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Home My WebLink About08-8663 CITY OF ZEPHYRHILLS 5335-8TH STREET (813)780-0020 8663 BUILDING PERMIT Permit Number: 8663 Address: 4550 BLOSSOM BLVD Permit Type: RE-ROOF ZEPHYRHILLS, FL. Class of Work: ROOF REPLACEMENT Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 15-26-21-017D-00500-00D0 Improv. Cost: 12,860.00 Date Issued: 12/19/2008 Name: HORVATH MORENE GRACE TRUST Total Fees: 95.00 Address: 4550 BLOSSOM BLVD Amount Paid: 95.00 ZEPHYRHILLS, FL. 33542 Date Paid: 12/19/2008 Phone: Work Desc: REROOF CONDOS -4550-4546-4548-4552 BLOSSOM BLVD YOWELL'S ROOFING REROOF RESIDENTIAL 95.00 DRY IN ROOF INSP TAPE JOINTS ROOF IN P FINAL / /4 REINSPECTION FEES: Reinspection fees will comply with Florida Statute 553.80(2)(c)when extra inspection trips are necessary due to any one 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 recd your notice of commencement." CONTRACTOR SIGNATURE PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 10d d IY,L01, Cty of -BUILDING DEPARTMENT RE: Permit# �Gi(r/„ 9/17/07 Inspection Affidavit I J2.J\ 110 td I ,licensed as a( Contracto /Engineer/Architect, (please print name and circle Lic.Type) 8 Building Inspector* License#; rLG d 5"7 4) On or about J ? I ?3 / , I did personally inspect the roo (Date&time) (� �� deck nailing and/or secondary water barrier work at _✓ __ ✓t M OS9O (circle one) (Job Site Address) 33fO Based upon that ex ti have determined the installation was done according to the Hurricane Miti e t M ual(Based on 553.844 F.S.) Sign STA1 OF FL RIDA COUNTY OF. �n Sworn to and subscribed before me t is day of I 200 3 Notary Pu , . +�,s* My COMMISS10Pl#DD eos671 EXPIRES OdobK 16,2MCII i ws (Print, Commiss' No.: TN (7 I Personally known Vor Y�< Produced Identification Type of identification produced. *General,Building,Residential,or Roofing Contractor or any individual certified under 468 F.S.to make such an inspection.Include photographs of each plane of the roof with the permit#or address#clearly shown marked on the deck for each inspection. TO/TO'd ZOT98₹6CT8 JNIdood S111SMOA 8Z:VT BOOZ-06-o a 813-780-0020 City of Zephyrhills Permit Application Fax-813-780-0021 Building Department _ / 3 Date Received Phone Contact for Permitting i - Owner's Name ,n /��SSd c C 0N� s Owner Phone Number Owner's Address C/ /S /6 S5 GAT /)/ (_ Owner Phone Number Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address p JOB ADDRESS Y D O ^S .Z //�0S so i Le w LOT# �� SUBDIVISION O/'n^` r I/,551®� N� � �r PARCEL ID#r/$ - /- o/70-SOS OO- O_P (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED e NEW CONSTR ® ADD/ALT Q SIGN Q MOVE Q DEMOLISH INSTALL REPAIR PROPOSED USE 0 SFR 0 COMM Q OTHER TYPE OF CONSTRUCTION 0 BLOCK E FRAME L STEEL 0 OTHER 1 DESCRIPTION OF WORK ✓' / ,� BUILDING SIZE ' a c /C SQ FOOTAGE S/ HEIGHT b / Elil BUILDING $ l O c9 ' VALUATION OF TOTAL CONSTRUCTION Elli ELECTRICAL $ AMP SERVICE 0 PROGRESS ENERGY Q W.R.E.C. PLUMBING $ Q MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION Elli GAS Q ROOFING 0 SPECIALTY Q OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA DYES QNO BUILDER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/N Address I License# ELECTRICIAN COMPANY SIGNATURE REGISTERED Y/ N FEE CURRENT Y/N Address I License# PLUMBER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/N Address License# I MECHANICAL COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/N Address License# OTHER � '''�"' COMPANY iP/7J G D SIGNATURE -- REGISTERED Y N I FEE CURRENT I Y/N Address Cv' ✓'1I 0 J59 License# ____ _ 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 w/Silt Fence installed, Sanitary Facilities& 1 dumpster;Site Work Permit for subdivisions/large projects COMMERCIAL Attach(3)complete sets of Building Plans plus a Life Safety Page;(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 w/Silt Fence installed, Sanitary Facilities&1 dumpster.Site Work Permit for all new projects.All commercial requirements must meet compliance SIGN PERMIT Attach(2)sets of Engineered Plans. ****PROPERTY SURVEY required for all NEW construction. IIIlIllIIIIIIIIIIllI 11111 Directions: Fill out application completely. Owner&Contractor sign back of application,notarized If over$2500,a Notice of Commencement is required. (A/C 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 A/C 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 IMPACTIUTILITIES 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'SIOWNER'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 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 is considered abandoned. justifiable cause for the extension. If work ceases for ninety(90)consecutive days, the job WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS OR TOY,BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. CONSULT WITH OUR LENDER FLORIDA JURAT(F.S. 117.03) AN ATTORNE OWNER OR AGENT CONTRACTOR Subscribed and sworn to(or affirmed)before me this Subscribed and sworn to(or affirmed)before me this by by Who is/are personally known to me or has/have produced Who is/are personally known to me or has/have produced as identification. as identification. Notary Public Notary Public Commission No. Commission No. Name of Notary typed,printed or stamped Name of Notary typed,printed or stamped Proposal Page of Pages Commanding Excellence since 1964 Yowell s Roofing Co. 2220 Old Cypress Creek Road Land O' Lakes, Florida 34639 (813) 949-4561 Fax (813) 948-6102 License No. CC- 0057952 — —-- S � � ` 1 Proposal Submitted To Phone Date - � I as e rr� 1 v�v cVl �Clls Street Job Location _ 0( 5 ►31 vs..sdM 1 Qiasse�nn 131 vc l City,State&Zip Code 1 = h Wit . 31 ±tO We hereby submit specifications and estimates for: / ear off old roof / layers ' �et Replace all rotten lumber at additional cost of 1 sq. ft. $ per fu 2 inch plywood 3. Dry in roof with / ply JJ3'O lb. felt Replace all lead boots: Size 1- r�'r 4 3�r 5. Replace _vent: Size /Q '` o. Replace_ 5_in. Eave metal: Color / OU-M) Painted Steel 7 :/ Replacevallev metal 8. _Install s J Type Class A fiberglass fungus resistant shingles by Owens Corning Color Q� { 9. + Shingles will be 6 nailed to meet Florida Codes for wind 10. Cut hole and install / b ft. of Owens Corning ventsure rollvent for proper ventilation _� 11. Built up roofing (flat/low slope) ) ' 12. Dry in with 43 lb. base sheet dd 13. Apply 1 ply modified roofing: Color 14. Replace in. eave metal: Color painted steel 15. vS?b l! AFT' :Lc +ty4f /'`-Sbie( fJ f'4) t All lea 6. LLdr/ �G� w 8`p• v / 44f/C 47 i 18. , Clean up and haul away all trash 25 year 3 Tab $ / 2. 841, / �j� 19. .Pull magnet around job to pick up any loose nails or staples 30 year Dimensional $ 20. Dump fee and permit included in price Duration (110mph-30yr) $ _ I 21. year workmanship warranty from date of completion Duration Prem.(130mph-50yr) S__ __ We propose hereby to furnish materials and labor-complete in accordance with the above specifications, for the sum of: dollars ($/ , f{� ) plus an Payment to be made as follows: Deposit of$ Balance of$ due upon completion. During the course of the roofing work,the customer agrees to hold harmless Yowell's Roofing Co.for any costs or damages resulting from asbestos materials n the roof system including but not limited to all costs of litigation and attorney fees. Yowell's Roofing Co.is not responsible for any mold or mildew found durnq or after roof work at anytime. Customer agrees to provide adequate roof access for trucks,equipment and personnel. Customer also agrees to furnish electricity:f ne?d_-a complete the job. Yowell's Roof Co.will not be held responsible for damage or cracks on driveway. Attorney Fees&Cost: In connection with any litigavor:ar:s r.,o;;t of this contract,the prevailing party shall be entitled to recover all costs,incudin reasonable attorney fees. Any final bill notpaid 9 upon completion of 1oi wr ie lect 10 a eighteen percent(18%)APR on unpaid balance compounded daily. All material is guaranteed to be specified. All work to be completed in a worxmariae manner according to standard practices. Any alteration or deviation from the above specifications involving costs will be executed only upon written orders arty v,:;i i• become an extra charge over and above the proposal. All agreements are con gent upon strikes,accidents or delays beyond our contract Owner to carry fire. tornado and other necessary insurances, Our workers are full vered b orkman's Compensation and Liability insurance. This proposal,s subject to acret_r ce within days and is void thereafter at the opt' e un signed. Authorized Signature / Ja /_.L€. ,/'* ? Acceptance of Proposal- T ove prices, ec lions and conditions are satisfactory and are hereby accepted. You are authorized to do the work:_a specified. Paymen It be de outlined above, accepting this proposal,it becomes our contract Signatur � i / / /q fignature STATE OF FLORIDA `' AlL IIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII COUNTY OF PASCO <„ C, 2008179820 THIS IS TO CERTIFY THAT THE FOR,EZ'i011S A.' ' . TRUE AND CORRECT COPY OF THE DOCUMENT OR OF PUBLIC RECORD IN THIS OFFICE4.,W�.{ ITNESS MY Rcpt: 1218197 Rec: 10.00 D AND OFFICIAL SEAL THIS AY;OF , ',J DS: 0.00 IT: 00p00 Clerk _2 z 12/19/08 — JED 1TMA ,CLER t F CIR UIT COURT rs DEPUTY,C ERK �ç _= - 12D/19/08 11-1 PASCO ICOUN COUNTY CLERK F I OR BK 7989 PG i 1 ! 1 NOTW- OF COMMENCEMENT Permit No. Property Identification No. `�j 'Q1-,Q tiD-1D p5"OO—Qo pcj THE UNDERSIGNED hereby give informs you that the improvement will be made to certain real property,and in accordance with Section 713.13 of the Florida Statutes,the following information is provided in this NOTICE OF COMMENCEMENT. 1.Description of property(legal escription: (D� .mac A.SX O,�y� Co 4o L(. C S' V v l�-f) a)Street Address: 2.General description of improvements: o 3.Owner Information a)Name and address: _ (-A;M c i'≤3 0 &o..c UM &egg Z5 ,/1 7 b)Name and address of fee simple titleholder(if other than owner) c)Interest in property /00% tractor Information �,�(+' / a)Name and address: s jqoo/ t^ (D- X10 Ll�t C ��S �'� k ' 7A e4' X? $ I ' C.3 b)Telephone No.: /,3 9y- 9 l Fax No. ( pt.) / 2 '2^ /°.2_ 5. urety Information a)Name and address: �c4 b)Amount of Bond: f/ c)Telephone No.: y.9 Fax No. (Opt.) 6.Lender a)Name and address: Phone No. 7.Identity of person within the State of Florida designated by owner upon whom notices or other documents may be served: a).Name and address: p/'l b)Telephone No.: ✓.t Fax No. (Opt.) 8.In addition to himself,owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes: a)Name and address: M •g b)Telephone No.: Fax No.(Opt.) 9.Expiration date of Notice of Commencement(the expiration date is one year from the date of recording unless a different date is specified): WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713,PART I,SECTION 713.13, FLORIDA STATUTES,AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,CONSULT YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. STATE OF FLORIDA COUNTY OF PASCOSignature of Owner or Owner's Athóri d Officer/Director/Partner/Manager Print Name The foregoing instrument was acknowledged before me this /7 day of Pe(. ,20 O ',',by in fact)for as Sfa c, Prr S '� (type of authority,e.g.officer,trustee,attorney (name of party on behalf of whom ins nt was execu Personally Known j OR Produced Identification Notary Signature Type of Identification Produced Name(print) J''1J/ C N111111111// • SSION dpi i. Verification pursuant to Section 92.525,Florida.Statutes.Under penalties of perjury,I declare that I ve� cl ��te�o'rlt8 gstd that the facts stated in it are true to the best of my knowledge and belief. FORMS/Noc,rvsd2007 r� ignature of Natural Person Si i g ove �i� 9''•.•Pubi1C O�� AC# "3 9 5 9496 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#L08082901775 .• - LICENSE NBR 108/29/2008 080006136 CCC057952 The ROOFING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2010 YOWELL, JOHN CARLTON YOWELL'S ROOFING CO 2220 OLD CYPRESS CREEK ROAD LAND 0 LAKES FL 34639 CHARLIE CRIST CHARLES W. DRAGO GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW PASCO COL T'I`Y BUSISS TAX RECEIPT 2(X)8-09 ' Issued pursuant and subject to Florida Statutes and Pasco County Ordinances. Issuance does not certify comp)-. : 1 zoning or other laws. This license must be posted conspicuously in place of business. Expires September 3G Mike Olson ACCOUNT NO: 012664 TAX COLLECTOR TYPE OF BUSINESS: SIC CODE: 1761 PASCO CO NT ORH)A ROOFING CONTRACTOR ofj"ES'''F LOCATION ADDRESS: 4P R ' 2220 OLD CYPRESS CREEK ROAD YOWELL JOHN C »` P LAND 0 LAKES YOWELLS ROOFING COMPANY • v A Y 2220 OLD CYPRESS CREEK ROAD LAND 0 LAKES FL 34639-5437 � , DATE RECEIPT AMOUNT 07/17/08 548176 42.50 L�ILd��L16��iIJJ��J�6d��6J61��d��LIII��Ldl 7 • ACORD CERTIFICATE OF LIABILITY INSURANCE ooiD ool DA03/04/osl PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION J.W. Edens & Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Commercial Ins of Brevard, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 325 Fifth Avenue, Suite 108 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Indialantic FL 32903 Phone: 321-725-7000 Fax:321-725-7856 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Canal Indemnity Company INSURERB: Mapfre Insurance Company 34932 Yowell's Roofing Company INSURERC 2220 Old Cypress Creek Road INSURER o. Land O' Lakes FL 34639-5437 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRAT�I LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM!DD/YY DATE MMIDDIYY 1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X ' COMMERCIAL GENERAL LIABILITY 1 GL90703 03/04/08 03/04/09 PRA UAEMSES(Eaoccuurreennce) i $ 50,000 CLAIMS MADE X ' OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 _ GENERAL A LAGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER , POLICY PE LOC PRODUCTS-COMP/OP AGG $ 1,000,000 AUTOMOBILE LIABILITY 4081500000351 03/04/08 03/04/09 I COMBINED SINGLE LIMIT $500 000 B ' X ANY AUTO (Ea accident)i r ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE ; $ j 1 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY. AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR . �I CLAIMS MADE .AGGREGATE $ �r----, -- ----$ - - DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND ' _ TORY LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? , I, E.L.DISEASE-EA EMPLOYEE'. $ If yes,describe under E - SPECIAL PROVISIONS below ! E .DISEASE-POLICY LIMIT I $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ZEPHRYH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City of Zephryhills NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Registration 5335 8th Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Zephryhills FL 33540 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Theresa C. O'Brien ACORD 25(2001/08) D C 88 FLORIDA ROOFING SHEET METAL&AIR CONDITIONING CONTRACTORS ASSOCIATION INC. P.O. BOX 4907•WINTER PARK, FL 32793• (407) 671-FRSA 1-800-767-3772 • FAX (407) 671-2520 CERTIFICATE OF INSURANCE ISSUED TO: COPY PROVIDED TO: City of Zephyrhills Yowell' s Roofing Company Building Department 5335 8th Street 2220 Old Cypress Creek Road Zephyrhills FL 33540 Land O Lakes FL 34639 ATTN: BLDG. DEPT. Date : 01/07/2008 This is to certify that Yowell' s Roofing Company 2220 Old Cypress Creek Road Land O Lakes FL 34639 being subject to the provisions of the Florida Workers' Compensation Act, has secured the payment of compensation by insuring their risk with the FLORIDA ROOFING, SHEET METAL & AIR CONDITIONING CONTRACTORS ASSOCIATION SELF INSURERS FUND. COVERAGE NUMBER: 870-032393______________ LIMITS 01/01/2008 Workers'Compensation Statutory-State of Florida EFFECTIVE DATE: 01/01/2 0 0 9 Employers' Liability $100,000-Each Accident EXPIRATION DATE: $100,000-Disease, Each Employee $500,000- Disease, Policy Limit REMARKS: Non-cancelable without 30 days prior written notice, except for non-payment of premium which will be a 10 day written notice. This certificate is not a policy and of itself does not afford any insurance. Nothing contained in this certificate shall be constructed as extending coverage not afforded by the policy(ies) shown above or as affording insurance to any insured not named above. This provides coverage for Florida policyholders and Florida domicile employees only. By: 2PIP. By: Brett Stiegel,Administra Debbie Kemmere -Underwriting Manager FRSA-SIF FRSA-SIF