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HomeMy WebLinkAbout10-10721 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813)780 -0020 10721 BUILDING PERMIT Permit Number: 10721 Address: 7928 GALL BLVD Permit Type: SIGN ZEPHYRHILLS, FL. Class of Work: WALL SIGN Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: ZEPHYR COMMONS Est. Value: Parcel Number: 35- 25 -21- 0130 - 00000 -0140 Improv. Cost: 3,416.00 ' x #7�� _; Date Issued: 7/15/2010 Name: ZEPHYR COMMONS LLC Total Fees: 75.00 Address: 3629 MADACA LANE Amount Paid: 75.00 TAMPA FL 33618 Date Paid: 7/15/2010 Phone: (813)933 -0629 Work Desc: INSTALLATION CHANNEL LETTERS SIGN 28' GREAT CLIPS - - a 1flk I N 75.00 FS• R ELECTRICAL U FINAL -( U 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 reco ing your notice of commencement." ro 4 1 41; ONTRACTOR SIGNATURE PERMIT OFFI �R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER City of Zephyrliills BUILDING PLAN REVIEW COMMENTS Contractor/Homeowner: '� 3 Date Received: 41124 j 0 Site: 7°IZ GAM // (/D Permit Type: 2 r AA-11 j Approved w /no comments: ❑ Approved w /the below comments: P Denied w /the below comments: ❑ j S nci I I'ni a it Re Atieene,45 © E Orr lAao (-P. 4 g71) - vil q c 4,) iX S I'S 3 & c) &WI vbor pryjecf „ore ■,,). DA from t l wwc1 coo ri tk �s "41 ' (tidy This co t sheet shall e kept with the permit and/or plans. , 7 73P / ii 7 Sitii‘ Kalvin wi er — P s Examiner Date Contractor and/or Homeowner (Required when comments are present) 813-780 -0020 City of Zephyrhills Permit Application Fax-813-780 -0021 Building Department 2 '7 '�J Date Received -7- / 2 rm (3 Phone Contact for PeiUi . / ) 3 / 1 _ , ' � owners Name 7 - 6 P1I Y LO M ,'`)3 Li— c_ Owner Phone Number 1 3 - 133 0( J`9 Owner's Address 3 G s -? Imo) *9 i C- -Fir 1 librn en Ft • 4 Owner Phone Number 1 Fee Simple Tkleholder Name I J ?1' C Owner Phone Number I Fee Simple Titleholder Addtess I JOB ADDRESS /9 2 ( q� /t- &c is G eP%iiyRn'Ib h . 1 LOT# I SUBDIVISION PARCEL ID#I3$?'1 . / — O/3e — 6000 ✓ — er' Y I (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED n NEW CONSTR 8 ADD/ALT 1 1 SIGN CZ n DEMOLISH INSTALL REPAIR PROPOSED USE n SFR El COMM 1 1 OTHER I ?€.7) :C I TYPE OF CONSTRUCTION n BLOCK Q FRAME 1 1( STEEL r( DESCRIPTION OF WORK I / 45 j, { C V-A ,-0A/EA.- L i VI S i ev-a <4 X.gat `(_G 0 5 BUILDING SIZE 1 I SO FOOTAGE I HEIGHT I r;` 7 1, I nBUILDING I 3i4 4 w VALUATION OF TOTAL CONSTRUCTION nELECTRICAL IS I AMP SERVICE n PROGRESS ENERGY n W.R.E.C. ( I 0 A) 0 e I ; 1 j a 4 L - '' n MECHANICAL 1$ I VALUATION OF MECHANICAL INSTALLATION nGAS n ROOFING 0 SPECIALTY 1 1 OTHER e ff FINISHED FLOOR ELEVATIONS I D ZONE AREA rIYES NO 1111111'111'11'`I'111'11''1 il 11 "" 11111 '11111111 1111111111111111 / BUILDER / RI r ,': v, COMPANY I 7 1 9 -777 A- Si Sr ). Zi ' SIGNATURE I REGISTERED I Y/ N I FEE CORREN 1 Y/ N I Address 116 1 ( 4 N , id r m @:S k , h - 1 ) P r r I License # 1 C C. C rs G O 7 ELECTRICIAN COMPANY I SIGNATURE REGISTERED I Y/ N ( FEE CURREN I Y/ N I Address 1 1 License* I PLUMBER COMPANY 1 SIGNATURE REGISTERED I Y 1 N I FEE CURREN I Y/ N I Address 1 1 License* 1 MECHANICAL COMPANY 1 SIGNATURE REGISTERED I Y/ N ( FEE CURREN I Y/ N I Address 1 I License* 1 OTHER COMPANY I SIGNATURE REGISTERED I Y I N I FEE CURREN I Y / N I Address 1 1 =1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R -O-W Permit for new construction, Mininum ten (10) working days after submittal date. Required onsite. Construction Plans, Stormwater Plans w/ Silt Fence instated, Sanitary FaciNbes & 1 dumpster, Site Work Permit for srabdiviabnsllarge projects COMMERCIAL Attach (3) complete sets of Buildup Plans plus a Life Safety Page; (1) set of Energy Forma. R -O-W Permit for new construction. Minimum ten (10) working days after submttal date. Required onsite. Construction Plans, Stormwater Plans w/ Silt Fence installed, Sanitary• Faciliies & 1 dumpster. Site Work Permit for all new projects. All commerdal requirements must meet compliance SIGN PERMIT Attach (2) sets of Engineered Plans. ""PROPERTY SURVEY required for a1 NEW construction. 5 1 I Directions: Fill out application completely. Owner & Contractor sign back of application, notarized If over $2600, a Notice of Commencement is required. (NC upgrades over 57600) " Agent (for the contractor) or Power of Attomey (for the owner) would be someone with notarized setter from owner authorizing same OVER THE COUNTER PERMITTING (Front of Application Only) Reroofs if shingles Sewers Service Upgrades A/C Fences (Plot/Survey/Footage) Driveways -Not over Counter if on public roadweys..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 743, 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 Constriction 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, Welland 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, 1 certify that fill wilt 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 1 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, wens, pools, an 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 Y • - LEN r R • i• RNEY B F •iE REC •1 DI G • • • ii E • F C •1. _NC E T. FLORIDA JURAT (F.S. 717. r � OWNER OR AGE CONTRACTOR Subscribed and awo ± r affirmed) • . • Swat and M ((or : L. • • • : me is 7-1240 by r ,4 n/ vr W) / 2 • ID by R: r� _ K 1244 r✓t Who jWWare personally known to me or hasRreae produced Who is/arnpersonally known to me or has/have produced ( t as identification. L, ('E vise. as identification_ R21 • � ,0 `' ., JACQUELINE BOGES e JACQUELINE BOGES 24 ' ° • (:nmmiksinn fnn Rotary public Y As I C ommisgion DD 021033 No1�' public - e. •`` _ s ? �;. -.:as Expires December 12, 2010 • 3 ! pRplros Dumber 12 2010 Commission No. p • . � , Bonded TANTroy Fain Insurance 800485-7019 ,• ... • . Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped , Ak 1 . >._ In 1 CC i i."A.N. V C r 5 'a 1 X\ P z p cc 0 — ___./ o "f" • I L'• ._ IN31,436va , NITILIN30ThM[10 [ 1 , I 1 1 [ 1 1 , I 1 I i 1 1 I 1 I , 1 , 1 [.• -: -- \[[ , /-. [ [[/./ ' ;'-'. 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D/B /A GREAT CLIPS 7928 GALL BLVD., ZEPHYRHILLS, FL, 33541; FOLIO #35- 25 -21- 0130 - 00000 -0140 To Whom It May Concern: As agent for the subject property, I hereby authorize Tampa Sign Inc. or their authorized agents to secure a sign permit for our tenant, "Great Clips ". Thank you for your assistance. Sincerely, Donya K. Beckman Director of Property Management As agent for Zephyr Commons, LLC State of Florida County of Hillsborough Sworn and subscribed to me this 30th day of June, 2010 by Donya K. Beckman who is personally known to me. ar' 1/ .4 El* Signature of Notary Public (seal) cc: Richard L. Trzcinski Managing Partner ;;;;;;v P °jo ,� CAROL SMIDDY P e r Notary Public • State of Florida � j My Commission Expires Aug 13, 2011 Commission B DD 703271 , '11° `` Bonded Through National Notary Assn. l 3629 Madaca Lane, Tampa, FL 33618 -2048 • Phone: 813.933.0629 • Fax: 813.935.3420 www.primericagroupone.com 111111111111111111111111111111111111111111111111111111111111 2010098492 Rcpt:1314901 Rec: 18.50 DS: 0.00 IT: 0.00 07/09/10 S. Shultz. Doty Clerk NOTICE OF COMMENCEMENT PAULA S.O'NEIL,Ph.D.PASCO CLERK & COMPTROLLER PermitNo. ?"0000 07/09/10 01:42 pm 1 of 2 Property Identification No. AS -Z,5 3 A ✓ Z( d� V - 0 f y0 OR BK 373 PG 142 THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance wth Section 713.13 of the Florida Statutes, the following information is provided in this NOTICE OF COMMENCEMENT. 1. Description of property (legal description tion :) S e a) Street Address: - LS 6c144_ sh , Zs.ph y -I U 1 ..7_, 3355E / 2. General description of improvements:1; /,". . 4.- Sllc r, lr2S llsc.. _47 3. Owner Information a) Name and addressZ eilyrCfJJrneroyf4 LLG 5 4 ifla .& * CH. Ter: pc, Fr 33(O /P b) Name and address of fee simple titleholder (if other than owner) c) Interest in property 4. Contractor Information a) Name and address Td g � " t shr . 847/Si N N. 1tm u Az_,� i 334' //5/ b) TelephoneNo.: Al 3 - -- 7 o 6 Fax No (Opt) �T 5. Surety Information a) Name and addres: b) Amount of Bond: c) Telephore No.: Fax No. (Opt) 6. Lender a) Name and address Phone No. 7. Identity of person within the State of Florida designated by owner upon whom notices or other document may be served: a) Name and address b) TelephoneNo.: Fax No (Opt) 8. In addition to himself, owner designates the following person to receive a copy of the Lienor's Notice as provided in Section 713.13(1) (b),Florida Statutes: a) Name and addres: 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 THE NOTICE OF 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 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 0 COMMENCEMENT. STATE OF FLORIDA COUNTY OF PASCO Signature of Owner or Owner' s Orficer/Director/PartnerMM n _ D)•-•y K, 13ec Es rl Print Name r^ The foregoing instrument was acknowledged befcre me this " day of 20L0_, by Do) V& g • 8E4 k#p,cc.rf as Dirge/I -a, dL F� 4q _ (type of authority, e.g. officer, trustee, attorney in fact) for Zephyr CrJ'v., ersAy►S, CL L. (n a ofp ot1'b ehalf I om instrument wa - ecuted). Personally Known / OR Produced Identification _ Notary Signature _ 4) A % --.4/1t1..._!...."%11 ' I lk Type of Identification Produced Name (print) Ca at, if/n l y Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the foregong and that the facts stated in it are true b the best of my knowledge and belief. L it...._ Signature of Natural Person Signing Above FORMSMOC,,vsd2007 p p 0 ` azp t ►,Y °6 s , . CAROL SMIDDY ` .+ `� Notary Public - State of Florida ii ▪ • My Commission Expires Aug 13, 2011 ` ▪ l,@e ;fie. Commission # DD 703271 ••nu Bonded Through National Notary Assn. 0 OR BK 8373 PG 143 2 of 2 • '--' phase, LEGAL DESCRIPTION Parcel A: A portion of Tracts 7, 10, 23, 26, 39, 42, 55 and 58, together with Tracts 8, 9, 24, 25, 40, 41, 56 and 57, Zephyrhnls Colony Company Lands Subdivision as recorded in Plat Book 1, Page 55 of the Public Records of Pasco County, Fiorlda, all tying within Section 35, Township 25 South, Range 21 East, Pasco County, Florida, and being more particularly described as follows: Commence at the Northwest corner of Section 35, Township 25 South, Range 23. East, Pasco County, Florida; thence along said Section line South 89 °59'50° East, 15.13 feet to the Point of Beginning; thence continue along said line South 89°59'50" East, 1,000.05 feet; thence leaving said section line, South 00 West, 2,618.58 feet to the North Right of Way One of Pretty Pond Road; thence along said North Right of Way line the following three (3) courses: 1) North 89 °53'13" West, 351.59 feet 2) South 00 °09'48" West, 5.00 feet; 3) North 89 °53'13" West, 532.38 feet thence leaving said North Right of Way line, North 01 °01'48" West, 633.10 feet thence North 89 °54'52" West, 102.90 Peet; thence North 00 °0545" East, 1,988.73 feet to the Point of Beginning. Less and Except The North 15 thereof platted as Road Right of Way. Also Less and Except The North 290.0 feet of the South 515.0 feet of the East 150.0 feet of the Southwest 1/4 of the Southwest 1/4 of the Northwest 1/4 of Section 35, Township 25 South, Range 21 East, leaving a portion of Tracts 56 and 57 Zephyrhiils Colony Company Lands Subdivision as recorded in Plat Book 1, Page 55, Public Records of Pasco County, Florida. b • t STATE OF FLORID COUNTY OF PASCO THiS IS TO CER THAT THE FOREGOING IS A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE OR OF PUBLIC RECORD IN TH1S OFFICE WITNES MY HAND AND + FICIAL SEALTH 2 6 0 • PAULA S O'N C i �a CO PTROLLER k �cti : , "UTY CLERK �• BY EnCon Services, Inc. Sign Design Calculations Job Description PREPARED BY: EnCon Services, Inc. Great Clips 2272 Jaudon Road 7928 Gall Blvd. Dover, FL 33527 Zephyrhills, Florida 813- 655 -3373 2' -0" x 14' -0" raceway wall sign F 813 - 655 -9814 Design per 2007 Florida Building Code, 2009 supplement, Section 16 Wind Load ASCE 7 -05 Aaron Biedenbach, P.E. Design Specifications I FL PE #52949, FL EB 9394 Importance Factor 1 OH PE 60756, OC #01893 Kzt 1 KY PE #20281, P #2463 Exposure Factor B IN PE #PE 19600322 Kd 1 FL CBC #060535, QB #22527 Kz 0.7 V 120 (mph) GCp -GCpi 1.28 Zone 4, H < 60 Feet Wind Pressure 33.0 (psf) Sign Information Height 2.00 (ft) Width 14.00 (ft) Thickness 1.00 (ft) f If f ft r,,� Distance grade to top 30 (ft) 1 Q . 8 d FHB �� A o V :�le rjsF • ; Wind Sheer Force 66.06 (Ib) � Q �, • 'y Weight of Sign 280 (Ib) ` No 5 2949 �, • • • Total Sheer Force = 287.69 (Ib) .k �` • , e. Total Tension Force = 924.84 (Ib) = •• 491. • R • ••4 ' Required Provided �i � s s tt o N p\, , 00% Fastener size (Nominal) 3/8 3/8 11141110 Minimum number of fasteners 8 8 Sheer Force per fastener (Ib) 36.0 280 Tension Force per fastener (Ib) 115.6 352 Combination Tension and 0.46 <1 O.K. Sheer ratio THREADED ROD THROUGH WALL IS PREFERRED IN ALL INSTANCES. IF IT IS NOT POSSIBLE TO USE THREADED ROD, SEE CHART BELOW FOR APPROPRIATE ANCHOR SELECTION. SIZE AND NUMBER REQUIRED ARE NOTED IN THE CHART ABOVE. WALL STRUCTURE ANCHOR TYPE WOOD BLOCKING LAG BOLT (3' EMBEDMENT) THROUGH BLOCKING EIFS OVER 5/8' PLYWOOD LIBERTY TOGGLE BOLT OR THRU BOLT WITH SLEEVE HOLLOW CONCRETE BLOCK, BRICK SLEEVE ANCHOR (1 -1/2' EMBEDMENT) SOLID CONCRETE WEDGE ANCHOR (2 -1/2' EMBEDMENT) CMU, SOLID CONCRETE, BRICK HILTI HIT ROD W/HY -20 ADHESIVE (3 1/2" EMBEDMENT) ALL ANCHORS SHALL BE CHOSEN AND PLACED IN ACCORDANCE WITH MANUFACTURERS INSTALLATION INSTRUCTIONS 7/8/2010 Great Clips Zephyrhills 2 -0 x 14 -0 RW 03 -17 -2010 ��y - Ef t 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: 05/02/2010 EXPIRATION DATE: 05/01/2012 PERSON: FAUSTRUM FRANK J FEIN: 593016581 BUSINESS NAME AND ADDRESS: TAMPA SIGN INC 8616 N HIMES AVE TAMPA FL 33614 SCOPES OF BUSINESS OR TRADE: 1- GENERAL CONTRACTOR 2- SIGN INSTALLATIONS /MAINTENANCE IMPORTANT: Pursuit to Chapter 440 . 05(14), 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 roller tkis chapter. Pursue to Chapter 440.05(12), F.S., Certificates of electioa to be exempt-.. apply only within the scope of the business or trade listed ea the notice of electioa to be exempt. Pursuant to Chapter 440.05(131, F.5., Notices of election to be exempt and certificates of electioa to be exempt shall be subject to revocation if, at any time after the filing of the Notice er the issuance of the certificate, the person named en 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 1allure of the person named on the certificate to meet the requirements el this section. QUESTIONS? 0150) 413-160. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES . *.` '' ; DIVISION OF WOR CERS' COMPENSATION j� + F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY , elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA ? ;: p L under this section may not recover benefits or compensation under this WORKERS' COMPENSATION LAW ? D chapter. EFFECTIVE 05/02/2010 EXPIRATION DATE: 05/01/2012 Pursuant to Chapter 440.05(12), F.S, Certificates of election to be PERSON: FRANK J FAUSTRUM H exempt.. apply only within the scope of the business or trade listed on FEIN 593016581 R the notice of elipri to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt TAMPA SIGN INC and certificates of election to be exempt shall be subject to revocation 8616 N HIMES AVE if, at any time after the filing of the notice or the issuance of the TAMPA, FL 33614 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 SCOPE OF BUSINESS OR TRADE person named on the certificate to meet the requirements of this 1- GENERAL CONTRACTOR 2- SIGN INSTALLATIONS /MAINTENANCE Section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records, DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 •� Date : July 13, 2010 933-83 • This letter authorizes Frank Faustrum to obtain and sign for permits from Zephyrhills Building Dept Address: 8616 N. Himes Ave Tampa, FI 33614 Phone: 813- 933 -8370 Email: tampasign @verizon.net Notary Area �1. , •� • `, �� STATE OF FLOR OA COUVTY H THE FOREGOING INSTRUMENT WAS kcKNOWIEDfED BEFORE ME THIS 13 DAY OF , 20�., 421 "' ?� MONICA MONTANE/ � MY COMMISSION # o0 923451 , BY WHO IS P KR PRODUCED . EXPIRES: November 28, 2013 A D z rrl liC n� a '0 a ., P m =gym co H co 4-3)21 H (D p G} w > ' ° "' i y ° z cn A) a ,- b , 0 rn 1 W ° po E.ai 3 I. ,, a X 0 c rI rf N ,,_k-s § Z $ A a rornrocn �•0rm a = G I , , ' H - 0 0 I-1; o °' rn -I -n -� ao 0 _ co O Z 7D O _ cam o O - <ti ro$r tY D� D D� m £ t+ HQ A► O H Q u.., °> Vi DZ - I D O Z frQ C n � 0- m TS �X W x fti W tn • . .mfZ rn x b S w m m o wL=J E ► z �cncn'^ a m e C /� m _ A m m _ m z �. CO n �"' of M 1.1 CZ z C x o W " -I N N [y t 0 co . w m 01 (Ito _ 'v — Z I'' td' Hcn N r d' at. :OH 'i yy co -xt z H � ' o m m . 0 O m m p n p C CO > . a m _ m Kro - x a - ? '' ` %` t''0 .... o ui ' H� _ mN On SI 1 r 0 z n HO > O _, 0 73 m o a � > m H H o N m O c$ c W ,� o 8' a � al i #3 i co T o3 y p . p t o D p 0 p 07/13/2010 15:48 8139350709 NEIGHBORHOOD INS PAGE 01/01 ACCORD AC DATE IMM /DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE -7/ 3/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 'THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on thls certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). coNTACT H rs PRODUCER NAME_ .. , — , -_ - ... Neighborhood Insurance Services P (913) 935 -1 (Af , No 107.3)935 -0709 (AIC, No, EXq: ) E -MAIL Neighborhood Insurance Service ADDRESS: PRODUCER A0001127 14949 N Florida Ave CUSTOMER ID , Y_, ... . . ._ . .. T ampa FL . 33 613 INSURERIS) AFFOROINO COVERAGE I NAIL s • INSURED INSURER A:Granada Insurance CO INSURER B : Tampa Sign, Inc, DBA: Faustrum, Frank INSURER C1 ___ ... . 5616 N Hines Ave. INSURER D: INSURER E : Tampa FL 33614 INSURER F : 1 - COVERAGES CERTIFICATE NUMBER:CL1071302365 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 V ITH 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, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, fris — — - POLICY EFF I POLICY EXP UNITS INSURANCE 'NMR I WVD POLICY NUMBER IMWDDIYYW MI ) (MODIYYYY) LTR 1 TYPE O F INS GENERAL LIASILtTY EACH OCCURRENCE $ 1,000,000 I ANCAME TO RENTED X I COMMERCIAL GENERAL LIABILITY PREMISES (Ea occuRpncn) 3 50,000 2010 /9/2011 A � CLAIMS -MADE. � X j OCCUR 01852FL00005933 1 /9/ MED EXP (Anyon9 parson) I $ 1,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 • GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2,000,000 1 X I POLICY , 1 JECT I. LOC .... ..... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT f (Es accident) ANY AUTO ' - - BODILY INJURY (Per person) $ ALL OINNED AUTOS BODILY INJURY (Per accident) 5 SCHEDULED AUTOS PROPERTY DAMAGE Is I HIRED AUTOS (Pnr OccIdenl) NON.OWNED AUTOS I $ I 1 UMBRELLA LIAR I I OCCUR ,_EACH OCCURRENCE $ EXCESS LIAe CLAIMS -MADE I AGGREGATE S I DEDUCTIBLE I 1 $ RETENTION S I I 5 woRKERS COMPENSATION 1 I WC. LIMITS I I O ER AND EM UABILRY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N EL EACH ACCIDENT 1 S OPPICER/MEMBER EXCLUDED' N 1A (Mandatory In NH) I i E.L. DISEASE - EA EMPLOYEE 5 Ir vns deearlbe under DESCRIPTION OF OPERATIONS below 1 i 1 _ E.L. DISEASE - POLICY LIMIT 1$ I , DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 vEHICLES (Atlecn ACORD 101, Additional Remarks Schedule, If Mon Apace Is required) CERTIFICATE HOLDER CANCELLATION (813) 780 - 0021 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Zephyrhills Building Department 5335 Bth St 2ephyrl FL 33542 AUTHORIZED REPRESENTATIVE D2_,(cFrLa GU ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. INS025 (200909) The ACORD name and logo are registered marks of ACORD co W(n Cn ..j� -� ` . t , � 5 c5 5 N � r }� } , z z z �`.,4,,. f.' ; i 3 , f ,t , 0 0 0 -=N-0 4 N L! 1)`, i s O ymm Z Fr C < O It i ` ■ m�0 oo�� ':.'. 1 1'1, i.4!! coil f m z z a co 3 II # N III �zt;ii 0 O m m �-� I o lh o. s • Z (-) w 3 1 . Q • I i 4 • m o - ' all .ACC ••. ` ! f i , t , 0 0 D a 0,... t 0. i ' , l , i , #, 1 II m v III :'. - / ,. , rn cp 4 i ,:..4.,,, : ' - -.... 1 :)) i 3 °_ I • ,; , , j .4. H r • ' : ? • ¢ cr n di s:. 0 CD al Ill ......,.. i OM - IrAF N CN uDimoQ -u ' . 0 -0 13 �p I c Z u0 > = C.TI°' mpwmZ * T v 12 'p. 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