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HomeMy WebLinkAbout10-10033 CITY OF ZEPHYRHILLS 5335 - 8TH STREET • , (813)780 -0020 10033 BUILDING PERMIT Permit Number: 10033 Address: 6843 STEPHENS PATH Permit Type: ADDITION /ALTERATION ZEPHYRHILLS, FL. Class of Work: 434 - ADD /ALT RESIDENTIAL Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 03- 26 -21- 0160 - 00000 -0560 Improv. Cost: 6,000.00 . y :. , ,, ' - s . ,... W y Date Issued: 1/27/2010 Name: MEIKLE, DAVID G Total Fees: 90.00 Address: 2135 LOWER DOWDA MILL RD Amount Paid: 90.00 BALL GROUND GA 30107 Date Paid: 1/27/2010 Phone: (770)735 -3771 Work Desc: POOL ENCLOSURE SQ FT 1188 447 `. Y l s " . 77: •, I . +e, F a , O I?s _ e ;. 4 ..„:. a t, ,'" a s 5 P•M :O •NTRA IN R IC INC BUILDING E 90.00 ndL petfrNif I 9756 - t i r ck IP 0 e/ I , / r f 0 KO ur k firt01 ( ,)Q,4 i , a A F•• ER 2ND R•U 'H 'PLUMB MI M►' IN ULATION EILI a % r " " FOOTER BOND DUCTS INSULATED SEWER W MISC. ROUGH ELECTRIC LINTEL MISC MISC. 1ST ROUGH PLUMB PRE -METER INSULATION WALL MISC. DUCTS INSTALLED WATER MISC DRIVEWAY PRE -SLAB SHEATHING MISC. MISC. CONSTRUCTION POLE FRAME MISC. MISC. 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 v r notice of commencement." i CONTRA SIGNATURE PERMIT OFFI FR PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION — 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER -- �` ` City of Zephyrhills BUILDING PLAN REVIEW COMMENTS Contractor/Homeowner: / 6® co,„iyayi Date Received: I _ /5 0 Site: 6 843 S ivemS pa Permit Type: i 1 & b 1. Ff ' Approved w /no comments:D Approved w /the below comments: Denied w /the below comments: 0 0 4-it f(/29(I //44f 4-Dfs Gild pf; sh I( Cy f i t, c cx -rri a 4 et i C t.2 Mai.-2,kei 67.1 bt ,i-e4:".),/ s ii .. ( 4 . 0Z) 1 0 .1-el Sidi k 1444 This comment sheet shall be kept with the permit and/or plans. j/ /b ,:. . KalvW 'Switzeiner Date Contractor an or Homeowner (Required when comments are present) 813 - 780 -0020 City of Zephyrhills Permit Application Fax - 813- 780 -0021 / Building Department oC rt'le ( • Date Received �■ / ./ b Phone Contact for Permittin D 13 523 -- 3(4 3 3 Owner's Name PlA\ ` \\( \ C\ 2T . Owner Phone Number Owner's Address L (,L t ) - Owner Phone Number Fee Simple Titleholder Name I V /J- Owner Phone Number Fee Simple Titleholder Address t.\ 11\ JOB ADDRESS ' c )1 l Oirl l 1•A4A LOT # SUBDIVISION S5e0 \'1rf)3 6\x.1'1 PARCELID# p3 -2l9 - 21- bItoo'Ccc 0- 0S�.QT- t (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED Fr NEW CONSTR ADD /ALT n SIGN n MOVE n DEMOLISH INSTALL REPAIR PROPOSED USE P. SFR n COMM n OTHER TYPE OF CONSTRUCTION n BLOCK n FRAME n STEEL n OTHER I DESCRIPTION OF WORK PCO �y11.0t;$ure. BUILDING SIZE , X c 4 4 4 ' SQ FOOTAGE 1 1 o HEIGHT ? �I f n BUILDING $ (v 000 GO VALUATION OF TOTAL CONSTRUCTION n ELECTRICAL $ l! AMP SERVICE f1 PROGRESS ENERGY n W.R.E.C. n PLUMBING 1 .0p-R4. LA. n MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION (�pi -kI U "7 I GAS n ROOFING n SPECIALTY n OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA 1 IYES n NO BUILDER COMPANY SIGNATURE REGISTERED 1 Y/ N I FEE CURRENT I Y/ N I Address License # ELECTRICIAN COMPANY SIGNATURE REGISTERED I Y / N 1 FEE CURRENT I Y/ N I Address License # PLUMBER COMPANY SIGNATURE REGISTERED 1 Y/ N I FEE CURRENT I Y/ N I Address License # MECHANICAL COMPANY SIGNATURE REGISTERED 1 Y/ N I FEE CURRENT I Y / N 1 Address a V � License # OTHER COMPANY I �JV � C01�?\1'C�C. +1 )�' � ( )`�(� SIGNATURE REGISTERED / N I FEE CURRENT I / N Address 5A 1 4 L1 c n 1%) e_ _ License # C IZe t '7)2.g1 &O ..... ..... 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 A i . i - EY BEFORE RECORDING YOUR NOTICE •, • • MENCEMENT. FLORIDA JURAT (F.S. 117.03) IN a0 OWNER OR AGENT CONTRACTOR L,.J" Sub cribel and swo n to (or armed bef i .r e t 's Sub rib:. and sworn . or .ffi t,,; r .ef.re - 3 1 . O by ` S ' • 11 0 1 10 by 1. , .� se • Atli a : �' a personally nnwn to m o r h s /have produced . T e personally kn ,wn to me or has /h. ve produced as identification. as identification. ii t t 1 . �. t Notary Public 0 k k0-[ Notary Public � c-� 1, - � `� mmission No. p tr `1 uo Co mission No. � ll2o IG�'lC\ Y r1CaY ea 1 OM ' Ir irtand PZ Name of Notary typed, printed or stamped Nam Notary typed, printed or stamped , '. 'r.: *ate.+. C ` gN ANDEZ ?stir � Pr ..�.vvwennnnnnn+ na6oz F DIANA HERNANDEZ uN a on it a n�S May l8, 2012 �' �, , p, � � � MY COMMISSION k DD774602 Pi "+aarr Discount Assac. Co. �R ` � EXPIRES: May 18, 2012 ^'` � " l ;ten 0' -oust asses. Co . ,)t I- 400J- NOTARY siH 11101111101111111111111111111111111110111 . NOTICE OF COMMENCEMENT 2009159932 • Rept:1272164 Ree: 10.00 DS: 0.00 IT: 0.00 Permit No. 11/05/09 - ____ Dpty Clerk ' Tax Folio No. 03 Vi- Zt- 01ea- a000-051.0 THE UNDERSIGNED hereby gives notice that improvements 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. 1.Description of property (legal description): is SL $r ,, G /,e .t S,X,,, A's As, r,, Pl' 3/ A.,. /SL - /S/ a) Street (job) Address: erri3 S4'4 '?s PR /r ,. FL 39ss 2,General description of improvements: S /' '.. / t 3.Owner Information (mc,i ) a) Name and address: O�.,d Afil f/e t: if V3 5 a A /4 Zt".4i 4.45- F[ .71552 b) Name and address of fee simple titleholder (if other than owner) 11111-, M1 c) Interest in property F l .Contractor Information • - - # a) Name and address: it 'ae, A. / / ive - y it/ekes #44 Aiie. 741,04 FL 734 b) Telephone No.: 8/T- f‘/- 2 7SF Fax No. (Opt.) 5.Surety Information a) Name and address: /tom /4 PAULA S O'NEJL, PASCO CLERK 1 COMPTROLLER b) Amount of Bond: • 11/05/09 1 4 of 1 • c) Telephone No.: Fax No. (Opt.) OR OK s LJ8' 1 PG 145 6.Lender - a) Name and address: /t/ /jt • Phone No. 7. Identity of person within the State of Florida designated by owner upon whom notices or other documents may be served: • a) Name and address: ,v�i9 . - b) Telephone No.: Fax No. (Opt.) •81n addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section . 713.13(IXb),.Florida Statutes: a) Name and address: A/Y/1 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 specified): • • WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF TBE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART 1, SECTION 713.13, FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT YOUR LENDER OR AN ATTORNEY BEFORE • COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. STATIL OF FLORIDA I0 . �� %^ `JE I -e COUNTY OF / ; ' ' 7 COUNTY Signature ofOwner or Owners Aut 7 or+aed r/Partner/Manager • )4 v215 K - 7Yf7iri e_ . Print Name • The foregoing instrument was acknowled before me this 21 ' day of t044 b•,- , 20 o q, by ti .„,d .M. ;J , as Sl /J (type of authority, e.g. officer, trustee, attorney in fact) for S-e /� (name of party on behalf of whom instrument was executed). Personally Known OR Produced'Identification Notary Signature "" iZ Type'of Identification Produced Name (print) - 7'j 4....-07..-- Verification. pursuant to Section 92.525, Florida Statutes. Under penal - 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 lip , �ortacuit�ea..erom ;.i;''''' TN BEJINOER L► 4. _ - ! * , � :� 1 * : t . MY COMMISSION # DD 522368 *nature of Naond Parson Signing (m line 110.) Aboye :PC.s..:$ a EXPIRES: Hoary P U nd0wo .Site. Location: and Wind Speed • FORE um • P'rc IL* +,, -. • Address:' . .:$ • . �- P L,e g... f.. .Zt. r kt ` ! It ti'Pip4 Br•ed; l�;pd;: I) :E g �: xsrrre: - c-12 . �' who Hor De Regio .: Is / A. . • IINI.- wwxs ,4, Milk l' - t% 1& .1 4 . , _ w " i!Ti • r ' i ll' • • 140 °? r , • .�• , 130 : � `� 1 Wind -Borne Debris Re ikk : - si lei ik. • . • • gion i • o • • 1 !. 120 mph & above (ASCE 7 -98) ` , . ....., 110 mph 1 mile of coas or a nge lb, , • (ASCE 7 -98) �� 0.4, • • • 1 • • ■. 1 (Exception) 1 mile of (Except: 1 ' - 1+ 1 I Basic Wind Speed . � , ,,r, 1). Vakies are nominal design, 3- second gust. wind • speeds in miles per hour. (mph) at 33 feet (10 m) above X010 ground for Exposure C Category . case. 2 map is accurate to the bounty..tocai governments �. 14 This p h ' establish spedficwiid speedhuind- borne detkis lines . - 9 � A -,.. ® r ll',rm � u and physical landmarks'such as' major roads: canals, . ® f 3) Islands and coastal areas outside the-last contour shag p 11 Fr. h. use the last wind- siieed contour of the coastal area. it 4) Mountainous terrain, gorges, ocean . special Wind regions shag be examined for unusual ad • �► . f; lot conditions. • h 5) Wind speeds are American Sodetyof Engineers .. � 1 ph Standard (ASCE 7-98) 50 -.100 - year • peak gusts. 'ilt • • ° d l Florida Building Code Table 1606.1.6.1 . . . , '* . • •Equivaient•Basic Wind Speeds • I a Fa e stiest Mlle 70 • 1100 80 + 85 11 90 100. 105 1 120 1. 25130 . , . 1 mph'= 0.447m/s • • iL � �'Pr.Fi w t l64 i1*1p C 'C1 32S�A ® he �I � y� �rW�i7' °ar bo � c l �. e e 3 x r - 01-28 - 2009 SINK E ALX SIN AL SIN CIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION 11) BE EXEMPT FROM FLORIDA WORKERS' COMPS * * CONSTRUCTION INDUSTRY EXEMPTION NSATION LAW This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 01/28/2009 EXPIRATION DATE: 01/28/2011 PERSON: POMBO YOESLANDY FEIN: 205242427 BUSINESS NAME AND ADDRESS: POMBO'S CONTRACTING SERVICES INC 5004 LANDSMAN AVE TAMPA FL 33825 SCOPES OF BUSINESS OR TRADE: 1- CERTIFI RESIDENTIAL CONTRACT t •'''.: .., CL: ^ e• 8:.: 0 .... . . CO • ii 0 14. . •-•. ...• 0 ••• ...CI D C. -.-.. 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H :- ■ __.. :-.: •••.:_ ,.... ... • 01/15/2010 10:04 Family Insurance of Tampa Bay (FAX)813 319 1089 P.0011001 ACORN ® DATE (MMIDDIYY) CERTIFICATE OF LIABILITY INSURANCE 01/15/10 PRODUCER Family Insurance of Tampa Bay, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 14020 N Florida Ave ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Tampa, FL 33613 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (813)963 -2227 Fax (813)319 -9245 INSURERS AFFORDING COVERAGE NAIC INSURED POMBO'S CONTRACTING SERVICES INC INSURER A: American Vehicle INSURER B. 5004 Landsman Ave INSURER C. TAMPA, FL 33624 INSURER D: 813 INSURER E: COVERAGES . INSURER F: THE POLICIES OF INSURANCE LISTED 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 BYTHE 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 TYPE OF INSURANCE POLICY NUMBER L TE (MMDDMYI MI DATE LTR iNSRD E (MDD/YY)) LIMITS NSRD DATE GENERAL LIABILITY EACH OCCURRENCE I 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000 ® 02162009P_590795 02/16/09 02/16/10 PREMISES (Ea occurence) 00 CLAIMS MADE ❑ OCCUR MED EXP (Any one person) 5,000 A ❑ ❑ PERSONAL &ADVINJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG 2,000,000 ® POLICY ❑ PROJECT ❑ 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 $ WORKERS COMPENSATION AND ❑ WC STATU- ❑ OTH- EMPLOYERS' LIABILITY TORY LIMITS ER ANY PROPRIETOR 1 PARTNER / EXECUTIVE E.L. EACH ACCIDENT OFFICER / MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I 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 City Of Zephyrhills Building Dept. 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 33335 8th St THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Zephyrhills, Fl 33542 AUTHORIZED REPRESENTATIVE 813 - 780 - 0021 (;) ACORD 25 (2001/08) QF ® ACORD CORPORATION 1988 d� U g 1 P-.0 1 M co °Egg ;�6?2 Ri 2 E =� g - 12 O .' Z �� ° V p '* N3 ° 1 >®0® : : a 1 PiFi,�� tip' p /2 � k' u II u u n 11 # a *o � I ?' 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