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HomeMy WebLinkAbout10-11346 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813)780 -0020 11346 PLUMBING PERMIT Permit Number: 11346 Address: 38620 NORTH AVE Permit Type: PLUMBING ZEPHYRHILLS, FL. Pe Y e. • Class of Work: PLUMBING RENOVATIONS Township: Range: Book: Proposed Use: NOT APPLICABLE Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: 11- 26 -21- 0010- 01900 -0020 Improv. Cost: 335.00 Date Issued: 12/20/2010 Name: COLLADO, RAYMOND & RAMON Total Fees: 60.00 Address: 5111 BERNADETTE DR Amount Paid: 60.00 ZEPHYRHILLS, FL. 33541 Date Paid: 12/20/2010 Phone: Work Desc: REPLACEMENT EXISTING WATER HEATER US HEATING & A IR CONDITI NING IN PLUMBIN FEE 60.00 -- � ( 1ST ROUGH PLUMB 2ND ROUGH PLUMB SEWER WATER 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 a 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 Complete Plans, Specifications and Fee Must Accompany Application. All work shall be performed in accordance with City Codes and Ordinances CONTRACTOR PER OF I v• PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTIO CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED PROTECT CARD FROM WEATHER 813- 78U -00ZU laty of Lepnyrnlns rermlt /Application / rd)-OIJ-I J Building Department j 11 .k Date Received la- 1) • 10 Phone Contact for Permittin! 0 3 62 ✓ - , 1 , Owner's Name V- P6- L) Li u A,..c is Owner Phone Number eY q` - 3,5"- 9 2 -`d Owner's Address 1 6Ci 2,0 fib! -4-in fi vc. Owner Phone Number I Fee Simple Titleholder Name . I Owner Phone Number Fee Simple Titleholder Address I JOB ADDRESS ( S 71,2,0 t\ s- +H tZ O P I)C Cpkkl� till , PI. ) 3 -4/ LOT# SUBDIVISION , PARCEL ID# f j '2C 2 Ir Q NO - 01 9 00 - 60 20 (OBTAINED FROM PROPERTY TAX NOTICE) WORK PROPOSED I I NEW CONSTR ADD /REPAIR ALT I I SIGN Q [J DEMOLISH PROPOSED USE I SFR In COMM I I OTHER I I TYPE OF CONSTRUCTION n BLOCK I FRAME I I STEEL Q DESCRIPTION OF WORK 1 [pigc t r?'; 2r\ 0 t- ( T ! l t l 5 / 4 r i j 3 0 5 F /Iri- L / c n., e `)./ If BUILDING SIZE 1 SQ FOOTAGE' I HEIGHT 1 'BUILDING $ VALUATION OF TOTAL CONSTRUCTION nELECTRICAL $ AMP SERVICE F] PROGRESS ENERGY n W.R.E.C. []PLUMBING Is 335 6 in MECHANICAL $ •7 VALUATION OF MECHANICAL INSTALLATION nGAS n ROOFING n] SPECIALTY 1 I OTHER FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA nYES NO BUILDER COMPANY I I SIGNATURE REGISTERED I Y/ N I FEE CURREN I Y/ N I Address I 1 License # I I ELECTRICIAN COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN I Y/ N I Address I 1 License # I / lJ I C I r ^ • i3 ccjt /; ( PLUMBER COMPANY ' O S . fL A C - 1, SIGNATURE REGISTERED I Y/ N I FEE CURREh / N Address I L1Lt P /P Out /cto7 P I- 14)Upk vit Z/. *igv License# I CFC 7I4°7 MECHANICAL COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREF I Y/ N I Address I 1 License # 1 I OTHER COMPANY SIGNATURE REGISTERED I Y/ N I FEE CURREN I Y / N I Address I 1 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-0-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, 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, 1 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 Tots Tess 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. 117.0 3 t /f OWNER OR AGENT 1 1J a — lit CONTRACTOI} ,cam � "` ( r 9-A,--,. Subscribed and sworri to�(or affirmed) before me this Subscribed and sworn tg.�or affirmed) before me this 12-17 - (U by /71� (211 - 10 bye /1/1 Who is/ re perso ally known to me or has/have produced Who is/are personally known to me or has/have produced L I ce rt e as identification. (.. C evz S� as identification. . ..,,,,,, .. • otary Public -��►- Notary Public irgw g. , 4052 ' "y,, JACQU n E BOGES Co Comm # E E 0 Com , . sion - _ ...... , ... 4, 4 4 t � � • 1 . .: Expires December 12, 2014 4.1. � - s_ --- `' 7V- A,'{ ` w ntledThu Tmy Rin In"sanee 800.3857019 Nam * . — •e• , printed or stamped Name of Nota — ,. Pasco County :'arce i : , t -26 -2 ; -t i `,i',. .. `.I',` , a Fe 0: Data Current as Of: W' _ eekly Archive - Saturday, December 11, 2010 Parcel ID 1 -26- 21-0010- 01900 -0020 (Card: 001 of 001) Classification I r 01 - Single Family — Mailing Address —_ -- -- Property Value COLLADO RAYMOND OLIVERAS & Ag Land $0 OLIVERAS RAMON & OLIVARAS 7 Land $12,217 5111 BERNADETTE DR Building $28,494 ZEPHYRHILLS FL 33541 -1998 Physical Address Extra Features $359 38620 NORTH AVE Market Value $41,070 ZEPHYRHILLS FL 33542 -2621 Assessed (Non - School Amendment 1) $41,070 Legal Description (First 4 Lines) Taxable Value $41,070 See Plat for this Subdivision ZH MB 1 PG 54 LOTS 2 3 3A BLK 19 EXC W 65 FT OR 8303 PG 356 OR 8303 PG 362 _ Land Detail (Card: 001 of 001) Line j Use Description j Zoning ' ■ Units Type j Price I Condition Value t 00 SFR 00R2 1 4,200.00 SF ! $2.84 ! 1.00 1 $11,928 ®; t t t t t • 825.00 SF I $0.35 1.00 , $289 i Additional Land Information Acres 0.16 ' Tax Area 30ZH FEMA Code ` X , Re id - ntial o. - , 2HLHLP2 I Building Information - Use 01 - Single Family Residential (Card: 001 of 001) Year Built 1972 Stories 1.0 Exterior Wall 1 Concrete Block Stucco 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 Carpet Flooring 2 None Fuel Electric Heat Forced Air - Ducted A/C Central Baths 1.0 Line Description Sq. Feet Repi. Cost New { 1 BAS 704 $31,173 I 2 FEA 140 $4,339 3 UST 60 $1,063 4 UCP 160 $1,063 5 UOP 51 $354 Extra Features (Card: 001 of 001) I Line I Description Year Units j Value 1 DWSWC 1974 200 1 $180 2 N CLFENCE 1984 240 $85 3 I UDU -M j 1985 1 $94 Sales History 1 Previous Owner 11 COLLADO RAYMOND OLIVERA & I Year Month Book /Page Type I Amount I 2010 I 04 8303 / 0356 j DD $0 2009 ' 09 , 8303 / 0362 CSC j $0 2009 09 8303 / 0360 QC $0 http: / /www. appraiser. pascogov.com /search/parcel.aspx ?sec =11 &twn= 26 &rng =21 &sbb =... 12/17/2010 _ •5■4:1 F - ` e4. 3 § • " - - topitt Permitting office: I Glenn C. Butts hereby authorize Anita McPheron to acquire plumbing , permits on my behalf in the city of , kt / in the state of Florida. Respectfully, Glenn C. C. Butts Contractor license # CFCO57167 NICOLE RIORDAN * MY EX C P °M IR M ES: April 1 o , n og- Bonded Tin Budget Notary Services WO - RAY OLIVERAS - rage 1 oir L Work Order Dispatch Information ' Job Name: AMERICAN HOME SHIELD (413239) WorkOrder No.: 455261 Seq. No.: 163067 WORKORDER Job Type: S/C Work Order: Status: COMPLETED Call Date: 12/13/2010 Job Site: RAY OLIVERAS Job Date: 12/14/2010 Address!: 38620 NORTH AVE Dept.: PLUMBING - Address2: Tech: BT- BRANDON C /S /Z: ZEPHYRHILLS, FL 33541 Sched. Start: 9:00 AM Start Time: 12:36 AM Phone: 813 - 355 -4288 Sched. End: 2:00 PM End Time: 1:12 PM Mobile: 813 - 355 -4288 Disp/WO /Claim #: 178822282 Contract #: 58519935 Deduct: $ 0 Email: Inv. #: 1007916 Auth. #: Quote: $ Alt. Name: - AK #: Job Amt: $ 335 Alt. Phone: Payment Type: WARRANTY ■ Chk/Auth# Amt Coll: $ 0 Work Order: No HOT WATER I F NO ANSWER CALL CELL 813 Internal Notes Notes Entered By Date GUST CALLED NOT HAPPY WITH PRICE OF THE PERMIT TOLJ TERRY MCGRATH 12/14/2010 2:52:49 PM HIM ITS A FLAT RATE AND THAT HE NEEDS TO CALL AHS COPY TO BRYAN NICOLE AND NORMAN AMANDA MORRIS 12/14/2010 2:38:32 PM COMPLETE BRANDON BARNES 12/14/2010 1:07:05 PM 30GAL ELECTRIC W.H. ELEMENTS BAD W.H. IS 50-40 YEARS OLD _ AHS IS GOING TO SEND NRW W.H. TO TAMPA OFFICE OLD W.H. BRIGGS CAN READ MODEL AND SERIAL EXTRAS PERMIT 135 EXPANTION TANK 125 BRANDON BARNES 12/14/2010 1:02:24 PM DISPOSAL OPIONAL 75 NEEF TO ORDER 3/4 BRASS 90 _ 3/4 BRASS TEE f'- 3/4 NIPPLE BY FOUR IN BRASS EXPANTION TANK ARRIVED BRANDON BARNES 12/14/2010 12:31:10 PM iN -ROUTE BRANDON BARNES 12/14/2010 11:01:31 AM RECEIVE BRANDON BARNES 12/14/2010 11:01:25 AM American Home Shield _. Autho Department (contractors only) 800/251 -1608 Customer Service Department (homeowners /contractors) 800/776. 4663 - Vendor #: 173372 Vendor: US HEATING & AIR CONDITIONING, !NC Phone Number (800) 321 -4830 Fax: (813) 623 -5818 Notes: -- AC FREON RECAPTURE COVERED ** 13 SEER COVERAGE ** Dispatch Type: Transfer Vendor Service Fee Due : $.00 — _---- -.. -._ Urgency : Normal Service Fee Paid: $.00 AHS 12/13/2010 2:07:57 PM Net To Collect : 8.00 Dispatch Date: I 1 . t 81 7 Date: 1 r Heater (Gas Or Elec) No Hot Water Brand Richmond Model # n/a • Serial # n/a Style/Type Standard Tank Size 50 gal Location Other Power Electric How Many 1. Other location laundry room Customer: RAY OLIVERAS Buyer ittp: //j obmanager. callushac. com /JobWorkOrderForm.asp ?CN =0 &JN= 413239 &ID = 4552... 12/15/2010 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DDNYYY) 07/19/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDEDBY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Neu of such endorsement(s). PRODUCER CONTACT Pat Di Pi etro Blackadar Insurance Agency PHONE Eat): 407.831 407.830.4681 No, 1436 N. Ronald Reagan Blvd. EMAIL Longwood, FL 32750 CUSTOMER ID S- Pat DiPietro INSURER(S) AFFORDING COVERAGE NAIC INSURED INSURER A: Southern- Owners Insurance Co 10190 US Heating & Air Conditioning Inc INSURER 6: American Economy Insurance Coe 624 Douglas Ave INSURERC: Scottsdale Insurance Company Ste 1402 INSURER D: FFVA Mutual Insurance Company 10385 Altamonte Springs, FL 32714 MISURERE INSURER F : COVERAGES CERTIFICATE NUMBER: 10 /11 incr LIMB limits REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM OF INSURANCE AD SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MWDD►Yyyy) (MMipp1YYYYl - GENERAL LABILITY 0646827267762710 0110/12010 0110•'12011 I EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY 1 DAMAGE TO RENTED $ 300 000 I PREMISES (Ea occurrence) . CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 A X Inds Contractual PERSONAL 6ADVINJURY $ 1,000 r 0 X Liability GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:' PRODUCTS - COMP /OP AGG $ 2,000,000 POLICY ITC' JECT I X LOc — - -- - - $ AUTOMOBILE LABIUTY 02CE21522110 02/09/2010 02/09 /2011 COMBINED StNGLE UNIT $ 1,000,000 1 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ B SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) X NON -OWNED AUTOS $ UMBRELLA LAB X OCCUR XL50064109 01/01 /2010 01/01/2011 EACH OCCURRENCE $ 5,000,000 C EXCESS UAB CLAIMS -MADE AGGREGATE $ 5,000,000 DEDUCTIBLE _ —. -_ RETENTION $ $ WORKERS COMPENSATION WC8 40001 7 5 5 3 20 10A 02/25/2010 02/2512011' X j TORY AIM S ER AND EMPLOYERS' LIABILITY y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 D OFFICER/MEMBER EXCLUDED? N 1 A (Mandatory in NH) . E.L. DISEASE - EA EMPLOYEE $ 1,000,000 Il yes desc ribe under DESCRIPTION OF OPERATIONS below. E.L. DISEASE - POLICY LIMB $ 1, 000, 000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Zephyrhills Building Department AUTHORIZED REPRESENTATIVE 5335 8th Street Zephyrhills, FL 33542 Lorrie Partridge /RPM © 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD ACORD AGENCY CUSTOMER ICJ: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Blackadar Insurance Agency US Heating & Air Conditioning Inc POLICY NUMBER Ste 1402 Altamonte Springs, FL 32714 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: ACORD Certificate of Liability Insurance Garage Liability INSR LTR INSRD POLICY NUMBER POLICY TE (M F M F IDD/YY) DATE (M IMIDDIYY) LIMITS AUTO ONLY - EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY AGG S Automobile Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE (MM/DDIYY) DATE (MMIDO/YY) B Excess /Umbrella Liability INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS C Other Liability INSR POLICY NUMBER POLICY POLICY V LIMITS ACORD 101 (2008101) O 2008 ACORD CORPORATION. An rights reserved. The ACORD name and logo are registered marks of ACORD