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HomeMy WebLinkAbout11-11369 CITY OF ZEPHYRHILLS 5335 - 8TH STREET (813) 780 -0020 11369 ANNUAL FIRE PROTECTION MAINTENANCE Permit Number: 11369 Address: 7446 GALL BLVD Permit Type: FIRE PROTECTION MAINTENANCE ZEPHYRHILLS, FL. Class of Work: FIRE - PROTECTION MAINTENANCE Township: Range: Book: Proposed Use: COMMERCIAL Lot(s): Block: Section: Square Feet: Subdivision: CITY OF ZEPHYRHILLS Est. Value: Parcel Number: Improv. Cost: Date Issued: 1/04/2011 Name: SYBEA,INC.(ARBY'S) Total Fees: 55.00 Address: 7446 GALL BLVD Amount Paid: 55.00 ZEPHYRHILLS, FL. 33542 Date Paid: 1/04/2011 Phone: Work Desc: FPM- SEMI HOOD CLEAN- ARBY'S - - - - 5.11 •1 -7• •- I A 1.11 C:/ ( 1 • - • 1 ina - Chapter 633, Florida Statutes, authorizes the City to charge and collect user fees to pay for the costs of fire prevention and protection related activities such as inspections, plan review, administrative fees, and other costs related to the aforementioned. Complete Plans, Specifications and Fee Must Accompany Application. Commencement of work without written approval of the Fire Department's Fire Marshal or required permits or opening up for commercial activity without an approved final inspection shall be charged double permit fee per day of operation or a minimum of $100.00, whichever is greater. All work shall be performed in accordance with City Codes and Ordinances. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMNT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." friP Ai ICY P � IT OFFICER PERMIT EXPIRES IN 30 DAYS WITHOUT APPROVED INSPECTION CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813- 780 -0041 . 4 If Permit Application Date Received Phone Contact for Permit Owner's Name I Wain it /s r 1 fl-A is a 12 0 u i1 J Owner's Phone Number I 1 1 Owner's Address 1 7 i /y6 aILL &UlJ z_E/w9'R id /=C. 335 Fee Simple Titleholder Name 1 Titehoider Phone Number Fee Simple Titleholder Address 1 • Job Address 1 74' 6;44i_ &U -7 e_: y2 l /iz L s i .--:_ G - Lot # Sub Division 1 ( Q Bio- Hazard Waste Storage - ANNUAL Q Fumigation Tent Comm Exhaust Kitchen Hood/Duct n Hazardous Material (Tier 11 or RQ Facility) ANNUAL a Controlled Bum ED Hood Installation F - 1 Emergency Generator < 30 kw n LP/Natural Gas - Installation sa6 u LEA n Emergency Generator> 30 kw = LP/Natural Gas- ANNUAL Sale ' ice /` / 0 Fire Protection Maintenance - ANNUAL a Places of Assembly- ANNUAL other l i Sprinkler ® 0 I 1I Recreational Bum �� • } t? 'f Fire Alarm ED 0 D ❑ I I n Sparklers a ` '/ d,' / 1 4 c Hood Cleaning Ei ❑ x ❑ I 1 [] Sprinkler System Installations Hood Suppression 0 ❑ ❑ ❑ I 1 in Standpipes (Sprinkler Sys) r'r 44 moo I/ El Fire Alarm Installation n Torch Roo ing /far Kettle 4a- J) / 7( _d Fire Pumps n Waste Tire Storage ANNUAL 7 Fire Works 1-- Mrl !'cer `o✓\ Flammable Application- ANNUAL 13/s 4 I Valuation of Project Fuel Tanks ^' f b ktee r Other: I ... �.: Contractor • I Company Fes/ uF.'�oA 5 9 Stem S Signature , ...ALA, ' / , ( , (4. 1. 1 - -.A Q 'i P Registered N Fee Ct� Y / N Address " 2.c C,"QAR -[) . - e L Y. _-- �r� - • , L '_ / I - License # I ELECTRICIAN Company Signature I Registered Y/ N 1 Fee Current [ Y/ N 1 Address [ I License # I PLUMBER Company Signature Registered Y/ N 1 Fee Current 1 Y / N 1 Address I I License* [ I MECHANICAL Company signature Registered •Y / N I Fee Curent [ Y / N [ Address 1 1 License # I OTHER Company Signature Registered Y / N 1 Fee Cr Went [ Y / N I Address I License # [ csmatergeenti Directions: Fill out application completely. Owner & Contractor sign back of application. notarized (Or, copy of signed contract with owner) If over $2500, a Notice of Commencement is required (Mechanical work over 55000) Supply two (2) sets of drawings with applicable documentation Allow 10-14 days for review after submittal date. Parcel # - obtained from Property Tax Notice (http : / /appraiaer.pascogov.com) - NOTICE OF'DEED:RESTRICTIONS: The undersigned understands this permit- may:besubject "deed " which may be more - restrictive -than County The. undersigned assumes - responsibility for compliance any applicable deed UNLICENSED .CONTZACTORS AND CONTRACTOR - RESRONSIBJLffIES: If the owner. has hired :a contractor or contractors underta ce work, they may be - 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 a misdemeanor violation under state law. if owner or intended contractor are uncertain as to what licensing may apply for the intended work, are advised to contact the Pasco CountyBuilding Inspection Division—Licensing Section at727 -847- 8009. "Furthermore, r : the owner has hired a contractor or contractors, he Is advised to have the contractor(s) sign portions of the "contractor Block" of this application for which - they will be responsible. If you, .as the owner sign as the contractor, - that may be an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco County. CONSTRUCTION .LIEN .LAW (Chapter778, Florida Statutes,:as amended): If valuation of work is $2,500.00 or more, I certify that I, the apr licant, have been provided with a copy of the "Florida Construction Lien Law— .Homeowner's Protection Guide" prepared by 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 the "owner prior to commencement. CONTRACTOR 'S /OWNER'.S.AFFIDAVIT: 1 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 wcrk or installation has commenced prior to issuance of a permit and that all work will be performed to meet starxiards 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 governme it agencies may apply to the intended work, and that it is my responsibility to identify what actions I must take to be in compliance. If I am the AGENT FOR THE OWNER, I promise in good faith to inform the owner of the permitting conditions set forth in this affidavit prior to commencing construction. I understand that a separate permit may be required for electrical work, plumbing, signs, wells, pools, air conditioning, gas, or other installations not specifically included in the application. A permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by the permit is suspend€ d 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 PAYINGTWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. FLORIDA JURAT (F.S. 117 03) OWNER OR AGENT CONTRACTOR Subscribed and sworn to (a affirmed) before me this Subscribed and swom to (or affirmed) before me this by by Who is/ are personally known to me or has/have produced Who Ware personally Imam to me or hasfhave produced as identification. as Identification. Notary Public Notary Public Commission No. Commission No. Name of Notary typed, printl or stamped Name of Notary typed, printed or stamped COUNTY LOCAL BUSINESS TAX RECEIPT POLK C 0/2011 ACCOUNT NO. 104761 CLASS: A 913 OWNER NAME I L DWIGHT R TEATER JR 413 BROWARD TER WINTER HAVEN BUSINESS NAME AND MAILING ADDRESS CODE ACTIVITY TYPE 810000 LTD OTHER SERVICES FIRE PREVENTION SYSTEMS 413 BROWARD TER WINTER HAVEN, FL 33884 -1502 PROFESSIONAL LICENSE (IF APPLICABLE) I OFFICE OF JOE G. TEDDER, CFC * TAX COLLECTOR CO LY D PLOAY IN ESS F= 1S ItJESS LOCATION BE PAID - 1206589.0001 -0001 08/24/2010 08/24/2010 NGG 12 31.50 COMMON POLICY DECLARATIONS `I/410# 9 C turfy Insurance Company POLICY UMBER 8720 Stony Point Parkway, Suite 300 GL 367 182 1 Richmond, VA 23235 RENEW L OF GL367. 182 -0 Underwritten By Colony Management Services, Inc. PDQ CO • E 91F 1. NAMED INSURED and MAILING ADDRESS: PRODUCER: 09002 FIRE PREVENTION SYSTEMS Amelia Underwriters, Inc. DWIGHT R. TEATER, JR. DBA 2384 Sadler Road 413 BROWARD TERRACE Fernandina Beach, FL 32034 3127 WINTER HAVEN FL 33884 From 01/08/2010 to 01/08/2011 12:0 • Standard Time at your M : iling Address above. k • : • • YMENT OF • : - BJECT TO ALL THE TERMS OF HIS POLICY, WE AG' 11 • ' se • • _ • • • " • - ANCE AS STATED IN THIS POLICY. 3. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS NDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. COVERAGE PARTS PREMIUM Commercial General Liability 1,174.00 Liquor Liability NOT COVERED Commercial Property NOT COVERED Commercial Crime NOT COVERED Commercial Inland Marine NOT COVERED Commercial Farm and Ranch NOT COVERED Owners And Contractors Protective I NOT COVERED Coverage for Certified Acts of Terrorism Rejected; Exclusion Attached. NOT COVERED (Per Policyholder Disclosure TRIA2002Notice attached.) TOTAL 1,174.00 Florida Hurricane CAT Fund Assessment 13.34 POLICY FEE 35.00 INSPECTION FEE 125.00 FLSO FEE 1.33 FLSL TAX 66.70 $ $ $ Premium shown is payable at inception. Total Policy Premium: $ 1,415.37 4 - • • LICABLE • • VERAGE PARTS: S - Schedule of Forms and Endorsements - U001 5. BUSINESS DESCRIPTION: KITC • N HOOD & EXHAUST CLEANING ► t, • PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INS RED BY SURPLUS NE •1 - - •'• NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT 0 THE EXTENT OF NY RIGHT OF RECOVERY FOR THE OBUGATION OF ANY INSOLVENT UNUCENSED INSURER. Countersigned: 01/26/10 B W A"" Date Auth rized Representative Includes copyrighted material of Insurance services Office, Inc. with its permission. DCJ6550 (07/05) Copyright, Insurance services Office, Inc., 1984 Insured co ? ui 3 .R CIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS m o ;overage Part consists of this Declarations Form, the Common Policy Conditions, the 0 0 = � ,h and the Endorsements indicated as applicable. (See "COMMON POLICY DECLARATIONS" for to sGeneral t and Liability POLICY NO. GL 3679182 NAMED INSURED FIRE PREVENTION SYSTEMS DWIGHT R. TEATER, JR. DBA 3. LIMITS OF INSURANCE General Aggregate Limit (Other Than Products - Completed Operations) $ 2,000,000 Products Completed Operations Aggregate Limit 1 1 IP Personal & Advertising Injury Limit $ 1,000,000 Each Occurrence Limit $ 1,000,000 Damage To Premises Rented To You Limit $ 100,000 Any One Premises Medical Expense Limit $ 5,000 Any One Person RETROACTIVE DATE (CG 00 02 only) - Coverage A of this insurance does not apply to "bodily injury" or 'property damage" which occurs before the Retroactive Date, if any, shown below. Retroactive Date: NONE (Enter Date or "None" if no Retroactive Date applies.) Location of All Premises You Own, Rent or Occupy (Same as Item 1 unless shown below): CLASSIFICATION CODE NO. PREMIUM BASIS RATE 1 PR / CO ANC1 i REMiAL1 OTHER JANITORIAL SERVICES 334 96816 P 16,700 64.29 1074 (P) PAYROLL 336 96816 INCLUDED PR S0URE APPARATUS 334 96816 "IF ANY" 336 INCLUDED •I D SA Dd E M ADDITIONAL INSURED (1) 100 4. FORMS / ENDORSEMENTS APPLICABLE: TOTAL PREMIUM SEE SCHEDULE OF FORMS AND ENDORSEMENTS - FORM U001 FOR THIS I $ 1,174.00 COVERAGE PART 5. FORM OF BUSINESS: © Individual LjJoint Venture OPartnership Organization (Other han Partnership or Joint Ventral n Corporation Audit Period: Annual unless otherwise stated: DCJ6553 (07 -02) Includes Copyright material of Insurance Services Office, Inc. with its permission. Copyright, Insurance Services Office, Inc., 1984 Insured FIRE PREVENTION SYSTEMS - Insured: DWIGHT R. TEATER, JR. DBA icy Number: GL3679182 SCHEDULE OF FORMS AND ENDORSEMENTS Forms and Endorsements applying to and made part of this policy at the time of issuance: NUMBER TITLE FORMS APPLICABLE - POLICY COMMON FORMS PJCG (09 -09) COMMON POLICY JACKET PJCIC FL(09 -09) COMMON POLICY JACKET DCJ6550 (07 -05) COMMON POLICY DECLARATIONS U001 (10 -04) SCHEDULE OF FORMS AND ENDORSEMENTS U002 (09 -04) MINIMUM POLICY PREMIUM U094 (07-02) SERVICE OF SUIT UCG2175 (01 -08) EXCL -CERT. ACTS OF TERRORISM AND OTHER A2TS OF TERRORISM IL0017 (11 -98) COMMON POLICY CONDITIONS IL0021 (04-98) NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT FORMS APPLICABLE - COMMERCIAL GENERAL LIABILITY DCJ6553 (07 -02) COMMERCIAL GENERAL LIABILITY COVERAGE PAT DECLARATIONS U003 07 -02 HAZARDOUS MATERIALS EXCLUSION U004 (07-07) MISCELLANEOUS EXCLUSIONS ENDORSEMENT U008R (07 -07) CONTRACTORS COVERAGE LIMITATIONS U015 10 -07 DEMOLITION EXCLUSION U048 09 -04 EMPLOYMENT- RELATED PRACTICES EXCLUSION U070 03 -08 DEDUCTIBLE LIABILITY INSURANCE U076 08 -07 WORK HEIGHT EXCLUSION U089 09 -04 SUBSIDENCE EXCLUSION U122B (05 -04) EXCLUSION - DESIGNATED WORK - RESIDENTIA_, NEW CONSTRUCTI U155 07 -08 ABSOLUTE AUTO, AIRCRAFT AND WATERCRAFT EXCLUSION U156 08 -07 ADDITIONAL INSURED - OWNERS LESSEES OR "ONTRATORS -SCHED U159 07 -02 LIMITATION OF COVERAGE TO BUSINESS DESCRCPTION U180 07 -02 OVER SPRAY PROPERTY DAMAGE EXCLUSION U612 05 -09 EXCLUSION - ASBESTOS LEAD OR SILICA CG0001 12 -04 COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG0067 03 -05 EXCLUSION - VIOLATION OF STATUTES THAT GOVERN E- MAILS, F CG2139 10 -93 CONTRACTUAL LIABILITY LIMITATION CG2167 12 -04 FUNGI OR BACTERIA EXCLUSION CG2186 12 -04 EXCLUSION - EXTERIOR INSULATION AND FINISH SYSTEMS FORMS APPLICABLE - STATE SPECIFIC UIL0255 (07 -02) FLORIDA CHANGES - CANCELLATION AND NONREAEWAL Important notice: See the actual policy forms attached for the full title, terms and conditions. 0001 (10/04) Page 1 of 1 Insured