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HomeMy WebLinkAbout09-9480 CITY OF ZEPHYRHILLS �~ 5335 - 8TH STREET (813)780 -0020 9480 MOBILE HOME SET -UP Permit Number: 9480 Address: 6101 AGATE ST 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: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 02- 26 -21- 0020 - 00300 -0010 Improv. Cost: 5,060.00 Date Issued: Name: ZACK WILLIAM E TRUST & MILDRED Total Fees: 175.00 Address: 10063 OAKS LN Amount Paid: 175.00 SEMINOLE FL 33772 Date Paid: 9/28/2009 Phone: (727)424 -8307 Work Desc: REPLACEMENT MOBILE 66 HOME SET UP 14 X 56 4 €'.�; f. .... a v # H BR• •K M•BILE •ME - VICE M•BILE H• L TRI AL 40.00 MOBILE H•M ET- P 60.00 MOBILE HOME MECHANICAL 35.00 MOBILE HOME PLUMBING 40.00 1 n ��rJ / I 7 ?) C t l e wAlr .a� M•BIL H•M T -UP MOBILE HOME ELECTRIC MOBILE HOME NC MOBILE HOME PLUMBING FINAL 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 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 CONTRACTORS SIGNATURE PERMIT OFFI ' - - PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 1 111111 11111 11111 11111 11111 11111 11111 11111 11111 11111 1111 1111 - NOTICE OF •COM IENCEMENT 2009138379 Permit No. Rcpt :1265642 Rec : 10.00 DS: 0.00 IT:0.00 Property Identification No. 02.- d4 a 1 04 db .- oO &CEO - 0a 1 c 09/28/09 Dpty Clerk TTY UNDERSIGNED hereby give informs you that the 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, { 0 - qtr` 3 t ()?'aC 0 s(' 0 -0S)i 0) • 1.D? c'ription of property (legal description:) rndbi park k ? i'' 3 q Grp . . a) Street Address: 2 y 944-11 (I5 Ft, ", 2.General description of improvements: asp ip ER- a ( c (via b . ler or w i '14 il)4,4A/ Old i., 3.Owner I n f o r m a t i o n 3 tS3 `j YL S G e n 4 - Name and address: 2 adIC s bA�,l� 51�� 11?d ► ( a. Itot .. tur L 1 f t zi /1,u-h. 1(s, FL 3 35tf _ � 4 b) Name and address of fee simple titleholder (if other than owner) c) Interest in property 4.Contractor Information • } w a) Name and address: B Cc L. s Mob' (_9 v b) Telephone No.: 513 - ‘c .•-4 ails �/� -- 376 -5,311, Fax No. (Opt.) Tj�nGtt✓S3S3€ , 3359z. 5 urety Information /� a) Name and address: 4 t ISo et - . ( 4 ,, h I n • Join ectr , Svc 4- Q r {or) ite' . l.--/ l.--/ b) Amount of Bond: S 0 0C3 317il c) Telephone No.: II 09 33 O .. 3 y 90 Fax No. (Opt.) 6.Lender Z' a) Name and address: u Phone No %7. Identity of person within the State of Florida designated by owner upon whom notices or other doe a is may b erved: .. a) Name and address: ale _aii Za 5f70 C' 2 /6 ��7�e rat . .,� : , /4 2_,)V -tc�a e(1 C- b) Telephone No.: 7z 7 _ , 5 .� g' 9i l Fax No. (Opt.) ,e• /I 133164 8.In addition to himself, owner designates the following person to receive a copy of the Lienor's otice as provided in Section 713.13(1)(b), Florida Statutes: a) Name and address: 3 b) Telephone No.: .Fax No. (Opt.) 9.Expiration date of Notice of Commencement (the expiration date is one year from the date of recording unless a different date is f specified): m tflg 1O • AN \.) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF CO m 00 at o _°� COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13, ` . FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. F THE NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE TH FIRST ~~ INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT YOUR LENDER OR AN ATTORNEY BEFORE li COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. o STATE OF FLORIDA / e COUNTY OF PASCO 0 x r Si of Owner or Owner' Authorized Officer /Drector/Pariner/Maneger " 0 o wf P -? . a 5 � fro 0 K,a ar Print Name . w i 0 The foregoing instrument was acknowledged before me this ly day of 5--e_. • 200/ , by A _j_n_ C _ __ as u P (type of authority, e.g. officer, trustee, attorney in f a c t ) f o r exit AL Oy41Ls. 4 R,• mu i i l.e ,' » "z PAekrtrame of party on b , : : •' .. „ ' , , , rent was executed). Personally Known OR Produced Identification k/ Notary Signature 4 - ' il . 0 ; � ; �4.'. y ROBERT A. WEBB Type of Identification Produced - At r e- - Name (print) _.: ■9 • •.= MY COMMISSION # DD 463699 %a••,.r� txrmES. Dentanbvi 19, 2009 174; Bonded Thru Notary Public Underwriters Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge and belief. Si of Natural P igning Above FORMS/NOC,rvsd2007 % 813 -780 -0020 City of Zephyrhills Permit Application ,� (( Fax- 813 -780 -0021 Building Department - •• ` ' . '1 Date Received • Phone Contact for Permittin! / i/ 3.." 650 __ / F . Owner's Name O)! 1 ,5 Lio! � ! ,) - �a ,wner,Phone Number 7 6 0 ? Ll. I 3O7 Owner's Address 38ST.3 ? 2 eSCe 01 Zef,I r'ii //S Owner'Phone Number Fee Simple Titleholder Name Z l4 5 tri (("" API.? /11' 1L Pk Owner Phone Number Fee Simple Titleholder Address 8,s `' jj- ap .f Tf Ze fh �'kt,it S JOB ADDRESS Z a C l l (i, -C� h I /l : (MID /??Z7 e LOT # SUBDIVISION PARCEL ID# 02 (- /- 00 Jo -0 /d -av /0 (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED n NEW CONSTR ADD /ALT I I SIGN n MOVE I 1 DEMOLISH I INSTALL REPAIR PROPOSED USE 4 SFR 1 1 COMM I I OTHER I I TYPE OF CONSTRUCTION 1 1 BLOCK I I FRAME I I STEEL I / ) OTHER I DESCRIPTION OF !t - GZ �pl ac>xt.e. At� M- t � •(tf►��Q, 1`'� 1� (D BUILDING SIZE O ni SQ FOOT 7 t/ HEIGHT w ir BUILDING $ <• , 5 - 62e) �` C e) VALUATION OF TOTAL CONSTRUCTION L r . ELECTRICAL $ T ' o b AMP SERVICE 1 1 PROGRESS ENERGY I 1 W.R.E.C. PLUMBING $ 1 0& JO WI MECHANICAL $ c+d VALUATION OF MECHANICAL INSTALLATION 1 GAS 1 1 ROOFING 1 I SPECIALTY 11 OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA 1 IYES I BUILDER , er,7 COMPANY 6 N c- L-c [' d/rr f Se..'. f r . SIGNATURE / REGISTERED I Y/ N I FEE CURRENT I Y/ N I Address 9 777 D- 6 /J/ ' e Rci License # 1 A/ 0949 .f 6 ELECTRICIAN Z (.......u,......71/71.7/ 4f COMPA V R NY N GAN c ildt /�1(L5 N /iV G/ SIGNATURE l Address �j License # L Z 3 z 0 P 0 e$ PLUMBER 3 COMPANY ,& E /.r /Xi ai /Z c (^/c/AY e SQL• SIGNATURE gC47fri._ REGISTERED I Y/ N 1 FEE CURRENT '/ N I Address 97/6 / 7,4 g ,q," e f!1P` License # 1717-'0coo g‘411 MECHANICAL COMPANY 1 (V 6. Ea"( /C 14-0 A r„ j( , SIGNATURE 7 REGISTERED I Y/ N I FEE CURRENT I Y/ N Address I 6 1 License # CA GI f 1 5 D OTHER COMPANY SIGNATURE REGISTERED I Y / N j 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 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 NOTIC OF COMMENCEMENT. FLORIDA JURAT (F.S 7.03) OWNER OR AGENT �_:� _ - . ∎ 1 % / CONTRACTOR Subscribed and sworn V' (or affirmegir ore me this Subscribed and sworn to (or affirmed) efore me this by p y 4 produced by has/have produced as identification. . a • - ' !/ L� G Who is /are e,on.11 n wn to me or has /have roduced VVho / je pers Wally knownto me or has / • dot ry Puhlic State of Florida n S4 on !674935 JERI LYNN BR0NS0 _ � o +" I " ota Public _ _ Notary Public, Stale of F or iaa - Commi :.n No. :u C d mm. ex' M r Co ! ssion No. _ Y Ir- - eirt s No ID 65 N. im • of .. r pe i , •o" . Name of Notary typed, printed or stamped R3artn (coo Ks Adtu- A—o Is:cunk ) t-tekto115 Ws r■svA,k-- 5/-7 2qo ,„ef QUELINE BOGES .DD 821833 s44,0 gres imuomber /2, 2010 Pvt Tray goo averanotioase5.7019 Pasco County Parcel: 02- 26 -21- 0020 - 00300 -0010 001 Page 1 of 2 Search Again Show Map Generalized Building Schematic Frequently Asked Questions Estimate Taxes Other Parcel Cards: 1 1 2 1 3 1 4 1 5 1 6 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 1 02- 26 -21- 0020 - 00300 -0010 (Card: 001 of 006) Classification 1 28 - Rental MH /RV Park I Mailing Address Property Value ZACK WILLIAM E TRUST & Ag Land $0 ZACK MILDRED S TRUST Land $3,005,819 ZACK WILLIAM E & M S TTEES Building $111,325 10063 OAKS LN SEMINOLE, FL 337722006 Extra Features $12,815 Physical Address -See All 213 addresses (First Shown) Market Value $3,129,959 6038 14TH ST Assessed (Save Our Homes) $0 ZEPHYRHILLS, FL 33542 Legal Description (First 4 Lines) Taxable Value $3,129,959 See Plat for this Subdivision -- SUB W1/2 OF SE1 /4 B 2 P 6 LOTS 1 4 5 8 BLK 3 & LOTS 12345 6 BLK 4 & LOT 1 BLK 5 EXC PCL 20 FT BY 20 FT WHERE LIFT Land Detail (Card: 001 of 006) Line H Use IlDescriptionll Zoning II Units II Type II Price II Condition Il Value 1 II 0210 II TRLR PARK 11 00M2 II 239.00 II UT 413,614.0011 0.92 II$2,993,4461 2 II 0100 II SFR II 00M2 II 0.11 II AC II$17,880.00II 1.00 II $1,967 I 3 II 0220 II RV PARK II 00M2 II 2.00 0 UT II $5,203.0011 1.00 II $10,406 I Additional Land Information I Tax FEMA Acres 20.58 Area 30ZH Code X Residential Code RMHPCL2 Commerical Code RMHPCL2 Building Information - Use 12 - Stores / Office SFR (Card: 001 of 006) I Year Built 1957 Stories 1.0 Exterior Wall 1 Concrete Block Stucco Exterior Wall 2 None Roof Structure Flat Roof Cover Built -Up Tar and Gravel Interior Wall 1 Plastered Interior Wall 2 None Flooring 1 Cork or Vinyl Tile Flooring 2 None Fuel Electric Heat Forced Air - Ducted A/C Central Baths 1.0 1 Line l Description II Sq. Feet II Repl. Cost New I 1 II BAS II 832 II I $47,840 1 2 II UST I I 55 I I $1,265 3 I 1 FCP 11 209 II $2,990 4 11 FEP 11 132 11 $5,290 Extra Features (Card: 001 of 006) Line 11 Description II Year II Units I Vlue 1 11 DWSWC I I 1975 44 $17 2 II UDG 1985 II 480 $922 3 II CANOPY I I I 1989 II 960 I1 $2,352 4 II CLFENCE 1975 11,400 II $4,019 II II II 0 http: // appraiser. pascogov. com / search /parcel.aspx ?sec= 02 &twn= 26 &rng=21 &sbb= 0020 &b... 8/26/2009 Ll — 16 _ ..j { 1 1 a 1 1 iF p l ' 1 ,k t 7 a' 56 1-1 °m -e. 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CD CL 0.m m m N= t m m -- — .` n 00 = to 0 .. ..a 3 Q.o iv -0 a a1 en V m O °� �, ° 3 � A- Q a a o m 3 � =0 CO m7 7C ° ?7 - ID j cp = = O � ,, m � O p 61 01. m� Q.� ° m o , � Q� ii m a O N co 0 CD _ \ p s1 0 m m m . -.. r p m to . m g _` m ca _ m m � \�,,`�� � Cr -. , -< o m 0 , - m p Q 0 ID ' • �Cm�m 3 m ` C Nx 7 O Z � m Em T R .R- � a -I 0 -‹ - 3 ' *11 5n a g o m � 7 ' m p • m _, Fa) co) o m ° C m m Q go .-I- _ 3 C . o mD °o Cr CD m g-mg 0 -h am 1e - G 00 p ,+ 1.9: -., m m C7D — m 0) G 0 Cnfn 0 S N 3 to q — n , N � . maaa CD m om n°_; = =Nnnn 0 C m m O m am O 7 7 S cD (0 w � m m a aaaa m -0 CI 74; z io �m* og3 0 D SD o * a m�� m co m 0 O - °-m Cl. a M i m m N = m bl N �W � (p 0 W da < , o N co co m N rt ACOR � ' DATE(MM /DD/YYYY) (J CERTIFICATE OF LIABILITY INSURANCE 8/6/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KILBRIDE INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 400 N Parsons ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Brandon, FL 33511 (813) 684 - 7467 INSURERS AFFORDING COVERAGE NAIC# INSURED Adam Brooks INSURER A: Burlington Insurance Company • Dba: Brooks Mobile Home Service INSURER B: 9716 Del's Acre Rd. INSURER C: Thonotosassa,FL 33592 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/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00( X COMMERCIAL GENERAL LIABILITY PREMISES (Ea E occurence) $ 50,00( CLAIMS MADE X OCCUR MEDEXP(Anyoneperson) $ 5,00( A 019B015372 11/03/08 11/03/09 PERSONAL & ADV INJURY $ 1 , 000 , 00( GENERAL AGGREGATE $ 2,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1 , 0 0 0 , 0 0 ( X !POLICY 7 JECT �I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANYAUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Peraccident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ ANYAUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR I CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCSTATU- 0TH- EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYE $ SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION-OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION City of Zephyrhills Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI 5335 Eight St. 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 SHAL Zephyrhi 11 s , FL 33540 IMPOS .0 OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OI RE" ES: TATIVES. A HORI ED REPR!SENTATIVy A>L t ACORD25 (2001!06) © ACORD CORPORATION 1988 a 0 z o o , co 3 0 0 w L0 0 O to w o O ` w 0 N O N D _' L 1 U) m = co) N Business Tax - *PAID* ct OZ w n di Doug Belden, Hillsborough Counts Tax troll F- c oi W Batch 4: 23209 012 rode ii guezf _ Receipt 016429 C) 2 OC Acct: 215051 Paa Code: 4106 Ce Z a h 1._ •1 W H X 03/06/2009 BR23 2010 13. Chanter 322, Florida Statutes, requires N c s L the deaartment to collect =social Z o v c o securito numbers for the issuance of J ° � H m �' E 0 1 3`1 8usiness $18 00 w Q c 0 00 Z o y Change T O 0 ash Tendered: $20. Cha_ndared: ($2.00) W c = >, co F — V Ce 0 O X m m m W J o > cz LU w X a� - 0 co J J N F- o 0 o Q ' a V m 0 0 0 d U < . F. - - O Q C. N N W w w > a) N 0 J w CO V) > c a Q• M o ° o� o W ( co 1.. x N a o X 10 CD Z m 0 w =p VZm < A O N c!) _c O W W 0 Zcn O M a c M 2 0 a w x O w a pi O 0= o c W W Q z a CD a I-- CD H E m > o Y m h w w W o Z a) m - Q > > m o n o_ 0) E Z m o = O o N O ra z m a) o O >- w N o m o co o o Z 0 cn - o Ct ~ o c� w ° L r ) 0 o 0 Z M a0 C7 (Ni Q d E 0 cn D CC -2 0 L p o Q LL E O = Zw a:� J CC� ' O 0_ m 0 g � v u) < c o cn o O U W m � c � n cn ¢� W VI L. o ° � ° 0 -II- YYw a p J C > 0 Z w 0 z 0 0a C7 O • J } o w d CO J C 00 00 0 w o co C Q m �2 CC Cr ♦A O 2 O 3 0• __I o cm al CO O a. - — x p w v♦ w o ill cu co 5E W N O v > o c O Q - to o E O v: Z Q N CC Z C o N w w o C7 • w 0 _ 0 cn cn sa .4) O° Z< 2 Z O LU Cr t ( a W m 0 V (c:\13. m Z � ° ¢ w O LL v- (\i N = x z 0o =m .t Y.1 z 440: t IEFLEMZING ALEX SINK CHIEF'FINANCIAL OFFICER STATE OF FLORIDA August 14, 2009 VERIFICATION OF AUTOMATIC EXEMPT STATUS FROM WORKERS' COMPENSATION COVERAGE REQUIREMENTS This letter verifies that the individual listed below is AUTOMATICALLY EXEMPT from Florida workers' compensation coverage requirements within the scope of the non - construction business or trade listed below and is not required to obtain an exemption issued by the Division of Workers' Compensation in order to achieve exempt status. PERSON: ADAM BROOKS BUSINESS NAME: BROOKS MOBILE HOME SERVICE LLC ADDRESS: 9716 DELS ACRE ROAD THONOTOSASSA, FL 33592 TYPE OF NON - CONSTRUCTION BUSINESS OR TRADE: MOBILE HOME SET UP CLASS CODE OF BUSINESS: 8380 This verification of automatic exempt status applies ONLY within the scope of the non - construction business or trade listed above, and applies ONLY to the individual listed above. However, if BROOKS MOBILE HOME SERVICE LLC employs four or more full or part -time employees, it must obtain workers' compensation coverage. A member of a limited liability company engaged in the non - construction industry is considered an employee if the member meets the definition of employee as defined in Section 440.02(15)(a), Florida Statutes. If a policy is in effect for the limited liability company engaged in the non - construction industry and the member meets the definition of employee as defined in Section 440.02(15)(a), Florida Statues, the payroll of such member may be included in determining the premium for the policy. If BROOKS MOBILE HOME SERVICE LLC engages in a construction- related activity as defmed in section 440.02(8), Florida Statutes, or in Rule 69L- 6.021, Florida Administrative Code, the automatic exempt status for ADAM BROOKS shall not apply, and BROOKS MOBILE HOME SERVICE LLC must comply with workers'. compensation coverage requirements for the construction industry. If ADAM BROOKS is a corporate officer as defmed in Section 440.02(9), Florida Statutes, this Verification of Automatic Exempt Status from Workers' Compensation Coverage Requirements does not apply. In order to become exempt, ADAM BROOKS is required to complete an exemption application and submit the application to the Division of Workers' Compensation. If the Division of Workers' Compensation determines that ADAM BROOKS meets the eligibility requirements for the issuance of an exemption, the Division of Workers' Compensation will issue an exemption to ADAM BROOKS. If you have any questions, please call (850) 413 -1609. DMSION OF WORKERS' COMPENSATION - BUREAU OF COMPLIANCE 200 EAST GAINES STREET - TALLAHASSEE, FLORIDA 32399 -4228 - PHONE 850 - 413 -1609 AFFIRMATIVE ACTION - EQUAL OPPORTUNITY EMPLOYER 1 . I' i I k ' pia City of Zephyrliills BUILDING PLAN REVIEW COMMENTS ok I Dbk +1' s Contractor/Homeowner: ko f , (� Date Received: e3' z4- 0 - l Site: (g (0 1 AO ac-te__ Permit Type: Re P(CeCCme 016 6:k Approved w /no comments: ❑ Approved w /the below comments: Denied w /the below comments: ❑ ( r o a r 51-1- Uv 1,,W C v ) ifk � j ° 5 l u t ( ci—e4f pn c ct,ck fkA-to Cc- . ia helm( -P OF r L This comment sheet shall be kept with the permit and/or plans. Kalvin tzer — Plans E finer Date ontrac . Homeo er (Required when comments are present)