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08-8463
CITY OF ZEPHYRHILLS 5335-8TH STREET (813)780-0020 8463 BUILDING PERMIT Permit Number: 8463 Address: 6026 GALL 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: 03-26-21-0010-12800-0000 Improv. Cost: 25,500.00 l ,F � iS Date Issued: 10/31/2008 Name:x HESS Total Fees: 305.00 Address: 6026 GALL BLVD Amount Paid: 305.00 ZEPHYRHILLS, FL. 33542 Date Paid: 10/31/2008 Phone: Work Desc: INTERIOR REMODEL FOR CHANGE OUT COFFEE EQUIPMENT DMAR GENERAL CONTRACTING BUILDING FEE 210.00 ELECTRICAL FEE 35.00 EXPRESS ELECTRIC OF TAMPA BAY IN PLUMBING FEE 35.00 FIRE PLAN REVIEW FEES 25.00 EXPERTS IN PLUMBING LLC 42 ?7 ° ., .. FOOTER 2ND ROUGH PLUMB MISC INSULATION CEILING 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." O TRACTOR SIGNATURE PERMIT OFFI R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER • D-MAR General Contracting And.Development, Inc. 1.453 Martin.Luther King Jr.Avenue S, Clearwater,Florida 33756 • (727)461.-476Q-Fax:(727)442-0752 Building-Department April 24 2009. 5335 8 'Street Zephyrhills,.Florida 33542 Re: Perm.it..# 8463 To Whom It May.Concern, We wish to cancel the above captioned permit# 8463 for an interior alteration to the Hess Station located at 6026 N Gall Blvd,Zephyrhills, Florida 33541. Our client has decided to cancel:the proposed work to be done,and h.as asked.us let the permit expire. I am aware that the permit is expiring:April 29, 2009Should require any further information from me may I ask that you respond accordingly to me. Thank you.for your assi.stance.in this matter. Don' bridge. Director of Operations Cell 727,421-6523 , www.d-mar.com 1453 MARnN LIMER KING JR. AVENUE S- CLEARWATER, FLORIDA 33756 Office 727 14760 Fax 727.442.0752 To: Pa9esa Fax: /j' - 6 ^o0 2-- Phone: S`,3 7 Fax. Z -yq y Q Urgenx ■ For Review ❑Please coemnent Q Please Reph► O Please Recycle 6907 [;)airy Road, phyrhiUs, rL. 33542 He i 1 Cii Ke th 'ti`v1 1"s ms iu (313) -80-0041 Fox (813) 3C i 0 4 FIRE SERVICE USER FEES Occupancy No.: Plan No.: — Contractor ( 1 'i4 Business Name: Si"j'IS Billing Address: /be. Ste. P� Business Address: & ( 4 Wes 3. 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 let Alarm WC Multi-Family .06 sf let Re-inspection WC Standpipes $50 2nd Alarm N/C (Minimum C 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 EJ0-25 Heads $50 violations corrected) Natural Gas $50 NOM COMPUANCE $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 systarn 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 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 WaluSmoke Wall $15 perMau Generator<KW $100 CO2 $50 LP Gas $25 pertank Generator>30 KW 150 Other $50 Natural Gas $25 per system BID-Hazard Waste $100 Annual KITCHEN EXHAUST Fumigation Tenting $50 Hood/Ducts $50 Tent 10`x10 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 Re-Inspection DBL (Per System) (other than annual) Spray Booth $50 JJ Inspection scheduled DBL and cancelled less than 24 hours 8 Construction Insp. N/C Emergency Vehicle Aa $50 FALSE ALARM PLANS TOTAL n r- INSPECTION TOTAL= PERMIT TOTAL! I TOTAL GRAND TOTAL 7�dy Comments: Date: �/ ,j Ins ctor. g �JG[t� Zephyrhills Fire Rescue 6907 Dairy Road,Zephyrhills,FL 33542 Fire Marshal Bus (813)780-0041 Kerry Barnett Fax(813)780-0044 E-mail: kbamett@fire.zephyrhills.fl.us Plan Review#: 08-13r/o Project: Hess# 09415 Number of Pages: 2 Date: October 29, 2008 I have reviewed the plans for the interior remodel to add a coffee line and small convection oven located at 6026 Gall Blvd therefore allowing this project to move forward. Paying for the permit acknowledges the contractor agrees to the items below. Should anyone have any questions, please do not hesitate to contact the Fire Marshal's office. 1. Change out exit lights at front door and rear door to combination exit/emergency lights or add separate emergency lights in those areas. 2. Install emergency light in restroom. 3. Rear exit shall have only one releasing motion. Install panic hardware or a hotel latch, (A lock that will always open from inside whether it is locked or not but can not open from outside without a key) 4. Ensure the oven is used in accordance with manufactured specs and only used for warming of donuts.If at any time a product is found in the oven that produces any type of grease laden vapor the oven will be removed from service until it is properly protected. Inspections Required: 1. Final KERRY BARNETT, 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. City of Zephyrhills BUILDING PLAN REVIEW COMMENTS Contractor/Homeowner: ID M90�& Date Received: I 0 - u Site: (D ? P Cpq ( ( a t Permit Type: 4 (J ` '�`` Jam' Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑ This c0n1me7t sleet sh 1 be kept with the permit and/or plans. Kal wi —Pl Examiner Date Contractor and/or Homeowner (Required when comments are present) 813-780-0020 City of Zephyrhills Permit Application 1 `�3 Fax-813-780-0021 It Building Department Date Received V'�?i` Phone Contact for Permitting O,lllllUJIIIHIIllIIIIIUJ. dM � � ( j ¢ f✓ �jT, �, Owner Phone Number I 3 ' SU -1 y Owner's Name ✓ o7��s Owner's Address U /l44..t Ohs 7. 4 w00O 0 0 17? Owner Phone Number Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address I ` J JOB ADDRESS (� i16 b L 6,4// / Z c if 'e,q'Z/ ' 3 LOT# C� SUBDIVISION 1A rl/S w`V PARCEL ID# V -Z6 Z! -to/O -I L `wl a (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED e NEW CONSTR - ADD/ALT L SIGN MOVE DEMOLISH INSTALL REPAIR PROPOSED USE Q SFR COMM O OTHER TYPE OF CONSTRUCTION f BLOCK FRAMEJ, STEEL OTHER nn DESCRIPTION OF WORK /LT �'O� h� A Ot OT BUILDING SIZE SQ FOOTAGE 2O HEIGHT BUILDING $ .Z ' VALUATION OF TOTAL CONSTRUCTION 2' , ccrO �'— ELECTRICAL $ ZVU O AMP SERVICE PROGRESS ENERGY /� W.R.E.C. �-- PLUMBING $ v MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION GAS ROOFING SPECIALTY OTHER V FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA YESUIfflUU 4L IL"�IZ (K Il-P�1/ vt T17J1'T//LO C.(J BUILDER v 1 COMPANY SIGNATURE REGISTERED Y/ N FEE CURRENT I Y/N Address /�/ Tz✓I 141J k.,� J/.�� S C'� -r� License# GG _ irU v ZLL 6AELECTRICIAN 1X % COMPANY �Y �—G l C7 r c' 4 SIGNATURE "' \\\(, flf REGISTERED Y/ N FEE CURRENT I Y/N Address License# s e- i 300�/ PLUMBER COMPANY KiZx:,r,, P/ 4.u SIGNATURE REGISTERED Y/ N FEE CURRENT Y/N Address ) OO 1✓1CL S trtt License# / Z6 2 3 j MECHANICAL I COMPANY SIGNATURE I REGISTERED I Y/ N FEE CURRENT Y/N Address I License# OTHER F COMPANY SIGNATURE I jREGISTERED I Y/ N I FEE CURRENT I Y/N Address I License# II II III(IIIIIIIIIIIIII IIIIIIIIIIIIILILILLLI 1111 ILIlIlILI LIII LIII LIL IIILIIIIIIIIIIIIIII IIlIIIIIIiIIIIIIIIIII IIIIlI1llIIIILlILl 1111IIIIL1111 11111111 IIILIIIIILLLIIIIIIIIIl IIILIIIIIIIIIIIIII 11111111 IIII'ILIIIIIIIILLIIIII I 11111111 IIIIIIIIIIIILIIIII III 111111111111111 1111111111111 IlLIllIllIlIl IIIIIIIIIIIIIIIIIIIIIII LILLIIIIIIIIIIIIIIIIII I .. ..'' RESIDENTIAL Attach(2)Plot Plans;(2)sets of Building Plans;(1)set of Energy Forms;R-O-W Permit for new construction, Minimum ten(10)working days after submittal date. Required onsite,Construction Plans,Stormwater Plans wi Silt Fence Installed, Sanitary Facilities&1 dumpster;Site Work Permit for 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. lIIjIIL11IIIILIIII1III IIIIIII IIIILIILII_IIIiIII_IIII_LII 111111111111111 111111111 IIIIIIIIIIIIIIiIiIIIII 111111111 111111111 111111 IIIIIIIIIIIIIIIII.I11III1II1II IIIIIIIIIIIIIILJ_II_III1II1II1I.II_IIIII_II1I 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 TICE 9F COMMENCEMENT. FLORIDA JURAT(F.S.p 117.03) /� A OWNER OR AGENT �fi�`��(1 d40 CONTTRACTOR Subscribed and sworn to(or affirm e1)befo me this Subscribed and sworn to r affir ed)before me this Zr DOV Oc.v by UHF ©oa s Zisr .f c i by D2L rsa,o€i L_ Who is/a ovally knovin to me or has/have produced Who is ar rsonally known to me or has/have produced as identification. as identification. Notary Public Notary Public Commission No. bD(oS fP l 9� Commission No. U�to8(o 19 S� stE ri'c , S, s►� Name of Notary typed,printed or statriped Name of Notary typed,printed amped SARA SHIPLEY SARA SHIPLEY Notary Public,State of Florida Notary Public,State of Flodde My Comm.Expires June 17,2011 My Comm,Expires June 17,2011 No.DD686195 No.OO686195 D-MAR General Contracting and Development, Inc. A Woman Minority Owned Business 1453 Martin Luther King Jr. Ave. S. Clearwater, FL 33756 State Certified CGC1504222 877-660-0667 Toll Free 727-442-0785 Fax 727-461-4760 Office DRUG FREE WORK PLACE Date: `'J. C I CONTRACT CUSTOMER: PROJECT: Installation Dunkin Donuts WEPROPOSE TO: • Install Dunkin Donuts equipment, mill work,electrical as depicted in plans and specifications provided by owner. PRICING Twenty Three Thousand and No Cents...........$25,500.00 Payment to be made as follows: Fifty percent(50%)of total cost upon acceptance and the remaining Fifty Percent upon completion. A change order will be issued upon discovery of hidden damages or added work not stated in this proposal. GUARANTEE All work performed by D-Mar General Contracting&Development, Inc.will meet or exceed local and state building codes and manufacturer specifications.All Required permits will be pulled and posted at the job site.Work will be performed in a neat,timely and professional manner. D-Mar General Contracting&Development, Inc. is licensed and insured.We hereb propose to furnish labor and material-complete in accordance with the above specifications. Authorized Signature: This proposal may be withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the work as specified. Payment will be made as outlined. SIGNATURE . ;l v'-.. DATE �'I� C) . SIGNATURE SIGNATURE DATE ________________________2y/� NOTICE OF COMMENCEMENT PermTax Fot lio 2008151965 03-26-21-0010-128b0-0010 I I0III VIII VIII IIII VIII VIII VIII VIII VIII VIII IIII hill 200815196 THE UNDERSIGNED hereby gives notice that 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 description): Zephyrhills colony co lands PB 1 PG 55 part of tracts 113&128 desc as com at se corner sec 3 th noodg 25'50"w 497.30 a)Street(job) Address: 6026 Gall Blvd Zephyrhills,Florida 33542 2.General description of improvements: Interior alteration Rcpt:1208971 Ree 10.00 DS:10 00 3.Owner information IT: 0.00 10/177/0/0 8 __�Dpty Clerk a)Name and address: Amerada Hess Corporation One Hess Plaza Woodbridge,New Jersey 07095 b)Name and address of fee simple titleholder(if other than owner) N/A c)Interest in property N/A 4.Contractor Information a)Name and address: D-MAR GENERAL CONTRACTING-1453 S.MLK JR.AVE,CLEARWATER,FL 33756 b)Telephone No.: 727-461-4760 Fax No.(Opt.) 727-442-0752 5.Surety Information JED PITTMAN PASCO COUNTY CLERK a)Name and address: N/A 10/17/08 03�:02pm 1 of 1 b)Amount of Bond: N/A OR BK 7949 PG 1195 c)Telephone No.: N/A Fax.No.(Opt.) N/A 6.Lender a)Name and address: N/A N/A Phone No. N/A 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: D-MAR GENERAL CONTRACTING-1453 S.MLK JR.AVE,CLEARWATER,FL 33756 b)Telephone No.: 727-461-4760 Fax.No.(Opt.) 727-442-0752 10.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 1,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 TH JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,CONSULT YOUR LENDER OR AN ATTORNEY BEFO COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. 10. Bud, SARA SHIPLEY Signature of O er or Owne A04 Authorized Officer/Director/Partner/Manager. Notary Public,State of Florida My Comm.Expires June 17,2011 No.DD686196 z Qy . . Print Name The foregoing instrument was acknowledged before me this ( 8 day of Srr�Tre�t86� , 20 .. by �"' tea---- o o as Qü.J t P & 0fS6w r A'fI / v (type of authority,e.g.officer,trustee, attorney in fact)for %A*0 4- 111« (name of party on behalf of whom instrument was executed). Personally known OR Produced Identification Notary Signature ______ � Type of Identification Produced Name(print) Js4t�t � pL Verification pursuant to Section 92.525,Florida Statutes. Under penalties of perjury,I declare that I have read the fore going and that the facts stated in it are true to the best of my knowledge and belief. Signature of N tural Pers n Signing(in line#10. )Above STATE C FLORIDA COUNTY OF PASCO THIS IS TO CERT''.�Y THAT THE FOREGOING IS A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE OR OF PUBLIC RECORD THS OFFICE WITNESS MY HAND A FFI IAL SEAL TH'.S_ DAY OF JED TMA LER' CIRCUIT C( AT BY LCC!FR!< 10-22-2008 02:45 EXPERTS PLUMBING 7275070228 PAGE1 EXPERTS IN.PLUNONG JIM-HOLZHAUER 5300 HOMER STREET r. CLEAR WATER`FL, 33760 ((727);4651060.:CELL (.727).5364388 OFFICE (727) 507 2Z8 FAX STATE LICENSED CF.C.°:`f426 23 Date: \ D - c�-� To - \- - \- \ s From: Re: \ - c c;;r Fax Number: V22 cfl Z T Number of pages including cover sheet Comments: Cv e d t c .\ The Information Contained in this fax transmission Is confidential.It is intended only for.the Individual or agency to whom it is addressed.If the reader of this message Is not the intended recipient,you are hearby notified that any dissemination, distribution or copying of this communication Is prohibited.lf you received this communication and error,Please notify us immediately by Telephone end return the original by postal ssrvlce.or desttoy. 10/23/2008 12:35 7274420752 D—MAR GENERAL CONTRA PAGE 08/11 10 i?^c-29083 02:34 EXPERTS PLUMBING 727500708 PH(ar4 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFBBBXONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 • 1940 NORTH MONROE STREET • TALLAHASSEE FL 32399-0783 HOLZHAUER JAMES LEE EXPERTS ITT PLUMBING LLC S300 HOMER ST CLEARWATER PL 33760 _ 038 r6 p � -� Z, —� Z 7 — C/ S'S —1 ° ti£j'13 l N.c= r,�+,� ,'�:' • .F•....vv,.yanThOFCet.QR!T�. l'.r..'��»`�y.�h�:�>:+.,.'.J,,:.•�;:,,'i'�Jj. Congrstulationcl With this Mac non you become one of the nearly one million Florldlans licensed by the Department of Business and Professional Reguation. ��'Rg ' L R Our professionals and businesses range from architects to yacht brokers,from ".,`:' `:;•'``":' _.': ;. boxers to•barbeque restaurant,and they keep Florida's economy strong. ZE2 3 ::'O7'/23O8:;pg0 >! Every day we work to Improve the way we do business in order to serve.you batter. ; For information about our cervices,please log onto www.myforideitcense,conn. :; �TIsF'I .,;. ! .C There you can find more Information about our divisions and the regulatione that OLZr ,;. L ,:' <,. n sletters and learn more about the ii WaC' Impact you subscribe to department aw �•�`' �' Department's Initiatives. Our mission at the Department is:Ucense Effltiently,Regulate Fairly.We con-stantly strive to serve you better so that you can serve your customers. :'• ,; '' g�yy ,, i;* !nsoDr� 'cirr4' Thank.you for doing business in Florida,and congratulations on your new Eicenael y, ,, ,rr0;� .2S . Y'.-7. [�,.•.tli Mrj• J .1`. .it•�% :�YSIr DETACH HERE .,: :n..q.IF4:, .q -r 'IIrpC•7,u:ars1 ^ pl+..,..._c•:' .' 1r rr^• v 1 r•. !� :1• w y t g Lyc i9iZVir!` v7@ , '..i. ...': T• • 'i: ;•t..` Q':r. I,'h ,Y:_. .,_ .y .Y.r. - ..tir r L - r ':Jiw • ,.. 1 r ,['1:'". :;•'Jf+—:l:"♦w;=•.•.1.. /•..:. ,� •i:' -''LZ.1`U:Io::r:In.�..�G��i'r: `� 'E,: .•� dun y .. {, •A' ."Jr' •M.` i T1 — i.11 YY ~0' k ,�,�n c TY:..y' }' �'�^�.. In h.'. •J•.' .�. .. f i 1'E i.3 1��. •i ' ar2� F Y OIaP, P r., I,wKt r.D••fl r,41`AW • :::.: 10/23/2008 12:35 7274420752 D-MAR GENERAL CONTRA PAGE 02/11 { AawZ -saa•a wAx c D Auaea { ; 1/.SOI ''u I1U.QR ' Np fOM !^sM1�1100 J r? y �A-13% M 8.09 A amo fF_ �» ISM\1RR t�,IfLMRtA •IOlylll d T.T11�'�� tlMMR10 gn�'MEhfW 1•It ��. - c L 10/23/2008 12:35 7274420752 D-MAR GENERAL CONTRA PAGE 09/11 PHGE5 i0-22-20J5 02:35 EXPERTS PLUMBING 7275071228' 03-20-2007' ALEX SINK STATE OF FI ORIDA' DEpARTMEItFi OF.P 4 M. iVICES. cola.FttrnNctaL ol�rlcER DMSION OF WbRI ERSr COMPENSATION CERTIFlCATE OF ELECT1UN TO 814 EXEMPT.'FROM.ft01RIDA=k:WORIIERSr COMPENSATION W CONSTRUCTION INDUSTRY EXEMPTION This•certifies that the .individual listed below has elet;ted• to be exempt frorli Florida Workers Coltipensatlori IaW EFFEC1'1VE DATE: 03120/200? EXPIRATION DA- 'B3ys/2009 PERSON: HOLZIIAUER JAMES L FEIN: , 760747035 BUSINESS NAME AND ADDRESS: EXPERT5 IN PI.C 7.N12 LLC S 00 HOMER STREET CL.EARWATER FL 33760 SCOPES OF BUSINESS OR TRADE - 1- CERTIPIED PLUMBING Ct]Ni',RACTOR IIMrORTANT, ps""at 10 Cheple, 040 , 06041, F_S_, 4 alfteM of a uaparitiw who rIOMe e:eagld•P (rem ate enopter by liltng a it GILEMP , elIT ow 0n H NN sedlae way 001 nlwrer heee!ite err aaplpeaset10a older IN' chOpter. pureeiP1 to CIMnr 440.06 I ), F.3_, Contflcileo N elErltel to be exempt.,, apply ce MTIIIHI Ito, ,cope of and et r4:ls Of 0.040 Hated en nta netfce Of aleenen he be ,XRMpt. Patmeat to Ch*p1Ar 440.ONNI*, (:.S., N0IIN16 of eleetrae 10 be eceotpr Bed RNdikehre nl arenlen to be exempt ena11 be eabjeel to rrveettlen 11, ,t my 11140 I" IN f►IIej of the suite or tho'lee•0•a al ere cerdfene, ere penes 0.0/04 aR the nentr! or car ifieate 00 loe0er aneta 1110 raearremonn of this 0001100 fir IMeeea Of a cerlRkaro, Tile eopMmmt welt revoke a caAllraete at my 010/0 for (aflen at'1110`perso0 aa•lee an Urn cerlilieele to iMet the reitmoviauU of this MOM,,. 0 1 413-1fi0! 'Ff REVISED 09 09 t1F'Ebb GT10N PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE-REFERENCE ,-r; IMPORTANT t I pp pa F PUrsuent to Chapter 440.05(14). F.S., an ofrioer of n coipo6f.el who `.'p 99.4 voQN-IIfUOUSTRY O elects exerrtptlon frtxtl this entlpter by filln9 a.eerU4lcAte of.elecdtm CCRlIPICA7EOF mmarm ro em E1lwvr.ROM FLCIRIOA L under this ssotien rimy not rerovar benefhs or oofitpensM4oti under tins WiORitl*ps'cifNlPEpasATlOb►f,AW D chapter. EFFECTIVE: 03/20/2007 EXPIRATXON DATE; 02/19/2000 pursuant to CMlpter 440,051121, E:5., Certificates of electiAll to be PERSON: * t1AME$ L HOLxWUIER H exempt. Apply o&y within thA scope of tiM! business or trade listed on 1=EIPk 790747035 E the nedce of election to be exempt. '19USINES$ NAME AND ADDRESS: E Pursuant to fRlepter 440.051131. F.S., Naticee 01 oleetlen to bo exempt 0MRrs IN PLUMBING uC end certificates of election to be exempt ph•II be subject to revocation se , r10MR STREET if, at any time otter the filing of the notice er the itStttMtoo 0f the CIEARM/ATEA F1 33760 certificate, the,person rromed on rho notice or certificate ne ionpr meets the requirements of this section for issutwmeof certificate. The the dapartmeM awl r i oweke • certificate at any me for SCOPE OF BUSINESS OR TRADE person named on,the certificate to meet the requirements of this 1• c!.RTIFIEO PLINAeMO cONTRACTOnSection, nUESTIONS? t90) 413-1609 CUT HER• E +t Carry bottom' portion on the job; k. p upper portion for, your racrords. . OVC-257. CERTIFICATE OF ELECTION TO BE EXEMPT RENSED 09-06 10/23/2008 12:35 7274420752 D-MAR GENERAL CONTRA PAGE 10/11 PRdEa .ø- E- 06 O34 EXPERTS PLUMBING c7597dr'E.S -- �-- t . V n.f 1 �;r...y..; ,:.�� IF:,�i _I,y."�i. . . :,•p°,'s. '..•' .rah;�:.:�,{1��Y))'•:-'4�-:�:;�•s. / �j�,rwi rt X X11^'L,I`r:�r'•:`.I I;�' �;,:'�r1.'q •�l• 4evr'• w•ir'�r' ... ,'oM1 Ctq;<<'li ,.;� /��::'•,/`' '. �'r t{�;., v.' tip:. •tP';, �'Ti,i ,r-i '�jy� I:r�rTI�,IAsw•�;}ra;. +'apti�• 1J 1•'s.:�IJIr' .l Qr�4+�T• ": 1 J v .f4'. ;rrtc r'• ' $1 • '�Jr�•1.:•'�'.'tl��J}✓�.1�.r��•F�,��tY,v�,.l�.t -,A.�A'••�:'' t •r"r ✓` 17th>,•1�t�•`•'V�r� + �a�f�•yMw� �' '�.• V,r Jt �vr�'•,. .`.C,' 10/23/2008 12:35 7274420752 D—MAR GENERAL CONTRA PAGE 11/11 PR-1CaErr_ TS PBING 727507OP-28 ...-- _- 10-22-2f�08 02:� EXPERTS LUM _ _ ..__... ppTIF�IMm>;mt AcIC►,Rz ___CERTIFICATE CAF LIABILITY INSURANCE ,az�ios ...•--�" —.-.— TMIf G T!1 r01A1llJBIJ ARk A MATT OF IN RMATION popk0mleop lMcMneo 2004(ci6gMstar� QM.Y AND CONFERS NO RIGNM UPON THE CERTIFICATE 2287 Gulf to Bay 910. M4LGER.1M CEWM ATC DOTS NOT AMEND,EXTEND OR CIRIIIW*ter,FL 33706 PrI0I1°(727)7e3,97oa R % (777B3477ra INSUWKS AFFORAE�GIcOIM!!AGE - •� Mfc S�ec�altY Insurance Compan NwRW Experts in Plumbing LLC 6300 Homer Street a o; Cleelwahr, FL 33760- II =; (TV)83ao3ee --- ' - -, — INSURER F: NOTwtTH1TD1► T11E PI 6 *F NSUIiA CISU4TCP FIAVF�W�cRN laduco To TMC If1a�1RCG O Y�Rt rf MV ' ANY aEOU1RGMEWT,TRRM OR CONDITION OF ANY CONTRACT OM OTMeR DC NT W'RH RUP5CT TO WMIIG'1 TNIS C 11PIOA1'D MY SE ISSUL", OR MAY PERTAIN.THE INSURANCE AF ORDID BY THE POLICIES DESORIRIED H! IN 10 SUI J!CT 7O All TM!1IiIL!XCWSIDN3 AND cONt flON$OF such PCL1CIi3E.ADOR!0ATE UNITE IlOWN NMY HAVE ►. BV PARC •• InsR AWk Ro61 1 1lpl ON T.I .TYPE OP MU94NOg 'CI.TgY MJIYpBR r R. oA?a 1 Q!NRRAL LdtDEJTY (4 QUM'IINUTAL OeN!RAL UABIUTY EAXOG-F Iwo?/00 10/07/0!e .00eul+ 50.000 CtASAS MAO R Cl OCCUR AilEO pllP fA�r P' II> a00 A t*ItRa`�anla.sA� Y 1,QOO,OGO C _,_, .,__, �. 0BNI ApRAL�REOATE 1 OO0,Ooo PRCp�T CC(tAPIppAGO _ 1.0o0 000 AGGREGATE UNIT APPLIES PRR• `"` .• . .. AUncM09ILE LIABILITY t P SINGLE UMIT .. ANY AUTO — ALL OWNED AUTOS AODf.Y INJURY Li ❑ &CHEDIJLED AIlr0? (Par . j] I•(I11LD AUTOS BCDU.Y INWRY J ❑ NON OWNIC AUTCG ___ � I __-_ - �—... AUTO ONLY- _.• . cL4PAoet LIAee.m►ANYAUTO OT1 CN TI IAN C[_ •� L�• n AUTO ONLY _^App — wxcwSIUMlWM.LAWAe1LrrT QAGMOOC:l1R � o CPpUCTMLE _...,- O 17LTm[TON p�,.� __ 1NWe{UtIwOOY 11Y10N .. •~--- INt,: COFi _ eMPLDviRs'LIAeIILI'TY E.L,rACMr NT's— 1, ANY PNOPUrrOR/PARTNER I UTWC .J OMCeR l MEMBER AXCLU0RA7 &J-E1IAEABRI;EA fiM r ,�_.�.. II es.Ae mndsr vu.DIB1•A+�._p0ulrY LIM T d IONS . . —. „ •"`—^'�' -'� OTHRlR OcRIPT7oN of OpRRA1f10Na!WCATICMVR/ OLNl1aROl." AflOED!!Y BpOOR 1• L PRiMl9111ON1 HOLO GANMGEL L A1101 , ,.-. ---- C:®gTIRICATI CR .�. •_.-..-- $NQULO Mn 0 THE AOCINE DII�CRIBBD POLIOIN BB CANCELLIC MMPORe THE P%FIRIrt1ON PATE YMMEOP,T1r IRIUINO Mr18UR WILL IMDIAVda TO SINN pAYB WRITTEN NOTICR TO THE CWWrN4CATE HOLpIIIR NAMED TO CITY OF L, P YRHILLB TR!L SLIT�T,o R1 LU 70 0010 WALL IMi'CNp No-KJMA �M orl LIAAILIT�• 5335 8TH LLS LT OF ANY KIND UPON THR WISU tIR,05 AGIONTS aR Rr'EROsWNTAtNE- _- ZEPHYRHILLS,FL 3"3642 Mo1WiID11EPlwrailmma ._. I__ I Randy Parker ACORD 2$42501AUII_GP • _ - ----^ eàoD CORPORATidiu 10ae OCT 212 " PME2 10-21-2908 03:58 EXPERTS PLUMBING 727597@E28 10/23/2008 12:35 7274420752 D-MAR GENERAL CONTRA PAGE @1/11 1453-MARTIN LUTHER KING JR. AVENUE S. CLEARWATER, FLORIDA 33756 Office 727-0614760 Fax 727442-0752 To o5 S From: /1 , •e Fax: 613 , -7 80— C2c) Pages: I ' Phone; S!3_ 780-- L 0 pate: 10•L -�O Re: `C�/ls[�. Pte- CC: 7c P/ c LLCM Fax. '1l -1— 'Nt-o75�. f r Cif.c • / �.— ❑ Urgent 0 For Review ❑Please Comment 0 Please Reply O Please Recycle /o L�IL � our Gvr, ��fs�'�- ? r `� A e � te�P 1 .0 fr4 ✓4 ' !s >L^ /99 r S7 i-r Jr4T L L1 CITY OF CLEARWATER DEVELOPMENT AND NEIGHBORHOOD SERVICES '1 MUNICIPAL SERVICES BUILDING, 100 S. MYRTLE AVENUE RM 210 POST OFFICE BOX 4748, CLEARWATER, FLORIDA 33758-4748 Telephone(727) 562-4567 Fax(727) 562-4576 Development Services 2008 -2009 OCL-0009326 LOCAL BUSINESS TAX RECEIPT THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN PLACE OF BUSINESS Owner Name&Mailing Address Business Name&Address ANDREW J CAUDELL D-MAR GENERAL CONTRACTING&DE D-MAR GENERAL CONTRACTING&DE 1453 S MARTIN LUTHER KING JR AVE 1453 S MARTIN LUTHER KING JR CLEARWATER FL CLEARWATER, FL 33756 727-461-4760 Category Quantity 037010 CONTRACTOR:CLASS"A"GENERAL I FL#CGC1504222 TAX YEAR PERIOD BEGINNING PERIOD ENDING PRINT DATE 2008-2009 October 1,2008 September 30, 2009 September 06,2008 FEE TYPE FEE BUSINESS TAX-RENEWAL $318.60 TOTAL FEES 318.60 THE ISSUANCE OF A BUSINESS TAX RECEIPT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY ZONING LAWS OF THE CITY OF CLEARWATER NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER LICENSE,PERMIT OR IMPOSED TRAFFIC IMPACT FEES. ANY CHANGE IN LOCATION,BUSINESS NAME,OR OWNERSHIP MUST BE APPROVED BY THE PLANNING AND DEVELOPMENT SERVICES DEPARTMENT. NON-REFUNDABLE DEVELOPMENT SERVICES DIRECTOR OCL_BathPrinL2008.rpt � wQ i A � Z :4 Min dm z o Ln rnas m r az � o � Mr' r n 2 `'.y mo C �] o vz Z m eezm �, z � CC R DnrnN � a tzc� E C o � O 'i1 m c z m d ' _ The Sunshine State UCOOE NU BER - C340-010-60-106-0 ANDREW JEFFERY CAUDELL 2124 FREDERIC CIR CLEARWATER,FL 33763-2964 BIRTH DATE SEX HGT. REST. ENDORSE. 03-26.60 M 6-10 10-27-08 03-26-10 00.00-00 SAFE DRIVER 10270079 Operation of a motor vehicle constihiMes consent to any sobriety test required by law STATE OF FLORIDA -- DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 CAUDELL, ANDREW J D-MAR GENERAL CONTRACTING & DEVELOPMENT INC 1453 S GREENWOOD AVE CLEARWATER FL 33756 AC# 3 9 31 811 1 STATE OF FLORIDA Congratulations! With this license you become one of the nearly one million DEPARTMENT OF BUSINESS AND Floridians licensed by the Department of Business and Professional Regulation. PROFESSIONAL REGULATION Our professionals and businesses range from architects to yacht brokers,from boxers to barbeque restaurants, and they keep Florida's economy strong. CGC1504222 08/20/08 070520080 Every day we work to improve the way we do business in order to serve you better. For information about our services,please log onto www.myfloridalicense.com. CERTIFIED± GENERAL; CONTRACTOR There you can find more information about our divisions and the regulations that CAUDELL,, ANDREW J impact you,subscribe to department newsletters and learn more about the D-MAR GENERAL CONTRACTING & D iTE- Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly.We constantly strive to serve you better so that you can serve your customers. IS CERTIFIED under the provisions of ch-.48} Fs Thank you for doing business in Florida, and congratulations on your new license! Expiration date: AUG010 1,08082001482-- '- M 31 DETACH HERE DEPARTMENTB ND ESSIGNAL REGULATION CONSTRtGN INDUSTRY. LICENSING BOARD - SEQ#L08082001482 LICEI+Yr 08/20/2008 070520080- 1CGd.15D4222. The GENERAL CONTRACTOR •• _ Named below IS CERTIFI17 Under provisions the of Chapter Expiration date AUG 31, 2010 ' r CAUDELL, ANDREW J II MAR GENERA r CONTRACTING & DEVELOPHNTINC 1433- S GREENWOOD AVE CLEARWATER FL 33755 : CHARLIE GRIST F . -' .•. CHARLES W DRAGO GOVERNOR f r SECRETARY STATE OF FLORIDA g 5 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 " ' MONROE STREET 1940 NORTH TALLAHASSEE FL 32399-0783 D-MAR GENERAL CONTRACTING & DEVELOPMENT INC 1453 S MLK JR AVE FL 33756 CLEARWATER O STATEOF FLORIDA sIN SO AND ROSO CATION 8259 x /0 '7. 0607583 QUALIFIED BUSINESS dRGANIZATIG: D-MAR GENERAL CONTRACTING & DE (NOT A LICENSE TO PERFORM:WORK- ALLOWS COMPANY. TO DO BUSINESS IT HAS A LICENSED QUALIFIER.) IS QUALIFIED under the,provisioas:.of Ch.489 Sspiration-.aate::.AUG 31, X20'09 LD-70604006 DETACH HERE DEPARTS C E REGULATION $EQ#L0.z 0604006 .• LICENSE NBR 106/04/2007 06.0758323 B,259.4 The BUSINESS ORGANIZATION_ Named below IS QUALIFIED Under the provisions of Chapter.-.4 ,9, ES. Expiration date: AUG 31, 2009:•- . (THIS IS NOT A LICENSE TO PER RM: Q THIS ALLOWS COMPANY TO :DO BUSINESS ONLY IF TTHAs IE3 . ) D-MAR GENERAL CONTRACTING & DEVELOPNEIT INC 1453 GREENWOOD : iVE S CLEARWATER FL 33756 PERMIT AGENT AUTHORIZATION LETTER ALL INFORMATION IS TO BE TYPED OR LEGIBLY PRINTED c'- rDt „7 =r t.z -CrC 15 O 4 Q a a , (Contractor Name) (Contractor License#) Hereby authorize the following to act as my agent(s) in obtaining permits in the State of Florida. Doreen DiPolito D143-168-66-802-0 Don Cambridge C516-199-50-268-0 John Devlin D145-475-58-444-0 Ken McLean M245-516-65-014-0 Sara Shipley S140-785-84-514-0 THIS LETTER SUPERCEDES ANY PREVIOUSLY SUBMITTED LETTER(S) OF AUTHORIZATION. This letter must contain only the people you want to pull permits in your name. To make changes to this letter, you must submit a new letter. This letter will delete and replace any previous authorization letter and the information contained thereon. This authorization is to remain in effect, unless cancelled in writing, by the undersigned. STATE OF LO t 1� COUNTY OF (Contrac or's Signature) Swgrn t �(or affirmed)and subscribed before me this ooLL day of Ø19C&f 20 O� By /o✓O?' cnt C,-.—/C>E L (Printed/Typed Name of License Holder Making Statement) Notary Seal NOTARY PUBLIC (Signature of otary) o are,Public State of on da iT 201 j'}(�A C' P Ef.( aic DOrS6;xc (Name oTNotary Typed,Printed.or Stamped) } My Commission expires' `���� ft 9 Ot I Personal( .(Cnown OR Produced Identification SUPI tL kt'JOw1\/ (Type of Identification Produced) 3/27/2008 Diane Benoit At:Roger Bouchard Insurance,Inc. FaxID: To:DON CAMBRIDGE Date: 10/21/2008 01:18 PM Page: 1 of 2 CORD. CERTIFICATE OF LIABILITY INSURANCE OPID DI DATE(MM/DDYYYY) DMARG-1 10/21/08 .,CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION achard-Clearwater ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE .1 Starcrest Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR O Box 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Clearwater FL 33758-6090 Phone: 727,-447-6481 Fax:727-449-1267 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A. 23396 Ameri5ure Mutual Insurance Co D Mar Gen Contracting & INSURER B: Aneiisuze Insurance Company 19488 Development Inc. INSURER C Amerisure Companies 09088 Doreen DiPoiitomP 1453 MLK Jr Ave S INSURER D Clearwater FL 33756 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 . SR DD1 POLICY EFFECTIVB POLICY EXPIRATION LTR NSRI TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY GL2006820080008 02/10/08 02/10/09 PREMISES)Es $50,000 CLAIMS MADE 1K OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 X POLICY flT LOC Emp. Ben. $1,000,000 AUTOMOBILE LIABILITY B X ANY AUTO COMBINED O BINE DtSINGLE LIMIT $ 1,000,000 CA2006817050008 02/10/08 02/10/09 a Al L OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC �$ AUTO ONLY. AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 A X OCCUR CLAIMSMADE CU2006821 02/10/08 02/10/09 AGGREGATE $ 1,000,000 DEDUCTIBLE $ RETENTION $0 $ WORKERS COMPENSATION AND X TORY LIMITS ER EMPLOYERS LIABILITY TY ANY PROPRIETOR/PARTNER/EXECUTIVE WC 201781703 02/10/08 02/10/09 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED' E L DISEASE-EA EMPLOYEE $ 1,000,000 If yes,descnbe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER C Leased/Rented Equi CF2006818030008 02/10/08 02/10/09 LEASE/RNT $100,000 EQUIPMENT DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: HESS DD9415, 6026 N GALL BLVD. , ZEPHYRHILLS, FL 33541 CERTIFICATE HOLDER CANCELLATION CITYZEP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL CITY OF ZEPHYRHILLS 5335 8TH STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ZEPHYRHILLS FL 33542 REPRESENTATIVES. AUTHORI PR SENTA ACORD 25(2001108) ©ACORD CORPORATION 1988 is Dane Benoit At:Roger Bouchard Insurance,Inc. FaxID: To:DON CAMBRIDGE Date:10/2112008 0118 PM Page:2 of 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08)