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HomeMy WebLinkAbout09-9773 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813)780 -0020 9773 FIRE ALARM SYSTEM PERMIT x 3 �`` ili 1' i ° a., ,, , + w § • . _ x ,. £ "!,„',, ' 77:. =, ;°' 771' 7 E. v,C R E 3 ° Permit Number: 9773 Address: 5344 9TH ST r k w . `' Permit Type: FIRE ALARM SYSTEM ZEPHYRHILLS, FL. Class of Work: FIRE ALARM SYSTEM Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 11- 26 -21- 0010 - 15100 -0160 Improv. Cost: 1 ,500.00 Wa4 =a Date Issued: Name: JORDAN, DANNIE & MARJORIE Total Fees: 150.00 Address: 10326 NEWSOME RD Amount Paid: 150.00 DADE CITY FL 33525 Date Paid: 11/19/2009 Phone: (813)783 -9119 Work Desc: INSTALL ADDITIONAL ALARM TO EXISTING SYSTEM :,:k4 #s` a0+ r ' : - _, t:eF '� * ' ^ .wa - �q� t la�.E. ,.., < -, - ;' z— a n y ft.�".w °`�,t:u r ti i = - •ADVI - IN - E ALA =M 50.00 IR P - VI E 50.00 FIRE INSPECTION FEES 50.00 i(0 I i ' U " ik• Fl A - AN Final FIRE ELEVATOR RECALL Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire prevention and protection related activities such as inspections, plan review, administrative fees, and other costs related to the aforementioned. Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All work shall be performed in accordance with City Codes and Ordinances. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMP - 0 - MENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FIN ' NG, ONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RE 1 e • 4�. OU - ' i - OF COMMENCEMENT." WilWareallilll■ riitint■ CONT TOR SIG .TURE IIIC 1 EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOURS NOTICE REQUIRED ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813- 780 -0041 Daniel M. Nardontonia, CET cell 727.215.3 Project Manager Comm; :ial Op., tions office 727.541. fax 727.541.1671 8222 118th Avenue N; Suite 670 . Largo, FL 33773 d b ro a dv i ew s e c u r ity. c o m BROADVIEW Certification #115846 SECURITY" Lic. # EF-0000921 813-780 -0020 ' City of Zephyrhills Fire 13 Fax-813-780-0021 Permit Application Date Received 1 r —72 ' 27 I Phone Contact for Permit 1 741 Ha I to !� Owner's Name 1 li�•r J Co 51,2 e—n 6t4 1 Owner's Phone Number 13.7 Z I 1 763 I n1 Owner's Address 53 ''l 4 / 9 Q 'd S ' 2E'p `4� /f� , i -g- 335 Fee Simple Titleholder Name Titleholder Phone Number Fee Simple Titleholder Address LL I , c �i J S3Y Job Address % 9 f� I • pAy ��, • t" .533-1,Z Lot # Sub Division Parcel # El Bio- Hazard Waste Storage - ANNUAL n Hazardous Material (Tier II or RQ Facility) ANNUAL n Comm Exhaust Kitchen Hood /Duct n Hood Installation I. n Controlled Burn a LP /Natural Gas - Installation n Emergency Generator < 30 kw n LP /Natural Gas - ANNUAL Sale i 0 , a Emergency Generator > 30 kw = Places of Assembly- ANNUAL Fire Protection Maintenance - ANNUAL = Recreational Burn / /e i►/� nS ry ISemil UM Other "' lo y Sprinkler CI ❑ ❑ ❑ 0 Sparklers `/ Fire Alarm CI ❑ ❑ ❑ l I n Sprinkler System Installations Hood Cleaning CI ❑ ❑ ❑ I 1 0 Standpipes (Sprinkler Sys) 1-11 Hood Suppression ❑ 11 ❑ I I n Torch Roofing /Tar Kettle Fire Alarm Installation = Waste Tire Storage ANNUAL Fire Pumps LJ Fire Works n Flammable Application- ANNUAL 1 / sew - 6 0 ( Valuation of Project El Fuel Tanks 1 Q Other: AbairTM.s TD Hite J�sTCt,... Contractor Company 73 a SC . 6 ,t I Signature � Registered Y / N I Fee Current I Y/ N Address ( 7 I License # ¢-rGGC Oyvt/ ELECTRICIAN Company Signature Registered Y / N I Fee Current I Y/ N I Address I License # I PLUMBER Company I Signature Registered Y/ N 1 Fee Current I Y/ N I Address ( I License # I I MECHANICAL Company Signature Registered Y/ N I Fee Current I Y/ N Address I I License # I OTHER Company I Signature Registered Y / N . 1 Fee Current I Y / N Address I I License # I 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 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. 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 BEF RE RECORDING YOUR ■ •TICE OF COMMENCEMENT. FLORIDA JURAT (F.S. 1 7 .,Q3) OWNER OR AGENT "' '- `�'� —�lJ� CONTRACTOR / °Alb Subscribed and sw ( 5 G iS' or ff��rrr�� ) e�ore me s Subscribed and sworn or affirr�ed) fore me this 1142 9 by � zoo ✓ 0061 ///2'v 9 by rA ,( � ll��a.�L. �(J E R f Who is /arg ep rsonaily known to me or has/have produced Who is /are personally known to me or has /have produced Gt�S2 as identification. Li C - as identification. /L'♦rr:�i We! Notary Public '. � . Notary Public Com JAR E LINE BOGES '" ( /E(JN C E Comn 'vI DU GQ1833 ommi o I{ � 80G ES !� ��; Expires December 12, 2010 � Try DD 621833 Name'6,fE1!ary peer,"pi7ite or stamped Name of Notary typed; prin ti 12' 2010 X7018 813 - 780 -0020 City of Zephyrhills Fire Fax- 813-780 -002 Permit Application Date Received Phone Contact for Permit Owners Name Owner's Phone Number Owner's Address Fee Simple Titleholder Name Titleholder Phone Number Fee Simple Titleholder Address I Job Address Lot # Sub Division Parcel # Bio- Hazard Waste Storage - ANNUAL Fu g � � Fumigation Tent n Comm Exhaust Kitchen Hood /Duct I Hazardous Material (Tier II or RQ Facility) ANNUAL Controlled Bum I I Hood Installation n Emergency Generator < 30 kw LP /Natural Gas - Installation n Emergency Generator> 30 kw LP /Natural Gas - ANNUAL Sale n Fire Protection Maintenance - ANNUAL I I Places of Assembly- ANNUAL 1Utrly1 (Semi UZI Uther Sprinkler n ❑ ❑ ❑ 1 Recreational Burn Fire Alarm ❑ ❑ ❑ 1 Sparklers Hood Cleaning ❑ ❑ ❑ I ( Sprinkler System Installations Hood Suppression 1 ❑ ❑ ❑ Standpipes (Sprinkler Sys) I I Fire Alarm Installation I Torch Roofing/Tar Kettle n Fire Pumps Waste Tire Storage ANNUAL Fire Works n Flammable Application- ANNUAL ` I Valuation of Project I I Fuel Tanks I I Other: I 3e'g'aV traMay. -zs8 .lriz �2 M .,.,zz.... 46P4. Contractor Company Signature Registered Y / N Fee Current I Y / N Address I I License # ELECTRICIAN Company Signature Registered Y / N Fee Current I Y / N Address I 1 License # PLUMBER Company Signature Registered Y / N Fee Current I Y / N Address 1 I License # MECHANICAL Company Signature Registered Y / N 1 Fee Current I Y / N Address I License # I OTHER Company Signature Registered Y / N I Fee Current I Y / N Address I I License # I •�-- _."Sm .R'Y&3.s.'�"a,a.Y r m. =.w zc.....x.warssz..sm,wA.x::.R:Fak e.w...,.., <u .._..a:..,a ...,.s.��., Fw _.... z.: ......wui.:zwu .... _+4*i..aE :'.::...... ... a.. _�:__.... _ <. __... . . 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) Brink's Home Security M emo To: Permitting Official From: Douglas P. Bassett Date: 9/24/08 Re: Authorization to Pull Permits The following individuals are authorized to, drop off and pick up it applications in my name. My State License nu . • — 's EF0000921. fa, Daniel Nardontonia � , Authorized Signature % ouglas P. Bassett Sworn to and subscribed before me this XI day of 1e-, , 2008. Notary Public _■/A Ashley Yaccarino :: M ASHLE YAC =''e .*: Y COMMISSION # CARINO DD 737273 '• '11f 80 de d N r ber 2 7, 20 t __ _ _ ` _ - Public _ __ t • Page 1 o 0 p 0 - N • z J co o Lo LL O O o o T T - (7 co LO o 3 . O = ¢ to; to rn en 0 CD co 0 04 W Q _ N CC W 0-o a: W W CC o W 1 - Q 0 CC a F- > u1 - w W LL 0 c in J .i:. - Q > . W H w Q '?s F; Z + X co CI celLAinitiV C) 73 a U O W W W MI 0 VJ N (r) a L ^ • Z O " > ii o W cr) , 4 4 , : ) ..... m w 0 /� H w act V z W O m cA 1-- L 0_H o l 2 ° z gU o W O o 00 a O Z a CO r > ~ W m 6 1< wo N ° d C/)< w PM cc)08M ♦ h L, w 0 p ( mmLH V II I w g ° W U o a o 1- LL U o a y o w N co O 0) CO a C7 1// m O ? a W -¢ w w N m-J z M< CCI a m z r4 4: qt (4 ,..kfte.,........LP , ry 1 kO Z ' r o O w w4 ao 44 ; 0 M�`%dto} ? +A - ; ; �P. ( ; Y "} '..1% CJ \'1�,y� OH t ,) ti Sro Ii Cnw Q wU s N. si >. 0 Oa iY, ,, m 2 o O a cn L a h,� , .,, o cc! 2 11J • �g lira ' ` 4,.....-,44...-.:-. ~ Q Q '1. Q 1 — 1-o a .- w " ' i.''. - a N 1 H i.4 .-- 4 ' ' rn (. m 04-4 � N n'1 p t- 4H w rzi al o ff a1-+ A H m oa Z o a al - a a i w o o A N U A r4 ,AL E ▪ W 0 Cu + H U w` j : , _ U A aHUI A a w w w P+ o w : z4 ? ",w: :, W g H O M 04 .q4 z.; ";fi • 44 E-I ' ,.... r4 w L M H q0 o m a m U a o a 10 ` :.,.4:03 z N w -.I C 0 ••- ;f A = M Z U m •• ''^ t:{7 w a ' a fx ;; :.., , u o w -,4 N ; . O U] PI U 0 " '. o Fil r:1 N P4 •zr - : UI H o td .. : '� Pi w ,wo w ay 0o w3 a �' HHUc'1 14 ( : rn 0 0 H9 x a0 o pK 0 . 0 u M N' 1 A 4 �a04ND0 0 k o EHZD rrl a ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 10/21/2009 PRODUCER Phone: 972 - 770 -1600 Fax: 972 - 770 -1699 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McQueary Henry Bowles Troy LLP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8144 Walnut Hill Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 16th Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Dallas TX 75231 - TX INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:ACE American Insurance Company22667 Broadview Security, Inc. INSURERS: 8880 Esters Blvd. Irving TX 75063 INSURER C: INSURER D: 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE IMMIDD/YY1 DATE (MM/DD/YY) LIMITS GENERAL. LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO - PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL 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: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION AND WLRC45705717 11/1/2009 11/1/2010 X O LIMI R E EMPLOYERS' LIABILITY TORY LIMITS ER A WCUC45705730 11/1/2009 11/1/2010 E.L. EACH ACCIDENT $2,000,000 A OFFICER/MEMBER EXCLUDED? SCFC45705729 11/1/2009 11/1/2010 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 2,000.000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATIONexce0t 10 days for non - payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY OF ZEPHYRHILLS BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 5335 8TH STREET CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO ZEPHYRHILLS FL 33542 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 • 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) ACORD , CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 10/21/2009 PRODUCER Phone: 972- 770 -1600 Fax: 972- 770 -1699 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McQueary Henry Bowles Troy LLP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8144 Walnut Hill Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 16th Floor ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Dallas TX 75231 -TX INSURERS AFFORDING COVERAGE _ NAIC # INSURED INSURERA:ACE American Insurance Company22667 Broadview Security, Inc. INSURERS: 8880 Esters Blvd. Irving TX 75063 INSURER C: INSURER D: 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD/YY) DATE (MM/DD/YY1 LIMITS A GENERAL LIABILITY XSLG24935930 11/1/2009 11/1/2010 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY PR S ( RENTED PREMISES (Ea occurence) $ 3 0 0, 0 0 0 CLAIMS MADE IX OCCUR MEDEXP(Any one person) $ 2 500 PERSONAL BADV INJURY $ 2,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 4,000,000 PRO- X _POL J FCT LOC A AUTOMOBILE LIABILITY ISAH08582555 11/1/2009 11/1/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $5,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE __ $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR /PARTNER /EXECUTIVE • E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ dyes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATIONexcept 10 days for non - payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY OF ZEPHYRHILLS BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 5335 8TH STREET CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO ZEPHYRHILLS FL 33542 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) © ACORD CORPORATION 1988 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) _ 10/21/2009 PRODUCER Phone: 972 - 770 -1600 Fax: 972 - 770 -1699 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION McQueary Henry Bowles Troy LLP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8144 Walnut Hill Lane HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 16th Floor Dallas TX 75231 -TX INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:ACE American Insurance Company22667 Broadview Security, Inc. INSURERS: 8880 Esters Blvd. Irving TX 75063 INSURER C: INSURER D: 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. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY) DATE (MM/DD/YYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISES (Ea occurence) $ CLAIMS MADE OCCUR MED EXP (Any one person) $ PERSONAL &ADVINJURY _ $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMP /OP AGG $ _ POLICY PCT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL 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: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WLRC45705717 11/1/2009 11/1/2010 X ORYLMITS ER A EMPLOYERS' LIABILITY WCUC4 5 7 0 5 7 3 0 11/1/2009 11/1/2010 E.L. EACH ACCIDENT $2,000,000 ANY A OFFICER /MEMBER SCFC45705729 11/1/2009 11/1/2010 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATIONexceut 10 days for non - payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED CITY OF ZEPHYRHILLS BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE 5335 8TH STREET CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO ZEPHYRHILLS FL 33542 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 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.: - C ontractor: ; . _ / Plan No.: R ,� yo � • --� � ■' Business Name: ff � 7 A r' Billing Address: _ ��� _ ,-. ,e� Business Address: ^J Business ' `` . " Business Phone No.: Billing Phone No.: i= T/Y , Si, 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 N/C — Muni - 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 El Plan Revisions DBL _ � 3rd Re inspection $250 Hoods �=' _ 4th Alarm $100 _ 4th Re- Inspection $500 Fire Alarm U _ 5th Alarm $150 _ SPRINKLER SYSTEMS (Business closed until _ LP Gas $50 _ 6th Alarm $200 _ 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 0 Per Riser $50 _ Hydrostatic Test $65 per system _ Fire Works $500 FIRE PUMP _ Acceptance Test $45 per system — Camp Fire $25 0 Per Pump $100 _ Hydrant Flow $75 _ Controlled Bum $100 IRE ALARM SYSTEM _ Hood/Duct $50 0 - 25 Devices FIRE ALARM SYSTEM _ Place of Assembly $50 Annual 26 plus Devices 1 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 WaIUSmoke Wall $15 per wall _ Generator < KW 5100 _ CO2 $50 — LP Gas $25 per tank _ Generator >30 KW 150 — Other $50 — Natural Gas $25 per system _ Bio-Hazard Waste $100 Annual KITCHEN EXHAUST Fumigation Tenting $50 0 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 fl Natural Gas installation $50 _ Re - inspection DBL (Per System) (other than annual) _ 0 Spray Booth $50 0 Inspection scheduled DBL _ and cancelled less than _ 24 hours Construction Insp. N/C — _ Emergency Vehicle Aa -' FALSE ALARM PLANS TOTAL INSPECTION TOTAL. PERMIT TOTAL TOTAL GRAND TOTAL 1 l5b J 1 Comments: Date: ' -7 /fir Inscoctor: — ,!i✓ -* / _% Business Name: _�C : -/ /& C. Uns L- ( 7 ; L Owner/Manager Name: /3L171/14? ,✓ Street: 5 3 4/-/ ,S _ ��' _..__ ___.,.......__. Installation Phone # ( / 3 _) - Y - � / / City: .- ' 7 ythi i // S Home Phone # (_ J - - County: f' ty >� u eS ( C..) Stat�><- :........ Zip: ,3 3 :S - V .2•-- Cellular Phone # ��. "Z` ) • 4 /� % - �' - 74:)_.d.-- Cross - Street: � /Z 00 4 `f _ .._.._._._.._..........._....__ Email: Date Scheduled: ❑ AM ❑ PM SYSTEM TYPE: 1 l S ! Gt jx✓' C f ❑ New Installation ❑ Conversion ❑ Takeover `Add ❑ CSR Add ❑ Move/STO ❑ Move (Previous Address) Building Style: ❑ Split -Level ❑ Multi -Story (Single Story Square Feet. -' g�U Basement: [] Finished ❑ Siab ❑ Unfinished Ceiling Height: 1 Attic/Ceiling: C! Open ❑ Vaulted/Drop "15f Crawl Space Flooring: ❑ Tile/Hardwood ❑ No Carpet (Partial Carpet ❑ Full Carpet Comments: Brink's Home Security' is providing the Equipment to you subject to the terms and conditions of your Fire System Service Agreement including Sections 6 through 8. You acknowledge that Brink's' has explained the full range of Brink'sa equipment available and you have selected the equipment listed below. QTY EQUIPMENT PRICE' Discount) TOTAL* e f' < - 1 u HIS ST 0 c.i. J I QC- r 7'L-' I 9 c'cf I c c) !n c t o C,> (A.) r re -1: ,S ci .,s-7-0 -t-i- S6 , ' (° 53 , I L 1 F /r'i S >'. - .. - -- $9, ' G g , 3G 1' 1 i -n t T G C. - la 1 0 r _ , , , C1 U k 1 -rnt u .- S ME- .-1° , -.. I A - - = ' ' 6 C:' . ' :I drireS'a.1,�1e iOJ iF, b .).1b , to 1 ' I_.�KV . . tr e. 6 5(i - 4 -.. , - ,- . &? K e y pc, ti -- lo n e. o " cc Ex c IA( t cAi•P <ax '; j°'1 -‘‘.,C, p c& 11 Si t".7 - f V 1 "Pricing and location quoted by a sales representative subject to approval of Brink's' technician. ( wWaae) `Additional $500 fee required to purchase Protective Equipment. POLICE/FIRE PERMIT /So 00 Of appal w.) ADMIN FEE (where allowed) j,S ,, ! 6 Technician Comments: , 1 SUBTOTAL' 2. ADJUSTMENT — - 3. TOTAL ',la.§ y ¢ i? '" (. Date /me Started _ / . / _ : -- _....._....... 4. TAX /O, 3s ,/-t - , ` DatefTime Completed —, - „_- r _ _ I _ 5. MONITORING ....................... (inqudina Taxl --- 6. SERVICE PLAN Date /Time Monitored - -_ — / / ._ Tech(sl ___ . 7. {TRd g Tax) IVITY 8. TOTAL /6/6, L/$76///, 06 4 VRT Verify#.....,. (Lnre3 a 9. LESS PREPAY g020 r Dps Rep. ..... 10. BALANCE DUE` 7eli (;*. 9' 1 Number and Location of Fire Alarm Devices Brink's will consult your local fire department or other organization, office, or individual responsible for approving equipment, materials, an installation, or a procedure relat- ed to fire protection in your location ( "AHJ ") to attain approval regarding required fire protection in your location. You understand that the type, quantity and location of the Equipment identified above are subject to approval and revision by the AHJ. You understand and agree that if the AHJ determines that any modifications or additional Equipment are necessary, you will pay Brink's additional charges for any resulting modification and/or additional Equipment. You accept t the Brink's' Protective Equipment and ackr 3wledge its placement, installation, demonstration and testing to your satisfaction. PLEASE CHECK WITH POLICE AND LOCAL GOVERNMENT ON PERMIT REQUIREMENTS, acknowledge that you h, a ;, ad and understand the information above regarding selection of fire alarm devices. You also acknowledge that yoti s n; o nsihle "or In. =,;far as eitated aixase. ,, Jacqueline Boges From: Kerry Barnett Sent: Monday, May 10, 2010 9:47 AM To: Jacqueline Boges Subject: RE: need to verify if a permit is complete Jackie, If this permit is reference to a fire alarm change /modification, it is complete. Kerry From: Jacqueline Boges Sent: Wednesday, May 05, 2010 3:20 PM To: Kerry Barnett Subject: RE: need to verify if a permit is complete Sorry about that I was looking at Broad view address s/b for address 5344 9th street From: Kerry Barnett Sent: Wednesday, May 05, 2010 3:00 PM To: Jacqueline Boges Subject: RE: need to verify if a permit is complete we dont have a newsome road From: Jacqueline Boges Sent: Wed 5/5/2010 2:31 PM To: Kerry Barnett Subject: need to verify if a permit is complete Kerry, Has the permit for #9773 -10326 Newsome Road been complete for fire alarm system. Thank you Jackie Boges Code Support Specialist ext. 3513 1