HomeMy WebLinkAbout11-11884 CITY OF ZEPHYRHILLS ��
5335 - 8TH STREET
(sis)�so-oo20 11884
BUILDING PERMIT
Permit Number: 11884 Address: 5142 9TH ST
Permit Type: ADDITION/ALTERATION ZEPHYRHILLS, FL.
Class of Work: 434-ADD/ALT RESIDENTIAL Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 11-26-21-0010-19400-0170
Improv. Cost: 7,000.00
Date Issued: 5/20/2011 Name: ESON, DALE & CASSAUNDRA
Total Fees: 105.00 Address: 5142 9TH ST
Amount Paid: 105.00 ZEPHYRHILLS, FL. 33542
Date Paid: 5/20/2011 Phone: (813)495-8963
Work Desc: SCRN RM W/ ELITE ROOF 7 X 23
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FOOTER BOND DUCTS INSULATED SEWER MISC.
ROUGH ELECTRIC LINTEL MISC MISC.
1ST ROUGH PLUMB PRE-METER INSULATION WALL MISC.
DUCTS INSTALLED WATER MISC DRIVEWAY
PRE-SLAB SHEATHING MISC. MISC.
CONSTRUCTION POLE FRAME MISC. MISC.
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 � 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."
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C T CTOR SIGNA PERMIT OFFI R
ERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
813 City of Zephyrhills Permit Application -� FaX-s»-�ao-oosi
Building DepartmeM r
Date Recelved /�/�! Phone Ca�tad for PermMM � � O O ��� I
_ �{
Ovmd'c Name I C Owner Phpne Number
' Owner's Address 1 n ' �' K Owner Phone Number
Fee Simple Titleholder Name Owner Phane Number
Fae Slmpe T1deMlder Addresa
J� ADDRESS �"'1 'J 1 "! I� � I L ^"( l0T # I� �
SUBDIVISION � (,t3 J') ('f.�� /' • PARCEL ID1t ' � � � � b� i b - l - ao - a� "�
(OBTAW� FROM PROPER7Y TAY NpTIGE�
WORK PROPOSED � N�nr CoN57R e ADD/ALT Q SIGN Q Q DEMOLISH
INSTALL REPAIR
PROPOSED USE � SFR Q COMM Q OTHER
TYPE OF COHSTRUCTION Q BLOCK Q FRAME Q STEEL Q
DESCRIP710N OF WORK `� {'1 Q p �p �, �
BUILDIN6 S17E � k Z� SQ FOOTAGE 1�` HEI(iHT �
�BUILDING $� O� , Du VALUATION OF TOTAL CONSTRUCTION
QELFCTRICAL E AMP SERVICE � PROGRESS ENERGY Q W. E.C.
QPLUMBING $ ( � �
l � �
QMECHANICAL E VALUATION OF MECHANICAL INSTALLATION �`-'
QGAS Q ROOFING � SPECIALTY Q OTHER � / ��
`1./ � ��
FINISHED FLOOR ELEVATIONS FLOO� ZONE AREA �YES N
BUILDER ,( � COMPANY �\[�\\ \� C��• lC1 �\v\S�� C� (Y� ,�J -
SI6NATURE v� REGISTERED / N �e cu n Y/ N
Add►eas � l7> � � License # ��
ELECTRICUW COMPANY
SIGNATURE r�c�srEaeo Y/ N FEE CURREn Y/ N
�^� License # � �
PLUNBER CDMPANY
SIGNATURE REGISTERED Y/ N �ECURaEn Y!N
��a License #
MECHANICAL COMPANV
SIGNATURE aEC�srEttEO Y/ N FEE CURREA Y/ N
'4ddre88 License # �
OTHER COMPANY �-
51GNATURE aEC�sr�xeo Y! N FEE Cl1RREn Y/ N
Add►ess Lic;ense #
IIII IIIIIIIIIIIIIIIIIIIIII�t��1111111111�11111111111111111I11111111
RE&DENTIAL Attach (2) Plot Plans; (2) sats of Bullding Plans; {1) set of Energy Forms; R-O-W Pertnit for new construGion,
Minimum ten (10) working days after submittal dale. Required msite, ConsWcGon Plans, Starmwaler Plens w! Sift Fence instaMed,
Sanitary Faalitiee 8 1 dumpster; Site Wdk Permit for su6dMsionsAarge projede
COMMERpAL Attach (3) complete sets of Building Plans plus a Lffe Safely Pape; (1) set of Endpy Forms. R-O-W Pertnit fa new conshuction.
Minimum len (10) working days after submittel date. Required a�site, Canstruction Plans, Stamwater Plens w/ Sitt Fence inst�ed,
Sanitary Facil�ies S 1 dumpster. Site Wak Permit for all new poJects. A1 commeraal requirements must meet compNance
SIGN PERMIT Attach (2) sets of Engincered Plaru.
""PROPERTY SURVEY required for ell NEW consWdim.
Dlractlons. •
FiN ou[ application completdy.
Owner 8 Contracta sign beck of epplication, notarized
1f over S2500, a Notice of CommencemeM Is requlred. {AIC upgrades over 57500)
" Agent (for the contrador) a Pov�er of Attomey (for the owner) would be Someone with notarized IeHer (ram owner autharizing seme
OVER THE COUNTER PERMITTING {Front of Application Only)
Reroofs if shingles Sewars Service Upgrades A/C Fences (PIoVSurvey/Footage)
Drlveways-Not ovar Counter if on pudic roadways..needs ROW
NOTICE OF DEED RESTRICTIONS: The undersigned understands that this pertnit may be subject to "deed' restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibiliry for cqmpliar►ce with any
applicaWe deed restrictions.
UNLICENSED CONFRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
conlractors to undertake work, they may be required ta ba 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 taw. If the owner or intended coMractor are uncertain as to what licensing requirements may apply for the
intended woric, they are advised to contad the Pasco County Building inspection Division--Licensing Se.�tion at 727-847-
8009. Furthermore, If the owner has hired a contractor or contradws, he is advised to have the contrador(s) sign
portions of the "contrador 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 liasnsed and is �ot entitled to pertnitting privileges in Pasco
County.
TRANSPORTATION IMPACTNTILf11ES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impad 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 speafied in Pasco County Ordinance number 89-07 and
90-07, as amended. The undersigned siso understands, that such fees, as may be due, will be identified at the time of
pertnimng. 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
flnal power release, the fees must be paid prior to permit issuance. Furthermore, 'rf Pa6co County WffieNSewer 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 52,500.00 or more, I
certify that I, the applicant, have been provided with a copy of the 'Florida Construction Lien Law—F{omeowner'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 °owne�' prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT• I certify that all the infortnation in this application is accurate and that all work
will be done in compliance uNth all applicable laws regulating consUuction, zoning and land developmeM. Applicatiwi is
hereby made to obtain a permit to do work and installation as indicated. I certify that no woric or installa6on has
commenced prior to issuance of a permit and that all work will be pertortned to meet standards of all laws reguladng
construction, County and City codes, zoning regulations, and land development regula6ons in the jurisdidion. I also
certify that I understand ihat the regulations of other govemment agencies may apply to the iMended work, and that it is
my responsibiliry to identify what actions t must take to be in compliance. Such agenaes indude but are not limited to:
- Department of Environmental Protedion-Cypress Bayheads, Wetland Areas and Environmentally Sensi�ve
Lands, Water/Wastewater Treatrnent.
- Soufhwest Florida Water Managemerrt Oistrict-Wells, Cypress Bayheads, WeUand Areas, Altering
Watercourses.
- Army Corps of Engineers-Seawalls, Docks, Navigable Waterways.
- Department of Health & Rehabilitative Services/Environmental Heatth Unit-Wells, Wastewater Trealment,
Septic Tanks.
- US Environmental Protection Agency-Asbestos abatement.
- Federal AviaHon Authority�Runways.
I understand that the following restrictions apply to the use of fill:
- Use of fiil is not al�owed 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 pertnitting which is prepared by a protessional engineer
licensed by the State of Florida.
- If the fill material is to be used in Flood Zone "A° in connedion with a permitted building using stem wall
canstruction, I certify that fill will be used only to fill the erea within the stem wall.
- If fiU material is to be used in any area, I certify that use of such fiA will not adversely affed adjacent
properties. If use of fill is found to adversely affect adjacent properties, the owner may be cited for violadng
the conditians of the building pertnit issued under the attached pertnk application, for lots less than one (1)
acre which are elevated 6y fiN, an engineered drainage plan is required.
If I am the Af3ENT FOR THE OWNER, I promise in good faith to inform the qwnet of the permitting conditions set forth in
this affidavit prior to commencing construction. I understand that a separate pertnit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other installa6ons not speaficaAy included in the application. A
permit issued shall be cansWed to be a license to proceed with the work and not as authority W viotate, cancet, alter, or
set aside any provisions of the technical codes, nw shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans, consUUCtion or violations af any codes. Every pertnit issued shalf be�me 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 woric is commenced. M extensian
may be requested, in writing, from the Building Official for a period not to exceed ninery (90) days and will demonstrate
justifiable cause for the extension. If waic ceases for ninety (90} consecutive days, the job is considered abandoned.
WARNINQ Tb OWNER: YOUR FAIIURE TO RECORD A NOTICE OF CdMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YatIR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT
FLORI�A JURAT (F.S. 117.0� �
01NNER OR AGENT J� �� �e� � co►rrRACraR �1�r"1 �(7 P.S� �
"y�u4sajbad �d�swom to�or� 4e� this Subscribed end swom to (or atfirmed be ore me this
d� fk y � J T-� �bY �r n� )�1 C
Whn are personally known m me or haslhave praduud Who I are personay kri6w�i to me or has/have produred
as iden6ficedon. �\"\ <�...ut�. as identification.
� 5Y�.1��� Notary Public a,(�� Notary PuWic
Commi6sion No._��, ) � � ` � \, � CpmmiSSion No V ^ � 1�
Neme of Notary typed, printed p stamped Name of Nota
ry typed, printed or stamped
---- a
'� AMANDA LEE JASIN :� '�: AMANDA LEE JASIN
:��'`'�:
'�'� "' MY COMMISSION # DD 817152 �� �, �'" MY COMMISSION # DD 817152
��;or�n�;�` EXPIRES August 24, 2012 '�' �'!,,,"'�•' EXPIRES August 24, 2012
1407)398-0153 FlontlaNOlaryServ�ce• �, /4071398-0153 FbntlaNO(aryService• ^,
Pasco County Parcel: 11-26-21-0010-19400-0170 001 Page 1 of 1
Data Current as Of: Weekly Archive - Saturday, May 07, 2011
' Parcel ID 11-26-21-0010-19400-0170 (Card: 001 of 001)
Classification 01 - Single Family
Mailing Address Property Value
ESON DALE P& CASSAUNDRA L Ag Land $0
5142 9TH ST Land $25,788
ZEPHYRHILLS FL 33542-5016 Building $39,935
Physical Address
5142 9TH ST Extra Features $1,832
ZEPHYRHILLS FL 33542-5017 Market Value $67,555
Assessed (Save Our Homes) $67,555
Le4al DeSCriDtion (First 4 Lines) Homestead 196.031 -$25,000
See Plat for this Subdivision ,�" Non-School Additional Homestead Exemption -$17,555
TOWN OF ZEPHYRHILLS
PB 1 PG 54 Non-School Taxable Value $25,000
LOTS 17-20 INCL BLOCK 194 School District Taxable Value �42,555
OR 5388 PG 1710 VNarning: 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)
Line Use Description Zoning Units Type Price Condition Value
�1 0100 SFR OOR2 8,400.00 SF $2.72 1.00 $22,848
� 0100 SFR OOR2 8,400.00 � $0.35 1.00 $2,940
Additional Land Information
Acres 0.39 Tax Area 30ZH FEMA Code � Residential Code ZHLHLP2
Buildina Information - Use 01 - Single Family Residential (Card: 001 of 001)
Year Built 1950 Stories 1.0
Exterior Wall 1 Concrete Block Stucco E�cterior Wall 2 None
Roof Structure Gable or Hip Roof Cover Asphalt or Composition Shingle
Interior Wall i Plastered Interior Wall 2 None
Flooring i Asphalt Tile Flooring 2 None
Fuel Electric Heat Forced Air - Ducted
A/C Central Baths 1.0
�— Line �� Sq. Feet Repl. Cost New
1 BAS � 1,449 $59,163
Extra Features (Card: 001 of 001)
Line Description �- Year Units Value
1 FIRE PL 1950 �— 1 �— $150
2 r DCFENCE 1999 1,152 $430
3 UDU-M 1999 1 $246
4 CO PTO 2001 273 $512
r 5 �r � 2001 r 141 � $494
Sales History
Previous Owner POBLICK )OHN A& KELLY M
Year Month Book/Page Type Amount
2003 06 5388 / 1710 WD $101,300
1998 04 3932 / 0936 WD $56,500
1994 08 3342 / 1764 WD $0
http://appraiser.pascogov.com/search/parcel.aspx?sec=11 &twn=26&rng=21 &sbb=0010&bl... 5/9/2011
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
Contractor/Homeowner: � ,�7 vwl� �.�
Date Received: � — � l
s�te: �= S�/ Y z ���� � J
Permit Type: 7X Z� `S'C�� I��
Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑
This co nt she hal be kept with the permit and/or plans.
��y
vin ' z — Plans Examiner Date Contractor and/or Homeowner
(Required when comments are present)
This spece for use by Clerk of the Circuit Court ool� IIIIII�III�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII'�IIIIIIIIIIIII
2011062752
Rcpl:1364112 Ree: 10.00
DS: 0.00 IT: 0.00
04/26/11 R. Giard, Dpt,y Clerk
NOTICE OF COMMENCEMENT
Permit Number• aau�a s o 'NEIL,Ph D PRSCO CLERK 6 COMPTRO�LER
Tax Folio No. 04 0R BK ��� 1 PG � 3693
T6e uedtrsigoed hereby siva ootiee t�at im proveoents will be mrde to cerfain reil property, a�d in accord�oee w�ith Sectloe 713.13 of the
Florida Stal�ta, tYc folbwi�g ioforma8o� is provided io the NOTICE OF COMMENCEMENT.
l Legal Description of property (street address required): 11-26-21-0010-19400-0170
TOWN OF ZEPNYRNILLS PB 1 P6 54 LOTS 17-20 INGL BLOCK 194 OR 5388 P6 1710
5142 9TH ST ZEPHYRHILLS FL 33542-5016
2. General description of improvements: ScPeen Enclosure
3a OwnerName: Phil (Dale) Eson
Owner Address: 5142 9TH ST ZEPHYRHILLS FL 33542-5016
3b. Owner's interest in site: Owner IOOye
3c. Fee Simpie Title holder (of other than owner)
� Address:
ContractorName: Liohtnina Aluminum
Address: PO Box 290144. Tampa. FL 33687 Phone: 813.984.1185
5 Surety Name: Amount of bond:
Address: Phone:
6. Lender Name: Contact:
Address: Phone:
7 Person within [he State of Florida designated by owner upon whom notices or other documents may be served as provided by
Section 713.13(1)(a)7, Florida Stamtes.
Name: Address:
Phone Number:
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.
Name: Address:
Phone Number:
9 Ezpiration date of Notice of Commencement (expiration date is one ( I) year from 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 UIYDER CHAPTER 713, PART 1, SECTION 713.13, FLORIDA
STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A fVOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB S[TE BEFORE THE PIRST INSPECTION. IF YOU
INTEND TO OBTAIN FINANCING, CONSULT WITft YOUR LENDER OR AN ATTORNEY BERORE COMMENCING WORK OR
RECORDINC YOUR NOTICE OF COMMENCEMENT.
�
Signature of Owner or Owner's uthoriud OfficedDiroctodPartnedManager
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
The fwegoing instrument was acknowledge before me this �� day of �{,�'( l, , Zp��,
bY � )��� ����, .as �l.r�� � � for �(��(� Q�� \ �-'�
Personally Known OR Prod ad Identification {�
Ty� of Identification Produced '� �' v �'
�Or� U�r S I I C� n s� � -
Signadue - Notary Public
Under penalties of perjury, I declare that 1 havc read the foregoing and that the facts stated in it aze true to the best of my lawwledge and belief.
'� C a .�. �,�;e�, �,._.�---
Sigpanue of Nan¢at Person SiBning Above
(w copy of any bond must be weched at �he tlme of �ecordation of �his Notice of Commmcem t� AMAPIDA LEE JASIPb ted Februery 2008
MY COMMISSION # DD 817152
�' ., EXPIRES Aupust 24, 2012
140713%-0733 FbMaNOta���9arvke � ^•
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`� �� PASCO
��'A�'� d�F ��.�1�ICiA� CO - ��GOING, IS A
THIS �� T� ���TI�Y THAT �
TRUE ANU CORRECT COP �. TH� QQ�n��NT _r
ON FILE QR �F PUBLIC R� p��HES OFFICE _
WITNE8S MY HAND AND i,`SEA� TF :"'
� DAY OF `- �� ,
PAULA O'NEIL, CL R ��,
�" EP P L`L.ERK
BY
4/25/2011 Map - Pasco County Property Appraiser
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� • • • • s • • •
Li htnin Aluminum
Inc.
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Nc113��x 2901-1-i }_mail.lt�fxnmgalummumcr�enzon.nct
I:�mp:i. t�l� i3t,tt' \Aebti�te www.li¢htninQaluminum.com
Yhnrn� (Y1�118-1-1IX� StateLirense St't-l;ll�Ut�(I1
f�a�. (`1�1 `��-1-R-}k i
March 9, 2011
Attention: City of Zephyrhills Building Department
5335 8 Street Zephyrhiils, FL 33543
To Whom It May Concern:
I, John Foens, authorize Amanda L. Jasin and Stewart Renfroe to act as a permit
agents for Lightning Aluminum, Inc. They can handle any/all licensing and
permitting tasks for Lightning Aluminum. My license number is SCCi31i5o6oi.
If you have any questions, please contact me at 813-309-2658 on my cell phone.
Sincer y
Jo W. Foens
Pre ident/Owner
Lightning Aluminum, Inc
PO Box 290144
Tampa, FL 33687
Phone: 813-984-1185
Fax:813-984-8483
li htmn�?aluminum(�verizon net
www. Li htningAluminum com
STATE OF Florida
COUNTY OF Hillsborough
Sworn to and subscribed before me by John W. Foens who is ersonally known to
me or produced ���wY1 as identification, and who did
not take an oath, this � day of March, 2o1i.
Notary P �blic
Print Name of Notary: Amanda L. Jasin
Commission Expires: 12 2 12
�� AMANDA LEE JA91N
�'; ;"E MY COMMISSION # DD 817152
� , � �� � � EXPIRES August 24, 2012
U0�1'9!•0183 FlondaNOtar�Serv�ce �
STATE OF FLORIDA
-_- DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
�� �� TALLAHASSEE FL 32399-0783
FOENS, JOHN W
LIGHTNING ALUMINUM INC
P.O. BOX 290144
TAMPA FL 33687
i
STATE OF FLORIDA A� 4 9�+� 5 5�,
Congratulations! With this license you become one of the nearly one million p�rp;�TMg�,;;.��,,;BUB'�N�S.�,��,AN'��� ,...
Floridians licensed by the Department of Business and Professional Regulation. =��:_ ,�,�pR������ ��;_k_��yG�,�,��,,,�;p� „
O u r p ro f e s s i o n a l s a n d b u s i n e s s e s r a n g e f r o m a r c h i t e c t s t o y a c h t b r o k e r s, f r o m , �•a��`; ; a,,., % - ,.;, „.; �'��,,;. :, .�,,; ,,, '
boxers to barbeque restaurants, and they keep Florida's economy strong. ��� `�" ��`"�,=. " ' "��' �� ,� r ia�
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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. CERTIFI�D -: �G,� 14b�,IC� G�NTRACTOR
There you can find more information about our divisions and the regulations that :` Fp��NS� �� ' ;:,�;;'w;� f '" '.~�".;. '� '�'�',�,;
impact you, subscribe to department newsletters and learn more about the �>,':"�� �,+�G�=�,� " `��:`-., , �;5.� :'�. , r �° .+-
DepartmenYs initiatives. - -��r���C�� �
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Our mission at the Department is: License Efficiently, Regulate Fairly. We �- ,� �.,'�`� . -
constantly strive to serve you better so that you can serve your customers. rs CBRTIFIEb undor��EHa ' rovieiona o ch.�ss gs
Thank you for doing business in Florida, and congratulations on your new license! • �;�iation�'�.te� Avi� 31�f ,�Q�.2 �i1o �;:
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From:Torinda Harris FaxID:Florida Insurance Ce Page 3 of 6 Date:7/G/2010 71 11 AM Page:3 of 6
�� CERTIFICATE OF LIABILITY INSURANCE OPID To DATE(MMIDDM'YY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. OH�g
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELQW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTMORIZED
REPRfSENTATNE OR PRODUCER, AND THE CERTIFlCATE HOLDER.
: f t e cert cate o er is an , t e po cy es must e en orse . su ect to
the terms and condltlons of the policy, certaln policles may requlre an endorsemeM. A statemeM on this certlflcate does not corifer rights to the
certiflcate holder In Iieu of such endorsement(s).
PRODVCER
NAME:
Florida Insurance Center Inc (ac, ��o, exty: �ac, No�:
414 N Alexander Street ADDRESS:
Plant City FL 33563 CUSTOMERID* LIt3HTNI
Phone:813-754-3561 Fax:813-764-8402 INSURER(S)AFFORDINGCOVERAGE NAIC;E
INSURED
INSURERA: South�=n Owmts Insuz�nc� co 10j9Q
Lightning Aluminum, Inc.
John Foens INSVRER B :
5504 Orient Road INSURERC
Tampa FL 33610
INSURER D •
INSURER E
MSURER F
COVERAGES GERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY 7FWT THE POLICIES OF INSlR2ANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOG
INDICATED NpNVITHSTANDING ANY REOUIREMENT, TERM OR CONDRION OF ANY CONTR4CT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE M4Y BE ISSUED OR MAY PERTAIN, T1iE INSURANCE AFFORDED BY 7tIE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY H4VE BEEN REpUCED BY PAID CLAIMS
LTR TYPE OF INSURANCE INSR POLICY NUMBER (MM/pD/YYYY) (MMIDD/YYYY) L�MR'S
GENERAL LIABILfTY
EACH OCCURREIJCE $ 1� OOO � OOO
A X COMMERCIAL GENEFPL LIABI�ITY 052109 OS/21/30 OS/21/11 PREMI3ES (Ee occurrence) S SOO � OOO
CLAIMSMADE a OCCUR MED EXP (My one person) $ j Q Q Q Q
i
�RSOruw a a,ov ir�,xHtr f 1, 000 , 000
GENERAL AGGREGAlE S 1� OOO � U OO
GEN'l AGGREGA7E LIMIT PPPLIES PER.
X POLICY jEa LOC PRODUCTS-COMP/OPAGG S 1� OOO � OOO
AUTOMOBILE LIA8ILT'
S
COfv�INEO SINGLE LIMIT $
ANY AUTO fEa ecadeM)
RLL 9WNED Ai_ROS BODIIY INJURV (Per pereunl S
SCHEIX1lED AUTOS BODI�Y INJIIRY (Per eccident� S
HIREDAUTOS PROPERTVDAMAGE $
(Per ecciderd)
MJN-dJVNED AUTOS
S
b
UMBRELIA IIAB OCCUR
EXCESS LIAB EACH OCCURRENCE $
CLAIM^rMApE AGGAEGATE �
DEDLICTIBIE
RE7eM�oN g $ .
�
AND EMPLOYERS' LIABILITIf Y/ N TORY LIMITS ER
ANY PROPR�Eh7F/PAR7NER/EXECUTIVE
OFFICER/MEMBER EXCLUDED7 ❑ ! A E L EACH ACCIDENT s
(Mandatory In NH�
II yes, descnbe under E L DISEASE - EA EIv�LOYEE $
DESCRIPTION OF OPERATIONS below
E 1. DISEASE - POUCV LIMIT $
DESCRIPTION OF OPERATONS / LOCATIONS ! VEFqCLES (Attech ACORD 101, AddMtond Rsmarka Seh�dula, H more �pacs is raquired)
CERTIFICATE HOLDER CANCELLATION
SHOIRD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Zephyrhills - Building Dept ACCORD'AN EOWR}ITHEPOLICYPROVIS NS.LBEDELNEREDIN
5335 8 St Zephyrhilis, FL 33542
S �. �-7 H O Z O AUTHORIZED REPRESEM'ATNE
� C f5 f@5@fVBf�.
ACORD 25 (2009/09) The ACORD name and logo are reglstered marks of ACORD
� - � �i
! 08 -31-2010
� �^�_�,� �
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: 70/30/2010 EXPIRATION DATE: 10/29/2012
PERSON: FOENS JOHN W
FEIN: 593459796
BUSINESS NAME AND ADDRESS:
LIGHTNING ALUMINUM INC
P 0 BOX 290144
TAMPA FL 33887
SCOPES OF BUSINESS OR TRADE:
1- ALUMINUM 2- CONSTRUCTION
IMPOHTAN7: Pursuent lo Chepler 440 05114►, F.S., �n officer ol s corporstton who elecls exemption from this ch�pter by flling s certilicete ol electton under Ihis
seciion msy na[ reeover 6enefits or compensstion enier thts ch�pter Pursuant to Chapter 440.051121, F.S., Ceritlic�[es ol elecllon to be ezempt.. spply only within the
scope ot the business or trsde listed on the notice of election to be ezempl. Pursuenl ta Chapler 440.05113), F.S., Nolices of elecllon to be ezempt and certificetes o(
elecltan to be exempt shall be subject lo revocation I(, at �ny lime �fter the liling of the notice or the issu�nce oI the cerlilicete, the person nemed on the notice ar
cerlilic�te no longer meets the reqetrements of this section lor issuence of e ceni(ic��e. The dep�rtment shalf revoke a certi(icate st sny time (or f�ilure af the person
nsmed on lhe certiffcate to meet the requtrements of this seclion.
OWC-Z52 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 QUESTIONS7 (850) 413-1609
-- -- --------------
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES IMPORTANT
DIVISION OF WORKERS' COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a cor oration who
CONSTRUCTION INDUSTRY � elects exemption from this chapter by filing a certificate of election
CERTIFlCATE OF ELECTION TO BE EXEMPT FROM FLORIDA �- under this Section may not recover benefits or compensation under this
WORKERS' COMPENSATION LAW
D chapter.
EFFECTIVE: 10/30/2010 EXPIRATION DATE: 10/29/2012
PERSON: JOHN W FOENS Pursuant ta Chapter 440.05(11), F.S., Certificates of election to be
H exempt.. apply only within the scope of the business or trade listed on
FEIN: 593459786 E the notice of election to be exempt.
BUSINESS NAME AND ADDRESS: R
LIGHTNING ALUMINUM INC E Pursuant to Chapter 440.051131, F.S., Notices of election to be exempt
P o eox 290144 and certificates of election ta be exempt shall be subject to revocation
TAMPA, FL 33687 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 shatl revoke a certificate at any time for failure of the
SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this
1- ALUMINUM 2- CONSTRUCTION section.
QUESTIONSI (850) 413-1609
CUT HERE
� Carry bottom portion on the job, keep upper portion for your records.
DWC-252 CEflTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06
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