HomeMy WebLinkAbout10-10770 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(813)780 -0020 10770
BUILDING PERMIT
Permit Number: 10770 Address: 6949 GALL BLVD
Permit Type: SIGN ZEPHYRHILLS, FL.
Class of Work: WALL SIGN Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 03- 26 -21- 0010 - 00100 -0011
Improv. Cost: 2,500.00 e,
Date Issued: 8/24/2010 Name: PHILLIP MICHAEL INC
Total Fees: 67.50 Address: 6949 GALL BLVD
Amount Paid: 67.50 ZEPHYRHILLS, FL. 33542
Date Paid: 8/24/2010 Phone: (813)780 -6101
Work Desc: INSTALLATION WALL SIGN ILLUMINATED 17.31 X 13
L ITA I •1 1 N .7.50
(Aqc_ LectrA fleValkr-
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ELECTRICAL ROUGH
FINAL
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 • ur property. If you intend to obtain financing, consult with your lender or an attorney
befo - - co • ' • your notice of commencement."
I - 44 4,1'' -
CO RA 4 EP SIGNATURE PERMIT OFFI ■1
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
JUL /,5 /2009 /WED 01:56 PM ZEPHYRHILLS BUILDING FAX No, 813 - 780 - 0021 P. 001
813 -780 -0020 , City of Zephyrhills Permit Application . .0 Fax- 813 - 780 -0021
Building Department
Date Received ,a y ♦ � ���
Phone Contact for Permittin, WV
Owner's Name ] ✓� � i 01
L - .� �
Owner Phone Number
/",
Owner's Address 1 439 5 , C� i t B Via, 1 I
Owner Phone Number
Fee Simple Titleholder Name I 1 Owner Phone Number 1
Fee Simple Titleholder Address I
Joe ADDRESS (9 4 G ti. BILi 8- t 7. 1 c-Ii t l is .33542-1 LOT # I
SUBDIVISION I PARCEL ID #' 0 3 2- ' -24 — 0010 — DO l DC3 —00 i I •
(OBTAINED PROM PROPERTY TAX NOTICE)
WORK PROPOSED I NEW CONSTR � l ADD /ALT ( DEMOLISH
INSTALL n REPAIR
P
•
ROPOSED USE 1 1 SFR 1 1 COMM J OTHER I
TYPE OF CONSTRUCTION 1 1 BLOCK Q FRAME 1 1 STEEL I 1 1 I
DESCRIPTION OF WORK T
�+7 I t_ 11 (.) i!'i \. n 4 '' .- ��' c�. L� I.� �.�' ii-..-, it., S'� I t �'� I
UUILDING SIZE 1 2 013 it t + )( 06 (VI SQ FOOTAGE' 17•11A I HEIGHT 1 (3 ! I
•
1-1BU1LDING I$
W r " I VALUATION OF TOTAL CONSTRUCTION
•
1- 1ELECTRICAL IS ` I AMP SERVICE 1 1 PROGRESS ENE '�"�,i1d W.R.E.C.
E— IPLUMBINO IS I a) . t c---
1 (MECHANICAL I$ I VALUATION OF MECHANICAL INSTALLATIO N N , r
I Q ROOFING I-1 (3
1 SPECIALTY 1 1 OTHER 'V p ' �fI/ /'
FINISHED FLOOR ELEVATIONS ( I FLOOD ZONE AREA 1 YES NO
11 l
BUILDER COMPANY I
SIGNATURE REGISTERED 1 Y/ N 1 FEE CURREN 1 Y/ N 1
Address # I License # I I
ELECTRICIAN COMPANY I
SIGNATURE REGISTERED 1 Y/ N 1 FEE CURREN 1 Y/ N 1'
Address I
1 License # I (
PLUMBER COMPANY 1 I
SIGNATURE REGISTERED 1 Y/ N 1 PEE CURREf 1 Y / N 1
Address I . I License # I I
MECHANICAL COMPANY I I
SIGNATURE 1 REGISTERED 1 Y/ N 1 FEE CURREN 1 Y/ N 1
Address _ "i
�� License I
_
OTHER t • L
SIGNATURE I ti as. i COMP �1 i � ' � t - . -T 7 � . � � � St K REGISTERED " � - CURREN r A�
Address
License # lag 1 2.1)005 6 d3
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 onslte, Construction Plans, Stormwater Plans w/ Slit Fence Installed,
Sanitary Facilities 8 1 dumpster; Site Work Permit for subdivisions /large 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. All 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 $7500)
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 If shingles Sewers Service Upgrades A/C Fences (Plot/Survey /Footage)
Drlvewaya - Not over Counter if on public roadways - .needs ROW '
•
JUL' 5%2009 /WED 01:56 PM ZEPHYRHILLS BUILDING FAX No. 813 - 780 -0021 P. 002
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 713, Florida Statutes, as amended): If valuation of work is $2,500.00 or mare, I
certify that 1, 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 1 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.
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, 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 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 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 becorne 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, thekJob is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT tN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING; CONSULT
WITH YO - L • ER • - AN ORN ? _ F • RE ' CORD G Y • UR N • TI E 0 CO , , E I ENT.
FLORIDA JURAT OWNER Ott AGENT S. 117.03) `` \ \* ERL_� �' CONTRACTOR
Subscribed and sworn to (or affirmed) befocme y�3 MMIs 7 • CO , � i 1 swo (or r b fore e this .
Who is/are personal) �
b y known to me or ha ro _`` si�e.p di�e � y Who Is/ a ersonally know me or has/have produced
as Iden i atik. o�, : 73 E as Identification.
• •
Viv
*/ Pti f ' Notary Public
3 St ate �• P . -
Commission No. i� / C s . . O F ` \S \ \� 0e `Z . Commission (`lo. • i
A �� 1! / /ltrt(9lltttt \ \ 1 rl ( - C? •
•
Name of Notary typed, printed or stamped Name 0 Notary typ - , printed or s : mped
,,-/- �jj�I1l�Rrrsi r a \
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Er ��
Project: Edward Jones
6949 Gall Blvd.
Zephyrhills, FL 33542
Attention Growth Management Dept. Building Division:
This is to grant written authorization to Carl von Thaden to act on my behalf to apply to the City of
New Port Richey, FL Growth Management Department / Building Division for a sign and/or electrical
permit for the work to be performed at the address & project referenced above. Carl von Thaden is also
the authorized agent for the purpose of obtaining any variances required to erect signage for the above
named project.
Sincerely,
0
Richard .1. Ranten Jr. ES12000566
STATE OF North Carolina COUNTY OF Surry
The foregoing instrument was acknowledged before me this 14 4s — day of 3�N� 2010 by
ci,- rb.. .3 �U ca y -G- �� 1
. 1' who is personally known to me/ ed
as- identifrsatiex and who did not take an oath.
State of_ N C- County of S �r ✓ — __
Y
Co missi # - - --
c
,_ i L ' -1; \" ANITA J. RICHARDSON
(Notary) , Notary Public - North Carolina
((((���� � Surry County
My Commission Expires: \,. .) 1
O M y Commission Expires k hµ, tiv -- it.f
Etat to.e.st4 Aolvt Ca0.4 A44i / 96 Fred Avenue / Dunedin, FL 34698 / Phone: 727 -505 -0713
/1/47 ,/ - -/v
Letter of Authorization
This letter authorizes Elite Images Advertising Consultants, as agents for Allied Graphics, to
act as my agent in obtaining the required and necessary permits, licenses and approvals, which
may be required for the installation of said signage, and to proceed with the installation if in
accordance with all governing laws, statutes and ordinances.
As owner of property, I hereby authorize Edward Jones Investments, as tenant and / or lessee of
property, to obtain new and / or change existing signage at the below referenced address.
Tenant Name: Edward Jones Investments # 09419
Address: 6949 Gall Blvd
City: Zephyrhills State: Florida Zip Code: 33542 -2586
Landlord / Owner Information
Landlord / Owner Name: 4 \ \
Address: CO
City: 7f',Pkki tLS State: V &C Zip Code: gf �j L
Telephone Number: 577 7P 4 - Ca I b Fax Number: ?• 750-8 I
ck ,kccteC_
Signature of Owner
State of r avidQ.
County of ?oLsco
Swom to and subscribed before me this a 44- day of JlAVle- gOI 0 b
11 A 0 maS VeuAate,y (name of person acknowledged) who is personally known
to me or who has produced (identi ication .
INS
Notary Public
Commission expires _ _ — — — _ — _ • 4 , ;e „" ,,,, S
LORI SANCN�SeaI)
I Notary Public - State of Florida
4 t = My Corms. Expires Jan S. 2014
� „
• Commission • 00 950215
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'• pi IRS
City of.Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contrr/Homeowner: A` -
. '✓i i ■ /1 7 •�7
Date Received: � -9 c.<2- - J6
Site: iy q 4 c
r
Permit T yp e: �al /�7- le a (%4 J $
Approved w /no comments: ❑ Approved w /the below comments: [ Denied w /the below comments: ❑
i nc-'5 f /�l et a (( -7 ; ` Z / f,j( -(-. b _ l?
o
This comment sheet shall be -•.t with the permit and/or plans.
://// C idii• e i
2 .,2770
Kalvin Switzer — ;.Examiner Date Contractor and/or Homeowner
(Required when comments are present)
NOTICE OF COMMENCEMENT_ /�
Permit No: 1 �i � ttAk I
Tax Folio No. _3 ` g - �- r 60/ O - 001 IJ iYa V I V f ( T'e C3
THE UNDERSIGNED hereby gives notice that improvements 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.
1.Description of property (legal description):
a) Street (job) Address: ('I Y1 6 al / is) „ Ze(:k i r 11 ,1 r G� 7 -----
2.General description of improvements: Liji, 41 S i 4i-t , '.c 5 {4 1(e
Information ,l 7 ll �
a) Name and address: t 1(i l� M. t. C c;, e ( Lv1 _ (x, ( & 1( 15(1/�'L 2- l . _ 33 � . L
/
b) Name and address of fee simple titleholder (if other than owner)
c) Interest in property
4.Contractor Information
a) Name and address: G I fEi ✓Lt(,i ,�1 Al s 1 l � ,9.,/ ,.-L
b) Telephone No.: '721 - S DC, - C,'„) - 7 (3 Fax No. (Opt.)
5.Surety Information
a) Name and address: ' WA -.
b) Amount of Bond:
c) Telephone No.: Fax No. (Opt.)
6.Lender
a) Name and address: l`J //'r
Phone No.
7. Identity of person within the State of Florida designated by owner upon whom notices or other_documents may be served:
a) Name and address: -M vv\Q
o S, \j 4 h . 4 e-.- j In, ` \ j) (A L U,1.4_e C.�
b) Telephone No.: 4q J7- Id o - 71 Le Fax No. (Opt.) 81z- 780 - 8I 5' 7
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 address:
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 OF COMMENCEMENT.
STATE OF FLORIDA --- .-- —
COUNTY OF4311.1•6434ppWg
I � . ,, �,`aY',e
BRENDA L BUCHANAN Si re of Owner or Owner's Authorized Of ficer/Director/Partner/Manager
a°, `v Notary Public - State of Florida ` Tt/� avv,0.` CL .t 4` e (-
• : " w •? My Comm. Expires Jan 31, 2013 Print Name
=?, ���icl Commission # DD 845603 r
The . ore ' �b i �t�"i r Ass 0 ���,y�
)U
e me this "day of 20 , b V(4.004-1
as I +aa.r
(type of authority, e.g. officer, trustee,
attorney in fact) for (name of par n behalf /� who'. • tru ent was executed).
Personally Known OR Produced Identification Notary Signatur n , /
—
Type of Identification Produced Name (Print) er ` =1/ � • � //�/i ( / /, /y�J��/� -,,
�S_tw��.�,�v. \'��Y_��.,r� \_ • (../fir( ��..11 � 1
Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, 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.nad2007
Signature of Natural Person Signing (in line # 10.) Above
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NOTICE OF ELECTION TO BE EXEMPT
Please thoroughly read the instructions before completing this application. Print legibly in each data entry field. If this application contains incomplete or
inaccurate Information or if tke handwriting is not legible, it may cause a delay in the issuance of year exemption.
SECTION 1: D
Applicant Name (please print): A t c llcir `f 1
Applicant's social security number: S 96 / G' / G*rS 7
Applicant's E -mail address (optional): R RArt/T &ry a. /,af ?c'/f c a,,
SECTION 2: I am applying for exemption as a (You must check only one box in this section):
CONSTRUCTION INDUSTRY (550 FEE REQUIRED) - The Division will accept a money order or a cashier's check made payable
to the PFS WC ADMINISTRATION TRUST FUND.
, 1 Officer ofa Corporation (Title): Vt. e -OR- ❑ Member of a Limited Liability Company (LLC)
NON - CONSTRUCTION INDUSTRY (NO FEE REQUIRED)
❑ Officer of a Corporation (Title): )
An officer electing an exemption under Chapter 440, Florida Statutes is not entitled to benefits under this chapter.
SECTION 3. The corporation of which you are an officer or the limited liability company of which you are a member must be
registered and in an active status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must
be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number (document number
shown on your Annual Report) on file with the Florida Division of Corporations.
Po 00000 a7 Li
SECTION 4. This exemption application applies only to the person signing the application, the Corporation/LLC that is listed
below, and the scope of business or trade listed:
Name of Corporation or LLC: Et .Z , sr,s l-c A,.jac . t;S,` „ 5 C0- /1 . FEIN: ?.1 OSS j (v6o4 6
S REGISTERED WITH THE FLORIDA DIN ION OF CORPORATIONS
Business Name: 4k L A-C Phone: (7)7) 5
IF APPLICABLE - LIST FICTITIOUS NAME: DOING BUSINESS AS (DIIA), ALSO KNOWN AS NAME (AKA)
Applicant's Address of Record: (Q FAG-01 A- ,,er?
INCLUDE APARTMENT OR SUITE NUMBER
City: un I n
State: �t--� Zip: 3 N(rt� e County: el nC- cis"
Scope of Business or Trade: 1..$i 9 Og3 C 2. 3. 4.
SECTION 5, List all certified or registered licenses issued pursuant to Chapter 489, F.S. held by the applicant, or the certified or
registered license numbers held by the qualifier for the corporation or LLC listed on this application of which the applicant is a
corporate officer: FS — /A c)oc
SECTION 6. If you have submitted an electronic payment for this application, write the transaction confirmation number in the
following space: A/1 i9
SECTION 7. Are you affiliated with any corporation (including LLC) other than the corporation (including LLC) to which this
application applies? [Wes No
IF YES, PLEASE LIST THE NAME(s) AND FEIN(s) OF THE AFFILIATED CORPORATION(s) OR LLC(s):
NAME: -- ---- -.
FEIN; <---
SECTION 8. If your corporation or LLC is engaged in the construction industry, you must provide the required proof of
ownership in the corporation or LLC.
A. To be eligible for a construction industry exemption as an officer of a corporation, the applicant must be a shareholder,
owning at least 10% of the stock of the corporation. A COPY OF A STOCK CERTIFICATE EVIDENCING THE
REQUIRED OWNERSHIP MUST BE ATTACHED.
B. To be eligible for a construction industry exemption as a member of a limited liability company, the applicant must
confirm ownership of at least 10% of the company. THE REQUIRED OWNERSHIP MAY BE ESTABLISHED BY
PRODUCTION OF DOCUMENTATION REFLECTING THE REQUIRED OWNERSHIP, OR BY
SUBMITTING A STATEMENT ATTESTING TO THE REQUIRED OWNERSHIP.
THIS APPLICATION IS CONTINUED ON PAGE ?�
DWC 250, NOTICE OF ELECTION TO BE EXEMPT— REVISED 1248; RULE 89L -.009, F.A.C.
•
NOTICE OF ELECTION TO BE EXEMPT — Page 2
SECTION 9. FRAUD NOTICE
A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or
employee, insurance company or any other person, files a notice of election to be exempt containing any false or
misleading information is guilty of a felony of the third degree.
B. Attestation of applicant - By signing below, I attest that I have read, understand and acknowledge the foregoing
notice.
SIGNATURE OF APPLICANT
SECTION 10. You must identify the workers' compensation insurance carrier that covers any non - exempt employees of your
business. Carrier Name: /v /A
AFFIDAVIT OF APPLICANT: 1 hereby certify that the information contained herein is true and correct to the best of my
knowledge and belief; that this election does not exceed exemption limits for corporate officers, including any affiliated
corporations as provided in §440.02 Florida Statutes.
APPLICANT'S SIGNATURE DATE SIGNED
NOTARY STATE OF OF Jt,..v
Sworn to and subscribed before me this`' day of N 1 c. s -1
Personally Known .7 : • • , - - • : ; . -- . . _ • * ubtic - North Carolina
Produced
Sorry County
NOTARY SIGNATUR on D i -25
c 'K-4-- c c._ (—o .� My Co , iij1, Z�:ii ii�+;L `
Please mail or submit your completed application, application fee, and any required attachments ,
to The Division of Workers' Compensation at the district office nearest your place of business
2295 Victoria Avenue, Suite 163 921 North Davis Street 401 NW 2^d Avenue Effective/Issue Date:
Ft Myers, FL 33901 Building 8, Suite#250 Suite #321, South Tower
Telephone (239)461-4006 Jacksonville, FL 32209 Miami FL 33128
Telephone (904) 798 -5806 Telephone (305) 536 -0306 Expiration Date:
610 E. Burgess Road
Pensacola, FL 32504 -6320 400 West Robinson Street TALLAHASSEE SUBMITTERS
Telephone (850)453 -7804 Room #512, North Tower Control Number:
3111 S. Dale Highway, Suite # 123 Orlando FL 32801 Waikvn submissions
West Palm Beach FL 33405 Telephone (407) 835.4406 or 2012 Capital Circle SE
Postmark Date:
Telephone (561) 837 -5716 (407) 245-0896 Tallahassee F Hartman 4389 2961
1313 N. Tampa Street, Suite #543 4 99 Northwest 70* Ave., S uite # 11 6 Telephone (850) 413 -1609
Tampa R 33602 Plantation FL 33317 Payment Number
Telephone (813) 221 -6506 Telephone (954) 321-2906 A4sHin submissions:
Live Oak Business Center 200 East Gaines Street Received Date:
1111 NE 25" Ave., Suite # 403 5969 Cattlemen Lane Tel h one (850 413 13413 -16228
Ocala FL 34470 Sarasota FL 34232 phone (609
Telephone (352) 401 -5350 Telephone (941) 329 -1120
The collection of the social security number on this form is specifically authorized by Section
440.05(3), Florida Statutes. The social security number will be used as a unique identifier in
Division of Workers' Compensation database systems for individuals who have applied for and/or
been issued a certificate of election to be exempt It will also be used to identify information and
documents in those database systems regarding individuals who have appfied for and /or been
issued a certificate of election to be exempt for internal agency tracking purposes and for purposes
of responding to both public records requests and subpoenas that require production of specified
documents. The social security number may also be used for any other
required or authorized by state or federal law." y purpose specifically
DIMC 250, NOTICE OF ELECTION TO BE EXEMPT- REVISED 12109; RULE 591-8.009, F.A.C.
NOTICE OF COMMENCEMENT I111111IIIII IIIII IIIII 1 111 III 11111 II
Permit No. Rept : 1320102 Rec : 10.00
DS: 0.00 IT: 0.00
Tax Folio No. �Ul�} --6Q i...) 08/10/10 L. Korb, Doty Clerk
THE UNDERSIGNED hereby gives notice that improvements 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.
1.Description of property (legal description):
a) Street (job) Address: , ti' ' 1 V J ,
2.General description of improvements: i, Q", L1 4 ir�r t i u 544 tied
3.Owner Information
a) Name and address: il t 11 i y t (, ' e- L H d S -- L 1 ' 2 - ht k 4
b) Name and address of fee simple titleholder (if other than owner)
c) Interest in property
4 _Contractor Information i
a) Name and address: l i' t& !,14.4 .-t 4 t t t9. Le 9U4 k: j _
b) Telephone No.: '72'1- SOS - - C , . - 1 , 1 3 Fax No. (Opt.) I ' 1 ' Z1 ' /i' / 2- n* Si : 7)4.
5.Surety Information
a) Name and address: ��`i� : :3 4 i
b) Amount of Bond:
c) Telephone No.:
6.Lender Fax No (Opt.)_
WA' PRULR s o NEIL,Ph.D.PRSGO CLERK &COMPTROLLER
a) Name and address: 08/10/10 02:48 m 1 of 1
OR BK 8394 PG 1576
No.
7. Identity of person within the State of Florida designated by owner upon h whom notices or other_ documents may be served:
a) Name and address: lab an GS, , h 4..4 4- 01 11 ► `1. ' 4 ' CIA e.1 a.-�n.-(-'
b) Telephone No.: aj ?.- ie v - 7 t L >® Fax No. (Opt) Ill- 780 -
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 address:
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 OF COMMENCEMENT.
STATE OF FLORIDA
COUNTY OF
1 v o BRENDA L BUCHANAN • • . re o Owner or Owner's Authorized Officer/D
o r °. ` % Notary Public -State of Florid T(j z»u.&\ V et, 4 4.+ e
1 N : A, • E My Comm. Expires Jan 31, 2013 ' Print Name
, ��� , ' Commission # 00 845603
The r tlir`t y in U ' a o ar A ss ' +l � L �
eme this �''e , Y Kam.In-r
as 4 � 20 lb by _
(type of authority, e.g. officer, trustee,
attorney in fact) for
(name of par /.n behalf , who 1 tru„ent was executed).
Personally Known, OR Produced Identification No tary Sigriatur: 40, i Oft > / '
Al Type of Identification Produced Name (Print) � i i ce.
Verification pursuant to Section 92.525, Florida Statutes. Und p of perjury, 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.
FORMSINOC.rvsd2007
Signature of Natural Person Signing (in line 4 10.) Above
STATE OF FLORIDA, COUNTY OF PASCO
THIS IS TO CERTIFY THAT THE FOREGOING ISA
TRUE AND CORRECT COPY OF THE DOCUMENT
ON FILE OR OF PUBLIC RECORD IN THIS OFFICE
WITNESS (1Y HAND AN OFFICIAL SEAL THIS
DAY OF p j O
P ULA S. O'NEIL, CLERK & OMPTROLLER
BY vL-0l G / - DEPUTY CLERK
All Wind Loads Meet 2009 Supplement with the 2007 Florida Building Code
209" * *REQUIRES U.L. & MANUFACTURER'S LABELS **
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0 BE COMPLETED BY OTHERS I - ALL ELECTRICAL COMPONENTS ARE UL LISTED Corrected
PRIOR TO INSTALLATION i - REQUIRES U.L. & MANUFACTURERS LABELS
- INSTALL AS SHOWN CENTERED IN SIGN BAND
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BODONI BOOK TYPESTYLE THIS I
Please sign & return drawing's to FASTSIGNS , 16 copy Width TEXT HEIGHT 1 5/16 PROPEF
INTEF
Signature below indicates approval of BOTH design & placement of signls 1 -COPY PREMIUM WHITE VINYL THE FIOR
SHALL NC
X DATE j *DRAWING IS NOT TO SCALE BUT IS PROPORTIONATE TO ACTUAL BUILDING* DIREC
USED
I FIELD VERIFY ALL MEASUREMENTS BEFORE BEGINNING ANY WORK. WITHC
LINT Name: � INSTALLER TO VERIFY MOUNTING SURFACE PRIOR TO INSTALLATION.
Robert W. Wall, PE 46021 A S and E, Inc.
CA 7882 24710 State Road 54 Lutz, FL 33559 Phone: 813 -948 -2812
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