HomeMy WebLinkAbout09-9394 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780 -0020 9394
MOBILE HOME SET -UP
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Permit Number: 9394 Address: 7918 KAY MARIE AVE LOT 306
Permit Type: MOBILE HOME ZEPHYRHILLS, FL.
Class of Work: MOBILE HOME SET -UP Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: GRAND HORIZONS
Est. Value: Parcel Number: 34- 25 -21- 0180 - 00000 -3060
Improv. Cost: 10,900.00 a '
Date Issued: 8/04/2009 Name: READY, LESTER & HAGERMAN, MARIE
Total Fees: 6,965.58 Address: 37501 GILL AVE
Amount Paid: 6,965.58 ZEPHYRHILLS, FL. 335421
Date Paid: 8/04/2009 Phone:
Work Desc: INSTALLATION OF MOBILE HOME 42 X 40
, £5d .•a : _ `' 'Val). g m F" t n w. aN Q
BMI LLC MOBILE HOME ELECTRICAL 40.00 S EWER CONNECTION MOBILE 1,005.00
JAMES 0 MORTON ELECTRIC CO.,INC. MOBILE HOME SET -UP 60.00 WATER CONNECTION MOBILE HC 320.50
BMI LLC MOBILE HOME MECHANICAL 35.00 MOBILE HOME PLUMBING 40.00
BAHR'S PROPANE GAS & A/C, INC. MOBILE HOME TIF /SUB 99% 3,595.68 MOBILE HOME TIF /SUB 1% 36.32
IRRIGATION METER 220.00 WATER METER RES 3/4" 220.00
IRRIGATION CONNECTION 266.00 PARK FEES MH 573.73
POLICE IMPACT FEE 254.00 FIRE IMPACT FEE 273.00
PUBLIC SAFETY 5% 26.35
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MOBILE HOME ELECTRIC
MOBILE HOME A/C
FINAL
MOBILE H9tAEZI VA',•
REINSPECTION FE P 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 inspection 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
Complete Plans, Specifications and Fee Must Accompany Application.
All work shall be performed in accordance with City Codes and Ordinances
CONTRA IRS SIGNATURE PERMIT OFF' -
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813 - 780 -0020 City of Zephyrhills Permit Application 9 3 Fax -813- 780 -0021
Building Department
Date Received •f - / 0t Phone Contact for Permitting 1 - --
Owner's Name `--1 i`6 (1 Owner Phone Number
Owner's Address 29 g f Ya.() NCI„ ‘C ) -e. hoe - Owner Phone Number
Fee Simple Titleholder Name / Owner Phone Number
Fee Simple Titleholder Address � ( /� CO
JOB ADDRESS - )9 7 , 9 I r 1 C- tV t hy' J �-- l p , LOT # 5V
SUBDIVISION C'3 t \rd 'T i i "I_C' PARCEL ID# 795 rg I ' 130 - - ` , G�
(OBTAINED FROM PROPERTY T AX NOTICE)
WORK PROPOSED WA NEW CONSTR ADD /ALT I I SIGN n MOVE I I DEMOLISH
Kg INSTALL REPAIR
PROPOSED USE Ell SFR I I COMM 1 1 OTHER I I
TYPE OF CONSTRUCTION 1 I BLOCK I I FRAME 11 STEEL n OTHER S i �1
DESCRIPTION OF WORK V cc \ - r 1� 1 \ \04 t J
BUILDING SIZE 4 a XL\ C) SQ FOOTAGE 11 VL'�"' HEIGHT
I BUILDING $) VALUATION OF TOTAL CONSTRUCTION
ELECTRICAL $ \ I ^ c0 , Oc) AMP SERVICE I 1 PROGRESS ENERGY n .R.E.C.
1 I PLUMBING $ L \ob • 06 C 4 ,
I I MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION ► " /
+ �,
� ti
I I GAS 1 1 ROOFING I 1 SPECIALTY I 1 OTHER 4� i'`1
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA 1 IYES lb NO
lt.i
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BUILDER S .J,S� COMPANY 6 -U-- 2- LC.>
SIGNATURE J VlY\ 62da_...Q.__k_. I Y/ N I FEE CURRENT I Y / N l
Address 5 ltSt:l1U1 _ 1I . 55 4- /i 0) Lic -. e . .�-/) - G7C /-"-�
/ / i_iifiswir /�iii� r/
Olt" 7 . ' F fr' I U ' • . /1. / 1
ELECTRICIAN �� ,� _" /� ( ' COMPA
SIGNATURE REGISTERED I / Y N I FEE CURRENT I Y /N (
W •
Address (,090 40 e; E)16. /e f (� cl - t it `� 15G -1 License # ar DI�� vj/
PLUMBER 1 COMPANY 8� + /,1 (_/!�V
SIGNATURE j \ � �', X ___ ' REGISTERED I Y / N l FEE CURRENT I Y / N 1
Address r" Y1 1 i ' Sie. Lt o l ` ' •540 License # rIl cr -) / "
MECHANICAL COMPANY
��'� ( J� h t'
SIGNATURE Il 't ` �� REGISTERED Y / N I FEE CURRENT I Y/ N I
Address -1(4 ` l 1 0-14,A 6 2. I` , 3 J `)St-. License # ( 60 0 - L , t 1 r U
OTHER COMPANY
SIGNATURE REGISTERED I Y/ N 1 FEE CURRENT I Y/ N I
Address 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.
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 tct "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 OCOMMENCEMENT.
FLORIDA JURAT (F.S. 11 t 3)
Iti *v� CONTRACTOR AI 1 File. Ita l e _ ■
OWNER OR AGENT �.► is Subscribed and sw. " to (or a "� qe.) be ore me this
ubs 0 and by (--- nor affirmed) be • ,�o J Q 1 t ON by L •<-.-- Kaok�'
QJnl Og by r_. s� �ao1�
Who Is /are personally known to me or has/have produced Who is/are personally known to me or has/have identification.
F t✓ 'D i_ as identification.
CJ� Notary Public
/ %.S-- ZNotary Public \� —
Commission No.
Commission No. A t 1
' \Q--, L N, \o- � r-.. RICHARD S. MARTIN 2 ----\Z �� . rk �> N \e -e T" "R ' CHiBn s TIM
Name of Notary typed, printed or stamped: comma D00535452 •
Name of Notary typed, printed or s E 4I?/2ot0 a ny Expires 112/2010
f t Bonded br 000/4324254 0 Bonded by ( 2.425
Florida Notary Assn., Inc 1 of Florida Notary Assn Inc
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•
Bahr'sPropaneGas&NC
4441 Allen Rd.
Zephyrhills, Fl. 33541
Phone 813 - 782 -5013 Fax 813 -783 -1374
July 30, 2009
City of Zephyrhills
Building Dept.
RE: Permit Authorization
State License #CAC043948, Mechanical, City #17
State License #001735, LP Gas-Cat. 1
Dear Sirs:
Effective immediately, the following individuals will be permitted to sign and
pick up permits for Bahr's Propane Gas & A/C, Inc:
• Bobbie J. Knight
• Harold Ogilbee
• Donna Moon
• Debbie Steve
• Sandra Bahr
• Leonard Bahr
• Jaime Misener
• Darlene Rice
• Kevin Bahr
• Suzanne Bahr, Pasco Permit Service
• Stacie Zullo
• Deborah Dokendorf
• Dennis Krouse
• Misty Easler
• Lisa Booker
This letter supercedes all previous letters.
License Hold r,
ty‹. NOTARY PUBLIC-STATE OF FLORIDA
" " " Sylvia A. Campbell
Kevin ahr Y -',', Commission #DD883699
Bahr's Propane Gas & AC, Inc. 1 .-„„/ Expires: JULY 19, 2013
BONDED THRU ATLANTIC BONDING CO,, INC.
STATE OF FLORIDA
County of Pasco y..\ The foregoing instrument was wedged beye his 3' day of dkd , 2009 PERSONALLY KNOWN TO ME CC lJ
Pasco County Parcel: 34- 25 -21- 0180 - 00000 -3060 001 Page 1 of 1
Search Again Show Map Building Schematic Unavailable Frequently Asked Questions Estimate Taxes
Other Agency Data: Tax Collector School Board Supervisor of Elections
I Data Current as Of: II Weekly Archive - Monday, July 27, 2009
Parcel ID II 34- 25 -21- 0180 - 00000 -3060 (Card: 001 of 001)
Classification II 00 - Vacant Residential
Mailing Address Property Value
READY LESTER W & Ag Land $0
HAGERMAN MARIE B Land $25,148
37501 GILL AVE
ZEPHYRHILLS, FL 335417795 Building $0
Physical Address Extra Features $0
7918 KAY MARIE AVE Market Value $25,148
ZEPHYRHILLS, FL 33541 -7708 Assessed (Save Our Homes) $0
Legal Description (First 4 Lines)
Taxable Value $25,148
See Plat for this Subdivision'
GRAND HORIZONS - PHASE FOUR
PB 61 PG 023
LOT 306
OR 8131 PG 711
Land Detail (Card: 001 of 001)
Line 11 Use I °Description° Zoning 11 Units 11 Type II Price 11 Condition II Value I
1 0200 MSUBM 00M1 6,000.00 SF
$4.00 1.00 $24,000
2 0200 MSUBM 00M1 2,087.00 SF
$0.55 1.00 $1,148
I Additional Land Information
I Acres II 0.19 II Tax Area II 3OZH II FEMA Code II -- IlResidential CodeIl GDHZLP1
I Building Information (Card: 001 of 001)
Unimproved Parcel 00 - Unimproved
Extra Features (Card: 001 of 001)
Line II Description II Year II Units 11 Value
No Extra Features
Sales History
Previous Owner BEAUCHAMP GERALD E & MARY K
Year II Month II Book /Page II Type II Amount
2009 07 8131 / 0711 WD
2006 II 11 1 1 7297 / 0458 II g2 11 $34,000
I 1995 I I 12 11 3508 / 0207 11 WD II $
Search Again Show Map Building Schematic Unavailable Frequently Asked Questions Estimate Taxes
Other Agency Data: Tax Collector School Board Supervisor of Elections
http: / /appraiser.pascogov. com/ search /parcel. aspx ?sec= 34 &twn= 25 &rng=21 &sbb= 0180 &bl... 8/3/2009
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.•r ; € Commission DD 821833
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NOTICE OF COMMENCEMENT 2 1 11 0 IIIIIIIIIII IIIIIIIIII IIIIII'IIIIIIIIIIIIIIIIIIIIII 1111
2009105657
State of Florida ' County of Pasco
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statues,
the following information is provided in this Notice of Commencement.
c L i - Zc - z1 — A) - 0'000 -3 060
t) Description ofProperty: Parcel No: 3 ��
Rcpt:1255955 Rec: 10.00
�' /t /SAY 6'1/1ff�i�= At/E Le/ 3 DS: 0.00 IT:0.00
(Legal Description of the property and street address if available) 07/30/09 Dpty Clerk
2) General Description of Itnprovements: / 0 ( 17 1 e...-/.. /40,14E 5/ % (J{� / �
T ) PRULR O'N, PRSGO GL & COMPTROLLER
07oR05. 6K9 EIL PG �3 1�7
3) Owner Information: Name 1.--65 le- //L I 125AP Y
> 3 7 so/ 61 tL- Ayr
J e0 ((� Address City State
Interest in Property: �/7/
/ 1' d Name of Fee Simple Titleholder: /{ /4
u other than owner)
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4 Address City State
(n
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6
9 Address
5) Surety: Name / v / /
Address City State
J 6) Lender: Name AV�-
t —
Cn Address City State
0 7) Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section
713.13(1)(x)(7), Florida Statutes:
-J G . Name /
U
`» Address City State
v € 8) In addition to himself, Owner Designates /✓fA
n � Of to receive a copy of the Lienor's Notice as provided in section
n 713.13(1)(b), Florida Statues.
9) Expiration date of Notice of Commencement is one year from the date of recording ss a di 'ferent date is specie 1
7 9-0 g / 4., 4 �. _ �•l[ /_t'mow► —
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State of Florida
County of / /).S
The foregoing instrument was aclatowledged before me the ''--j (-- ( l Q 2 1 Z
/ 2-00 ? (Date), by
L I 5 /Z ty /eFA,v 1 (name of person acknowledging), who is personally known to me or who has produced
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4 ,0 N , 61 y Public State � SEA ( G /4 ' 04 T.,: ? °
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MY i;om6lission DD566784 NOTARY
" 'ono expires 06f22/2010
�_� — r/L is . A 561:57C-
STATE OF FLORIDA, COUNTY OF PASCO
THIS IS TO CERTIFY THAT THE FOREGOING IS A
TRUE AND CORRECT COPY OF THE DOCUMENT
ON FLE OR OF PUBLIC RECORD IN THIS OFFICE
OITTNESS MY H' ' • ' 1 OFFI - IAL SEAL THIS_
DAY +
�=; ULA . O' , LE" & C0 'TROLLER
v+-----"'- DEPUTY CLERK
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: 6AA5 Ll-
Date Received: 7-30-09
Site: 9/0 kal / a4 e, ,
Permit Type: / � 7'��i(XiC Q-1�(o /4/64//e kyft-e_ ' l ��
C
Approved w /no comments: Approved w /the below comments: ❑ Denied w /the below comments: ❑
This co e sheet all kept with the permit and/or plans.
Kal in Switzer — P s Examiner Date Contractor and/or Homeowner
(Required when comments are present)
From:Nieta Alford FaxID:Beall Insurance Sery Page 2 of 2 Date:7/31/2009 03:24 PM Page:2 of 2
a'/� f�
E2 CERTIFICATE OF LIABILITY INSURANCE OP ID _ 0 DATE (MM/DDIYYW) 07/31/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Vinson Group , LLC -Zeph ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Beall Insurance Services HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
5710 Gall Blvd. , Suite C ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Zephyrhills FL 33542
Phone: 813- 788 -5900 Fax: 813- 788 -9654 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A
Burlington insurance Company
INSURER B Businessrirsi insurance Cowpan
BMI , LLC.
Lisa Booker INSURER C
39838 Stewart Road INSURER D:
Zephyrhills FL 33540
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.
INblr WUU L POLICY NUMBER POLICY EH- ECTIVE POLICY kXPIRATIOA LIMITS
LTR NSRD TYPE OF INSURANCE DATE (MMIDD/YYYY) DATE (MM/DD/YYYY)
GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 , 000
A X COMMERCIAL GENERAL LIABILITY 1838006424 01/14/09 01/14/10 PREMISE (Ea occurence) $ 100 , 000
CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5 , 000
PERSONAL & ADV INJURY $ 1 , 000 , 000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ included
— 7 POLICY P JECT 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 $
7 OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION X TORY LIMITS I
AND EMPLOYERS' LIABILITY Y / N
X ANY PROPRIETOR/PARTNER /EXECUTIVE SUSINEssrxpST INSURANCE 05/13/09 05/13/10 EL EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E L DISEASE - EA EMPLOYEE $ 100 , 000
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
City of Zephyrhills REPRESENTATIVES.
Jackie
5335 8th St. AUTOO REPRESS T
(Zephyrhills FL 33542 _
ACORD 25 (2009/01) -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
\I
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U - 7 . No(- PERFORMANCE BUSINESS PRODUCTS, INC. 813- 719 -8008 FAX 813- 719 -7919
CITY OF ZEPHYRHILLS
ZEPHYRHILLS, FLORIDA
WATER ACCT. NO. DATE I) T . 9
,..,
OWNER/ 2....e>i
RENTER r1d 1.4r,
MAILING ! 6� &1( 0
z A rA, 1f s *G- 33 (5 - S9
SERVICE ADDRESS 7 6 / 4 ' a y j� A/ e 4/"-' �� / #&
pb WATER
SHUT OFF SERVICE ❑
❑ SEWER
TURN ON SERVICE
INSTALL METER � ❑ GARBAGE
IN CITY
READ METER ❑
❑ OUT CITY
CHECK METER ❑
No. OF UNITS
OTHER ❑
DEPOSIT AMOUNT
14 j' !/� v a / (� AMOUNT LAST BILL
" 7
9 3 9 , DATE
pezyk
MISC. CHARGE
METER: full
irrigation
WORK COMPLETED BY ORDER`fAKEN BY
& DATE COMPLETED
t
O N BY
IN
if 11 arriqfLA,,
Retain white form in office at all times.
Send pink & yellow forms to Water Service Dept.
Water Service Dept. to sign yellow form & return to office.
4411 Y"' r'
USOVIN■ .. PERFORMANCE BUSINESS PRODUCTS, INC. 813 - 719 -8008 FAX 813 - 719 -7919
CITY OF ZEPHYRHILLS
ZEPHYRHILLS, FLORIDA
WATER ACCT. NO. DATE 9-V-09
OWNER/ Cr.44 riZO/1
RENTER
MAILING 1 76 45 6-reefiSkPe bi
2 ( A , ` (s 335- 5f/
SERVICE ADDRESS -7•/ 8 Kay /M'- 'e i - b
WATER
SHUT OFF SERVICE ❑
❑ SEWER
TURN ON SERVICE
❑ GARBAGE
INSTALL METER
IN CITY
READ METER ❑
❑ OUT CITY
CHECK METER ❑
No. OF UNITS
OTHER ❑
DEPOSIT AMOUNT
j �� J ,� AMOUNT LAST BILL
oedil
p g391‘ DATE
MISC. CHARGE
METER: full
irrigation
WORK COMPLETED BY ORDER TAKEN BY
& DATE COMPLETED �l
IP
O R GIVEN BY
1" B 0
Retain white form in office at all times.
Send pink & yellow forms to Water Service Dept.
Water Service Dept. to sign yellow form & return to office.