HomeMy WebLinkAbout09-9474 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780 -0020 9474
BUILDING PERMIT
.,. -
Permit Number: 9474 Address: 5921 FOREST LANE
Permit Type: MECHANICAL ZEPHYRHILLS, FL.
Class of Work: A/C CHANGEOUT Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: FOREST VILLAS
Est. Value: Parcel Number: 10- 26 -21- 0110 - 00000 -0100
Improv. Cost: 4,940.00 x
Date Issued: 8/26/2009 Name: SHONYO, HEATHER & SMOTHERS, DANA
Total Fees: 55.00 Address: 5921 FOREST LANE
Amount Paid: 55.00 ZEPHYRHILLS, FL. 33542
Date Paid: 8/26/2009 Phone: (813)310 -6532
Work Desc: NC CHANGE OUT 2 1/2 TON §
:!.41.40•7;7777- s fi r 3 � � G .. � ; .. . �, 4 9 t � m a J a w ...�c .. 3 j
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RON 1 - �A' H O • LI 1 HAN • UT 55.00
i n - Li) ;f
D T I ALL
DUCTS INSU TED
FINAL y- /d -0 1
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."
4 1 la
CONTRACTOR SIGNAT - PERMIT OFFI �R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
•
813 -780 -0020 City of Zephyrhills Permit Application #q(( rcuk-u W-4.,
Building Department
Date Received Phone Contact for Pennitli , S • • ♦ (ic Q.
Owner's Name ,7 $ IL • , HUI I LSD Owner Phone Number MilignitIMIAI.
Owners Address 1 :U4 r. G ` Q. 61 L 1- ThUULt ' 1 Owner Phone Number I 13 NO- l.o I
Fee Simple Titleholder Namel ( Owner Phone Number 1 I
Fee Simple Titleholder Address I I
JOB ADDRESS , La i 11 J Chi . I LO I
SUBDIVISION • • I r e - . Vi U Q S " . 1 PARCEL Ktlfl 10 &lQ -a.l -- c l l d "' 00000 - O1 OD I
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED • I I INSTALL CONSTR I I REPAIR J SIGN 0 MOVE Q DEMOUSH
PROPOSED USE . n SFR [ - CORM ( OTHER I
TYPE OF CONSTRUCTION n BLOCK n FRAME - .F1 STEEL n OTHER I
DESCRIPTION OF WORK -, ! . At. L f I "
•
BUILDING SIZE SQ FOOTAGE HEIGHT I I
• ( BUILDING I; I VALUATION OF TOTAL CONSTRUCTION •
I ELECTRICAL (: I AMP SERVICE r PROGRESS ENERGY n W.R.E.C.
r -i PLUMBING 1$
MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION
(- GAS n ROOFING J I SPECIALTY n OTHER
FINISHED FLOOR ELEVATIONS I ( FLOOD ZONE AREA nYES 1\4 INO
BUILDER COMPANY
1 I
SIGNATURE REGISTERED 1 Y/ N I FEE T I Y/ N I
CURRENT
Address I 1 . License # I I
•
ELECTRICIAN COMPANY I I
SIGNATURE REGISTERED " 1 Y/ N 1 FEE CURRENT I Y/ N I
Address I 1 License # I I
PLUMBER COMPANY
I I
SIGNATURE REGISTERED 1 Y/ N I FEE CURRENT I Y/ N I
Address I I License # 1 I
MECHANICAL I (S,) ,) M COMPANY l 0 'c
^ • , COOLLY) , L • .
SIGNATURE � �>"' "' "'�C. ' I .Thb REGISTERED rill N FEE • ,. N z W e
Address I 1 Use # I I
OTHER COMPANY •
SIGNATURE REGISTER& I I Y/ N I FEE CURRENT I Y/ N I I
Address I 1 License # I I
RESIDENTIAL Attach (2) Piot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Penult for new construction,
Minimum ten (10) working days after submittal date. Required onsite. Construction Plans, Stonnwater Plans w/ Silt Fence installed,
Sanitary Fac Bides & 1 dumpster; Site Work Penult for subdivisions/large projects
COMMERCIAL Attach (3) complete sets of Building Plans plus a Ufa 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, Stonnwater Plans w/ Sift Fence installed.
Sanitary Facilities & 1 dumpster. Site Work Permit for all new projects. AN commercial requirements must meet compliance
• SIGN PERMIT Attach (2) sets of Engineered Plans.
""PROPERTY SURVEY required for at NEW construction.
Directions:
FIN out appllcado n completely.
Owner & Contractor sign bads of application, notarized •
If over $2500, a Notice of Commencement is required. (ANC upgrades over ;5000)
.. Agent (for the contractor) or Power of Attomey (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
understands that this permit may be subject to °deed' restrictions"
NOTICE OF DEED RESTRICTIONS: The undersigned understands
assumes responsibility for compliance with any
which may be more restrictive than County regulations. The undersigned
applicable deed restrictions. ' ES: if the owner has hired a contractor or
UNLICENSED CONTRACTORS AND CONTRACTOR REST with state and local regulations. If the
contractors to undertake work, they may be required to be licensed in � c for a misdemeanor violation
contractor is not licensed as requited by law, �' the owner hr th
under state law. If the owner or intended contractor are uncertain as to what licensing real pt timemer:fs may app y e
for for or e
they are advised to contact the Pasco County Budding Inspection Division -- Licensing s sign
portions of the 'contractor Block' of this application for which they 9
8009. Furthermore, if the owner has hired a contractor or � 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 prtvleges in as Pasco
County. The undersi
TRANSPORTATION IMPACTIUTILITIES IMPACT AND RESOURCE RECOVERY c o nstr r co new bu understands change of
that Transportation Impact Fees and Recourse Recovery Fees specified � Pasco County Ordinance number 89-07 and
use in existing buildings, or expansion of existing buildings,
90-07, as amended. The undersigned also understands, that such fees, as may be due, will be identified at the time of
impact Fees and Resource Recovery Fees - must be paid prior to
permitting. It is further understood that Transportation P� does not involve a oerfi�ate of occupancy or
receiving a `certificate of occupancy' or final power release. If the project
must be paid prior to ewer Impact
Water/Sewer final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County W at e r/S es.
permit issuance in accordance with applicable Pasco County
fees are due, they Florida Statutes, as amended): If valuation of work is $2,500.00 or more, I
CONSTRUCTION LIEN LAW (Chapter 713, provided with a copy of the `Florida Construction Lien Law—Homeowners
Prote Protection 1, the repar have been pro Agriculture and Consumer Affairs. If the applicant is someone
Protection Guide' prepared by the Florida Department
other than the 'owner", I certify that I have obtained a copy of the above described document and prom ise in good faith to
deliver it to the 'owner prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT: I certify laws that all construction, m ��g and land development. Application is
will be done in compliance with all applicable regulating r n has
hereby made to obtain a permit to do work and installation as indicated. I that no work k oar i l in sta to llation ation has
it and that all work will be performed to meet
commenced prior to issuance of a perm an aactons, and land development regulations in the jurisdiction. 1 also
construction, County and City codes, zoning regulations, �n� may apply to the intended work, and that it is
certify that 1 understand that the regulations of other government Such induce but are not limited to:
my responsibility to identify what actions 1 must take to be in compliance.
_
Department of Environmental protection - Cypress
s, Wetland Areas and Environmentally Sensitive
Lands, Water/Wastewater Treatment. s, Wetland Areas, Altering
- Southwest Florida Water Management District-Wells, Cypress Bayhead
Watercourses.
- Army Corps of Engineers - Seawalls, Docks, Navigable Waterways.
Department of Health & Rehabilitative Services/Environmental Huth Unit-Wells, Wastewater Treatment,
Septic Tanks. abatement.
- US Environmental Protection Agency-Asbestos
Federal Aviation Authority-Runways.
- I understand that the following restrictions apply to the use of fill:
an addressing a
e'
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 d a a plan add
e ngineer
•compensating volum will be submitted at time of permitting
licensed by the State of Florida. rued building using stem wall
- ff the fill maternal is to be used in Flood Zone �A'in n within the stem w al l. affect ant to
�s n, I certify that fill will be used only
I that use of such fill will not adversely
p p material is to fe used in any area, � adjacent properties, the owner may be cited for violating
- properties. If use of f�i is found to adversely Win, for lots less than one (1)
the conditions of the budding permit issued under the attached perm it application,
acre which are elevated by fill, an engineered drainage plan is required.
If 1 am the AGENT FOR THE OWNER, I promise in good faith to inform the owner conditions set forth in
it may be required electrical work,
to commenting construction. I understand that a separat perm included in the electrical w ,
this plumbing, signs, prior s , air condfioning, g or other installations not specifically alter, A
p mbt is es wells, a nd with the work and not as authority to. violate, cancel,
n or shall issuance of a penult prevent the Budding Official from thereafter
permit issued shall be construed to be a license to proceed it issued shall become invalid or
provisions of the tec codes. Every perm
set aside any p ect i on of errors in plans, construction o r violations of any codes. it issuance, issued
if work become invalid
. by
requiring a correction ed by such permit is commenced within six months t An extension
unless the work penno3z of six (6) months after the time the work is commenced. permit is suspended or abandoned for a period not to exceed ninety (90) days and will demonstrate
• stifiable cause for the extension. may erequested, in writing, from the Building. Official for a p b is considered ab d demonstrate may be reques (90) consecutive dam extension. if work - _- -
R
CEMENT MAY RESULT IN YOU
WARNING TO OWNER= YOUR FAILURE TO RECORD A TY YOU D
TO OBTAIN FINANCING, CONSULT
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPP ER Ye' _Ai- J.I. E •1 C •_: i- C –1_, T.
11,_:__, = •,; RECD
FLORIDA JURAT . $. X17.03) ! ���� f me itds a -
CONTRACTOR ��.
OWNER Q n ` :�` . , f or affi med) before me this '+ Sum and y
Subscribed and Who PB< known t rim or hasfhawe
by
produced
Who____ Persa Y known to as identification. as identification.
Notary Public
Notary PubNc
Commission No.
Commission No.
Name of Notary typed, printed or stamped
Name of Notary typed, pied or stamped
• • • • • • • • • • • • • • • IF
°D R on lerna Heating & Cooling, Inc.
( c - =i i 21 L S H«v 41 North • Lutz. FL 33549
Local (8 1 3 ) 9-18 -6355 • Fax (813) 9.9 -9266
f Tol! Free ( 866) 323 -COOL • Lakeland (863) 859 -0062
4
=t: 1.f.. ,- ^ • Qaalin in = QB26 202 • Licensed. Bonded & Insured
4 L k) + `1 1 Y • tk «v.. IemaAir.com
tIE A ry
c r- • �,� , • -� _ } , i DATE ORDERED
ZIP ' DATE SCHEDULED
I MAKE MODEL SERI NUMBER 0 0 4 3 7 9
I I 1 0 0 9
WORK PHONE
_ CELL PHONE
— ■ \`, SUBDIVISION ❑ T O ROG
ORIGINAL COMPLAINT • r
LAKELAND
� - ❑ ELECTRIC
S ❑ FPNL
ADDITIONAL PARTS LISTING TOTAL PARTS 4 I r - 0 WITH LACOOCHEE
ON BACK OF PART 3 ❑ O THER
❑ COMPRESSOR I
❑ SUCTION PSI DESCRIPTION OF WORK PARTS
■ 9 HEAD PSI 1
•!'
❑ VOLTS AMPS
❑ ELECTRICAL CONNECTIONS I 1 L C _ , `,�.� ' 1 . 1114
O CONTACTS TIGHT & CLEAN -
❑
•
OIL LEVEL & CONDITION 1 i
.SUPERHEAT I-- 1C \ 0 ` A,1 _ • /1! 1r j � J 1Qr C - G ,
il
❑ SUB COOLING
0 LIQUID LINE TEMP. I -, - .-. r
!7 SUCTION LINE TEMP. - ' �{ j ('t
STATIC PRESSURE POS. _ NEC. ! _c_ ki�}� B V} ( I /j�' tit t t I ` I Q � 1 1 _ 9 j ^�
❑ CONDENSER COIL 1 t T 1 1 1, I V ( 1 111 ` ` �Z 1 ' ! f }
1 ^ u CLEAN COIL &CHECK FIN COND. + . 1 \syl 1 ❑ REFRIGERANT G ---
-F� �� Y L
I 7: LEAK D. CHARGE C - cd V f
❑ FAN &MOTOR
-7 E LECT RICAL CONNECTIONS
0 CONTACTS TIGHT & CLEAN OLTS AMPS I ` l � f , ` Y a lVl j�(� k - q ' '.
❑ ELECT ma L _ .� �; / �- '
/ � r y _ . � • \./ 4 V I •
FAN PULLEYS (ADJUST BELT ' ( - --•- ` •' CLQ\QJ � �ii � ( t k C .IV 1 ' � A )
i G� / `
❑CH ECK LUB BEARINGS & MOTOR 't --�"' ` n
, ❑ CFO S / T'C. 1 . I
C EVAPORATOR COIL , �•J��
' CLEAN COIL & CHECK FIN \ �. ` 1 1 I "
O CONDENSATE AREAS � i� \ WM
! ❑ INSPECT & CLEAN DRAIN PAN
❑ INSPECT & CLEAN DRAIN
❑ AIR FILTERS I -- ,
i CLEANED REPLACED .. r,
- � ;��� —
FILTER SIZE { K i
1 0 HEATING ASSEMBLY
❑ BURNER & HEAT EXCHANGER ! "
0 FUEL SUPPLY & PRESSURE .
PARTS WARRANTY �- -
■
❑ PILOT ASSEMBLY ` ARRIVE ;DEPART
E FLAME ADJUSTMENT : ALL PARTS AS RECORDED ARE WARRANTED AS PER _
MANUFACTURER SPECIFICATIONS ■
❑ PRIMARY RELAY & FLUE CANCELLATIONS
9 FAN & LIMIT SWITCH OPERATOR LABOR GUARANTY
I ❑ BLOWER ASSEMBLY THE LABOR CHARGE AS RECORDED HERE RELATIVE
! D RV VALUE TO THE EQUIPMENT SERVICED AS NOTED. IS GUARAN-
TE FORA PE OF 3 DAYS ALL CANCELLATIONS ARE SUBJECT TO ANY PERMIT
❑ STRIP HEAT FEES INCURRED BY SAID COUNTY. APPLICABLE FEES
❑ DEFROST CYCLE ■ DIRTY /CLOGGED AIR FILTERS. TRIPPED BREAKERS
I ❑ ELECTRICAL COMPONENTS I AND CLOGGED DRAIN LINES ARE NOT WARRANTY WILL BECOME THE FINANCIAL RESPONSIBILITY OF
^_ RELAYS 0 CONTRACTORS Issues
_ PURCHASER AND / OR PROPERTY OWNER.
o OVERLOAD 9 PRESS. SWITCH WE DO NOT, OF COURSE GUARANTY OTHER PARTS '-
❑ THERMOSTAT I THAN THOSE WE SUPPLY. IF REPAIRS LATER BECOME 1 `/
_ .
OK 9 REPLACE NECESSARY DUE TO OTHER DEFECTIVE PARTS. THEY T TECH # '
' � RELOCATE I WILL BE CHARGED SEPARATELY. 5
EQUIPMENT - '; CHECK ` LIST TERMS: DUE UPON COMPLETION - SUBTOTAL $ CM
! CHANGED
SYSTEM
TYPE I HAVE THE AUTHORITY TO ORDER THE ABOVE WORK AND DO SO
(DEPOSIT)! $
! OUTrOP
REFRIG ply, -, REPLAC D _ ORDER AS OUTLINED ABOVE. IT IS AGREED THAT THE SELLER WILL
-- ` -- , RETAIN TITLE TO ANY EQUIPMENT OR MATERIAL FURNISHED UNTIL
_ _ 1 DISMANTLED' _ _ ' FINAL & COMPLETE PAYMENT IS MADE. AND IF SETTLEMENT IS NOT TAX 1 $
R RECOVERED? rES rcc QTY .ES NC MADE AS AGREED, THE SELLER SHALL HAVE THE RIGHT TO REMOVE
REFRIGERANT DISPOSAi
' E -- , SAME AND THE SELLER WILL BE HELD HARMLESS FOR ANY DAMAGES TRIP
F RESULTING FROM THE REMOVAL THEREOF. PAYMENTS NOT RECEIVED j CHARGE $
R RECYCLED? TES NO OTY. WITHIN 10 DAYS ARE SUBJECT TO A SERVICE CHARGE OF 1.5% ON
OUR PERSONNEL RECOMMEND • UNPAID BALANCE. RETURNED CHECKS SUBJECT TO ALL APPLICABLE " I —I (j RECIAIMED'7 .•4 N? OTY ' FEES. C/C FEE
E
I pt
I RETURNED TO _._.__ �. • t9.�' C ! ' \ ,
Pasco County Parcel: 10 -26 -21 -0110- 00000 -0100 001 Page 1 of 2
Search Again Show Map Generalized Building Schematic Frequently Asked Questions Estimate Taxes
Other Agency Data: Tax Collector School Board Supervisor of Elections
I Data Current as Of: I Weekly Archive - Saturday, August 15, 2009 I
Parcel ID II 10 26 - 21- 0110 - 00000 -0100 (Card: 001 of 001) I
I Classification II 01 - Single Family
Mailing Address Property Value
SHONYO HEATHER & Ag Land $0
SMOTHERS DANA
5921 FOREST LN Land $6,276
ZEPHYRHILLS, FL 335423260 Building $48,993
Physical Address Extra Features $1,130
5921 FOREST LN Market Value $56,399
ZEPHYRHILLS, FL 33542 -3260
Assessed (Save Our Homes) $56,399
Homestead 196.031 - $25,000
Legal Description (First 4 Lines) Non - School Additional Homestead Exemption - $6,399
FOREST VILLAS UNRECORDED PLAT Non - School Taxable Value
PARCEL 10 DESC AS COM NE COR $25,000
SECTION 10 TH N89DEG 38'40 "W School District Taxable Value $31,399
Warning: A significant taxable value increase
671.73 FT ALG NORTH LINE OF may occur when sold. Click here for details
and info. regarding the posting of exemptions.
Land Detail (Card: 001 of 001)
I Line II Use IlDescriptionll Zoning II Units II Type II Price II Condition II Value I
1 I 0100 II SFR II 00R4 _II 3,338.27 II SF II $1.88 II 1.00 II $6,276 I
I Additional Land Information
I Acres II 0.08 II Tax Area 11 3OZH II FEMA Code II X ([Residential Co dell FVLALP1 I
I Building Information - Use 01 - Single Family Residential (Card: 001 of 001) I
Year Built 1981 Stories 1.0
Exterior Wall 1 Concrete Block Stucco Exterior Wall 2 None
Roof Structure Gable or Hip Roof Cover Asphalt or Composition Shingle
Interior Wall 1 Drywall Interior Wall 2 None
Flooring 1 Cork or Vinyl Tile Flooring 2 Carpet
Fuel Electric Heat Forced Air - Ducted
A/C Central Baths 2.0
Line II Description II Sq. Feet II Repl. Cost New
1 I BAS II 968 II $49,542
2 I II 208 II $5,323 I
3 II FOP II 64 II $819
4 FGR II 360 I
II $7,370 (
Extra Features (Card: 001 of 001)
Line I Description I Year II Units II Value I
1 I) DWA 0 1981 I 300 I $194
2 II FIRE PL I 1981 II 1 II $435 I
3 II CON PTO I I 1981 II 417 II $501 I
Sales History
Previous Owner I D'AMORE THOMAS I I
Year I Month II B ook /Page 11 Type II Amount I
2005 I I 09 II 6625 / 1558 11 WD (I $106,000 I
II II I
http: / /appraiser.pascogov.com/ search /parcel. aspx ?sec= 10 &twn= 26 &rng=21 &sbb= 0110 &b... 8/26/2009
ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID B8 DATE(AIAIIDD/YYYY)
PRONwcER RONIE -1 08/26/09
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
AND Brown & Brown of Florida, Inc . HOLLDER. THICONFERS ERTIFICATE DOES NOT AMEND,, EXTEND R
P . 0. Box 15519 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa FL 33684 -5519
Phone: 813 - 226 -1300 Fax: 813- 226 -1313 INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Bridgefield Employers Ins . 10701
Ron Ierna's Beating & Cooling, INSURER B:
Inc INSURER C:
19121 US Highway 41 N INSURER D:
Lutz FL 3359
INSURER E:
COVERAGES
THE POUCIES 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
T1LTTR ARE TYPE OF INSURANCE POLICY NUMBER T ( M ID � D T (M UNITS
DAELIIIDD
GENERAL LIABLITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY UAMAGt I U HtN i tU
PREMISES (Ea occurence) $
CLAIMS MADE OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: -
POLICY PRO PRODUCTS - COMP/OP AGG $
JECT LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
(Ea accident) $
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS —
BODILY
accident INJURY
-0 $
NONWNEDAUTOS )
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO
EA
OTHER THAN ACC $
AUTO ONLY: AGO $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
DEDUCTIBLE -
RETENTION $ —
WORKERS COMPENSATION AND S fA I U- OTH-
A EMPLOYERS' LIABILITY X I TO LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE 0830 -42368 07/05/09 07/05/10 E.L. EACH ACCIDENT a 500000
OFFICER/MEMBER EXCLUDED?
If yes, describe under ON E.L. DISEASE - EA EMPLOYEE $ 500000
SPECIAL PROVISIS below
OTHER E.L. DISEASE - POLICY LIMIT $ 500000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYZEP SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WLL ENDEAVOR TO MAL 010 DAYS WRITTEN
City of Zephyrhi l is NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Bldg Dept IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
5335 8th Street REPRESENTATIVES.
Zephyrhills FL 33542 AUTHOR NTATIVE
ACORD 25 (2001/08) ® ACORD CORPORATION 1988