced as identification. Notary Public ~ ..~ Canm . ~ElINE B~GES ~1: - " " .: i omm/SSIO(1 no ~2 Name of NQ.ta~p~/ilMQeQfmi<>rri~010 . ;" ' ~ fl(1M Thm T. . t1eJr" J my F.,n Insurance 800-385-7019 Notary Public Commission No. Name of Notary typed, printed or stamped Jul 02 08 04:42p SG "tileD Fire & Security Sil7lplexGrinnell 813-313-1606 p. 1 Simplex Grinnell LP 50 Technology Drive Westminster, MA 01441 (978) 731-2500 AP FAX: (978) 731-7756 Payment Requisition Form This form is to be usedQD.!ywhen payment is required and an invoice is not available ( Le. permits, drawings, bids). If an invoice Is available please go through the standard payment procedures for submitting invoices to accounts payable. Please provide a detailed reason for payment and attach any available back up when submitting request. Please supply vendor number. If not available, send an emaillosg.apinquiry@tycoint.com. Please fill in "Request for vendor number" in the subject line. Reference the full remit-to address in the body of the email. You will receive either a response with the current vendor number or information on how to have the new vendor setup. This payment will be made per system payment terms. Exceptions will require additional approval. (RM < $25k or VP > $25k) Note: Signature cards must be on file with Accounts Payable for all approvers stating their approved dollar limit. Request Date: iY;7!f-o.)./DQ I I Requestor: Email Address: Chris Brackett cbrackett@simplexqrinnell Vendor Number: 056313 Pay-to Vendor Name: Remit-to Address Line 1 : Remit-to Address Line 2: City I State I Zip: City of Zephyrhills 5335 8th Street Zephyrhills. fl 33542 Payment Amount: $50.00 Need by Date: 07/02/08 Checks will be cut on Tuesdays & Thursdays Reason for Payment: Permits for fire alarm inspections at Sun Medical Center and Zephyr Haven Nursing Home in Zephyrhills. FL. Delivery Method: U.S. Mail 0 FEDEX L..IJ o Deliver to District District Number: 292 Fed Ex Contact: Scott Brackett Pennanent / 1 Per District U Deliver to Vendor Vendor Name: Contact: MaiHo Address Line 1: Mail-to Address Line 2: City I State / Zip: Telephone: Approver (Print Name): Title: Signature: Date: Cost Distribution Qj PO Num $ Amt "0 #1 1/ L- a OJ #2 (fJ rn #3 ..c EJ #4 :J 0.. #5 Subtotal $ - (j) Proj Num etrl DiS! $Amt 0 #1 U ..Q #2 0 ..., #3 13 ~ #4 (5 #5 Subtotal S - a. Acet Num Dept Dist $ Amt x #1 62477 652 292 $ 50.00 UJ "0 #2 ro Q) #3 ..c Qj #4 > a #5 Subtotal $ 50.00 Grand Total $ 50,00 Cost Distribution in balance. Additional Approvals (when applicable) Print Name: Title: Signature: Date: Print Name: Title: Signature: Date: NUMBER PRODUCER ;436693 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON lliE CERTIFICATE HOLDER OlliER THAN lliOSE PROVIDED IN lliE POLICY. llilS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER lliE COVERAGE AFFORDED BY lliE POLICIES DESCRIBED HEREIN. COMPANIES AFFORDING COVERAGE COMPANY A: AI South Insurance Co. COMPANY B: American Home Assurance Co. COMPANY C: Commerce & Industry Ins Co COMPANY D: Illinois National Insurance Co. COMPANY E: Insurance Company of the State of PA Marsh, Inc. 1166 Avenue of the Americas New York, NY 10036 Telephone (212) 345-5000 INSURED SimplexGrinnell, LP 4701 OAK FAIR BLVD TAMPA, FL 33610 United States COMPANY G: New York Marine & General Insurance Co. (Lead) COMPANY H: White Mountain Insurance Co. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIRMENTS, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES LISTED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE LTR POLICY NUMBER POLICY EFFECTIVE POLICY DATE (MMlDDIYY) EXPIRATION LIMITS GENERAL LIABILITY X COMMERCIAL GENERAL CLAIMS MADE [KJ OCCU OWNER'S & CONTRACTOR'S GL 1595415 6/29/2007 10/1/2008 GENERAL AGGREGATE PRODUCTS-COM~OPAGG PERSONAL & ADV INJURY EACH OCCURRENCE FIRE DAMAGE (Anyone fire) $15,000,000,00 15000000.00 B 10/1/2008 10/1/2008 10/1/2008 COMBINED SINGLE LIMIT $7,500,000.00 $1,000,000,00 $10,000,00 $7,500,000,00 B B B AUTOMOBILE LIABILITY X ANY AUTO ALLOWED AUTOS SCHEDULED AUTOS CA 1606992 (MA) CA 1606993 01A) CA 1606994 (AOS) 6/29/2007 6/29/2007 6/29/2007 BODILY INJURY (Per person) X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY (Per accident) PROPERTY DAMAGE PROPERTY B o A F C EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS COMPENSATION AND EMPLOYERS' LIABILITY THE PROPRIETOR! PARTNERs/EXECUTIVE OFFICERS ARE: OlliER EACH OCCURRENCE AGGREGATE SEE PAGE TWO SEE PAGE TWO SEE PAGE TWO EL EACH ACCIDENT EL DISEASE-POLICY LIMIT EL DISEASE-EACH INCL EXC DESCRIPTION OF OPERATlONS/LOCATlONSNEHICLESISPECIAL ITEMS Please see page 2 for additional insureds and any additional language. City of Zephyrhills 5335 Eighth Street Zephyrhills, FL 33540-4312 SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THF INSI JRFR AFFORnIN~ r.OVFRA(:';F ITS Ar.FNTs OR RFPRFSFNTATIVFS OR THF 1!It.~IJFR OF THIS r.FRTIFIr.ATF \ ..:J~ ~ J MARSH USA INC. BY: David Kong, Casualty Program CERTIFICATE NUMBER 436693 PRODUCER COMPANIES AFFORDING COVERAGE Marsh, Inc. 1166 Avenue of the Americas New York, NY 10036 Telephone (212) 345-5000 INSURED SimplexGrinnell, LP 4701 OAK FAIR BLVD TAMPA, FL 33610 United States WORKERS COMPENSATION POLICIES Carrier Policy Number Eff. Date Exp. Date State (B) American Home Assurance Co. WC 1616749 6/29/2008 10/1/2008 CA (D) Illinois National Insurance Co. WC 1616750 6/29/2008 10/1/2008 MI (A) AI South Insurance Co. WC 1616751 6/29/2008 10/1/2008 GA (B) American Home Assurance Co. WC 1616752 6/29/2008 10/1/2008 PA (F) New Hampshire Ins. Co. WC 1616753 6/29/2008 10/1/2008 NY,OH,WI (B) American Home Assurance Co. WC 1616754 6/29/2008 10/1/2008 NJ (C) Commerce & Industry Ins Co WC 1616755 6/29/2008 10/1/2008 FL (E) Insurance Company of the State of PA WC 1616756 6/29/2008 10/1/2008 AR,MA, VA (B) American Home Assurance Co. WC 1616757 6/29/2008 10/1/2008 OR (B) American Home Assurance Co. WC 1616758 6/29/2008 10/1/2008 AOS (B) American Home Assurance Co. WC 1616759 6/29/2008 10/1/2008 TX LIABILITY PROGRAM Certificate holder is added as an additional insured for General Liability and Auto Liability, but only to the extent of the Named Insured's negligence. Additional Insureds: City of Zephyrhills Project: Various Inspections If there is a question regarding this certificate please contact Robert Walp (Email: rwalp@tycoint.com Phone: 813-626-5482) City of Zephyrhills 5335 Eighth Street Zephyrhills, FL 33540-4312