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HomeMy WebLinkAbout10-10961 CITY OF ZEPHYRHILLS 5335 8th Street (813)780 -0020 10961 • ELECTRICAL PERMIT Permit Number: 10961 Address: 37630 NEUKOM AVE LT #17 Permit Type: ELECTRICAL MISC ZEPHYRHILLS, FL. Class of Work: ELECTRIC SERVICE /NEW Township: Range: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Contractor: LEE ELECTRIC INC Book: Page: Square Feet: Subdivision: GRAND HORIZONS Est. Value: Parcel Number: 34- 25 -21- 0090 - 00000 -0170 Improv. Cost: 1,600.00 = Date Issued: 9/24/2010 Name: MILLER, JAMES & MARYLIN Total Fees: 40.00 Address: 37630 NEUKOM AVE LT #17 Amount Paid: 40.00 ZEPHYRHILLS, FL. 33541 Date Paid: 9/24/2010 Phone: (813)779.3999✓ 9 3 31‘ Work Desc: INSTALL 2 MOTION LIGHTS /FLOOR RECEPTACLES& INTERCOM/LIGHT IN CLOSET ELECTRICAL FEE 40.00 ROUGH ELECTRIC CONSTRUCTION POLE PRE -METER FINAL /V (-> 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 inspection called d) work not ready for inspection when called e) permit not posted on job site f) plans not at job site g) work not accessible. NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county, and there may be additional permits required from other governmental entities such as water management, state agencies or federal agencies. The payment of inspection fees shall be made before any further permits will be issued to the person owning same. "Warning to owner: Your failure to record a notice of commencement may result in your paying twice for improvements to your property. If you intend to obtain financing, consult with your lender or an attorney before recording your notice of commencement." Complete Plans, Specifications and Fee Must Accompany Application. All work shall be perform in accordance with City Codes and Ordinances. 6 02- 21 44 i t , TRACT PERMIT OFFL -R PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 813- 780 -0020 City of Zephyrhills Permit Application Fax- 813- 780 -0021 Building Department 4 I cj Date Received Phone Contact for Permitting -- Owner's Name T /M ' 1 — ^ // tr. Owner Phone Number Cf.s r,3 7 767 - 9 3 Owner's Address 3 '7 6 1 0 NF (,K"Q h. r R � Owner Phone Number Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address JOB ADDRESS 3 76 10 h/1,1/K ) . 1 k _ LOT # SUBDIVISION PARCEL ID# (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED NEW CONSTR ADD /ALT I 1 SIGN i I 1 I DEMOLISH INSTALL REPAIR PROPOSED USE I 1 SFR n COMM I I OTHER I TYPE OF CONSTRUCTION I I BLOCK n FRAME I 1 STEEL I I I DESCRIPTION OF WORK 7?3't{. L S ptook2 /Z Cbaj• -r epi / wt £ cc L / y rj) / (=Las 6-7 BUILDING SIZE SQ FOOTAGE HEIGHT 1 (BUILDING $ GOO VALUATION OF TOTAL CONSTRUCTION E LECTRICAL $ AMP SERVICE I I PROGRESS ENERGY I I W.R.E.C. 1 (PLUMBING $ 1 (MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION 1 )GAS L I ROOFING n SPECIALTY 1 1 OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA I IYES NO BUILDER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN I Y/ N I Address License # I ELECTRICIAN / COMPANY LEE t LE urn; C , ••••c SIGNATURE REGISTERED I ep N I FEE CURREI' I Y/ N 1 Address / o f 1, I �2 /dov C ' Th-. -fir" / 354 k 7 License # I PLUMBER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN 1 Y/ N I Address License # I MECHANICAL COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN I Y/ N I Address License # I OTHER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN Y/ N I Address License # I RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R -O -W Permit for new construction, Minimum ten (10) working days after submittal date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed, Sanitary Facilities & 1 dumpster; Site Work Permit for subdivisions /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 NC Fences (Plot/Survey /Footage) Driveways -Not over Counter if on public roadways..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 713, Florida Statutes, as amended): If valuation of work is $2,500.00 or more, l 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. Such agencies include but are not limited to: Department of Environmental Protection - Cypress Bayheads, Wetland Areas and Environmentally Sensitive Lands, Water/Wastewater Treatment. Southwest Florida Water Management District - Wells, Cypress Bayheads, Wetland Areas, Altering Watercourses. - Army Corps of Engineers - Seawalls, Docks, Navigable Waterways. - Department of Health & Rehabilitative Services /Environmental Health Unit - Wells, Wastewater Treatment, Septic Tanks. - US Environmental Protection Agency- Asbestos abatement. - Federal Aviation Authority- Runways. I understand that the following restrictions apply to the use of fill: Use of fill is not allowed in Flood Zone "V" unless expressly permitted. - If the fill material is to be used in Flood Zone "A ", it is understood that a drainage plan addressing a "compensating volume" 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 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 CONTRACT , Subscribed and sworn to (or affirmed) before me this Scribed and sworn to or affi - - this by 2`F—L0 by . Who Is /are personally known to me or has /have produced Who is /are personally knor� i e or h. ave produced L1 as identification. CfLA&. as identification. • Notary Public - Notary Public Commiss No. �.z JA CQUELIN E BOGES Commission No. . D . 3 • Ex fires December 12, 2010 • '�,,pF F`QP` w,...i T}M T. r Pem re insunee 800 - 385 -701 Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped Pasco County Parcel: 34- 25 -21- 0090 - 00000 -0170 001 Page 1 of 2 Data Current as Of: Weekly Archive - Saturday, September 18, 2010 Parcel ID 34 25 -21- 0090 - 00000 -0170 (Card: 001 of 001) Classification 02 - Mobile Homes Mailing Address Property Value MILLER JAMES D & MARYLIN J Ag Land $0 37630 NEUKOM AVE Land $27,326 ZEPHYRHILLS FL 33541 -9300 Building $100,980 Physical Address Extra Features $1,523 37630 NEUKOM AVE ZEPHYRHILLS FL 33541 -9300 Market Value $129,829 Assessed (Save Our Homes) $116,443 Legal Description (First 4 Lines) Homestead 196.031 - $25,000 See Plat for this Subdivision Non - School Additional Homestead Exemption - $25,000 GRAND HORIZONS -PHASE ONE PB 34 PGS 99-102 Non - School Taxable Value $66,443 LOT 17 School District Taxable Value $91,443 OR 4264 PG 1250 Warning: A significant taxable value increase may occur when sold. Click here for details and info. regarding the posting of exemptions. Land Detail (Card: 001 of 001) j Line Use Description Zoning Units Type Price Co ndition Value 1 0200 M SUBM 00M1 6,000.00 SF $4.31 1.00 $25,860 2 0200 MSUBM 0OM1 2,665.00 SF $0.55 1.00 $1,466 Additional Land Information Acres II 0.20 11 Tax Area II 3QZH II FEMA Code II X IlResidentiai Codell GDHZLP1 1 Building Information - Use 02 - Mobile Home (Card: 001 of 001) I Year Built 2000 Stories 1.0 Exterior Wall 1 Above Average Exterior Wall 2 None Roof Structure Gable or Hip Roof Cover Asphalt or Composition Shingle Interior Wall 1 Drywall Interior Wall 2 None Flooring 1 Sheet Vinyl Flooring 2 Carpet Fuel Electric Heat Forced Air - Ducted A/C None Baths 2.0 Line Description Sq. Feet Repl. Cost New 1 I I 2,356 l� $115,491 I 2 II FCA I 504 II $4,951 3 II I 264 I I $5,833 1 . 4 II 144 II $3,186 Extra Features (Card: 001 of 001) Line Description Year Units Value 1 DWSWC 2000 468 $878 2 CAC -4 2000 1 $420 3 CON PTO 2000 I 120 I $225 1 Sales History I Previous Owner II GRAND HORIZONS INC I Year Month I _ Book /Page Type Amount 1999 11 4264 / 1250 WD $16,900 1996 03 3557 / 0946 _ pc. $0 1995 12 3508 / 0207 WD $0 http: // appraiser. pascogov. com / search /parcel.aspx ?sec= 34 &twn= 25 &rng =21 &sbb= 0090 &b... 9/24/2010 'CERTIFICATE OF LIABILITY INSURANCE 1 9/ Producer: Lion Insurance Company This Certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter 2739 'U.S. Highway 19 N. the coverage afforded by the polides below. Holiday, FL 34691 Insurers Affording Coverage NAIC • Insured' Insurer A: Lion Insurance Company 11075 South East Personnel Leasing, Inc. 2739 U.S. Highway 19 N. Insurer B. Holiday, FL 34691 Insurer C: Insurer D: 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 poi cies. Aggregate limits shown may have been reduced by paid claims. INSR ADDL Policy Effective Polley Expiration Date LTR INSRD Type of Insurance Policy Number Date Limits (MM/DD/YY) (MM /DD/YY) GENERAL LIABILITY Each Occurrence $ Commercial General Liability Damage to rented premises (EA Claims Made Occur occurrence) $ - Med Exp $ Personal Adv Injury $ General aggregate limit applies per: 31 Poky 0 Project a LOC General Aggregate $ Products - Comp/Op Agg $ AUTOMOBILE LIABILITY Combined Single Limit — Any Auto (EA Accident) $ All Owned Autos Botliy Injury 1■1 (Per Person) $ Scheduled Autos Hired Autos Bodily Injury r..w Non -Owned Autos (Per Accident) $ Property Damage (Per Accident) $ EXCESS/UMBRELLA LIABILITY Each Occurrence Occur ❑ Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2010 01/01/2011 X I WC Statu- OTH- Employers' Liability toy Limits ER Any proprietor/partner/executive officerhnember E.L. Each Accident $1.000.000 excluded? E.L. Disease - Ea Employee $1.000.000 If Yes, describe under special provisions below. E.L. Disease - Policy Limits $1.000.000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AM B # 12616 Descriptions of Operations /LocationsNehicles /Exclusions added by Endorsement /Special Provisions: Client ID: 37-66-897 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. that are leased to the following "Client Company': Lee Electric, Inc. Coverage only applies to injuries incurred by South East Persomel Leasing, Inc. active employee(s) , while working in Florida. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937 -2138 or by calling (727) 938 -5562. Project Name: FAX: 813 -443 -5129 & 813 -780 -0021 / ISSUE 09 -24 -10 (TD) Begin Date: 8/29/2005 CERTIFICATE HOLDER CANCELLATION CITY OF ZEPHYRHILLS - Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left. but failure to do so shall impose no obligation or liability of any kind upon the insurer. its agents or representatives. 5335 8TH STREET ZEPHYRHILLS, FL 33542 0 i . µ STATE OF FLORIDA AUf 419,271 too Congratulations! With this license you become one of the nearly one million 4^r: , DEPARTMENT OF BUS ES Floridians licensed by the Department of Business and Professional Regulation. ' " W Our professionals and businesses range from architects to yacht brokers, from PRCir SS . .., ANION boxers to barbeque restaurants, and they keep Florida's economy strong. , ; . EC0.0.0.19/ ' ` :% ;0 '09817 Every day we work to improve the way we do business in order to serve you better ,,,e, For information about our services, please log onto www.myfloridalicense.com. CERTSFT 1 z-`n a R • t..r NTRACTOR There you can find more information about our divisions and the regulations that E_SFEL, a = ° ` °` impact you subscribe to department newsletters and learn more about the LEE =ELE , 4 �� Department's initiatives. � • Our mission at the Department is: License Efficiently, Regulate Fairly. We E £� constantly strive to serve you better so that you -can serve your customers. .. . .. Thank you for doing business in Florida, and congratulations on your new license! ticn dax•a. AUG,; 3� 20y2; L1 006«I,Q - Q976 DETACH HERE 2010 - 2011 HILLSBOROUGH COUNTY BUSINESS TAX RECEIPT EXPIRES 9 - 2011 FOLIO NO. FACILITIES OR MACHINES ROOMS SEATS EMPLOYEES 0 0 0 1 RENEWAL 209909.0000 OCC. CODE BUSINESS TYPE H. WASTE TAX SURCHARGE 090.008 ELECTRICAL CONTRACTOR 18.00 BUSINESS 4911 MELROW CT LOCATION TAMPA 33624 • NAME ESPEL LUIS A MAILING LEE ELECTRIC INC ADDRESS 4911 MELROW CT TAMPA FL 33624 BUSINESS TAX RECEIPT DOUG BELDEN, TAX COLLECTOR PAID - 1196 - 85 HAS HEREBY PAID A PRIVILEGE TAX TO ENGAGE 813 -635 -5200 07/07/2010 *** 18.00 IN BUSINESS, PROFESSION, OR OCCUPATION SPECIFIED HEREON. THIS BECOMES A TAX RECEIPT WHEN VALIDATED. 6 1 3 - 908 - vv 3S X 313 - 3— 9 (432 Sep. 24. 2010 11:49A N o 999 P. 1/2,00,, AGurcu =KTIFICATE OF 'LIABILITY INSURANCE 09/24/2010 PRODUCER 813.933.6691 FAX 813.932.6287 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Adcock & Ad Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 315 W. Fletcher Ave. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Tampa, FL 33612 -3414 Li sa Wal lace INSURERS AFFORDING COVERAGE NAIC # INSURED Lee Electric , Inc . INSURER A: Old Dominion 40231 DBA : Luis Espel INSURER B: P.O. Box 17222 INSURER C. Tampa , FL 33612 INSURER D. 1 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 ADM. POLICY EFFECTIVE POLICY EXPIRATION LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY(Y) DATE (MMIDOTYYYY) LIMITS GENERAL LIABILITY MPG72873 08/08/2010 08/08/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES SES (Ea occurrence) $ 500, 000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 10,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 1 POLICY PRO- I�I — JECT I f LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO — — OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE — RETENTION $ — $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. ACH ACCIDENT OFFICER/MEMBER EXCLUDED? $ (Mandatory in NH) E.L DISEASE - EA EMPLOYEE $ If yes. describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS !VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT l SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Ci ty of Zephyrhi 11 s NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Building Department IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 5335 8th St REPRESENTATIVES. Zephyrhills, FL 33542 AUTHORREDREPRESENTATIVE John Alexander Green /LPW # ACORD 25 (2009/01) FAX: 813.780.0021 ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Sep. 24. 2010 11:49AM No. 9992 — P. 2/2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01)