HomeMy WebLinkAbout10-10646 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
• (813)780 -0020 10646
BUILDING PERMIT
:.. ° ""4 M,..`: 2.` 3 - a � s , • Yw`S'�h,', '^'` as
Permit Number: 10646 Address: 6107 SILVER OAKS DR
Permit Type: ADDITION /ALTERATION ZEPHYRHILLS, FL.
Class of Work: 434 - ADD /ALT RESIDENTIAL Township: Range: Book:
Proposed Use: SINGLE FAMILY RESIDENTIAL Lot(s):125 Block: Section:
Square Feet: Subdivision: SILVER OAKS
Est. Value: Parcel Number: 03- 26 -21- 0120 - 00000 -1250
lmprov. Cost: 59,186.80
Date Issued: 6/28/2010 Name: STILES, RICHARD & DEBORAH
Total Fees: 487.72 Address: 6107 SILVER OAKS DR
Amount Paid: 487.72 ZEPHYRHILLS, FL. 33542
Date Paid: 6/28/2010 Phone: (813)780 -7070
Work Desc: 20 X 31.6 ADDITION LIVING ROOM /BEDROOM
7'1 0i
L �N R TIIN : IL'IN E 326.40 EL - AL F 72.00
ZEPHYRHILLS ELECTRIC SERVICE PLUMBING FEE 48.00 MECHANICAL FEE 35.00
CHRIS BAHR PLUMBING RADON 6.32
BAHR'S PROPANE GAS & NC, INC.
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FO•T R 2ND •U H PLUMB MI C I ULA I•N C IL N
FOOTER BOND DUCTS INSULATED SEWER 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 your notice of commencement."
air 44 4 .11
CONTRACTOR SIGNATURE PERMIT OFFI FR
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: - L- Tcle
Date Received: -7 3--J o
Site: 7O7 Si /i Oa tS
Permit Type: - 4717 ieln aid k2i 6 3 11e7L
Approved w /no comments: ❑ Approved w /the below comments: 0' Denied w /the below comments: ❑
-mt 514-bcAcks 5W] be 014A-
This comment sheet shall be kept with the permit and/or plans.
§.( ,_2_,_to
Kalvin Swit . Plans Examiner Date Contractor and/or Homeowner
(Required when comments are present)
NOTICE OF COMMENCEMENT 1 111111 11111 1 1111 1111 11111 X11111111111111111 11111 1111111
2010089293
Permit No. Rcpt:1311855 Ree: 10.00
DS: 0.00 IT: 0.00
Property Identification No. 03- (p — (Z— 0420- 40 0 000— fa-SjD 06/23/10 K. Garcia, Dpty Clerk
THE UNDERSIGNED hereby give informs you that the imp' ovement 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.
p Ma �s e-
1 .Description of property (legal description: St 1_,f a_ OAKS 1 -SE 0 i LOT 125, OQ 4 S' 59 ft t i D 21
a) Street Address: 6I 07 SLL4 r 0A-r 5 D12 Z.EPt- 1- Lie alas 3 a 2-
2.General description of improvements: _ 1 V t , 1t • a r (6 ,,__
3.Owner Information ----.
a) Name and address: IS (�G,ri: -A b nt h 1 \ t--5---- b) Name and address of fee simple titleholder (if other than owner) �'n-�. CS �'-� b30 �/Q
c) Interest in property Ok,3 . ( ,
4.Co ntractor Information .74.37 gT
R a) Name and address: !S' L �'�Q / L S Cc\ v\ ) 3 f rUC-f i on 'Ze�N- -126t 41.E -5 R 3 3 5X/ 2 At
b) Telephone No.: 1. 1 (2 - 4 y Z Fax No. (Opt.)
5.Surety Information .,
a) Name and address: "
b) Amount of Bond: -o
c) Telephone No.: Fax Na. (Opt.) D
6.Lender xt w N
a) Name and address: `(v \ o
Phone No. m m
, 7. Identity of person within the State of Florida designated by owner upon whom notices or other documents may be served: CO F
a) Name and address: Wii, T-
b) Telephone No.: Fax No. (Opt.) ag
8.In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 03 T.
713.13(1)(b), Florida Statutes:
` -o o
a) Name and address: co p
b) Telephone No.: - Fax No. (Opt.) ° m
9.Expiration date of Notice of Commencement (the expiration date is one year from the date of recording unless a different date is •• A
specified): 1■b■ o
z
WARNING T() OWNER: ANY PAYMENTS MADE THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF rr
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.
A NOTICE OF COMMENCEMENT MUST BE RECORDED Alip POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CO' ULT YOUR LENDER OR AN ATTORNEY BEFORE
COMMENCING WORK OR RECORDING YOUR NOTICE OF CO :4 NCEMENT.
STATE OF FLORID C —
COUNTY OF PASC r
i � -4 JUWI M CAVALt17Zl .,...
-` = MY COMMISSION A DD 801827 Si a ' re of Owner or Owner's Authorized Officer/Director/Partner/M • g
-'� le EXPIRES: June 30, 2012 ; GANG-4- & \ti - 1 f C
•
•P, f,�;c. &aided tnn, Notary Pubic undmwdters t'' �, . c� ` 7 i \-e Print Name
The foregoing instrument was acknowledged before me this \) day of 3Une__ , 20 10 , by p v SQS
Or+G OPbCo.h Stlt2S as Ot k )rtie".r (type of authority, e.g. officer, trustee, attorney
in fact) f o r — M c v $ \ QS (name of party on behalf of whom instrument was executed).
Personally Known OR Produced Identification Not. Signature( vj�Q,,,.
Type of Identification Produced Name (grin. JO m. Lav al VZ7-1
Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perj • 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. )
FORMS/NOC,rvsd2007 Signature of Natural Person Signing Above
_'•.H1 }
— „ s 'i >1i�A, c$1 ASpO
- - FIFY TO \T T1-1E FOREGOING'IS A
-.1 1,ORRECT-'COPY.QF THE DOCUMENT ,;`
L 0- OF PL UC RECORD IN THIS OFF ICE
_ _. _�� . , i.c MY HAND hN OFFVCi/ ;, E AL 'FHIS -;
v2 -' DAY Or 4:40 ; -',
t_c,'- O,jN�IL, C:L'''K & Co ' 0,Li Rte- _;
DE;'r'JT CLE8K.
813-780 -0020 City of Zephyrhills Permit Application , ........... .-- - --
Building Department ` 41 /06 4
Date Received Phone Contact for Permitting - _ - _ - �� 7 - 1,
••••• 1,1 (_ q C . ,:'.G 1 ) C`� O wner Phone Number q -S � r `- `--
Owners Name . �I I .fi _ I
Owners Address
I G 1 07 , 1 --- CC upr Owner Phone Number 1
Fee Simple Titleholder Name Owner Phone Number I
Fee Simple Titleholder Address r �/
/:
JOB ADDRESS I l3 t b / Sl . . {• U Z' C`F •1 _s i ) Y� I LOT 0
SUBDIVISION 1 I PARCEL ID#EI 03 - 249- z.t --o1 z-0 - U0 °co - 1 Z- SO
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED I I NEW CONSTR r I ADD/ALT 11 SIGN I I MOVE I I DEMOLISH
INSTALL REPAIR
PROPOSED USE SFR 1 J COMM 1 1 OTHER I
TYPE OF CONSTRUCTION -- BLOCK I I FRAME I I STEEL I J OTHER 1 I
DESCRIPTION OF WORK (1 . 3 1 . ,1 r 1 '0, .. t ' i \ "`o 0 ri-,„.... ii ji,. IL
BUILDING SIZE IBC )( I. e 1 SQ FOOTAGE 1 iC 3a HEIGHT I / 1
I71 BUILDING $ -; - ma VALUATION OF TOTAL CONSTRUCTION
ELECTRICAL ; --
AMP SERVICE I 1 PROGRESS ENERGY I 1 W.R.E.C.
oC ; PC} 0. 0 0
1x'1 PLUMBING $ ( / / / / -J 2 5e I�
�l T t /'✓V t/✓ �L�y A-)&C
F I MECHANICAL $ 2 V ALUATION OF MECHANICAL INSTALLATION 0 � j C i
I 1 GAS - ROOFING 1 1 SPECIALTY! 1 OTHER (•I, , e (,2,40 G JI `� „ r-
FINISHED FLOOR ELEVATIONS / FLOOD ZONE AREA I IYES 'ill NO L J ' l �
BUILDER i s ,/ l COMPANY 6 . L L. ST 045,,u t �MI C,J
SIGNATURE REGISTERED (�%'� ii
Address 37 ( - a.4_ Alt I li:l - 4ir c dicks 335414- License# I t:l a- V3 -.3-) 39
ELECTRIC • i COMP 1 Z� IAN y, j ( c -t'. -s Lam: C' / l C_ W �N
SIGNATURE �---_ ` : � i WC V /. I
REGISTERED 1 Y / N 1 FEE CURRENT 1 Y / N 4 /1" ) .
Address -1 j .LioJiL) C- /-- - &..Y a14,r:.S Lr 359/1 License # 1 t tr ----
PLUMBER / , 4 A/ COMPANY 1 4e- -' * .-- /"'vz pL `' `e r 416 bi--
SIGNATURE `i�(iiv - / 7".„, " l REGISTERED I Y/ N 1 FEE CURRENT ( Y / N I V
Address ( 1 License it I CPC / f t6 ?•Z
MECHANICAL -• / COMPANY
SIGNATURE v Jt REGISTERED ( Y/ N 1 FEE CURRENT 1 Y/ N 1
Address 1 -ii-R4( / 4 / ( . ‹ , - - e O 0-f-/;11 i - 3 3 c 4 1 / 1 License # I
OTHER COPANY
SIGNATURE REGISTERED I 1 Y/ N I FEE CURRENT 1 Y/ N 1
Address I 1 License # I
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/Iarge 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. M 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 (PlotSurvey /Footage)
Driveways -Not over Counter If on public roadways..needs ROW
NOTICE OF DE� ED 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 IMPACTNTILITIES 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 t 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' Win 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 acct 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. ft 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 FOR4MPROVEMENTS TO YOUR PROPERTY. iF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER AN A ,� ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
FLORIDA JURAT (F.S. 117. ) 1>'\ . CONTRACTOR
OWNER OR AGENT y Subscribed sw to or affirmed) me
Subscribed and sw t�l(or affirmed) me this 7 et-G lr ) by 4 � e "
tc{ t 1 O by 1L;[ Vt[\rQl N ;`�a 1 �`i 11 5 Wh is/are pally to me or has/have produced
Wtm Is/are personally known to me or hasmave produced as identification.
- 1 - )i - s v 'LA <,-42 � -4e .-. a s identification.
c (
1 C - C�� v ' ft h Notary Public
`1. x �j a� Notary Public
�m - n No. ---' 4 2i b21 Commission No. , p . .
(.IC -, ii "iE (Jr FLORIDA
Storie Hartwig
J '` = Ca m " m w Z:1" Name of Notary typed, printed or s ii Commission # DD926164
Na ` Expires: OCT. 16, 2013
.�KM. CAVAii� BOND DTHRU:4TI.A..Vi CBONDINGCO., INC
.
?*: :A MY COMMON ON 1 D0801827
V -�. kr EXPIRE& June 30, 2012
inrh:' BoxisdThu Nary Pubic Undsi rs
SQ. FEET PRICE
MAIN OR LIVING: 632 $ 93.65
OTHER AREA UNDER ROOF: - $ 91.00
OTHER: - $ -
VALUATION $ 59,186.80
FEE SHEET $ 320.00
ADDRESS
DRIVEWAY
BUILDING: $ 326.40
ELECTRICAL: $ 72.00
PLUMBING: $ 48.00
MECHANICAL: $ 35.00
SUB -TOTAL $ 481.40
RADON: $ 6.32
TOTAL $ 487.72
SEWER:
WATER:
IRRIGATION: $ -
TOTAL: $ -
WATER METER:
IRRIGATION METER $ - I
FIRE DEPARTMENT FEES
PLANS TOTAL:
INSPECTION TOTAL:
PERMIT TOTAL
TOTAL: $ -
PUBLIC SAFETY IMPACT FEES
POLICE
FIRE
5% $ -
TOTAL: $ -
SUB -TOTAL $ 487.72I
PARK IMPACT FEES $ - I
SIF'S: $ -
100.0% $ -
1.0% $ -
TOTAL: $ -
TI F'S r
99% $ -
1% $ -
I TOTAL: $ 487.72I
AC# ! STATE,OF FLORID
D ISFAR T T O F EQS1 BS, A O SS1oN . RE rION
CONSTRUCTION= TIENISTRT, - ItieBNBIEtt - BO L1I10 -0644
LIC SE° R 1..
05/11/2010 090479680 C13CO221 F ' '-
The BUIr4DI1ic Co1TtACfioR. ' 4 _
Named below 19 CERTIFT ,
Under the _
provisions of Chaps 4 �'
,, ,�,
Expiration dater AUG 31, 2612 �. ;
STEVE GARY_ LOWELL , ` #9.7.;_:- ,
G L - .S +EVE CONSTRUCTION .- .. -
37651 8TH AVE
ZEPHYRHILLS FL 33542 ` r >- a b: r _.
CHARLIE CRIST - CBARLI LZEM
GOVERNOR iI+ ER1M SECRETARY
DiSPiAY REQUIRED BY LAW `
�' PP� &sco COUNTY BusI Ess TAx RECEIPT 2009 -
Issued pursuant and subject to Florida Statutes e. Pasco , snty Ordinances. Issuance does not certify compliance with
zoning or other laws. Thus receipt must be ,.osteu c. , . .:.,. ,dcuaousiy in place of business. Expires September 30.
Mike Olson
ACCOUNT NO: 003750 TAX COLLECTOR TYPE OF BUSINESS
SIC CODE: 1541
EUILDING CONTRACTOR
PA ; , r FLORI
.--0-,E&?-' LOCATION ADDRESS:
y = . 37651 8TH AVE
ZEPHYRHILLS
G L STEVE CONSTRUCTION .. " "
37651 8TH AVE
ZEPHYRHILLS FL 33542 -3328 • . car. DATE RECEIPT AMOUNT • � I
07/16/09 568657 31.25
L. 11... 11.. 1. 1.. I.. 6. 1. 1.. I1. ..11...1.11..1..1.1....1I...Ii1
4
Windows Live Hotmail Page 2 of 4
http: / /sn 141 w.snt 141.mail.live.ca lmai hlnboxLight.aspx ?n= 1014974764 6/21 /2010
Owners Page 1 55039 (11 -87)
Issued 06-07 -2010
INSURANCE COMPANY TAILORED PROTECTION POLICY DECLARATIONS
6101 ANACAPRI BLVD., LANSING, MI 48917 -3999
Reissue Effective 06 -03 -2010
AGENCY LEE REED INSURANCE INC
12-0154 -00 MKT TERR 052 (813) 782-5502 POLICY NUMBER 972312 - 20548117 -10
INSURED GARY STEVE
DBA G L STEVE CONSTRUCTION
Company POLICY TERM
ADDRESS 37651 8TH AVE Bill 12:01 a.m. 12:01 a.m.
ZEPHYRHILLS, FL 33542 -3328 06- 03- 2010 06 -03 -2011
COMMON POLICY INFORMATION
BUSINESS DESCRIPTION: Carpentry /Painting
ENTITY: Individual
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S). PREMIUM
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
COMMERCIAL GENERAL LIABILITY COVERAGE $2,219.00
FLORIDA HURRICANE CATASTROPHE FUND ASSESSMENT 22.00
EMERGENCY FLORIDA INSURANCE GUARANTY ASSOCIATION ASSESSMENT 4.66
FLORIDA INSURANCE GUARANTY ASSOCIATION ASSESSMENT (2006) 3.99
FLORIDA INSURANCE GUARANTY ASSOCIATION ASSESSMENT (2007) 14.42
FLORIDA INSURANCE GUARANTY ASSOCIATION ASSESSMENT (2009) 24.63
TOTAL $2,288.70
PREMIUM SHOWN ABOVE FOR COMMERCIAL GENERAL LIABILITY COVERAGE IS AN ADVANCED PREMIUM
DEPOSIT AND MAY BE SUBJECT TO AUDIT.
FORMS THAT APPLY TO ALL COVERAGE PART SHOWN ABOVE (EXCEPT GARAGE LIABILITY, DEALER'S
BLANKET, COMMERCIAL AUTOMOBILE, IF APPLICABLE)
55003 (01 -87)
A 5% CUMULATIVE MULTI - POLICY DISCOUNT APPLIES. SUPPORTING POLICIES ARE MARKED WITH
AN (X): COMM UMB( ) COMM AUTO(X) WC( ) LIFE( ) PERSONAL( ) FARM( )
Countersigned By: LEE REED INSURANCE INC
Page 2 55040 C11/87)
OWNERS INS. CO. Issued'06 -07 -2010
AGENCY LEE REED INSURANCE INC Company POLICY !NUMBER 972312- 20548117 -10
12- 0154 -00 MKT TERR 052 Bill
INSURED GARY STEVE Term 06 -03 -2010 to 06 -03 -2011
CONMERCIAL GENERAL LIABILITY COVERAGE
LIMITS OF INSURANCE
General Aggregate $600,000
(Other Than Products-Completed Operations)
Products- Completed Operations Aggregate 600,000
Personal Injury And Advertising Injury 300,000
Each Occurrence 300,000
Damage to Premises Rented to You (Fire Damage) 50,000 Any One Premises
Medical Payments 5,000 Any One Person
Twice the "General Aggregate Limit", shown above, is provided at no additional
charge for each 12 month period in accordance with form 55300.
AUDIT TYPE: Annual Audit
FORMS THAT APPLY TO THIS COVERAGE: 59350 (01 -08) 55068 (08 -89) I10021 (11 -85)
IL0017 (11 -85) 55188 (09 -04) 55238 (06 -04) 55296 (07 -05) 55300 (07 -05)
55371 (01-07) 55376 (02 -07) CG2149 (09 -99)
LOCATION OF PREMISES YOU OWN, RENT OR OCCUPY
LOC 001 BLDG 001 37651 8Th Ave
Zephyrhills, FL 33541 -3328
TERRITORY: 006 COUNTY: Pasco
Premiu�
Classification Subline Basis Rates Premium
CODE 21340 Payroll Each 1000
Premier Contractors Class Prem /Op 100,000 14.354 $1,435.00
Carpentry - Residential Prod /Comp Op 100,000 3.355 $336.00
1 -3 Stories
CODE 21585 Total Costs Each 1000
Premier Contractors Class Prem /Op 250,000 .499 $125.00
Sub- Contracted Work Prod /Comp Op 250,000 1.203 $301.00
TERRORISM - CERTIFIED ACTS SEE FORM 59350 $22.00
LOCATION 001 PREMIUM $2,219.00
ACORD CERTIFICATE OF LIABILITY INSURANCE RBJ965AU 1 06/21/201
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF WIFORMATION .
Risk Transfer Programs, LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
219 Fast Livingston Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Orlando, FL 32801 ALTERTHE COVERAGE AFFORDED BY THE POUCIES BELONG
866- 481 -9363
INSURERS AFFORDING COVERAGE NAIC 1
INSURER A: SUA Insurance Company 40134
mum)
Global Employment Solutions P80 IL, Inc.
INSURER B:
3350 Bushwood Park Drive INSURERC:
suite 200
Tampa, PL. 33618 INSURER D:
INSURER E:
COVERAGES
THE REOU IT , TE1 OR LISTED OF CONTRACT OTHER DOCUMENT T WITH RESPECT O WH POLICY
THUS PERIOD ICA MARY BENOTWITHSTANDING
ANY MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALLTHETERMIS, EXCLUSIONS N40 CONDITIONS OF SUCH
POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECflVE DAM VAR : PO U CY NUMBER ANTE O YY► LIAM
TYPE OF SitAIANCE EACH OCCURRENCE $
CiBIEAAL WLSIUT'Y P
uwoomiL S � IH NYikU s
COMMERCIAL GENERAL LIABILITY MED ESP (Any = one encs) $
1� CLAIMS MADE OCCUR
PERSONAL & ADV INJURY $
_ GENERAL AGGREGATE $
PRODUCTS - COMP/0P AGG S
GEM..N3GREGATE LIMIT APPLIES PER:
POLICY fl I I L
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT $
(Ea =Olden!)
ANY AUTO
ALL OWNED AUTOS BODILY INJURY $
.... SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Pa accident)
NON- OMfNED AUTOS _
PROPERTY DAMAGE $
(Per accident)
AUTO ONLY - EA ACCIDENT $
GARAGE UABIUTM EA ACC S
ANY AUTO � ONLY
AGG $
EACH OCCURRENCE S
ETLCEiBAJMBREI.LJIUAMURT'
OCCUR n AGGREGJITE S
CLAIMS MADE $
_s
DEDUCTIBLE $
RETENTION S ' WCS1I I
A womaNE COrPBisATTONAND WSLTHPE 000082 -06 12/31 /2009 01/01/2011 X TOIIY 1,000,000
EMPLOYERS' UABILJTY E.L. EACH ACCIDENT S
ANY PROPRE1ORIPARTNERIEXECUTIYE L. DISEASE - EA EMPLOYEE S 1,000,000
OFFICERIM IMBED, EXCLUDE07 1 1,000,000
000 , 000
H describe PROVISIONS belay
S El. DISEASE - POLICY LIMIT $ PEt:IAL PROVISIO
CRIER
oescRr ION OF OPERATIONS / LOCATIONS /VEHICLES I EICUJmONB ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
Coverage is extended to the leased employees of alternate employer (Alabama, Colorado, Florida, _G_' ConstructionjlF ,
Michigan, Mississippi, Missouri, South Carolina, Tennessee, and Texas Operations Only):
5003187 (Effective 08- 01 -02)
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the
representative or producer, and the certificate holder, nor does it affirmatively or "negatively amend, extend or alter
the coverage afforded by the policies listed thereon. CANCELLATION
HOLDER SHOULD ANY OF R* ABOVE DESCRIBED POLICIES BE CANCELLED BB 0RERIE EIPIRATION
DATETNEEIBOF,INEMUMS Si.niERMILL ENDEANORTO MBAS DAMS WgTT®I NOTICE1O
THE CERTIFICATE MOLDER NAMEDTOTME LEPT, BUT I#ILIAIE W 0010 SMALL SSPOSE NO
osmium OR mammy OF ISIS unarm SS)INBEB, STAIN* OR
R
City of Zephyrhills
5335 8th Street AUTIRORIZED REPUBIENSIRIVE
2ephyhills, FL 33540 Page 1 of 1
0 ACORD CORPORATION 11)118 � ACORD 25 (20171108)