HomeMy WebLinkAbout09-9201 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813) 780 -0020 9201
ANNUAL FIRE PROTECTION MAINTENANCE
Permit Number: 9201 Address: 5344 9TH ST
Permit Type: FIRE PROTECTION MAINTENANCE ZEPHYRHILLS, FL.
Class of Work: FIRE - PROTECTION MAINTENANCE 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
Im rov. Cost:
Date Issued: 6/04/2009 Name: JORDAN, DANNIE & MARJORIE
Total Fees: 25.00 Address: 10326 NEWSOME RD
Amount Paid: 25.00 DADE CITY FL 33525
Date Paid: 6/04/2009 Phone: (813)783 -9119
Work Desc: FPM- FIRE ALARM ANNUAL- RTD CONSTRUCTION OFFICE- SCH WK 1ST JUNE
BRINKS HO SECURI FIRE PERMIT FEES 25.00
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FIRE ACC Final
Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire
prevention and protection related activities such as inspections, plan review, administrative fees, and other
costs related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
COMMENCEMNT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS
TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE
OF COMMENCEMENT."
A f - i 1 0 1 2Y
P '� IT OFFICER
PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813- 780 -0041
Douglas Bassett
IIIIBRINKS Florida Qualifier
HOME SECURITY 12821 Commerce Lakes Drive, Suite 3
Ft. Myers, FL 33913
Lic. # EF- 0000921
Office: 800 - 874 -8882, Ext. 76202
Care: 800 - 445 -0872
Fax: 239 - 275 - 1874
E -mail: douglas.bassett@brinks.com
www.brinks.com
813- 780 -0020 City of Zephyrhills Fire 4r q 2/0 1 Fax -813- 780 -0021
• Permit Application `fi
Date Received Phone Contact for Permit
Owner's Name 1 K T P 6' on #120 et /i41 I Owners Phone Number 1 6 117 ,33 I F I `? / /q
Owner's Address 1 3 lig 9 4 A re . .3t) l 'd ) / L J i q 7
Fee Simple Titleholder Name I I Titleholder Phone Number I I I I
Fee Simple Titleholder Address I
Job Address 1 5 Y 9 r: ? VE 2- rqh /II s ! ..- ... 351-/O 1 I Lot # i , ......w, e., ....
Sub Division I °` ° I Parcel #
E Bio -Hazard Waste Storage - ANNUAL El Hazardous Material (Tier II or RQ Facility) ANNUAL
11 Comm Exhaust Kitchen Hood /Duct I Hood Installation
E Controlled Bum ri LP /Natural Gas - Installation
El Emergency Generator < 30 kw 1 LP /Natural Gas - ANNUAL Sale
Emergency Generator > 30 kw
R n Places of Assembly- ANNUAL
Fire Protection Maintenance - ANNUAL rI Recreational Bum
an Mull (J Other
Sprinkler 11 ❑ ❑ n Sparklers
Fire Alarm ❑ ❑ 6l' I 1 n Sprinkler System Installations
Hood Cleaning E ❑ ❑ ❑ ( 1 I1 Standpipes (Sprinkler Sys)
Hood Suppression E ❑ ❑ ❑ 1 1 n Torch Roofing/Tar Kettle
El Fire Alarm Installation 71 Waste Tire Storage ANNUAL
Fire Pumps
E Fire Works
Flammable Application- ANNUAL I I Valuation of Project
0 Fuel Tanks
Q Other: I I
Contractor /�1 Company <, r;, sees -
Signature (J��" Registered , / N I F / Fee Current I Y/ N I
Address ( License # ( F1 I
ELECTRICIAN Company I
Signature Registered Y/ N I Fee Current I Y/ N I
Address
License #
PLUMBER Company I
Signature Registered Y/ N I Fee Current I Y/ N I
Address I
I License # I
MECHANICAL Company I
Signature Registered Y / N I Fee Current I Y/ N I
Address I
I License # I
OTHER Company
Signature Registered Y/ N I Fee Current I Y/ N I
Address License #
d ons . .. F _ .,
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)
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Certificate of Insurance
THIS CERTIFICATE ISSUED AS A MATTER OF INFORMATION. ONLY AND CONFERS NO RIGHT UPON YOU THE CERTIFICATE HOLDER. TIIIS CERTIFICATE IS NOT AN
INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER TIIE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW.
This is to Certify that INV
[BRINK'S HOME SECURITY, INC.
NAME AND sh ' L
8880 ESTERS BOULEVARD ADDRESS �
OF INSURED � M iti
IRVING TX 75063
is, at thc issue date of this ccrtificatc, insured by thc Company under the policy(ics) listed below. The insurance afforded by the listed policy(ics) is subject to all their terms, exclusions and
Conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be issued.
EXP DATE -
TYPE OF POLICY ❑ CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
❑
EXTENDED
® POLICY TERM
WORKERS WA7 -61 D- 259825 -018* COVERAGE: AFFORDED UNDER WC EMPLOYERS LIABILITY
COMPENSATION 11/1/2009 LAW OF THE FOLLOWING STATES:
WC7- 611 - 259825 -028" *All States except Monopolistic Bodily injury b
States 2.000.000 Each Accident
• WI & OR Bodily Injury By Disease
2,000,000 Pnli v 1 imit
Bodily Injury By Disease
2.000.00 0 Each Pnvm
GENERAL LIABILITY General Aggregate Other than Products / Completed Operations
❑ OCCURRENCE Products / Completed Operations Aggregate
❑ CLAIMS MADE
Bodily Injury and Property Damage Liability
Pcr Occurrence
RETRO DATE Personal Injury
Pcr Pelson / Organiz tion
Other rthcr
AUTOMOBILE I Each Accident Single Limit
LIABILITY B.I. And P.D. Combined
❑ OWNED Each Person
❑ NON- OWNED
Each Accident or Occurrence
❑ HIRED
Each Accident or Occurrence
OTHER
ADDITIONAL COMMENTS
• If the certificate expiration date is continuous or extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date
SPECIAL NOT1C&O111O: ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATIN(, A FRAUD AGAINS "C AN INSURER, SUBMITS
AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DFCEPTIVF STATEMENT 15 (IIILTY OF INSURANCE FRAUD.
IMPORTANT NOTICE TO FLORIDA POLICYHOLDERS AND CERTIFICATE HOLDERS: IN THE EVENT YOU HAVE ANY QUESTIONS OR NEED INFORMATION ABOUT
THIS CERTIFICATE FOR ANY REASON, PLEASE CONTACT YOUR LOCAL SALES PRODUCER WHOSE NAME AND TELEPHONE. NUMBF.R APPEARS IN THE LOWER
RIGHT HAND CORNER OF THIS CERTIFICATE. THE APPROPRIATE LOCAL SALES OFFICE MAILING ADDRESS MAY ALSO BE OBTAINED BY CALLING THIS NUMBER. Liberty Mutual
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) Insurance Group
BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE
INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE
OF SUCH CANCELLATION HAS BEEN MAILED TO:
[City of Zephyrhills
Gay Medley
c Irving / 0949 AUTHORIZED REPRESENTATIVE
2100 Walnut Hill Lane, Ste. 100
5335 8th Street Irving TX 75038 972 - 550 -7899 6/3/2009
L Zephyrhills FL 33542 ° PHONE DATE ISSUED
This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772
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Protective Insurance Company Date issued: 06/02/09
1099 North Meridian Street SEQ# 00001625
Indianapolis, Indiana 46204 00043590 -001
(317) 636-9800 Ext. 254
CERTIFICATE OF INSURANCE
This certificate issued to:
CITY OF ZEPHYRHILLS
5335 8TH STREET
ZEPHYRHILLS, FL 33542
Certifies placement of insurance coverage for the account of
BRINK'S HOME SECURITY, INC.
8880 ESTERS BLVD.
IRVING, TX 75063
With the following insurers, individually and not jointly, providing insurance as listed:
Protective Insurance Company Policies: X001686
For the following coverages:
General Liability including Personal Injury and Property Damage
For Limits of $2,000,000 CSL per occurrence/$4,000,000 General Liability Aggregate
Effective: November 01 , 2008
Expiration: November 01 , 2009
In the event of policy cancellation or material change, every reasonable effort will be made to advise
the certificate holder named hereon, at the address indicated, of such cancellation or material
change within 30 (Thirty) days thereof.
Signed at Indianapolis, Indiana this 2nd day of June , 2009
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER COVERAGE AFFORDED BY THE
POLICY LISTED HEREIN.
BY: /fribie y s