HomeMy WebLinkAbout10-10691 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
- (813)780 -0020 10691
BUILDING PERMIT
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Permit Number: 10691 Address: 38518 CR 54 EAST
Permit Type: ADDITION /ALTERATION ZEPHYRHILLS, FL.
Class of Work: 434 - ADD /ALT RESIDENTIAL Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 02- 26 -21- 0060 -00000 -0010
Improv. Cost: 500 Cz3T.I:, _ s�. , 11
Date Issued: 7/12/2010 Name: LIIERTY PROFESSIONAL INC
Total Fees: 107.50 Address: 12603 LAKE HILLS DR
Amount Paid: 107.50 RIVERVIEW, FL
Date Paid: 7/08/2010 Phone:
Work Desc: CLOSE FIRE WALL
PUN - •N - :UILDIN FEE 52.50 FI- IN P C •N S 30.00
FIRE PLAN REVIEW FEES 25.00
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F• • • 2N. R•U H PLU 1 C INSULATION C ILIN
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 rec ., F1 IT. gvc'i ■ ,:_of commencement." _
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CONTRACTOR SIGNATURE PERMIT OFFI FR
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION — 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
-"mom .®.s, a:
City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
ap Contractor/Homeowner: l---/ - PVLSI il)
Date Received: 7— 6' -- /O
Site: 'E8jf15 (1
Permit Type: r)--E. • vOcc.OZ__
Approved w /no comments: El Approved w /the below comments: Denied w /the below comments: ❑
1 ) CC ift i.J it n S p. 141 I T,� c «v c C� r� ,C, J
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i �s r o i ! De) s �. II • (� e e i3,9 '`ie ma, ec c-,-/
This comment sheet shall b
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kept with the permit and/or plans.
K vin S tzer s Examiner Date Contractor and/or Homeowner
(Required when comments are present)
813 -780 -0020 City of Zephyrhills Fire tr f V I 71 _ F. 1 , 780 -0021
Permit Application CCCIC '
Date Received * /, ®,Q Phone Contact e 33
t t .,a
for i j �J /3 1 ( 1 .-Z
— Owner's Name l_1 ``. 1 '0zf _ S 0Q, 1Q .\—c Owner's Phone Number —
— Owner's Address kali, 6Z L.Ak X1'1 Q p ) / ik V�A R� / f ')`.. S(4 g Q
Fee Simple Titleholder Name , ` Titleholder Phone Number Ct .. 1 (0•14 1 (P
Fee Simple Titleholder Address I
y Job Address 3 R5 , S OZ_ � � _ H '(, -) Lot #
Sub Division Parcel #
:,..nararzfaut16 NA:- ,,:,,,..t cnt,'StttafmAlwsvwngfnmna;Mawas'Vtimngi,tmeaZdgPMnml,ngpzIkaq,,z,,gch;..a.V.ieaaioaglatt,
Bio- Hazard Waste Storage - ANNUAL n Fumigation Tent
n Comm Exhaust Kitchen Hood /Duct n Hazardous Material (Tier II or RQ Facility) ANNUAL
n Controlled Bum n Hood Installation
n Emergency Generator < 30 kw I I LP /Natural Gas - Installation
n Emergency Generator > 30 kw n LP /Natural Gas - ANNUAL Sale
n Fire Protection Maintenance - ANNUAL n Places of Assembly- ANNUAL
IQtriyi ISemil I LJ Other d ,47,x____
Sprinkler n ❑ ❑ ❑ n Recreational Bum e
Fire Alarm n ❑ ❑ 0 I I n Sparklers `10.
Hood Cleaning n ❑ ❑ ❑ I n Sprinkler System Installations
Hood Suppression 1 ❑ ❑ I I n Standpipes (Sprinkler Sys)
El Fire Alarm Installation n Torch Roofing/Tar Kettle
n Fire Pumps n Waste Tire Storage ANNUAL
n Fire Works
n Flammable Application- ANNUAL I I Valuation of Project
n Fuel Tanks
s l Other: I CQo.) % 1 F o ice 1
.., i�.< S ^.,F�si„.:,.�z...G.,m:�TM`?�°�� . r , ": .� .�, aA. , e, . :: t �sa ;¢:^?� �'ta�z.�:ri: .. '•�_ ''' 4. e3€ga vr .n akara .a..., ,0 .e,.aan .f wa,meiw,.s
Contractor J Company
Signature �'c�` Registered Y / N I Fee Current I Y / N
Address I License # I J
ELECTRICIAN - Company I
Signature I Registered Y / N I Fee Current I Y / N I
Address I I License #
PLUMBER Company
Signature Registered Y / N I Fee Current I Y/ N I
Address I I License* I
MECHANICAL Company
Signature Registered Y/ N I Fee Current I Y / N I
Address I I License #
OTHER Company
Signature Registered Y/ N j Fee Current I Y/ N
Address,' License# I
.� tme4:saw..,a....,..w «r.«z ,ca w . ..,.,..aa:LU 9:m a :..:z..., cramssa,.,:W .,. 4aa tir,.,da,M .w....•: 4,43, -' ' S« , a�au ce„ s, s.,,M .¢., >a•. c ,.,.,:.,......,,, ,, r '.,UnCi oll , :.
Directions:
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)
NOTICEsOF :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 for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
contractors 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.
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 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.
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 70 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 CONTRACTOR
Subscribed and swom to (or affirmed) before me this Subscribed and sworn to (or affirmed) before me this
by b y
Who is /are personally known to me or has /have produced Who is /are personally known to me or has /have produced
as identification. as identification.
Notary Public Notary Public
Commission No. Commission No.
Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped
Zephyrhills Fire Rescue
6907 Dairy Road, Zephyrhills, FL 33542
Fire Marshal Bus (813) 780-0041
Kerry Barnett Fax (813) 780 -0044
E -mail: kbarnett@fire.zephyrhills.fl.us
Plan Review #: 10 -079
Project: Fire Wall Installation
Number of Pages: 2
July 6, 2010
I have received and reviewed the plans for the installation of a firewall to close in an
existing opening of a rated wall located at 38518 CR54 E 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. Screws as the same length as nails noted in listing will be allowed.
2. Install wall in accordance with listing submitted.
3. Use fire rated mud and tape
Inspections Required:
1. Screw Inspection (after installation -no mud or tape)
2. Final
KERR :' TV'''TT, 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 -004 Fax (813)780 0044
FIRE SERVICE USER FEES
Occupancy No.:
Plan No.: /O Q 7 j Contractor: 6 do S/ 0
Business Name: Billing Address:
Business Address f1•4 4_ ,..3.35Z9
Business Phone No Billing Phone No.:
Business Fax No.: Billing Fax No.: I
Contact: Contact: I
PLAN REVIEW FEES INSPECTION FEES _ PERMIT FEE 1 —
FALSE ALARM FEE
Site Plan
u N/C Annual N/C _ Sprinkler $501 —
$100 1st Alarm N/C
tti- Family /Common ial .06 sf _ 1st Re_ inspection N/C _Standpipes $50 2nd Alarm N/C
0 (Min• _ 2nd Re- inspection _Fire Pump $50 3rd Alarm N/C
• an - evlsions DBL _ 3rd Re- inspection $250 _ Hoods $501 - 4th Alarm
$100
_ 4th Re- Inspection $500 Fire Alarm $501 _ 15th Alarm $150
SPRINKLER SYSTEMS (Business closed until LP Gas $501 _ 6th Alarm $200
—
^ 0 - 25 Heads $50 violations corrected) Natural Gas
_ $50 NON COMPLIANCE $1$0
26 plus Heads $100 SPRINKLER. SYSTEMS Fuel Tanks - per tank $501
—
STANDPIPE SYSTEM Hydro Undergrounds $45 _ Sparklers $10
0 Per Riser $50 Hydrostatic Test $65 per system _ Fire Works
$500
FIRE PUMP Acceptance Test $45 per system _ Camp Fire $25�
0 Per Pump $100 Hydrant Flow $75 _ Controlled Bum $100
_ FIRE ALARM SYSTEM _ Hood/Duct $50 -
— 0 - 25 Devices $50 _ FIRE ALARM SYSTEM _ Place of Assembly $501 Annual
26 plus Devices $100 _ System Acceptance $50 _ Fire Protection - $251
_ SUPPRESSION SYSTEMS _ Recall Acceptance $50 _ Flammable Application $50 Annual
_ Wet $50 OTHER — 0, _ Waste Tire Storage . $50 Annual
Dry $50 IA ' Ire Wall/Smoke Wall _ Generator < KW $10
_ CO2 $50 ` LP Gas $2 per tank _ Generator >30 KW 150
—
Other $50 N Natural Gas $25 per system _ Bio- Hazard Waste $100 Annual
KITCHEN EXHAUST _ _ Fumigation Tenting $50
❑ Hood/Ducts
$50 ^ Tent 10'x10' or greater $15 portent _ Torch Pot/Applied $501
OTHER _ Fire Pump $45 _ Haz. Materials 5100, Annual
LP Installation per tank $50 _ Fire Suppression $30
_ 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)
0 Spray Booth $50 0 Inspection scheduled DBL
and cancelled Tess than
—
24 hours
Construction Insp. N/C
Emergency Vehicle AC $50 FALSE ALARM
PLANS TOTAL PSI INSPECTION TOTAL 1 PERMIT TOTAL I I I TOTAL I I
GRAND TOTAL
'7 5737 0 a
Comments; I
i
Date: 7/1/
Inspector: 9. ,r44 . /Z. 1
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SHALL COMPLY WITH ALL
PREVAILING CODES, FLORIDA BUILDING
CODE, NATIONAL ELECTRIC CODE AN
CITY OF ZEPHYRHILLS ORDINANCES
, may
REVIEW DATE - 7 7--/0 _
CITY OF ZEPHYRHILLS
PLANS EXAMINER X-5
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07/09/2010 03:17 7884774 DUN RITE PAGE 01
002-
COVER SHEET
ATTENTION 136.0
FROM: .DAVID COLLINS
DUN-RITE CONCRETE INC.
RE: (.Dni affi-Pka4
TOTAL PAGES:_____
DATE,L119/1 _
813-345-8666 OFR E, & FAX
813419-8362 ELL
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2 LICENSE YEAR NOTICE �� FLORIDA .
ACCOUNT 057698
SIC CODE 1522
PAYABLE TO:. MIKE OL,SON, TAX COLLECTO P.O._BOX 276, DADE CITY. FL 335
G1 26 -0276 •
•
I E !G-` ,. "4 1 CERTIFY THAT ALL INFORMATION PROVIDED IN THE ABOVE
APPUCA770N FOP Tblig BUSINESS TA: RECEIPT 15 'TRUE AND
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DUN —R I r E. CDNCR_ E INC y r ;
12! �LEY r IJN - =j _r,_' -c...17 4 ._ P 413 AUTHORI SIGNA 1 r i7ATE
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PASCO COUNTY T BUSINESS NESS TAX RECEIPT 20094 .
Issued pursuant and subject to Florida Statutes cl PescaCounty Ordinances. Issua. -s o , ,r . - . ; ? 7 ?r,e l ;t,.
zoning or other laws, This receipt must. be posted consp!cuously in piece at Ous;n_ss.. : ... e . -_t•. ,
Mike Olson .
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ACCOUNT �NO � 057688 r � r T' �._
SIC CODE= 1522 `'� -''�'" �`i •TYPE OF .BU$1 BUSINESS
a ASCQ ' •• - T MI? ' GENERAL COUTRACTOR . •
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LOCATION ADDRESS: .
26524 PKEASEN1 RUN
DON RITE CONCRETE INC ° " Y_' WESLEY CHAPEL.
26524 PNEASENT RUN
WESLEY CHAPEL FL — •��� �
33544 2473 : �r .. ; = DATE RECEIPT AMOUNT
IuhIn. 11.11 .. I.. I. I.. Iu .I.�.I.ul1u.I..11,alI. 09/11/09 575348 31..23
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STATE OF FtOR-pq ACO 3'909464 .
DEPARTMENT OF BUSINESS AND
PROPESSIONAZ REGCLATION
CRC1328214 -- etil2/es tattiness
CERTIFIED RESIDENTIAL CONTRACTOR
COLLINB, DAVID NAYNE
DUN -RITE CONCRETE .INC
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as.. AUG 31, 2010 L08001.202417
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05/11/2005 19:52 9417395608 ASSURE LLC PAGE 01/01
ACORDW - CERTIFICATE OF LIABILITY INSURANCE DATE(YY)
7/9/2010 2010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ASSURE LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2511 Manatee Avenue E HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Bradenton, FL 34208 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
(941) 739 - 5121 INSURERS AFFORDING COVERAGE
i NSUREO NAICe
Dun -Rite Concrete Inc INSURER k Accident Insurance Company
Dun -Rite Construction INSURER B: 21st Century Insurance
26524 Pheasant Run INSURER C: United Specialty .Insurance co
Wesley Chapel, FL 33544 INSURER D. 1lrs.dgaticld Emp{oyera Ifl uranaa Co
)813- 345.8666 F 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 ADO'L
LTR IroSRD TYPE OF INSURANCE POLICY NUMBER POLICcY F ECTIVE POLICYEXPIRATI N
DATE( y� I CTI DATF(MM/RONY) LIMITS
GENERAL uABIUTY
EACH OCCURRENCE $ 1,000 , 000
UnivrAtat 10
X COMMERCIAL GENERAL LIABILITY PREMISES (Ea oca,re nce) $ 100,000
CiLAIMBMADE X OCCUR
MED EXP (Any one Demon) S 5,000
A X PD Ded: $1000 AGL84749 09/03/09 09/03/10 PERSONAL & ADV INJURY f 1, 000, 000
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GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000 2,000,0
— I FOLIGY [ JEC El T LO
AUTOMOBILE LIABILITY
X ANYAUTO (c d SINGLE LIMIT $ 2,000,000
_ ALL OWNED AUTOS ^--
X SCHEDULED AUTOS BODILY INJURY f
(Per parson)
B X HIRED AUTOS AIG1071720 09/02/09 09/02/10
X NON- oWNEDAUTOS BODILY INJURY $
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(PereocberB
GARAGE LIABILrr AUTO ONLY -EA ACCIDENT $
_ ANYAUTO
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ 1,000 s____ OOO
X I OCCUR CI CLAIMSMADE AGGREGATE $ 1,000,000
UEP000017 09/03/09 09/03/10 $
C DEDUCTIBLE
8
RETENTION S
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WORKERSCOMPENSATIONAND WCSIArU OTH-
EMPLOYERS' LIABILrTY x TORYLIMITS FR
ANY D OFFICER/MEMBER PROPRIETOR/PARTNER/EX
ExcLUOEO? Rc� E.L EACH ACCIDENT $ 1,000,000
ff $ de-cn BER r 830-42887 09/02/09 09/02/10 E.L DISEASE. EA EMPLOYEE $ 1, 000,
Z 0 E EL DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
City of 2ephyrhilla - Building Dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
5335 8th St DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL3O DAYS WR(17EN
NOTICE TO THE CERTIIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $O SHALL
Zephyrhills , FL 33542
FAX: 813 - 780 -0021 IMPOSE NO OBLIGATION OR LIABILrrV OF ANY KIND UPON THE INSURER, ITS AGENTS OR
RED sassug ss.
AUTHORIZED REPRESENTATIVE r /J����
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CORD CORPORATION 1988
• ACORDe CERTIFICATE OF LIABILITY INSURANCE 1 L` ' ormyr
7/9/2010
Fleouucw:
1 THIS CERTIFICATE IS ISSUED AS A RATTER OF INFORMATION
ASSURE LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2511 >!1a>natss alvrnoe _ ' 140LDER. Ties CLRT$ICATE DOES NOT AMEND, EXTEND OR
Bradenton, PL 34200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
: (9 -5121
INS 4 INSURERS AFFORDING COVERAGE NAIL%
Dun -Rite Concrete 2 I essAIReR,k Act surancs Company " -------- s
Dun -Rite Construction ( ,N a, 2 st�Cetatusy Insurance
26524 Pheasant Run INSURER C: Un itild 8 p eC tyy Insnranco Co
Wesley Chapel , FL 33544 ; INSURER D: irr '• ° • •Ar• • Co
,813- 345 -6666 F I INSURER E 1
COVERAGES
THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO'7VVITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MTh 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 NAVE BEEN REDUCED SY PAIO CLAIMS. IC E
� * O i TYPE Of INNI IRANC.P� I POLICY NUMBER �[�?A7' .1 p ( 1 s
G ENERAL Loftin I I EACH OCCURRENCE 1t I 11000,000 E 0
coMMERCIAI. GENERAL LIABILITY VAN >u Hl:llntD
� PRENNEe(Eroccw«w► S 100 000:
CLAIMSMADE I b l OCCUR , MEDEXPIAnrwle MOB _ r ^ 5 , _ , 0000
A, X PD Ded: $1000 AGL84749 09/03/09 09/03/10 PERSONALSADVINJURY I s 1, 000, 000 •
GENERAL AciGREGATE 1 a 2 , 000,000 {
LIMIT AGGREGATE LT APPLIES PER , I PRODUCTS • COMPIOPAOG 1 i 2,000, 000 ,
. . POLICY rx 12CT LOC I 1 7
: I AUTOMOBILE LIASILITY
1
X 'vn A"'° cOM G OON sINGL u"ar s 1,000,000
I ALL OWNED AUTOS
III SCHEDULED AUTOS BODILY INJURY f
F -i Ow Perron,
a I X ` HIRED AUTOS I A1G1071720 09/02/09: 09/02/10 1
I 1 (s
' X NON -OWNEDAUTOB I
1
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PROPERTY GARAGE I$
fPrecaor111
i GARAGE LIABILITY AUTO ONLY. EA ACCIDENT f
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ExC I i ! EACN OCCURRENCE !, 11000400
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X . occuR cI. aeINADL� r oGCIREGATS i $ 1,000,000
DEP000017 09/03/09 109/03/10 s i
C; . DEDuCTI$LE
' RETENTION s
5
S
' W0RRERISCOMPENSATIONAND , X 1 WCSTATU- I D R.I
• GMPLOYER9' LIABILITY
dI.Y pHoPARroimurrNER•Exmonye ! 1 E.L. EACH ACCIDENT , II 1,000,000 ■
D , 1 °" `"Otl °' 830 -42687 09/02/09 09/02/10 E.L DISEASE • E„E re
MPloi s 1, 000, 000
SPECIAL PAOVIBIOIVB EL DISEASE- POLICY LIMIT 1 s 1,000,000
oTH
•
.
C•ESCRIP•TION OF OPERATIONS J LOCATIONS I veacus/ EX ,CLU ADDED 611/ ENDORSEMENT /SPECIAL PROVISIONS I
I
1
CERTIFICATE HOLDER CANCELLATION
SHOUL AN
D Y OF THE DESCRIBED POLICIES OE CANCELLED BEFORE THE EXPIRATION
City of Eophyrhilla - Building Dept
5335 81;h St OATS THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO mAn.30 DAYS WRITTEN 1
NOTICE To THE CERTIFICATE HOLDER N
Zephyrhillal , PL 33542
TO THE LEFT. Out FAALRE TO 00 a0 SHALL
RX 813 -780 -0021 WOW NO OBLIGATION OR Lu8WTY OP ANY (ND UPON THE INSURER, as AGENT6 OR I
REPRESENTATIVES.
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