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HomeMy WebLinkAbout10-11001 CITY OF ZEPHYRHILLS �-- 5335 - 8TH STREET (813)780 -0020 11001 BUILDING PERMIT Permit Number: 11001 Address: 39023 CARD I NAL AVE LT 12 Permit Type: RE -ROOF ZEPHYRHILLS, FL. Class of Work: ROOF REPLACEMENT Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: EASY ACRES Est. Value: Parcel Number: 13- 26 -21- 0100 - 00000 -0120 Improv. Cost: 3,750.00 Date Issued: 9/30/2010 Name: KINNEY, JOHN Total Fees: 55.00 Address: 39023 CARDINAL AVE LT12 Amount Paid: 55.00 ZEPHYRHILLS, FL. 33542 Date Paid: 9/30/2010 Phone: (813)598 -4778 Work Desc: REROOF SHINGLE L • IAL 55.00 V i ns TAY (�`C_/ I ,, ":.",.•. mgt evE 1 7:3 TAPE JOINTS Fjg,QF ASP FINAL J/t/l - 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 recording your notice of commencement." CON T • A' e' SIGNATURE PERMIT OFFI ti PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER !.afrC� at U� r c Pll `i r I ; 7F t y s �F [t ACCOUNT NOt 084941 TYPE OF BUSINESSt SICCODE: 1799.05 FENCE INSTALLATION LOCATION ADDRESS: I PASCO FENCE CO -INC 4254 PLUM ST 4254 PLUM ST ZEPHYRHILL "S ZEPHYRHILLS FL 33542 -5939 DATE RECEIPT AMOUNT I 09/27/10 597158 33.75 IIIIl aa a nlaalaiIlal�dll�lIIIiIIlla llrlll 111 �IIuI111 1 I111 I ' .. :.:. ...., ,. ., _.::� x�..:. •rsJas� ,.Y S. :_. .. F . ,« .. 4•.`Y X ' >:.'.R_'F'iSM1tilflkY9a.,'!S.":. .. m�,. t u,.'. ..ar .... ....: .. ..gym .:. .. r. ... Z 09 -16 -2010 slo 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: 09/16/2010 EXPIRATION DATE: 09/15/2012 PERSON: WILTON TOMMY FEIN: 273132876 BUSINESS NAME AND ADDRESS: PASCO FENCE CO INC 4254 PLUM STREET ZEPHYRHILLS FL 33542 SCOPES OF BUSINESS OR TRADE: 1- FENCE ERECTION IMPORTANT: Pursuant 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 under this chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the 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 person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 ,ivir City of Zephyrhills Receipt N i 5335 Eighth Street • Zephyrhills, Florida 33542, (813) 780-0015 Date ' L- , _ i L ::,.., ( - '....) 20 / ..i Physical Address Amount Due" ' ) j; , (_ ) Paving Assessment Tax Parcel ID # ( _) Other ' r // 1 ,i-- ".i. / i 1 i Name , Street No. - ‘ IF City, State, Zip \,.. ..1 / NOTICE: All assessments are due and payable within (30) thirty days after date and will bear interest at the rate of 9% per annum thereafter. Please send postage for return receipt.4' 813 -780 -0020 City of Zephyrhills Permit Application Fax 813-780 -0021 Building Department 4t' 0 V 1 Date Received — 37 ._ 0 Phone Contact for Permitting -- IIIIIIIlililtllLLLL1' Q Owner's Name ...J Of/AI / xiN/�/L Y" Owner Phone Number g,3 ".�� ` .177 d 23 fibnALAV(z #4,�� j 2 7 2 Owner's Address .S'��"� Own Phon Number �3 � 3 Qar[J 9 Fee Simple Titleholder Name Owner Phone Number Fee Simple Titleholder Address LOT # ,� JOB ADDRESS ..�.�I/4!'7e SUBDIVISION 64% r Ao,1E� PARCEL ID# /-3:26,—;14i— GIOC r.0 —. e/20 (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED NEW CONSTR ADD /ALT I I SIGN I I MOVE I I DEMOLISH INSTALL I REPAIR PROPOSED USE 11 SFR I I COMM I I OTHER I TYPE OF CONSTRUCTION I 1 BLOCK I I FRAME I I STEEL I I OTHER I I DESCRIPTION OF WORK S J-, / / Lf_' &- RoO BUILDING SIZE SQ FOOTAGE HEIGHT BUILDING $ 3 � 7so. (2F, V VALUATION OF TOTAL CONSTRUCTION I I ELECTRICAL $ AMP SERVICE I I PROGRESS ENERGY I 1 W.R.E.C. PLUMBING $ w E ' Di ) - 6 - ( - e _ _ , 1 I MECHANICAL $ V ALUATION OF MECHANICAL INSTALLATION f" S 31 I I GAS 1 ROOFING I 1 SPECIALTY I I OTHER C (kb FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA I IYES 1 INO W ' C ' BUILDER COMPANY SIGNATURE REGISTERED 1 Y/ N I FEE CURRENT I Y/ N I Address • License # I ELECTRICIAN COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT 1 Y/ N 1 Address License # PLUMBER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/ N I Address License # MECHANICAL COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURRENT I Y/ N 1 Address License # OTHER • COMPANY Tte AooriaG SIGNATURE a4 REGISTERED I (I/ N 1 FEE CURRENT I t') I Address p D, i3.7)( / 7-6 ../Dt. L Ca) ' -33,5 License# e - -2 6)420, 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 wl 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 $5000) ** 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 Sewers Service Upgrades A/C 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, 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. 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 is considered abandoned. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING LENDER OR AN ATTORNEY O BEFORE FINANCING, CO WITH YOUR UR ORE RECORDING YOUR NOTICE OF OMMENCEMENT. FLORIDA JURAT (F.S. 117.03) OWNER OR AGENT CONTRACTOR Subscribed and swom to (or affirmed) before me this Subscribed and sworn to (or affirmed) before me this by by Who is /are personally known to me or has /have produced Who Is /are personally known to me or has// tiff d uce n d as Identification. Notary Public Notary Public Commission No. Commission No. Name of Notary typed, printed rinted or stamped Name of Notary typed, printed or stamped 111111 1 10111111 I I I I 1 1111111111 I I I I 1 1111111111 I U I 1 1111 I U I 2010140190 Rcpt:1328410 Rec: 10.00 DS: 0.00 IT: 0.00 09/30/10 C. Cook, Doty Clerk NOTICE OF COMMENCEMENT PAULA S. 0 NE rt. , Ph. D. PASCO CLERK B COMPTROLLER 09/30/10 ke 1 of 1 Permit No. OR BK $(', PC 1393 Property Identification No. 1 3 ' 2 6 -a? /'- U /00 -00000 - 04.20 THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Section 713.13 of the Florida Statutes, the following information is provided in this NOTICE OF COMMENCEMENT. 1. Description of property (legal descjpption : fJ,5 y ,QES P,B /O / /00 /0 772 °A '.1586. a) Street Address: 3 yt i12V /4/ / 41/E fe/'h'y,€Hi1Ls /Z 3.3S�i Plr /�k 2. General description of improvements: 4F_ SLA /.70 0 F //1/4 3. Owner Information � �- - a) Name and address: -.7 /, �� //✓/V y �`�90 3 C1�,Qp1,�q� Awe z- c� p 3W/, ' b) Name and address of fee simple titleholder (if other than owner) c) Interest in property aim/6e., 4. Contractor Information a) Name and address: T� C /�OOf //✓4 j?Q, 130x- 17515 D (� l ; c !`'. 33521' r b) Telephone No.: / ' �$�— 6 610 73' Fax No. (Opt.) 5. Surety Information a) Name and address: b) Amount of Bond: c) Telephone 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 documents may be served: a) Name and address: b) Telephone No.: 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 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 C 0 NCEMENT. di e STATE OF FLORIDA COUNTY OF PASCO S _nature of Owner or • er's Authori d Officer/Director/Partner /Manager 644/ T 4' 4/4/9 • Print Name / The foregoing instrument was acknowledged before me this p Q day of ( -�_ 1' 7 , 20 `O , by JOh ✓L - r - 44 as (type of authori e.g. officer, trustee, attom in fact) for (name of party on behalf of • . • instr m-- as exe -d). Personally Known OR Produced Identifications Notary Signatur= Type of Identification Produced T I Name (print) _ Note (print) USA IIc, State of Florida � ' Commission# D' 7' . My comm. expires Aug. 22, 2012 Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, . ec are at ave real t e oregoing and that the facts stated in it are true to the best of my knowledge and belief. STATE OF FLORIDA, COUNTY OF PASCO THIS IS TO CERTIFY THAT THE FOREGOINp IC ,; TRUE AND CORRECT COPY OF THE DOCU , `f.N1e of Natural Person Signing Above FORMSlNOC,rvsd2007 ON FILE OR OF PUBLIC RECORD IN THIS OFFICE ,N;TN . MY HAND D OFFICIAL SEAL THIS DAY 0 2 0/ 0 PAU S. O'NEIL, CL F & COMPTROLLER BY (j A l /�'J (AIL UEP DEPUTY CLERK , 0 c\ o ci . 4 )004> ti o g /2 / i CCC7311/20i ALL MOP WPM nu UCINIIIILL ssum ow mem a r MN EiTrATq CALL MIKE THURSTON OFFICE: (352) 4073 -4"--7) CELL: (352)450-7101 PROPOSAL SUBMITTED TO WORKED TO BE PERFORMED AT Name y/V ,Hi �N e/ Street Street 3 9 (Y c. 3 A) r r/, ,-, `, / City City 2. A, / State Zip State /,C. .f I „,_ - Zip 5 2 Owner of Property Phone Number .S 5 �” '7 7' S �J Fax Phone Number Fax f' /3 7P3 .ryS 1 q We hereby propose to furnish all the materials and perform all the labor necessary for the completion of: Remove existing shingle roof 0 Replace bad fascia boards at $ r /. c per foot 0 Remove existing built -up roof 0 Install 5d feet of ridge vents Dry-in with 0 15 Ib>ii3 30 Ib. 0 Install modified bitimen (granulated) torch down roofing 0 Install new galvanized valley metal black, white or other color \ EI Install new lead boots �© Install 25 yr. fungus resistant 3 -tab shingles 4? .5 0.0 0 0 Install new exiose vents S 0 Install 30 yr. fungus resistant dimensional shinglh 1 J A S b , o.) N NIZEI Install new drip edge, color 0 Shingle manufacturer S A V color 0 Install new flashing as needed 0 Install TPO, white rubberized roofing membrane / mil Replace plywood at $ 9 5, o a per sheet I I Other: /7 r / ,.:2 / ,. 9 (7 I � 5 / 50. oc; 0 Repair rotten trusses at $ W , oo per foot /y2 e ta / 77 (i 4 -itc *Woodwork is an additional charge, see pricing above All material is guaranteed to be as specified, and the above work is to be performed is accordance the drawings ands ecifica- tions submitted for above work and completed in a substantial workmanlike manner for the sum of $ �- � 3�, Q ci with payments to be made as follows. Payment due in full on completion, unless otherwise noted. Thank You. Credit cards accepted, additional 2.8% charge. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. At agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tomado and other necessary Insurance Officer /Agent upon above work. Workers' Compensation and Public Liability insurance an above Note: This proposal may be withdrawn by us if not accepted work to be taken out by Roofing Contractor. within days. Client gives permission to drive on driveway to deliver materials. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. I have read the back of this Proposal /Contract, which contains Florida Statues 713.001- 713.37. Payment will be made as outlined above. Accepted Signature .. . ,,'� Date $ e// ...2 c>2° : 6 Signature • AcoRf�r CERTIFICATE OF LIABILITY INSURANCE C10- 1 600050 -9292 0 A C10- 1000502929280 10/01/2010 12:45 PN PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Righpoiat Risk Services LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 14160 Dallas Parkway 8500 HOLDER. THIS CERTIFICATE DOES NOT (WEND, EXTEND OR Dallas, TX 75254 - (800) 632 -5096 (972) 715 -0959 INSURERS AFFORDING COVERAGE INSUAED: AMS l /c /f: INSURERA: Companion Property and Casualty Insurance C TLC ROOFING, LLC INSURERS: Companion Property and Casualty Insurance C PO BOX 1745 DADE CITY, FL 33526 INSURER C: (352) 437 -4073 Fax: () - INSURER D: INSURER E: COVERAGES THE POUCIES OF INSURANCE UBTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTYNTII8TANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI8 CERTMICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN B SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH p � R POUCIES. AGGREGATE URNS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMML p p�� I rp TYPE OF INSURANCE POUCY NUMBER R A Y NIS tI 0NN UMTS 5ENERALuAaI.ITY 08/22/2010 08/22/2011 BACHOCCURfENCE $ 1000000 FLG3081595 }( 100000 COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (My One Fire) a "-'.- CLAIMS MADE © OCCUR MED EXP (Any one person) $ 5000 A �... PERSONAL aADVINJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLES PER: PRODUCTS - COMP/OP AGO $ 2000000 71 POLICY n n LOC AUTOMOBILE UABIUTY COMBINED SINGLE LIMB $ ANY AUTO (Ea accident) INJURY ( ALL OWNED AUTOS BODILY INJ ) HIRED AUTOS BODILY INURY NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $ _ R ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGO $ EXCESS LABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE _` S _ s _ DEDUCTIBLE ' E RETENTION $ $ WORKERS COMPENSATION AND x 1.%& Tim' O i EMPLOYERS'LIABLITY WC77779991701 04/01/2010 04/01/2011 E.L. EACH ACCIDENT $ 1000000 El. DISEASE - EAEMPLOYEE $ 1000000 E.L. DISEASE• POLICY Lett $ 1000000 OTHER LIMITS LM.1ITS , $ DESCRIPTION OF OPERA11ON$ LOCATONSNEHq.ESIEXcLUSION8 ADDED BY EI1ORBEIENTBPECIAL PROVISIONS 1. This certificate remains in effect, provided the client's account is in good standing with AMS. Coverage is not provided for any employee for which the client is not reporting wages to AMS. Applies to 100% of the employees of AMS leased to TLC ROOFING, LLC effective 04 /01/2010 2. Insured is afforded Workers Compensation & Employers liability as a co- employer under the policy for employees leased from AMS Staff Leasing, Inc. CERTIFICATE HOLDER 1 1 A OfflONIAL imam; "URER LETTER' CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIM EXPIRATION DATE THEREOF, THE IBSUBI0 M.I. ENDEAVOR TO MAL 30 DAYS WRITTEN CITY OF ZEPHYRHILLS BUILDING DEPARTMENT NOTICE TO THE CERTWICATEHOLDER NAMED TOTE LEFT, BUT FALURETODO808HAU. H ATTN: KAREN MILLER OSE NO OBIGATIONOR UABLRY OF ANY KIND UPON THE ENSURER, TTSAT8ENT80R 5355 8TH STREET REPRESENTATIVES. ZEPHYRHILLS, FL 33542 AUTHORIZED REPRESENTATIVE ACORD 25.5 (7/97) ® ACORD CORPORATION 1988 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ',` CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395 l',;Q 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 MILLER, BRADLEY TLC ROOFING LLC 35224 SARAH LYNN DRIVE 104 DADE CITY FL 33525 • arks► ACI 5116755 Congratulations! With this license you become one of the nearly one million DEPARTMENT OF `'BUSINESS AND Floridians licensed by the Department of Business and Professional Regulation. PROFESSIONAL REGULATION Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. CCC1328205 Z 108046328 Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. CERTIFIED 4. G &ACTOR There you can find more information about our divisions and the regulations that MILLER, =a � ; , impact you, subscribe to department newsletters and learn more about the TLC ROOF 4 Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. 2s CERTIFIED w+skos tno proviaicos of 04.489 r: Thank you for doing business in Florida, and congratulations on your new license! s:psraeso. diktat AUG 31. 2012 i 10082402391 DETACH HERE GI 5116755 DEPARTMENT OF STATE ©F FLORIDA CONSTRUCTION S S AND PROFESSIONAL EN I BOARD TION SEW, L10082402381 Tr: .-.. 41 . LICENSE NBR 08 24 2010 108046328 CCC132820 The ROOFING CONTRACTOR Named below IS CERTIFIED Under the provisions of 'Chapter. Expiration date : AUG 31, 2012 tat MILLER BRADLEY TLC ROOFING. LLC 35224 SARAH LYNN DRIVE 104 DADE CITY FL 33525 ""f k01 CHARLIE GRIST CHARLIE LIE GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW x � Ato '* tit t ACCOUNT NO: 072443 TYPE OF BUSINESS: SIC CODE: 1761 ROOFING CONTRACTOR LOCATION ADDRESS: TLC ROOFING LLC 35224 SARAH LYNN DRIVE 01 35224 SARAH LYNN DRIVE 0104 DADE CITY DADE CITY FL 33525 -8478 DATE RECEIPT AMOUNT 09/08/10 594539 31.25 III HOPi liii 1h11dUligahhh qllPlllP llilPhiki _ e.-:.. .:. :;: .: ...... s r..rc .•.v:::. 'srw.w .. %dMhrtx....v'a.oFhuM.. .. .. — _� .. •