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HomeMy WebLinkAbout10-10731 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813) 780 -0020 1 731 ANNUAL FIRE PROTECTION 'MAINTENANCE - . a s . e.. ' 'vim"... :ice t � � ✓"�'� - � .,. 1 ° " ? q; r fi r ` f tirffi , i Permit Number: 10731 Address: 7441 GALL BLVD PermitType: FIRE PROTECTION MAINTENANC ZEPHYRHILLS, FL. Class of Work: FIRE - PROTECTION MAINTENAN •E Township: Range: Book: Proposed Use: COMMERCIAL Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 34- 25 -21- 0000 - 00300 -0040 Improv. Cost: 77 :1777:77V Date Issued: 7/16/2010 Name: LONG JOHN SILVERS,INC. Total Fees: 25.00 Address: 7441 GALL BLVD Amount Paid: 25.00 ZEPHYRHILLS, FL. 33542 Date Paid: 7/16/2010 Phone: Work Desc: FPM- SUPPRESSION SEMI- LONG JOHN SILVERS 1: 2 7 1; - ;TIWEEZetratWigiMIN 7 ? - A •A T I` . A IN FI =E P - M 25.00 C (0 cam' f 2 „ ,,., " , e ... n g a s "� � € i� „ 4'I A4 A - AN inal .- 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 $100.00, whichever is greater. All work shall be performed in accordance with City Codes and Ordinances. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMNT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." -,?■0 P �• IT OFFICER PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR REQUIRED ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813 - 780 -0041 813 -780 -0020 City of Zephyrhills Fire j �'1 Fax- 813 - 780 -0021 . Perrnit Application Date Received 7 --/g 70 Phone Contact for Permit ) 32 1 / vc, I ...::. E: ^a�:�i9 ..- sxsn4i .. N.iwau uFt` >.e . ......,....w '. .w� . ,» uv.. w •`w,.on..�.u.«w.u'a«::.k$��fWFF >A..,3:�mE.a .�z..:sa%�$h...��.atu"F:$... ,�.,zc'T,�'..:h .... Ce e.n 4 . 5.... sl:. ml.- �a' vcw .ir�R....az...o., >.«s...w».. : nmXcanaxv.vace r �M"..s rk wxn. a., w.v..mv Owner's Name [ Cans ') n S ,.1 Ver I Owner's Phone Number I Owner's Address 7 4 1 (_Q, 1 f? i U a Fee Simple Titleholder Name Titleholder Phone Number Fee Simple Titleholder Address I I M ., MME M V, ; M,.,ZS LI ;:.:. >.e L' A " ? _ V,.... . k "'tr ?S' -, Ffi� ... MERE .. IN r grail �o ?t mis'a � '� > ��...�:. g M. 3.... . Job Address _) 4 1 ) C.--C\ l , U ((/ Oi - Lot # Sub Division Parcel # s'tAM. s, acilm ar �'"."*g .. .. r aggi a ....�.�.� octive.,e� mum N- tia ti a arA0a4:, M .M..us e"' ..z, vr.�.�iti f ng.t.i',.Z ri. C W n Bio- Hazard Waste Storage - ANNUAL I Fumigation Tent n Comm Exhaust Kitchen Hood /Duct l I 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 FT Emergency Generator > 30 kw n LP /Natural Gas - ANNUAL Sale n Fire Protection Maintenance - ANNUAL n Places of Assembly- ANNUAL IQtrlyl 'Semi' Ann Other Sprinkler 0 ❑ ❑ ❑ n Recreational Bum Fire Alarm n ❑ ❑ ❑ I I n Sparklers Hood Cleaning p El ❑ I I n Sprinkler System Installations Hood Suppression " t q� ❑ I I h Standpipes (Sprinkler Sys) Fire Alarm Installation !/ n Torch Roofing/Tar Kettle FT Fire Pumps n Waste Tire Storage ANNUAL E Fire Works n Flammable Application- ANNUAL ( I Valuation of Project n Fuel Tanks FT Other: I aE6.1 ..A r VEMSV sin , M u sOZAvigx M Ng€?a =a te ,a.,", imatamtmargin llama zw w,n_= Contractor Company 7C C Leas 1 `, 3/1-4k L� Signature Registered Y N 1 Fee Current I Y / N j Address I -/2c /11414o r ^. 111 em% 1 - X S / 4,Ed FZ -I P-941Rense # I I ELECTRICIAN Company I Signature I Registered Y/ N J Fee Current I Y/ N I Address I I License # I I PLUMBER Company I Signature Registered Y/ N I Fee Current I Y/ N I Address I 1 License # I MECHANICAL Company I Signature Registered Y / N I Fee Current I Y / N I Address I I License # ( I OTHER Company I Signature Registered Y/ N j Fee Current I Y/ N j Address I I License # ,.. >,M� tea°'. _ —".�m _M M ��,r� v.:�aEL .M._.u, „gr...«..gg Directions: Fit 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.OFDEEDRESTRICTIONS: The undersigned understands thatthis :permit maybe subject to "deed' restrictions" which may be more 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 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. CONSTRUCTION LIEN LAW (Chapter 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 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 CONTRACTOR Subscribed and sworn to (or affirmed) before me this Subscribed and swom to (or affirmed) before me this by by 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 07/16/2010 13:25 3217831516 -1 NEW FAX! SPACE COAST PAGE 02/03 May. 25. 2010 12:35PM LRA Insurance No, 5696 P. 1/1 Act> R d CERTIFICATE OF LIABILITY INSURANCE DATE 9' PRODUCER (321) 453 -1530 PAX: (321)452 -3925 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Lutabra Robinson. S 11AiAtocia **.ea -Hrev d ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 300 Magnolia Avenue Suite B HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9n ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. , Merritt Island • N'L 32952 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A Crum & Forster Specialty Space Coast Tire and Safety, Inc. INSURER a Bridgefield Employers INSURER a colony Insurance Caopany 420 Manor Drive INSURER D. Merritt ( Island FL 32952 INSURER E COVERAGES THE POLICIES of INSURANCE LISTED BELOW HAVE PEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN DING 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 I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSUCH POLICIES. AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIR NSRD TVPF lIP IYCIaMANCE POLICY rHNABER DATE r (MMEIOIYYYY) DA LIMITS GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000 X COMMERCIAL GENERAL UABIUTY P R RE EMII SE S � (E e occurrence) 5 50 , 000 A I CLNMS MADE © OCCUR GL0161089 8/24/2009 8/24/2010 MEDEXP (Any on, person) i Excluded PERSONAL & ADV INJURY t 1,009_, 000 GENERAL AGGREGATE t 2.000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AG,G r 2 , 000, 000 POLICY 76 I1 LoC AUI'DMOB9.E LIABILITY COMGINED SINGLE UNIT $ 1,000,000 _ ANY AUTO (Ea =cant) A ^ ALL OWNEDAUTOS 2Loi61099 8/24/2009 8/24/2010 BODILY INJLIRY _ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY 1 X NON -OWNED AUTOS (Perecddcna PROPERTY DAMAGE (Per ea de d) GARAGEUABaITY REVISED UMBRELLA. AUTO ONLY - EA ACCIDENT S H ANY AUTO SEE BELOW om THAN EA ACC t AUTO ONLY: AGO 1 EXCESS I UMBRELLA LIABM-ITY EACH OCCURRENCE S 2,000,000 OCCUR I1 CLAIMe AGGREGATE S 2,000,000 A R DEDUCT1BLE as 0131031 8/24/2009 8/24/2010 S _. RETENTION $ $ g WORKERS COMPENSATION X I TWCSr1RY 1 ATV- R I MOTH. AND EMPLOYERS' UNARY VI T IMIT FR ANY PROPR$TORIPARTTERIE)eCUTIVE E.L. EACH ACCIDENT S 1,000,000 OPPICERMEMBER EXCLUDED? 1MenastaryInNH) 0830 -43054 10/22/2009 10/22/2010 E.L. DISEASE - EA EMPLOYEE S 1,000,000 Ifyes, descnpe ands BPEaAL PROVIBIOr4G moo. Et. DISEASE - POUCY LIMIT $ 1,000,000 OTHER C Contractors Install. Mus11460 09/20/2009 09/20/2010 sae,000. 11ste Float= DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 OCCLUSIONS ADDED BY ENDORSE/AGRI) SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANYOFTNEAYOVG DESCRIBED POLICIES BECANCELLED BEFORE EXPIRATION DATE THEREOF, TIC ISSUING USURER WILL GNDEAYOR TO MAIL DAYS WRT('EN NOTICGTD THE CERTIFICATE HOLDER NAMED ?OWE LEFT, BUT FALURB TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILIT OF ANY KIND UPON THE INtURRR, ITS ACGNTS OR ReES9JTATIVES. Ausim aix9 RIPR66EJTATN6 • B Richard /BARB IE dr3h ACORD 25 (2009/01) (D1988 -2008 ACORD CORPORATION. All rights reserved. 19025 Romp ) The ACORD name and logo are registered marks of ACORD 07/16/2010 13:25 3217831516 -1 NEW FAX! SPACE COAST PAGE 03/03 Fom Request or Taxpayer i Give fern to the (Rev. OCCber 2007) er. Do not Iderlitlficatian plumber and Certification 1 request` send to the IRS. eztir•M .r tna Treasury internal Revenue sanice ( !Varna ('•4 Fhpwn on yci !- Ornf tax return) o I • ° pace ^ cast • F and S a f ety !nc D 1 Ejc n^p nsrre. If y -rapt r. -r.., 7ht-' a a c • I Check =- ppropr'•a12 box: ❑ IndNiduai /Sole proprietor 0 Corporation ❑ Partnership @:err t : - U Limited company. Enter the !2t classification (Cxdiare Gad entity, Ccorcoration, P= rshl ? I'y P Ss part ,e N) I 0 P¢p e_ G = 1---, Other (see irsirJeiias) r Address ( number, street, and apt or suite no.) Reoueter's name And address (optional) 0 420 Manor Drive .7 City, state, and ZIP code r Merritt Island, FL 32952 8 List account numbers) hero (optional) Part 1[ Taxpayer Identification NumberJTtN) Enter your TIN in the appropriate box. The 1N provided must match the name given on Line 1 to avoid Social security number backup withholding. For individuals, this is your social security number (5SN). However, for a resident i i alien, sole proprietor, or dlsregarded entity. see the Part I instructions on page 3, For other entities, it is your employer identmcait'on number (~1N). If you do not have a number, see How to get a 77N on page 3. or Note. if the account is in more than one name, see the chart on page 4 for guidelines on whose IIr., p1cyer !dent c:sedon number number to enter. I 59 1 3444060 _ Part Il Certification Under penalties of perjury, I certify that: 1. The number shown on this forrn is my correct taxpayer identification number (or I am waiting for a number to be lesued to me), and 2. I ?m not subject to backup withholding because: (a) I am exempt from backup withholdln3, 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. nitizen or other U.S. person (defined balovr). Certification ! nstructions. You must cross out item 2 above if you have been nctified by the IRS that you are currently subject to backup withholding because you have failed to report ell interest and dividends on your tax return. For real estate transactions, rem 2 dons not apply. For morgags interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you aro not required to sign the Certirication, but you must provide your correct TIN. See the instructions on page 4. Cty.t Signatu re of /� i 0 AA o r e I u.E. person V-- 7)--- ��^ datte 0- ei LV General Instructions Definition of a U.S. person. For federal tax purposes. you are Section references are to the Internal Revenue Code unless considered a U.S. person if you ere: otherwise noted. • An individual who Is a U.S. citizen or U.S. resident alien, e 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 retum 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 detlned in Regulations section transactions, mortgage interest you paid, acquisition or 301, 701 -7). . abandonment of secured property, cancellation of debt, or Special rules for partnerships. Partnerships that conduct a cortributi,::s yo:i made to an IRA. trade or business In the United States are genersliy 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 T1N 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 ars a partner is a foreign person, a,,d pay the withholding tat;. waiting for a number to be issued), Therefore, it you are a U.S. parson that Is a partner in a 2. C that you are not subject to backup v /ithholdln or partnership conducting a trade or business in the United States, i g' provide Form W -9 to the partnership to establish your U.S. 3. Claim exernplion 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 certirying that as a income. U.S. person, your allocable share of any partnership income from The parson who gives Form W -9 to the partnership for a U.S. trade or business is not subject to the withholding tae; on purposes of establishing fts U.S, status and avoiding withholding foreign partner_' share of effectively connected income. on its allocable share of net income from the partnership Note. If a requester givers 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 forrn 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) 07/16/2010 13:25 3217831516 -1 NEW FAX! SPACE COAST PAGE 01/03 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES " - ;_ DIVISION OF STATE FIRE MARSHAL TALLAHASSEE FLORIDA FIRE ER"1'INGIIIS$ER PERMIT THIS CERTIFIES THAT THOMAS A SPINA EMPLOYER: SPACE COAST FIRE AND SAFETY 420 MANOR DRIVE MERRITT ISLAND, FL 32953 - LICENSE NUMBER: 92364900012002 , FIRE EQUIPMENT CLASS D LICENSE HAS COMPLIED WITH FLORIDA STATUTES AND HAS QUALIFIED FOR THE TYPE AND CLASS SHOWN HEREON TO SERVICE, REPAIR, INSTALL, INSPECT ALL TYPES OF PRE - ENGINEERED FIRE EXTINGUISHING SYSTEMS. Chief Financial Officer (/(�. i /I • 01 0112010 09 04 Brevard 09876200012002 1730900002 12 31 2011 Issue Date Type Class County Licease/Permit Application # Expire Date • G l� 5 5 „� P.e ►� m�