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HomeMy WebLinkAbout08-8348 CITY OF ZEPHYRHILLS • 5335-8TH STREET (813)780-0020 8348 BUILDING PERMIT Permit Number: 8348 Address: 37915 EILAND BLVD Permit Type: COMMERCIAL ZEPHYRHILLS, FL. Class of Work: ADD/ALT COMMERCIAL Township: Range: Book: Proposed Use: COMMERCIAL Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 03-26-21-0010-06400-0031 Improv. Cost: 28,900.00 Date Issued: 9/25/2008 Name: GOLDEN PANDA Total Fees: 504.10 Address: 37915 EILAND BLVD Amount Paid: 504.10 ZEPHYRHILLS, FL. 33542 Date Paid: 9/25/2008 Phone: Work Desc: INTERIOR REMODEL 11 E FLORIDA SUN CONSTRUCTORS INC BUILDING FEE 232.50 ELECTRICAL FEE 35.00 WILLIAMS DENNIS(INDIVIDUAL) PLUMBING FEE 35.00 FIRE PLAN REVIEW FEES 201.60 GERRY POLITSCH ELECTRIC INC o / ______ _ qçQ sLffiI11JJ S CE £6a.' s FOOTER 2ND ROUGH PLUMB MISC INSULATION ILING FOOTER BOND DUCTS INSULATED SEWER MISC. ROUGH ELECTRIC LINTEL MISC MISC. 1ST ROUGH PLUMB PRE-METER INSULATION WALL MISC. DUCTS INSTALLED WATER MISC DRIVEWAY PRE-SLAB SHEATHING MISC. MISC. CONSTRUCTION POLE FRAME MISC. MISC. 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 recording your notice of commencement." CONT CT ØR NATURE PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER K) &Md /i' City of Zephyrhills BUILDING PLAN REVIEW COMMENTS Contractor/Homeowner: Date Received: 'l 37 Vs ;4A f " S Site: �,, / O" �� rr> Permit Type: Approved wino co Approved w/the below comments: ❑ Denied w/the below comments: � C r lnlci o pIu , c2) tI ' LI k c- y � O � o or be S • T. This comm.ent-sheet shall be kept with the permit and/or plans- Kal Switzer ans Examiner Date Contractor andlor Homeowner (Required when comments are present) LETTER OF CONSENT I, "Chun Le Yang" Owner of the "Golden Panda Chinese Buffet", located on 37915 Eiland Blvd, Zephyrhills FL, 33542 Give Consent to General Contractor "Florida Sun Constructors, Inc." to work on the stated job location, upon the approval of the plans that were submitted, at amount of$28,900 Signed, Date 1 Owner, Chun Le Yang Zephyrhills Fire Rescue 6907 Dairy Road,Zephyrhills,FL 33542 Fire Marshal Bus (813)780-0041 Kerry Barnett Fax(813)780-0044 E-mail: kbarnett@fire.zephyrhills.fl.us Plan Review#: 08-103 Project: Golden Panda Number of Pages: 6 with 2 revised on 8 '/s"x 11 Date: September 23,2008 The plan review process has been completed for the interior remodel located at 37915 Eiland Blvd. and is allowed to move forward with the renovation. The comments provided below shall be complied to receive an acceptance final. Should you have any questions,please contact me at the information above. 1. New assembly permit will need to be obtained from the Building Department prior to performing final on the renovation. Inspections to be completed: 1. Building Final KERRY TT,FIRE MARSHAL ***Please be advised this review of plans submitted is a cursory review to assist the contractor in compliance with applicable fire safety codes.This review is not intended to be a final approval of the submitted plans.It is the contractor's sole responsibility to ensure that the plans are in complete compliance with all applicable NFPA codes and local ordinances.In the event that further examination or site inspection reveals areas of non-compliance,it shall be the contractor's sole responsibility,at their sole expense to bring those areas in compliance.The City assumes no responsibility for the contractor's failure to be in compliance with all applicable NFPA codes and local ordinances. ZEPHYRHILLS FIRE DEPARTMENT 6907 Dairy Road, Zephyrhills, FL 33542 Fire Chief Keith Williams Bus(813)780-0041 Fax (813)780-0044 FIRE SERVICE USER FEES Occupancy No.: Plan No.: — l�� Contractor: Pr •4) Business Name: t., arOf Billing Address: o r Business Address: ' \ AL4--A ►ate / __ Business Phone No.: Billing Phone No.: Business Fax No.: Billing Fax No.: Contact: Contact: PLAN REVIEW FEES INSPECTION FEES PERMIT FEE FALSE ALARM FEE Site Plan N/C Annual N/C Sprinkler $50 1st Alarm WC NJ Mufti-Family/Commercial .06 sf 1st Re-inspection N/C Standpipes $50 2nd Alarm N/C (Minimum Charge$25.00 2nd Re-inspection $100 Fire Pump $50 3rd Alarm N/C Plan Revisions DBL 3rd Re-inspection $250 Hoods $50 4th Alarm $100 4th Re-Inspection $500 Fire Alarm $50 5th Alarm $150 SPRINKLER SYSTEMS (Business closed until LP Gas $50 6th Alarm $200 8 0-25 Heads $50 violations corrected) Natural Gas $50 NON COMPLIANCE $150 26 plus Heads $100 SPRINKLER SYSTEMS Fuel Tanks- per tank $50 STANDPIPE SYSTEM Hydro Undergrounds $45 Sparklers $100 Per Riser $50 Hydrostatic Test $65 per system Fire Works $500 FIRE PUMP Acceptance Test $45 per system Camp Fire $25 Per Pump $100 Hydrant Flow $75 Controlled Bum $100 FIRE ALARM SYSTEM Hood/Duct $50 8 0-25 Devices $50 FIRE ALARM SYSTEM Place of Assembly $50 Annual 26 plus Devices $100 System Acceptance $50 Fire Protection $25 SUPPRESSION SYSTEMS Recall Acceptance $50 Flammable Application $50 Annual Wet $50 OTHER Waste Tire Storage $50 Annual Dry $50 Fire Wall/Smoke Wall $15 per wall Generator<KW $100 CO2 $50 LP Gas $25,pertank Generator>30 KW 150 Other $50 Natural Gas $25 per system Bio-Hazard Waste $100 Annual KITCHEN EXHAUST Fumigation Tenting $50 fl Hood/Ducts $50 Tent 10x10 or greater $15 per tent Torch Pot/Applied $50 OTHER Fire Pump $45 Haz.Materials $100 Annual LP Installation per tank $50 Fire Suppression $30 Fuel Tank Installation $50 System Acceptance (Per Tank) $50 Exhaust Hood/Duct -$30 Natural Gas Installation $50 8 Re-inspection DBL (Per System) (other than annual) Spray Booth $50 fl Inspection scheduled DBL and cancelled less than 24 hours 8 Construction Insp. N/C Emergency Vehicle AG $50 FALSE ALARM PLANS TO AL= INSPECTION TOTAL!____ PERMIT TOTAL TOTAL GRAND TOTAL Comments: Date: Z3 fl Insgl,gctor: ' @9/24/2008 11:34 8137791635 DENNIS WILLIAMS INC PAGE @2 _�• ^ - <. L LIPENr9ING..BOARU , , i.=••a :' :' 854-x,;,; C 01A251 `.' .. .;y F, rM .;��v _:�a4 ::Sila 1;�'\/ �• .. ... _ ��'?�A_a.,pppC)T•y( •.� `[• Y4 ,, .iT.r'� aF!�1i•`�bF',�,(lyMx�" - - h,. .3'�• " i/iti1'• �+y �� � , '^� '„ . `ate. _ ..ire..!, ` •'�'-i:;'i- • J �xk� l F+#f # �AC�� ��i ��; t,: •X;• :,t:.:,.':,r�r � 3.3 '1• '\�3'_?% '1;�: r-"ti,3.:i:�. :1: 'ti�;�;;. 1 .^J_: 1 .7, lie r7r; �.�: .....'' _ p':_„�1::_:`�ly,�'.�': e;'� - .•1rs� a, t�nRf, � � /S��•/`'; t •. ._ .. r .-.;� ••ha .¢ ,.,}�,�:,- _ '�1 ( 1 1� k I7'u y� ;ti .rc>,' ;, �. 11 1i+�5i`4:7 /•.�,, � �� �...�:�' ,� ,�(��,� �. :� .. w r �� l -r;C•,„ (: I+� �; ��a��a`�• „ , °a CAUCK DRAt3OijI • ._:... .: INTERIM BECRETAR• U:IR�D�` Y LAW ' PASCO .COLM. Y BUSINESS. TAX REC I -• PT 2008-O9 7Q"ln9A r and suws to. Iroe a Statutes end Pasco County Ordlnsnces. laeuarico.doos not cwtlfycompliance wkn or otAer laws. TMs I Knee must be Foaled conspicuously In place of badness.Expires September 30, Mike Olson ACCOUNT NO, 020503 j.T,` SIC .CODEr 1711.03 I"-=�'C R TYPE OF IUSINESS-r • PASC COUNTY FLORIDA .PLUMBING CONTRACTOR ,:s;. LOCATION ADDRESS :. i'• 38744''COUNTY 'ROAD 54 DENNIS ° • ZEPHYRNILL5._S: .WILLIAMS INC -`.38744 COUNTY ROAD 54 ZEPNYRNILLS FL 33542-2759 •'•,•� ; ••.:• DATE RECEIPT AMOUNT ;..,'••�.. 111 II 1 1 1 1 1 1 III 1 I1 I I 1 • ••• 07/07/08 $45005 3.1.25 08-07-08 PRODUCER A MATTER OF INFO AIIAATiON Boyd-Wallace Agency ONLY AND CONPERE NO RK lifE UPON ThE CERTIFICATE 2511 Park Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR Sanford, FL 32773 M.TER T E COVE AFFORDED b'(� POLICIES EELoW. (407) 322-0814 ' AFFORDING COVERAGE `�LAINY Auto Owners Ins Co Donald A W iceman, and OONe""" A++ RATED Florida Sun Constructers, Inc 7A, P0Box846C Altamonte Springs, FL 32715 — ... ............. .............. ...... .. ........ -- — �MPAkY 0 TH19 IS TO CERTIFY T At1FD POLICIES OF* URANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTW17HS1ANDPI ANY REQLHREMENT.TERM OR_CONf11TNON OF.ANY CONTRACT OR OTHER 0QCUMENT WITH RESPECTTO WHICI,{THIE., , _ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE.FF0RDED.THE POLICIES DESCRi9ED HEWN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOmONS OF SUCH POUCICS,LINTS SHOWN MAY HAVE BEAN REDUCED BY PAID CLAIMS. CD POLIOr5PPlawa POLICY87iPINA LTA TYPE OP 01SURANON POLIC7f NLNMSil1 OA1161 r) OA'Ie{MNSDgIVY► LSIRIY GEI!R • ITY GENERALAWREGATE $ 2,000.000 ERCIAL GENERA.UASMY 1 PRODIXrra•WMProp AOB $ 2.000.000 jjj a1 72575470-08 06-14-08 106-1409 a�� l� I;���•��� OWNEA'S4COHTAAC'R1R'BPBQIj I EACHOOOURRENCE $1,000,000 —•-! _ FIRE DAMAciE U we%s 0 100,000 I i MEO E7(P onl t 10000 i-AUTOMOBILE LIABILITY �._ AP1 AUTC i ooMelNEoeMICiLELMAfT =500 000 ALLOWN�DAMS 41-916-632-00 - i 4-16-08 04-16-09Y„ ,Y SCHEDULED AUTOS (POrFFS01) VIREO AUTOS NON OWNEDAUTOE i PROPERTY DAMAGE S W ARAQE UABILIVY AUTO ONLY•EA ACCIDENT 0 ANY AUTO _ V OTHER THAN AUTOONLY ? EACH ACC►gfilOT lltCess LIA81LfTY EACH OCCURRENCE S UMBRELLA FORM <THEA THAN — ••---- - S W0RICRS COMPENSATION AIW EMPLOYER&•UASIUTY EL EACH aaaOLhrr ` i ,TIEPFIpPliie►�, BIOL LICENSE # C C 02594 i ELOWEABE•POLICYUMIT j PARTNERS/P.XECUTIVE I ARE EL DISEASE•EA EMPLOY OTHER FAX 813-780-0021 DESCRIPTION OF OPERATIO CIAL fl�INB _ I. _ SHOULD ANY OF 'i I " M!CESCRre50 POLIOIIIS BI!CAMCEW,EO BSFOnn 1II6 — C I TY OF ZEPHYR H ILLS up MtATIDN RATE TIMOR, THE ISBUNO COMPANY WE 5NDSAVOR To MAIL 5335 EIGHT STREET 10 °AYR MINTTlN W. TO THS CENTIRCATE HOLDER NADED TO THE LEFT, SLIT PALUM TO MAI.M M!10'I'ICE SMALL IMPOSE NO OOLIBATION OR UAGNM Z E P H Y R H I L L S, F L 3 3 542 ANY "M uPow co ns oN a5wTATIYB& " °" O73961 Acs 3920981 STATE.OF FLORIDA DRIyAit'`b�EN'T` Ogg gS&'As.I) PROFESSIONAL REGULATION CpNST1itiT :�vI STRY %LICENSING BOARD SE( 2.0.808 .551637 LICENSE'I•TBR: ::. 04/3-5/2008 10800.94584 CGcO259.46:. `.�: Tb,e GENEItAL; CONTRACTOR Named .below•.IS;CERTIFIED:. Under the provisions of. 4;89.,FS Expiration date: AUG 3]., 2010 = ;. WISEMAN, DONALD P .= : % FLORIDA SUN CONSTRUCTER INC, =-;:` 1930 HOBSON ST = LONGWOOD PL 3"2`'50 CHARD CEYST '{ •_ : -':;' CRARLTS W. DRAGO . /: SECRETARY btpLl `SL'1S! QUIREDJ-:BY LAW AC# 3.261103 .STATE OF FLORIDA DEPARTMENT OF BUSINESS:'AND PROFESSIONAL REGULATION CONSTRUCTIO USTRY LICENSINN G BOARD. SEQ#Lo3o6xsoo9e •LU L1Ii1LICENSE NBR 106/13/2007 060780.208 84 7.6 " .:•. The'._BUSINESS.-ORGANIZATION Named.. below I :_,'QUALIFIED Under the proviñiona of; chapter _489 FS. Expiration dato: AUG 31, 2009-- :. :.:L (THIS -IS NOT .A LICENSE ::TO PER ORM WORK!. THIS ALLOWS COMPANY TO DO ;BUSXNESS-: ONLY.' I? IT HAS A.;:QUALIFIER. ) FLORIDA SUN CONSTRUCTERS :INC .' - •• •1930 :.BOBSON. ST • LONGWOOD FL 32750 Clam E.` RXST: HOLLY BEN5UN GOVERNOR flIPL&Y AS cFrJJIRFn Ry LAW SECRETARY SEMINOLE COUNTY BUSINESS TAX RECEIPT RAY VALDES. SEMINOLE COUNTY TAX COLLECTOR PO Box 630 ' Sanford,FL 32772-0630 " Telephone: 407-665-1000 www_seminoletax.org VALID THROUGH 09/30/09 FLORIDA SUN CONSTRUCTERS INC 1930 HOBSON sr Account#:054876 LONGWOOD,FL 32750 REG1n DONALD A WISEMAN (OFF.ICER) State Lie.#-CG CO25946 Qualifier-DONALD A WISEMAN Reeeivt#: 10402008081.503173 Amount Paid: S 45.00 Date Paid:08/15/2008 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation•who CONSTRUCTION INDUSTRY O elects exemption frem this chapter by filing a certificate of election CERTIFICATE OF ELECTION To BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW D chapter. EFFECTIVE 06/14/2007 EXPIRATION DATE: 05/17/2009 Pursuant to Chapter 440.05(17), F.S., Certificates of election to be PERSON: DONALD A WISEMAN H exempt_ apply only within the scope of the business or trade listed on FEIN: 593247411 E the not, a ^4 election to be exempt R BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt FLORIDA SUN CONSTRUCTERS INC and certificates of election to be exempt shall be subject to revocation Po sox 848 if, at any time after the filing of the notice or the issuance of the ALTAMONTE SPRINGS, FL 32715 certificate, the person named on the notice os certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF BUSINESS OR TRADE parson named on the certificate to meet the requirements of this 1- CERTIFIED GENERAL CONTRACTOR section. QUESTIONS? (550) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 08/07/2008 14:43 4073220815 BOYDWALLACE AGENCY PAGE @1 08-07-08 PROOUCBR THIS CERTIFICATE IS ISSUED AS A MATTER OF iNI~ORMATION Boyd-Wallace Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 2511 Park Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Sanford, FL 32773 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (407) 322--0814 COMPANIES AFFORDING COVERAGE -- °AA"Y Auto Owners Ins Co INSURED Donald A W iceman, and CO rf A++ RATED Florida Sun Constructers, Inc — P 0 Box 846 C COMPANY Altamonte Springs, FL 32715 ' COMPANY D T}NS IS TO CERTIFY THAT 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TYPE OF INSURANC$ POLICY NUMBER POLICY EFFECTRIE OOLIGY EXPIRATIO GATE(MMID " DATE pwmm YY) LN n !ENERALLIABILITY GENERAL AGGREGATE $ 2,000.000 COMMERCIAL GENERA1.LIABILI Y'' I - _ "' CLAIMBMADEX,`r OCCUR 7257547O-O8 06-14-08 °`�---�"�'"roP"°° s 2'aoo,000 06-14-09 PERSONAL A ADV xJJURY 31,000.000 OWNER'S&CONTAACTOti S PpOT EACH OCCURRENCE I 31,000.000 FIRE DAMAGE(Anyone%v) S '100.000 MED EXP Any eng pgt S 10,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S 500 000 ALL OWNED AUTOS :41-916-632-00 04-16-08 0416-09 SCHEOULEDAUTOB BODILYIWURY ( S (PM n Pen) 1 HIRED AUTOS HI--- NON-OWNED AUTOS I I BODILY INJURY I Foreccbenq ` $ ^.._..._..__._ -- � PROPERTY DAMAGE $ OARAOE UAOILRY AUTO ONLY-EA ACCIDENT S —H ANY AUTO I„---- OTH ER THAN AUTO ONLY: `' j; ;N`"IMP- tip' EACH ACCIDENT $ EXClBS LIABILITY AGGREGATE! S iJ UMBRELLA FORM I EACH H OCCURRENCE ' S OTHER THAN UMBRELLA M AGGREGATE S ..- I WOMMSCOMPW*ATIDNAND i EMPLOYER$LIABILTY WC s; ";^q'►�'+�+ I I—_zoRY LIMI §Rtiu .afG; S,' ARTNMPRIETCU ,' LICENSE # C C 02594 ' ELF�CHaCC1pENT S PARTNERS/EXECUiIV E INCL ----- EL DISEASE•POLICY LIMB OFFICERS ARE; EXCl OTHER EL DISEASE-EA EMPLOYEE. S FAX 813-780-0021 DESCRIPTION OF OPERATIONBILOOA?KMV EIpCLRSf8PEC1AI.ITlA18 SHOULD ANY OF THE ABOVE DESCRIBED POUCRFB ME CANCELLED BEFORE THE CITY O F Z E P H YR H I L LS IRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 5 3 3 5 EIGHT STREET 1 o DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. 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OSroa3NOIS3O 01 031a0d3a 38 1Sf1/1 S31ONVd3aOSl0 lYllfLLOfla1S N30OIH TIV * aO a3NMO 3H1 .10 ALIIBISNOdS3a 3111 39V SNAU)ONOOO 30VdafS8fS ONV SLV3VI3SV3 3181S1A NON aO 03L)NNl TIV T •03aIl0331 SV STTYM 1SIX3 )aOM3a ONV )IaOM ONLLIV.S 3a0438 SNOISN3MIO ONV SNOUJaNOO ONLLSD(3 AdIa3A ONV )I03H0 INNS a01OYLLLNOO 'Z 53000 WOOL HLM S3ldWOO 031014 SV NOI13f1a1SNO0 'l LON Z i bSoB-P�2 ,1. aL Lu I __ :8�� Vb �r•RaI I j �� s ��gE•[g ��22cc` li zfl r z i lit ., . o a� I ti f z 3 r Sii a«S E- I I II tlil �v�iri� �� 3 A M v i LiL __ __AP 4 O ,a �8£+IIN Da JI0 T T£=00:0 680809ZL06T8 Wd£Z:t0 8Z/9f1V T03'II 3LON/aaxs 39Yd 3I IS'Id0J TI3AIaD2I L .L2IY,Ls 3LVU # (xi ) Xv3 Wd vZ : Q anZ/LOOZ/8Z/onv TO/TO ' d Hoch i NOILDVSN\rxs P. 05 AUTOMATIC COVER SHEET DATE : SEP - 24 - 08 05 : 04 PM TO FAX f : 101098718137800021 FROM : GERRY POLITSCH ELECTRIC FAX #l : 407 365 3884 5 PAGES WERE SENT ( INCLUDING THIS COVER SHEET ) SEP-24-08 05 :03 PM GERRY POLITSCH ELECTRIC 407 365 3884 P. 04 12-04-2006 TOM GALLAGHER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers Compensation law. EFFECTIVE DATE: 12/O4/2OO6 EXPIRATION DATE: 12/03/2008 PERSON: POLITSCH GERRY FEIN: 800104314 BUSINESS NAME AND ADDRESS: GERRY POLITSCH ELECTRIC INC 1303 ALFONZO CIRCLE WINTER SPGS FL 32708 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED ELECTRICAL CONTRACTO IMPORTANT: Pursuant to Chapter 440 . 051141, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this unction may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt... apply only within the grope at the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S„ Notices of election to be exempt end certificates of elactian to he exempt stroll be subject to revocation if, at any time oiler the filing of the notice or the issuance Cl the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time Ion loilure of the person named oa the cert;licate to meet the requirements of this section. QUESTIONS? (8501 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 SEP-24-08 05 :02 PM GERRY POLITSCH ELECTRIC 407 365 3884 P. 03 ACORD.N CERTIFICATE OF LIABILITY INSURANCE OATE,MM/Z005) 04/14/2008 PRODUCER (407)788-3000 FAX (407)788-7933 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Insurance Office of America, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 162207 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BEPOLIC' S BELOW. Altamonte Springs, FL 32716-2207 INSURERS AFFORDING COVERAGE NAIC 8 INIW Gerry Polltsch Electric, Inc. INSURERA: Old Dominion Ins. Co 40231 1303 Alfonzo Circle INSURER B. Winter Springs, FL 32 708 INSURER C INSURER 0 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 AH-OHUED 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. TYPE OF INSURANCE POLICY NUMBER POI.4Y EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY MPG69626 04/10/2008 04/10/2009 EACII OCCURRENCE $ 1,000.00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 500,0 CLAIMS MADE LI JI J OCCUR MED EXP(Any one person) $ lop 0 A — PERSONAL&ADV INJURY $ 1,000,0 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000 0 POLICY T PRO LOC ' JEC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Pet person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) _ —,__— PROPERTY DAMAGE (Per accident) OARAOE LIABILITY AUTO ONLY-EA ACCIDENT 5 ANY AUTO OTHER THAN EA ACC S AUTO ONLY AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR []CLAIMS MADE AGGREGATE $ DEDUCTIBLE _ $ RETENTION $ WORKERS COMPENSATION AND WG S7ATU OTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? E L.DISEASE-EA EMPLOYEE S M yyeea,describe undo: -- SPE.CIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S OTHER OE RIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS TIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL • City of Zephyrhills 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, • au11 ding Department BUT rAILURE TO MAIL OUG11 NOTIGC O11ALL IMr•OOC NO OOLIOATION OR LIABILITY 5335 8th St. OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Zephyrhills, FL 33542 AUTHORIZED REPRESENTATIVE II Mark Manfre/TRICIA 25(2001/08) FAX; (813)780-0021 ©ACORD CORPORATION 1988 � I� POLICY j cT LOC AUTOMOBILE.LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY S (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accitlenl) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per actidenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXGESS/UMBRELLA LIABILITY EACH OCCURRENCE _ $ OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLE _________________-- RETENTIONS i S WC STATU- I 1OTH- WORKERS COMPENSATION AND I TORY11m1 - .E& EMPLOYERS'LIABILITY E L EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEM$ER FXCI UDFD7 E L DISEASE-EA EMPLOYEE 3 M s,Oesonbe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT 3 OTHER CRtPT10N OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL I o nAVQ woITTFN WnTini:Tfl THE f:FBTIFI(;ATF N(H { ACOBDM CERTIFICATE OF LIABILITY INSURANCE oii4/2009 t0QUCER (407)788-3000 FAX (407)788-7933 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Insurance Office of America, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR 3.0. Box 162207 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Altamonte Springs, FL 32716-2207 INSURERS AFFORDING COVERAGE NAIC 4 Gerry Politsch Electric, Inc. INSURERA: Old Dominion Ins. Co. 40231 1303 Alfonzo Circle INSURER 8. Winter Springs, FL 3Z708 INSURER C: INSURER 0: INSURER E :OVERAGES 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 OH U I HER DOCUMENT WITH RESPECT TO WI IICH THIS CERTIFICATE MAY BE ISSUFn 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. TYPE OF INSURANCE POLICY NUMBER PODGY ECTNE P Y EJIPIRA LIMITS GENERAL LIABILITY MPG69626 04/10/2008 04/10/2009 EACH OCCURRENCE S 1,O00,00 X COMMERCIAL GENERAL LIABILITY DAMA E TO RENTED f 500,00 CLAIMS MADE a OCCUR MED EXP(Any one person) $ _ 1O 00 I. PERSONAL&ADV INJURY $ 1 0O000 GENERAL AGGREGATE S 2,000,00 . T soot ics Oro PRODUCTS-COMP/OP AGG S 2 000 00 SEP-24-08 05 :01 PM GERRY POLITSCH ELECTRIC 407 .365 3884 P. 02 + � SII SST.AX REC'FiPT F'� NOLE COUNTY SL'SI. F ' k \ \ ' t DES. SEMI\OLE C'OL`N71' TX CUI.I LC' 1'Oit rt) IIo O ' Snrord, ri. )2772.0630 fckp 1 111t ,senh1floIvt.iS.0r1 — VAT TD THROUGH 09,'30!09 GERRY• POLITSCIL ELECTRIC INC Account N:007922 1303 AL.FON7.O CIR WINTER SPRINGS, FI. 32708 RF.(il l a'fl L.) Statc 1..ic.� - F.C 1J00178 CURRY 4 POUTSCH (OW1i:R) Quoitficr. GERRY PULL 1 SCH Rccul t 9: 10272008082002286 Amoun PaJ__d: $45.00 Dulc Paid: 08,20;1008 SEP-24-08 05 :01 PM GERRY POLITSCH ELECTRIC 407 365 3884 P. 01 Li 3794971 . •bLP�h pp' M�` ' gg N I.� ItE�uL�TION xR R � C �N HOARD L �+,.•ti:r, („ SEQ* o 052200632 • sZI DRICAL Cots 1 s :_: - _ � I :waled below 20 C$RTgZ XEQ . wiz the Pdat : AVO 31 iracica date : `�:':• +w SCH ERRY J1 T °: !1 p g Ii? % RY �RxST 1, ' CHUCK D 90 GO '(-- : '' INTERIM SECkETARY ._..____._..._ AtAI�AY "}2�QU'IRE0 BY LAW I3o3 A .ro,3zo 14ec 813-780-0020 City of Zephyrhills Permit Application raj ✓Fax-813-'80 0021 Building Department Date Received, —]--UF3 Phone Contact for Permitting4/ 7 I 1jt -- 953Y I Owner's Name C kN 4' 11nZ Owner Phone Number 7 5' N . c � �wrlf Owner's Address D Owner ner Phone Number Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address JOB ADDRESS aacO1 1 wlyx 5 #73 5 iui,,,514 Z#y'b'// F 5i LOT# I I SUBDIVISION I PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED e NEW CONSTR ADD/ALT �] SIGN = MOVE = DEMOLISH INSTALL REPAIR PROPOSED USE = SFR COMM = OTHER TYPE OF CONSTRUCTION = BLOCK = FRAME = ST EL = OTHER DESCRIPTION OF WORK , .A flee ' &h1 BUILDING SIZE SQ FOOTAGE HEIGHT �' �� BUILDING $ �3 bO'O VALUATION OF TOTAL CONSTRUCTION ELECTRICAL $ _ AMP SERVICE = PROGRESS ENERGY Q W.R.E.C. If E0 PLUMBING $ y0O' •� = MECHANICAL $ iA VALUATION OF MECHANICAL INSTALLATION 0()& EIIII GAS = ROOFING = SPECIALTY OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA =YES ONO BUILDER r ,t COMPANY ZLc SIGNATURE REGISTERED Y/ N I FEE CURRENT I Y/N Address .O. OTC C ♦ /NL License# K-Gc cpz6w ELECTRICIAN /41 z7,-L)J } COMPANY I kI POLE sc4 9Z71L LL- SIGNATURE /3o3 r^ � /' ` REGISTERED Y/ N FEE CURRENT Y/N Address f -30 3 /4 � rairo 2Q (9i& /nJ!-LS LPL/¢ License# EC 13 310 /7 6 ≥- PLUMBER COMPANY ,`.N " �vt ' ��/'r . SIGNATURES REGISTERED I Y/ N I FEE CURRENT F Y/N Address �i 334 ' License# MECHANICAL //tl COMPANY SIGNATURE / Ia REGISTERED I Y/ N I FEE CURRENT I Y/N Address I License# OTHER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/N Address I 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. III 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 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 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 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 OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF l MENCE ENT. FLORIDA JURAT(F.S. 117. 3) OWNER OR AGENT o l!G- CONTRACTOR Sus bed and sworn to(or affirmed)before a this Subscribed O or a r b me this �3vioe by by Who Is/ar perso ally knovfgl to me or has/have produced Who Is/are personally known to me or has/have produced I{ �j^ - 1506 as Idenfifica o-t�n— F L��- � 5 g� y�" a as identification. LL V—l`1-w Notary Public Y K�iu � Notary Public Commission NoT � (4"1 E5 1 Commission Name of Notary typed,p njiipTEPHANlE L EBLING name of Notary typed,grin ,tampedp,TEPHANIE L EBLING PAY COMMISSION#DD675514 '', ",: MY t OMMISSION#DD675514 EXPIRES May 16 2011 '> EXPIRES May 16,2011 )407)398 0 RoridaNctaryService.com + i . PlondallotaryServIce.com AUG/08,'2iiU7AVED 10:52 AM ZEf'HiRHILLS BUILDING FX ido, 13 'I 0 i►U 1 F. U)1;'UU1 -• • ••'• Illllillllll 11111 OF COA1II IENCEMENT llllllllll IIIIIIIIII IIIIIIIIIIillllllllllll ' 2008139427 permit No. property Identi£cation No.C'3-2 Z/ /0 -e G S'e o - / `'�'t,o: oa/a aoz, fl 3p ti DP SIGNED hereby.give inform[you that'the improvement will be made toi certain real property,and in accordance with Section 713.13 of the Florida Statutes;the thllowinj hifonnatl,gnis prov 1 in th )4OTJCE OF CO ENCEME I.Description of property(legal descrpIlvm) A4 /h C SL v�'o r•y 4 v ye6yro,dl t5.-4 C5 •Z/ a)-Street Address:. 2'.Qe l description upYflCi1ts: d ..a• . :_/ / ! ' . ( Z dI qei ,44 ,j I r Z yia// 3.Owner Information a);Name and address: 4"G. . 7 '1 , in/G b)Name and address of fee simple titl elder•(if other than owner) m`` c).Znferest in•property f . 4 Contractor Information /� dp s)Name,and address:. a / `sN LK �'6/l .10 /'G . b)Telephone No.: . =—•Fax No.(Qpt•) 5.Surety Information a)Nance and address .a A b)Auwimt of Bond. • c)Telephone No.: -' ' Pax No.(Opt.). m 6.Lender . a)Name and address•. �Ch' Phones No. 7.Identity of person within the 5 to ofPleridiesignated by owwl up whom notices anther gcunments may seivcd: a)Name and address: q 'a" eo bj'I elephone INo:: — om: Pax No.(OIit.) — 8 I addition*to himself,owner designates"the following person to receive a copy of the T,ienor's 11otice as provided in Seaton 713.13(1)(b),Florida Statutes: a)Name mad address b):Telephone No.: _.Fax-No.,(Opt.) m 9.expiration date of Notice of Commencement(the expiration date is one year from the date of•recording unless.a difLbremt date is specified): • WARNING TO OWNER: AivY PAYMENT S.MAHE]BY 11th OWNIIt AFTER THE EXPTBATTON•O1 THE NOTICE OF �m a COMMNCE1AENT ARE CONSIDERED Ir"ROPER PA'Y1MI)I NTS UNDER-CRA 'ER 113,-PA(T I,SECTION 713.13,., FLORIDA STA TUTES,AND CAN REStiL T IN YOUR PAYING TWICE FOR I PRQ'VEM$NTS TO.YOIJR.1'ROFERXY. A NOTICE O COMMENCEMENT MUST 1sE RECOlWEI)AND•IPOSTED ON'TRE JOB SITE BEFORE THE uffEST IV3 .k1NSI']EG 'ION. IF yOU•INTEND-TO OBTAIN FINANCING,CONSULT YO1J1 LENDER OR AN ATi ORNEI'BEFORE n 0 COMMENCING WORK OR RECORWING.YOUR NOTICE OF 9OMMENCMENT. STATE OF FLOhfl)A G • COUNTY OF PASGO • • •t 3ignatura of 0 er or OwaoZZ77 . c+r rn PrintNwao, . • The foregoing instrument was aclmowledged before me this`______d of__MC_ 2Q ,b9 as ___________(type of euethority,e.g o$1cer;trustee,attorney in fact)for _•._••_• (name of party on,behalf of whom instrument was executed). Personally Known OR Produced Identification Notary 5ignnture ) tk t <(print)Name o� _-( - • Type of Identification Produce �1 .L-• .. . ro Verification pursuant to Section'92.525,Florida Statutes tinder penalties of perjury,I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge'and belief. �oo4v P" STEPHANIE L EBI.ING /� . l/ _ . *• `" Ml'COMMISSION#DD675514 Slgnrtttue ofNeturel Person nq AboW¢ a EXPIRES May 16,2011 (4W)399-0+`? FtoriAallotaryService.corn ...--.— STATE OF FLORIDA COUNTY OF PASCO THIS IS TO CERTIFY THAT THE FOREGOING IS A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE OR OF PUBLIC RECORD IN THIS OFFI E V H D AND OFFICI L SEAL THIS T C PI LEI F CIFj�UI OUt�w,, �" BYtT7f1 A C "\ T I `� CITY OF ZEPHYRHILLS 5335-8TH STREET (813)780-0020 8349 ANNUAL ASSEMBLY PERMIT es _ Permit Number: 8349 Address: 6251 FORT KING RD Permit Type: FIRE PLACE OF ASSEMBLY ZEPHYRHILLS, FL. Class of Work: FIRE-PLACES OF ASSEMBLY Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 03-26-21-0010-09500-0000 Improv. Cost: Date Issued: 9/24/2008 Name: ALLIANCE CHURCH OF ZEPHRYHILLS Total Fees: Address: 6251 FORT KING RD Amount Paid: ZEPHYRHILLS, FL. 33542 Date Paid: Phone: Work Desc: PLACES OF ASSEMBLY-THE ALLIANCE CHURCH OF ZEPHYRHILLS-NO CHARGE PER FIRE PERMIT FEES 0.00 Iv FIRE SITE INSPECTION-Final OCCUPANCY LOAD: Occupancy by more than the number of persons above shall be considered dangerous and unlawful. Occupant load determined by Florida Fire Prevention Code, NFPA101, Section 7.3.1.2 FIRE MARSHAL OFFICE: 813-780-0041 I IC R PERMIT EXPIRES IN ONE (1) YEAR FROM DATE OF ISSUANCE THIS PERMIT NEEDS TO BE POSTED IN VISIBLE LOCATION IN MAIN ASSEMBLY AREA ZEPHYRHILLS FIRE RESCUE DEPT - 6907 Dairy Rd, Zephyrhills, FL 33542 813-780-0020. City of Zephyrhills Fire � (j� Fax-813-780-0021 Permit Application t Date Received I Phone Contact for Permit .. �..,,.... . ....,,.. ........ ........ w. ,. Owner's Name crnZ 7L / Owners Phone Number 74 I '65 I AtcOwner's Address f Fee Simple Titleholder Name Titleholder Phone Number Fee Simple Titleholder Address ttti _____________ Job Address Lot# Sub Division Parcel# �..E.,::': , ...u:a..zo".F:�� „ �,t.a ..,::.srr„�`.,.ts��...z .;wx�; ,�' �'"'Wts*,J ,.'=w� .,.'.'�� ��k ,,3aS, €� ,....,�...::�✓"�'�is,.N;�,w.�������u.m;:�?�f ' 3� ,��F.:..:M.�**�..a ,..,,.,�4:���€� a i.,.�...::��. Bio-Hazard Waste Storage-ANNUAL Fumigation Tent Comm Exhaust Kitchen Hood/Duct Hazardous Material(Tier II or RQ Facility)ANNUAL Controlled Bum Hood Installation Emergency Generator<30 kw LP/Natural Gas-Installation Emergency Generator>30 kw LP/Natural Gas-ANNUAL Sale Fire Protection Maintenance-ANNUAL Places of Assembly-ANNUAL .j( t tlI y emi ®n Other � Sprinkler ❑ O ❑ Recreational Bum Fire Alarm ❑ ❑ O I Sparklers Hood Cleaning ❑ ❑ ❑ Sprinkler System Installations Hood Suppression O ❑ ❑ I Standpipes(Sprinkler Sys) Fire Alarm Installation Torch Roofing/Tar Kettle Fire Pumps Waste Tire Storage ANNUAL Fire Works Flammable Application-ANNUAL II Valuation of Project Fuel Tanks Other: k ''k � '' Contractor Company Signature Registered Y/N Fee Current j Y/N Address License# ELECTRICIAN Company Signature Registered Y/N Fee Current I Y/N Address License# PLUMBER Company Signature Registered Y/N Fee Current Y/N Address License# MECHANICAL Company Signature Registered Y/N Fee Current Y/N Address License# OTHER Company Signature Registered Y/N Fee Current Y/N Address I License# ...uz ,:.es . '..:' ". rr;s..i., u..�;..s ... Directions: 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(http://appraiser.pascogov.com) `NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit maybe 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. CONSTRUCTION LIEN LAW(Chapter713, 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. 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 OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. FLORIDA JURAT(F.S.117.03) OWNER OR AGENT CONTRACTOR Subscribed and sworn to(or affirmed)before me this Subscribed and swornto(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