HomeMy WebLinkAbout10-10279 CITY OF ZEPHYRHILLS
• 5335 - 8TH STREET
(813) 780 -0020 10279
COMM EXHAUST HOOD /DUCT PERMIT
Permit Number: 10279 Address: 5538 GALL BLVD
Permit Type: FIRE COMM EXH HOOD /DUCT ZEPHYRHILLS, FL.
Class of Work: FIRE -HOOD SUPPRESSION SYS Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 11 26 - 0010 - 05700 - 0250
ate` c
Improv. Cost:
Date Issued: Name: WELLESLEY DEVELOPMENT doRP
Total Fees: 160.00 Address: 34619 SR 54 W
Amount Paid: 160.00 ZEPHYRHILLS, FL. 33542
Date Paid: 4/07/2010 Phone:
Work Desc: INSTALL ADJUSTMENT TO SUPPRESSION SYSTEM
R U 1 1' A V N - - - I 50.00 N P I S N 30.00
FIRE PLAN REVIEW FEES 50.00 CONTRACTOR CERTIFICATE 30.00
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Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire
prevention and protection related activities such as inspections, plan review, administrative fees, and other
costs related to the aforementioned.
Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of
the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final
inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All
work shall be performed in accordance with City Codes and Ordinances.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF
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
RECOR • ING YOUR NOTICE OF COMMENCEMENT." �r
C• T CTOR .IGNATURE P IT OFFICER
P • MIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813 - 780 -0041
813-780 -0020, City of.Zephyrhills Fire, 1' /a 27c/
Fax - 813 - 78042021
Permit Application
Date Received '3 16 lb
Phone Contact
for Permit WERE 1 iLZ, 3 1 (�
Owner's Name I— /
/Z�4 a,.. Owner's Phone Number T
Owner's Address 5.57.5 y3 _ B t /'0 ,/ /46jc , 3.5s1/
Fee Simple Titleholder Name Titleholder Phone Number I I I I I I
Fee Simple Titleholder Address I
,:;a , ..,. :, a T ,., ' . a'"I e '1., 0M„ , u' a «1` UMBRMS f?.' SEas ..> ea Ir �a 1 : " s ,c " >
Job Address �53� GAt� 45 LA) 2n2Jo ky 'Xk ,. *JS�� ,r ,.. m . °, .._. Lot
Sub Division Parcel #
„ .: ., ,r s, w utnO4141E,a saU. ,, .tea ay_.
r w a,:1; v,.; k Ar �4144vi ..J.R§iA t 0 „ ,e.,s , nw
MI Bio-Hazard Waste Storage - ANNUAL r----1 Fumigation Tent
`gi Comm xhaust Kitchen Hood /Duct I Hazardous Material (Tier II or RQ Facility) ANNUAL
IIIIII Contro e -- I I Hood Installation
I I Emergency Generator < 30 kw I
LP /Natural Gas - Installation
I I Emergency Generator > 30 kw I I LP /Natural Gas - ANNUAL Sale
1 Fire Protection Maintenance - ANNUAL I I Places of Assembly - ANNUAL '� '
�
I(2trlyl ISemil Other
Sprinkler 71 ❑ ❑ ❑ I Recreational Bum
e6
Fire Alarm TI ❑ ❑ ❑ I Sparklers (D, , 3a
Hood Cleaning n ❑ ❑ ❑ I I Sprinkler System Installations � l
Hood Suppression I ❑ ❑ ❑ I I Standpipes (Sprinkler Sys)
I 1 Fire Alarm Installation I Torch Roofing/Tar Kettle ( .71 il J
I Fire Pumps r 1 Waste Tire Storage ANNUAL
Fire Works
Flammable Application- ANNUAL I I Valuation of Project
71 Fuel Tanks
ET Other: I
....,: .v 3a sa&ZIEt w a ..,: b " `M :� I - :;'.s« .. tg.C, .�. �_ lEkd�,ad,. tom' NWZi,r.3 .. ,.ea ... �......�.,,s.. V u
".'..d,"rsa.0 - , ...: a<»:��.^:a:w3's t" ..'; ' . .°,., ti:; z. ;fur;:, a cw..: ,�.,_�,"'�1t:
Contractor C mpany �y+O p/ jr ���� �- I
Signature Registered Y / N Fee Current 1 Y / N
Address y'] . r d /� g.te tp 7t3 License # 033 3 85 -00 7 60
ELECTRICIAN I Company
Signature Registered Y / N j Fee Current 1 Y / N
Address I I License #
PLUMBER Company
Signature Registered Y / N Fee Current I Y / N
Address I License # I
MECHANICAL Company
Signature Registered Y / N Fee Current I Y / N
Address I License # 1
OTHER
Company
Signature Registered Y / N I Fee Current I Y / N I
Address I License #
Directions:
i� ..,Y ,w__ �. _ �. a .a, •..: �._., _�u : ,
Fill out application completely.
Owner & Contractor sign back of application, notarized (Or, copy of signed contract with owner)
If over $2500, a Notice of Commencement is required (Mechanical work over $5000)
Supply two (2) sets of drawings with applicable documentation
Allow 10 -14 days for review after submittal date. Parcel # - obtained from Property Tax Notice (http: / /appraiser.pascogov.com)
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit maybe subject:to "deed "restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for:complian-ce‘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 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 7.27 -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.
CONSTRUCTION LIEN LAW (Chapter713, 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 and
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.
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 OF COMMENCEMENT.
FLORIDA JURAT (F.S. 117.03) /
OWNER OR AGENT CONTRACTORK • •- 1 -
Subscribed and swom to (or affirmed) before me this Subsc be and swom to (o affi :.•) before me this
b . ('" (V by li •
Who is /are personally known to me or has /have produced Who is/arq personally known to me or has /have produced
as identification. A `0 as identification.
Notary Public 1� -v Notary Public
Commission No. C.1. issio ..
all ;1 JA BOGES
Name of Notary typed, printed or stamped Name of Not- ,
RF;f4`," e r 12 2010
end Th ru Tro Fain Insurance 9 00.355,7019
CITY OF ST. PETERSBURG FLORIDA
LOCAL BUSINESS TAX RECEIPT
ACCOUNT NO. DATE 2010
69577 September 23, 2009 EXPIRES 9/30/2010
•
BUSINESS: St.p
www.stpete.erg
RESCUE 1 FIRE SAFETY SVS INC
2736 22ND ST N
SAINT PETERSBURG FL 33713 -4014
10- 00028131 DESCRIPTION OF OCCUPATION, PROFESSION, OR BUSINESS
- FIREPROTECTIONI EQUIP CONTR -- — — — — - -- — — - -- -- tO -.01
UNCLASSIFIED
#83388500031996 FIRE EQUIPMENT CLASS C #86688500251996 FIRE EQUIPMENT CLASS D
#83388500041996 FIRE EQUIPMENT DEALER MOBILE SERVICE OF FIRE EXTINGUISHERS
ZONING APPROVAL IS FOR LIGHT MANUFACTURING, SERVICE & REPAIR.
0.00
092209 65.00 1032408 TOTAL 0.00
MAIL:
RESCUE 1 FIRE SAFETY SVC INC
2736 22ND ST N
SAINT PETERSBURG FL 33714
This local busint,a tax
Changes in business name, address, mailing name or address, as well as receipt does not How the
additions to the business; activity, may require additional applications. holder to violate any city
Please contact this office; before making changes or if the_description on ___ __. law, ordinance -a .
this receipt does not reflect your entire business activity. Additional regulation. It is I, of an
activities may require additional taxes. endorsement, ap-'roval or
Failure to renew before the expiration date may result in penalty fees being disapproval of tl holder's
assessed. skill or compete' ce or of
Display this receipt conspicuously at all times in the place of business. the compliance c non-
If there is no place of business, this receipt must be presented to any compliance of th holder
police officer or officer of the city upon their request. with other laws, :regulations
Many business taxes aretransferable from one owner to another, or one or standards.
location to another. To transfer this receipt, contact our office for information
and price, and fill in the following.
1, hereby assign all my rights, title and interest in lc :al business
tax receipt # to
(name of new owner) (signature of previous: wner)
Office -hours = Monday through Friday, 8:00 a.m. to 5:00 p.m. Phone = 727 -- 893 -7241
i
i 4v
STATE OF FLORIDA is h Uv " ,.. ►F
DEPARTMENT OF FINANCIAL ~.
CIAL SERVICES ✓� * . � 4 �t j -;.
DIVISION OF STATE FIRE MARSHAL
TALLAHASSEE, FLORIDA 4. —
FIRE EQUIPMENT DEALER LICENSE
THIS CERTIFIES THAT: RESCUE 1 FIRE SAFETY SERVICES
2736 22ND STREET NORTH
ST. PETERSBURG, FL 33714 -
QUALIFIER: DEAN H HOYLMAN
HAS COMPLIED WITH FLORIDA STATUTES AND HAS QUALIFIED FOR THE TYPE AND CLASS SHOWN HEREON TO SERVICE, REPAIR,
INSTALL OR INSPECT ALL TYPES OF PRE - ENGINEERED FIRE EXTINGUISHING SYSTEMS. EXCLUDES ANY SERVICE, RECHARGE, REPAIR,
INSTALLATION OR INSPECTION OF ANY TYPE OF HALON EXTINGUISHER.
a o t e7v
Chief Financial Officer
0110112010 07 04 Pinellas 83388500041996 1749550001 1213112011
Issue Date Type Class County License/Pennit Number Application # Expire Date
•
- m e,, .
1 : 11 9 Nr
1 -- 04 -24 -2008 •
Goo woo'
ALEX SINK STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 04/24/2008 EXPIRATION DATE: 04/24/2010
PERSON: HOYLMAN DEAN
FEIN: 200689835
BUSINESS NAME AND ADDRESS:
RESCUE 1 FIRE SAFETY SERVICES INC
2736 22ND STREET N
SAINT PETERSBURG FL 33713
SCOPES OF BUSINESS OR TRADE:
1- FIRE EXTINGUISHER SERVICE
IMPORTANT: Pursuant to Chapter 440. 05414), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the Notice of election to be exempt. Pursuant to Chapter 440.05413), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the p named on the notice or
certificate No longer meets the requirements of this section for issuance of a certificate. The department shell revoke • certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 QUESTIONS? (850) 413-16
•
•
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE "'x""'
o
PRODUCER Phone: (407) 332 Fax (407) 332 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE SOLUTIONS OF AMERICA, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
910 BELLE AVENUE, SUITE 1140 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
WINTER SPRINGS FL 32708 ALTER THE COVERAGE AFFORDED BY THE POI CES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Interstate Fire and Casualty Company
RESCUE 1 FIRE SAFETY SERVICES, INC. INSURER B:
2736 22ND STREET NORTH
SAINT PETERSBURG FL 33714 INSURER C:
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 MATH 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 Ate TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION
LTR INS9L POLICY NUMBER DATE IAIYIDDIYYI DATE RIINCID/TY) LIMITS
GENERAL LIABILITY RFS1001085 07/15/09 07/1 EACH OCCURRENCE E 1,000,000
X COMMERCIAL GENERAL LIABILITY S ce) amuen E 100,000 RENTED
CLAIMS MADE X OCCUR MED. EXP (Any one person) $ 5,000
A -- — PERSONAL 8 ADV INJURY E 1,000,000
GENERAL AGGREGATE E 2,000,000
GENL L AGGREG LIMIT PER:
PRODUCTS-COMP/OP AGG. E 2,000,000
I ICY I JECT F LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
(Ea accident) S
ALL OWNED AUTOS BODILY INJURY
son
SCHEDULED AUTOS (Per Pte) E
HIRED AUTOS —
NON -OWNED AUTOS BODILY INJURY S
(Per ac Gent)
(P PROPERTY t) DAMAGE S
er acaden
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE E
S
DEDUCTIBLE — S
RETENTION _
E
WORKERS COMPENSATION AND INC STATU OTi1�
EMPLOYERS LIABILITY TORY LIMITS
ANY E.LEACHACCIDENT E
M yes, O5 EM user
E L DISEASE-EA EMPLOYEE S
SPECIAL PROVISIONS Wow EL DISEASE -POLICY LIMIT E
OTHER:
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
Broderick & Associates SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
5514 Park BMd. EXPIRATION DATE THEREOF, THE ISSUING INSURER YNLL ENDEAVOR TO MAIL 10 DAYS
5514 Park
Park, FL 33781 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO
DO SO SHALL IMPOSE NO OBUGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS
AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Attention: Scott Lugering
ACORD 25 (2001/08) Certificate # 3302 ® ACORD CORPORATION 1988
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Zephyrhills Fire Rescue
6907 Dairy Road, Zephyrhills, FL 33542
Fire Marshal Bus (813) 780 -0041
Kerry Barnett Fax (813) 780 -0044
E -mail: kbarnetta ire.zephyrhills.fl.us
Plan Review #: 10 -030
Project: Hood Suppression (duct and plenum only)
Number of Pages: Packet
March 23, 2010
I have received and reviewed the plans for the suppression system located at 5538 Gall
Blvd and will allow the project to move forward. Please note that this review does not
eliminate any further requirements as the project continues moving forward. By receiving
permit, contractor acknowledges to comply with the items listed below. Should anyone
have any questions, please do not hesitate to contact the Fire Marshal's office.
1. System installation shall comply with NFPA 96 and 17A.
2. System shall be connected to fire alarm system (if present), if not system
shall be connected to horn, bell or strobe to provide occupant notification.
3. Appliance under hood, gas and /or electric, shall shut down on system
activation.
4. Exhaust air shall remain on and makeup air shall shut down upon system
activation.
5. Install placard for use of K Class extinguisher above extinguisher.
6. Install placard above remote pull indicating of the remote pull and its use.
Inspections Required:
1. Acceptance Test
KERR B 1 4 1 ' , FIRE MARSHAL
** *Please be advised this review of plans submitted is a cursory review to assist the contractor in
compliance with applicable fire safety codes. This review is not intended to be a final approval of the
submitted plans. It is the contractor's sole responsibility to ensure that the plans are in complete compliance
with all applicable NFPA codes and local ordinances. In the event that further examination or site
inspection reveals areas of non - compliance, it shall be the contractor's sole responsibility, at their sole
expense to bring those areas in compliance. The City assumes no responsibility for the contractor's failure
to be in compliance with all applicable NFPA codes and local ordinances.
ZEPHYRHILLS FIRE DEPARTMENT
6907 Dairy Road,.Zephyrhills, FL 33542
Fire Chief Keith Williams Bus (813)780 -0041 Fax (813)780 -0044
FIRE •SERVICEUSERFEES
Occupancy No.: / ��
Plan No.: //) — 23a Contractor: Zi / ir'�
Business Name: 1tt /e 1 Billing Address: 2735 2Z/4C
Business Address: 5'" T , mil/ s'7 C r 5... J .?
Business Phone No.: Billing Phone No.:
Business Fax No.: Billing Fax No.:
Contact: • Contact:
PLAN RE
_ REVIEW FEES — INSPECTION FEES _ PERMIT FEE FALSE ALARM FEE
_ Site Plan N/C — Annual N/C — Sprinkler $50 — 1st Alarm N/C
Multi Family /Commercial .06 sf 6.- 1st Re- inspection N/C _ Standpipes 550 2nd Alarm N/C
(Minimum Charge 525.00 _ 2nd Re- inspection 5100 Fire Pump 550 3rd Alarm N/C
Plan Revisions DBL _ 3rd Re- inspection 5250 Hoodspf 4th Alarm 5100
_ 4th Re- Inspection 5500 _ Fire Ala -� • ~_ 5th Alarm 5150
SPRINKLER SYSTEMS (Business closed until _ LP Gas 550 _ 6th Alarm 5200
0 - 25 Heads 550 violations corrected) _ Natural Gas 550 NON COMPLIANCE $150
26 plus Heads 5100 _ SPRINKLER SYSTEMS — Fuel Tanks - per tank 550
STANDPIPE SYSTEM _ Hydro Undergrounds $45 _ Sparklers - 5100
0 Per Riser 550 _ Hydrostatic Test 565 per system _ Fire Works 5500
FIRE PUMP _ Acceptance Test $45 per system _ Camp Fire 525
0 Per Pump 5100 Hydrant Flow $75 ` Controlled Bum 5100 •
— FIRE ALARM SYSTEM _ Hood/Duct 550
0 -25 Devices 550 FIRE ALARM SYSTEM Place of Assembly 550 Annual
— 26 plus Devices 5100 _ —
Acceptance System Accept 550 Fire Protection 525
_ _
SUPPRESSION SYSTEMS _ Recall Acceptance $50 Flammable Application $50 Annual
Wet 550 — OTHER — Waste Tire Storage 550 Annual
Dry 550 Fire Wall/Smoke Wall $15 P er wall Generator < KW $100
_ _
CO2 550 _ LP Gas $25 pertank _ Generator >30 KW 150
her 0 _ Natural Gas 525 per system ` Bio-Hazard Waste $100 Annual
KITCHEN EXHAUST _ _ Fumigation Tenting $50
0 Hood/Ducts $50 _ Tent 10'x1 or greater $15 perte — Torch Pot/Applied $50 .
OTHER ` Fire Pump , 545 _ Haz. Materials $100 Annual
LP Installation per tank $50 T�1Fire Suppression 0
_ Fuel Tank Installation $50 ((--' System Acceptance
(Per Tank) $50 _ Exhaust. Hood/Duct $30'
0 Natural Gas Installation $50 Re - inspection DBL
(Per System) (other than annual) _
❑ Spray Booth 550 0 Inspection scheduled DBL
and cancelled Tess than
—
24 hours
Construction Insp. N/C
�} Emergency Vehicle Ac $50 7 J) FALSE ALARM
PLANS TOTAL , / INSPECTION TOTAL a PERMIT TOTAL Ir�,-y-'tI' TOTAL
GRAND TOTAL , /30 — I
Comments: •
Date: 5/2171
InsA ctor: pie y C1� "f - "
•
F orm W Request for Taxpayer Give ibrrrt to the
(Rev. October 2pp7) identification Number and Certification requester. Do not
Department of the Th send to the IRS.
Internal Revenue Service
Name (as shown on your income tax retum)
° NNi
dl Business name, if different from above
RE*C -Lr' 1 I F‘Q£ y 5 W -1rL�5
0
at C Check appropriate box: ❑ Individual/Sole proprietor 9<orporation ❑ Partnership /1
Z. ❑ Limited liability company. Enter the tax classification (D= disregarded entity, C .orporatk n, P=partnership) ► ..4i. 1---1 Exempt
0 0 ❑ other (see rezone) ►
s. Address (number, street, and apt. or suite no.) Requester's name and address (optional)
a2:73 F Zz••-dl °r/w.t
City, state. and ZIP code
Pe ISRsei,..1t -FL .- n l
33 List account numbers) here (optional)
to
Part 1 Taxpayer identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid social security number
backup withholding. For individuals, this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity, see the Part 1 instructions on page 3. For other entitles, It Is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. or
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter. 2.0 .: 04414183S
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be Issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax retum. For real estate transactions, item 2 does not apply.
For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payment other than Interest and dividends, you are not required to sign the Certification, but you must
provide your correct TIN. See the instruct ns on age 4.
Sign Signature of r i
Here p•rson Date D. — - IC)
us. ►
General Instructions Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
Section references are to the Internal Revenue Code unless
otherwise noted. • An individual who is a U.S. citizen or U.S. resident alien,
• A partnership, corporation, company, or association created or
Purpose of Form organized in the United States or under the laws of the United
A person who is required to file an information return with the States,
IRS must obtain your correct taxpayer identification number (TIN) • An estate (other than a foreign estate), or
to report, for example, income paid to you, real estate • A domestic trust (as defined in Regulations section
transactions, mortgage interest you paid, acquisition or 301.7701 -7).
abandonment of secured property, cancellation of debt, or Special rules for partnerships. Partnerships that conduct a
contributions you made to an IRA. trade or business in the United States are generally required to
Use Form W -9 only if you are a U.S. person (including a pay a withholding tax on any foreign partners' share of income
resident alien), to provide your correct TIN to the person from such business. Further, In certain cases where a Form W -9
requesting it (the requester) and, when applicable, to: has not been received, a partnership is required to presume that
1. Certify that the TIN you are giving is correct (or you are a partner is a foreign person, and pay the withholding tax.
waiting for a number to be issued), Therefore, if you are a U.S. person that is a partner in a
2. Certify that you are not subject to backup withholding, or partnership conducting a trade or business in the United States,
provide Form W -9 to the partnership to establish your U.S.
3. Claim exemption from backup withholding if you are a U.S. status and avoid withholding on your share of partnership
exempt payee. If applicable, you are also certifying that as a income.
U.S. person, your allocable share of any partnership income from The person who gives Form W -9 to the partnership for
a U.S. trade or business is not subject to the withholding tax on purposes of establishing Its U.S. status and avoiding withholding
foreign partners' share of effectively connected income. on its allocable share of net income from the partnership
Note. If a requester gives you a form other than Form W -9 to conducting a trade or business in the United States is in the
request your TIN, you must use the requester's form if it is following cases:
substantially similar to this Form W -9. • The U.S. owner of a disregarded entity and not the entity,
Cat_ No. 10231X Form W -9 (Rev. 10 -2007)
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04 -24 -2008 •
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ALEX SINK STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 04/24/2008 EXPIRATION DATE: 04/24/2010
PERSON: HOYLMAN DEAN
FEIN: 200689835
BUSINESS NAME AND ADDRESS:
RESCUE 1 FIRE SAFETY SERVICES INC
2738 22ND STREET N
SAINT PETERSBURG Fl 33713
SCOPES OF BUSINESS OR TRADE:
1- FIRE EXTINGUISHER SERVICE
IMPORTANT: Pursuant to Chapter 440 . 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing ■ certificate of election Nader this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of blectioa to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and eartifientes of
election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or
certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
owed on the certificate to meet the requirements of this section.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 QUESTIONS? (850) 413 -16
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2010 Florida Annual Resale Certificate for Sales Tax II DR -13A
R. 01/10
DEPARTMENT THIS CERTIFICATE EXPIRES ON DECEMBER 31, 2010
OF REVENUE
Business Name and Location Add c Certificate Number
RESCUE 1 FIRE SAFETY SERVICES 62-8013652848 -5
2736 22ND ST N •
ST PETERSBURG FL 33713 -4014
This is to certify that all tangible personal property purchased or rented, real property rented, or servicel purchased by the above business are being
purchased or rented for one of the following purposes:
• Resale as tangible personal property. • Re-rental as real property. • Incorporation as a material, ingredient, or
• Re- rental as tangible personal property. • Incorporation into and sale as part of the repair of component part of tangible personal property
• Resale of services. tangible personal property by a repair dealer. that is being produced for sale by manufacturing,
• Re- rental as transient rental property. compounding, or processing.
This certificate cannot be reassigned or transferred. This certificate can only be used by the active registered dealer or its authorized employees.
Misuse of this Annual Resale Certificate will subject the user to penalties as provided by law. Use skirted photocopy for resale purposes.
Presented to Presented by
(Insert name of seller on photocopy) (date) Authorized Signature (Purchaser) (date)
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STATE OF FLORIDA l dt0
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF STATE FIRE MARSHAL C \ S ;
TALLAHASSEE, FLORIDA
FIRE EQUIPMENT DEALER LICENSE
THIS CERTIFIES THAT: RESCUE 1 FIRE SAFETY SERVICES
2736 22ND STREET NORTH
ST. PETERSBURG, FL 33713 -
QUALIFIER: DEAN H HOYLMAN
HAS COMPLIED WITH FLORIDA STATUTES AND HAS QUALIFIED FOR THE TYPE AND CLASS SHOWN HEREON TO SERVICE, RECHARGE,
REPAIR, INSTALL, OR INSPECT ALL TYPES OF FIRE EXTINGUISHERS EXCEPT RECHARGING CARBON DIOXIDE UNITS AND TO CONDUCT
HYDROSTATIC TESTS ON WATER, WATER CHEMICAL AND DRY CHEMICAL TYPES OF FIRE EXTINGUISHERS ONLY. EXCLUDES ANY
SERVICE, RECHARGE, REPAIR, INSTALLATION OR INSPECTION OF ANY TYPE OF HALON EXTINGUISHER.
Chief Financial Officer
0110112010 07 03 Pinellas 83388500011996 1749880001 1213112011
Issue Date Type Class County License/Permit Number Application # Expire Date
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