HomeMy WebLinkAbout11-11886 , , CITY OF ZEPHYRHILLS
5335 - 8TH STREET
(si3)�so-oo20 11886
BUILDING PERMIT
Permit Number: 11886 Address: 6005 GALL BLVD
Permit Type: SIGN ZEPHYRHILLS, FL.
Class of Work: WALL SIGN Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 03-26-21-0010-11200-0041
Improv. Cost: 2,350.00
Date Issued: Name: SHIVA 6005 GALL LLC
Total Fees: 135.00 Address: 8100 SW 178TH ST
Amount Paid: 135.00 PALMETTO BAY FL 33157-6163
Date Paid: 7/15/2011 Phone:
Work Desc: REPLACE 2 CANOPY SIGNS W/ LED PRICER SIGN
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LIGHT EMOTIONS DESIGN LLC
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ELECTRICAL ROUGH
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 calied d) work not ready for
inspection when called e) permit not posted on job site � plans not at job site g) work not aocessible.
NOTICE: In addition to the requirements of this permit, there may be additional restrictions appiicable to this property that
may be found in the public records of this rnunty, 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 commenceme "
✓
CONTRACTOR SIGNATURE PERMIT OFFI R
PERMTT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
, CITY OF ZEPHYRHILL� �
5335 - 8TH STREEf
�ai3��so-oo20 11886
BUILDING PERMIT
Permit Number: 11886 Address: 6005 GALL BLVD
Permit Type: SIGN ZEPHYRHILLS, FL.
Class of Work: WALL SIGN Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 03-26-21-0010-11200-0041
Improv. Cost: 2,350.00
Date Issued: Name: SHIVA 6005 GALL LLC
Total Fees: 135.00 ►i Address: 8100 SW 178TH ST
Amount Paid: PALMETTO BAY FL 33157-6163
Date Paid: Phone:
Work Desc: REPLACE 2 CANOPY SIGNS W/ LED PRICER SIGN
� 75. .
LIGHT EMOTIONS DESIGN LLC
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ELECTRICAL ROUGH
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 � 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."
CONTRACTOR SIGNATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
Paul Lima
Project Manager
p►pp�e
SI n & Cel1:813.731.1495
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�ffice:�1�.���.�220
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Fax: 813.948.2403
1635 N. Dale Mabry Hwy.
' Suite 7 Lutz, FI. 33548
813-780-0020 City of Zephyrhills Permit Application Fax-8�3-�so-oo2�
, Building Department
Date Received �—� 7'� ( I Phone Contact for Permitting O�✓ �v -- Q�
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Owner's Name ,a"7�� �A��� ����. �'�' _ Owner Phone Number _ '�/ ���
Owner's Address g�� �'� f/O Jf _ Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number
Fee Simple Titleholder Address
JOB ADDRESS � VD. LOT # C�
SUBDIVISION PARCEL ID# D3'�� �0 (/w�"'��� � D�J7�
(OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED B NEW CONSTR e ADD/ALT [� SIGN � MOVE Q DEMOLISH
INSTALL REPAIR
PROPOSED USE Q SFR {� COMM Q OTHER
TYPE OF CONSTRUCTION 0 BLOCK 0 FRAME � STEEL Q OTHER
DESCRIPTION OF WORK I�GG� o� (��/D �✓G�J ��� � ��� �"" — '—
BUILDING SIZE ya � %�' SQ FOOTAGE 7D� HEIGHT I S
�� BUILDiNG $ ^� � � VALUATION OF TOTAL CONSTRUCTION
ar
� ELECTRICAL $ �� AMP SERVICE � PROGRESS ENERGY Q W.R.E.0
•
� PLUMBING $ ( � � �t7
�
MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION �
Q GAS � ROOFING 0 SPECIALTY Q OTHER
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA �YES QNO
BUILDER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRENT Y/ N
Address ri License # "
ELECTRICIAN ' � ' COMPANY U�'�T '�" � �`
SIGNATURE REGISTERED Y N FEE CURRENT /
Address � ��. .7 �• � 3 ~ f�p1 License #
PLUMBER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRENT Y/ N
Address License #
MECHANICAL COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRENT Y/ N
Address License # �
OTHER � COMPANY �P/'1f�G ..7✓v►f/ �+'^'���b �
SIGNATURE REGISTERED N FEE CURRENT N
Address .� A # License # Ga.�II f����
RESIDENTIAL Atlach (2) Plot Plans; (2) sets of Building Plans; (1) set of Energy Forms; R-O-W Permit for new construction,
Mi�imum 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 �lans, 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 ali 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 $5000)
** Agent (for the contractor) or Power of Attorney (for the owner) would be someone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (Front of Application Only)
Reroofs Sewers Service Upgrades A!C Fences (PIoUSurveylFootage)
Driveways-Not over Counter if on public roadways..needs ROW
NOTICE OF DEE�D RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable d�d restrictions. ' '
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIE$: Ifi the owner �has hired a contractor or
contractors to undertake work, they may be required to be ticensed in accorda�ce with stat� and local regulations. If the
contractor is not licensed as required by law, both the owrier and cont�actor'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.
TRi4NSPORTATiC3N IMPAGTIUTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that fransportation Impact Fees and R�course Recovery Fees may apply to the construction of new buiidings, change of
use in existing buildings, or exp�nsion of existing buildings, as specified in Pasco County Ordinance number 89-07 and
90-07, as amended. The undersigned also underst�nds, 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 pYoje:ct 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 �re �ue, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONS�'f2UCtION L��N EAW (C�ap'ter 7'13� �Iprida 6tatutes, as aa�ended): If valu,atiop s�f wprl� 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 Agricutture and Consumer Affairs. If the applieant 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'SlOWNER'S AFFIDAVIT: I certify that all the information in this �pplioation 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 th,�t 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 Watenways.
- 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 rtQt alJowed in Flood Zone "V" unless expressly permitted.
� If the fill mate�i�l 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 .conne,ction 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 properfies, 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
, Qermit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or
set aside an'y prdvjsions ofi the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans, con'struction or violations of any codes. Every permit issued shall become invalid
unless th� work authorized by su ned for eriod of six {6) m after he t me the wo kas commenced An
the peq'mit is•suepended or aband , P d� s and wi11 demonstrate
may be requested, in writing, from the Bi►ilding� Official for a period not tq exceed rlinety �90� Y
the ob is considered abandoned.
justifiable cause for the extension. If work ceases for ninety (90) consecutive days, j
WARNING TO O . YOUR F V � OUR PROPERTY. YOU INT�END OBTAIN F NANCING, CONSULT
P A Y I N G T W I C E O R I M P O N T S
WITH YOUR LE R A OR Y BEFORE RECORDING Y O U R N O T I C E O F �c O M M E N C E M E N T.
FLORIDA JURAT (F.S. . ) _-
CONTRACTOR
OWNER OR AGENT Sub cnb d and swom to (or a ed) before me this ,-
Su scrib d and sworn t(or affirmed) before me thls � �,,���� r.n� ;;� 'c� �r1/� I! It '�—�l �
� , bY a�n� ,E r �,nn,� =?��."�y.—bY
Who is/ re ersonall known to me or has/have produced Who Is/ re personally known to me or has/have produced
as identiflcation.
as idenGfication.
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� -- ; % � I � Z �(,� Notary Public
� ; �,� ��-' � L Notary Public
Commission No.
Commisslon No.
r� Name of Notary typed, printed or stampe
Na ty ��S ampe =o �►�`� � Notary Public State of Ftorida
� My Commission DD937327 �. Deborah E Buyer
�?��o� Expires 11I01/2013 � < My Commission DD937327
�? Expires 11/Ot12013
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AS (JWNE(�(S) QF THE PROPERTY LISTED AB�VE, W� GRANT APPLE S(�N & AV1JNlN� LLC.
PERMISSIQRI T� INSTALL SIGN, '��_�. C}F APPL� SI+GN & AWNING LLC.
TtJ ACT AS OW�IEI2S AGENT 1'CJ OBTAIN SI�N PEI�MIT. i
O�WNERS NAM�; �Y� t �t�. �0�� �
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C�WNERS SfGNATURE ,
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Sworn to and subscribe before me this
NtJTARY� ____ �'''`=da ot_�/I�4� z0 � E
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�EAL Signature of �tary Pub!ic-Sta`� c` ;"lor�da r
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Print, �ype o� S��,n��; i'�,�r;�� ofi ►yoiary Public
❑ Personaily known to me, or
C-�f'roduced identification: �'D �- �
Type of identificafion !
1635 N. l3ale Mabry Hwy. Suite 7 Lutz, �Ic�rida 33�d8 813-948-2220 Fax 813- 94�-ZdCl3 C-mali: apple.signsl @vc�rfzan.net
� � S and E, Inc. 24710 State Road 54 (813) 948-2812
Lutz, FI 33559 Fax: (813 949-2016
Name: Apple Sign Project Valero
Wind Speed 130 mph Ail Wind Loads meet 2009 Supplement with the
Mean Height 60 ft 2007 Florida Buildin Code
Wind Code ASCE 7-05 Exposure C Importance Factor �
Wind Pressure (WP) 41 56 psf
Shape Factor (SF) 1 20 Total Pressure = WP*SF 49.87 psf
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SHALL COMPLY WITH ALI.
COD �LECTRI� CODE�AND
ONAL pNCES
Letter Height (in) 2 ft 10 in Connectio o es:
Letter Width (in) 4 ft 2 in Use min�mum (4) - 3J8" dia threaded thru bolts
Area 11.806 sq ft into structural metal studs
Number of Bolts 4 �t����N DATE �' ��'��
Shear Value 280 Ibs C��' �?F ZEPH
Tension Value 322 Ibs LANS EKAMINER
Shear per bolt = Area * 10 psf 29.51 Ibs
Tension per bolt =Pressure * Area 147.17 Ibs
Bolt Value=Shear per bolt / Shear Value + Tension per Bolt / Tension Value
Bolt Value 0.56 < 1.00 O.K.
General Notes Connection design only All wind load calculations
based on code reference section 1609, which references ASCE 7
Shape factor are determined per ASCE 7 If site conditons differ
from stated reference contact A S and E, Inc
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Robert W. Wall, PE
FI Reg #46021
All Wind Loads Meet 2009 Supplement with the 2007 Florida Building Code
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CA 7882 24710 State Road 54 Lutz, FL 33559 Phone 813-948-2812 �
. , All Wind Loads Meet 2009 Supplement with the 2007 Florida Building Code
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Lutz, FL 33548
813-948-2220
Robert W. Wall, PE 46021 A S and E, Inc. ( ��
CA 7882 24710 State Road 54 Lutz, FL 33559 Phone: 813-948-2812
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
,
Contractor/Homeowner: S (
Date Received: �j '� 7 — '
Site: ���5 W f� l I N I!� �
Permit Type: � � 0 S'j . ' !!�C'°C
Approved w/no comments: Approved w/the below comments: ❑ Denied w/the below comments: ❑
This co en he a e kept with the permit and/or plans.
�� �-�/
alvin Swi — ans Examiner Date Contractor and/or Homeowner
(Required when comments are present)
May. 19. 2011-11:23AM. APPLE �IGN & AWNING No, 7542—r—,F. 2%2... ....
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PaoouCEa THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Oakes � Associates Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4111 Land O' Lakes Blvd .#10A ALTER THE COVERAGE AFFORDED BY THE POLI�IES BELOW
Land O' Lak�s EL 34639 COMPAN AFFORDING COVERAGE
GOIAPANV " -.. _'-
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INSURED �pMPAryY
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COMPANV � �� .�— .—
App,�e 3igz� 6 Awning, LLC C
1635 N. Dale Mabry Hwy � 7 COMPArvY
Luta FL 33598 p
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THIS 19 TO CERTIFY THAT TNE POLICIE5 OF INSUiL4NCE �IgT�O B�I.OW MAVE BEEN �SBUED TO THE IN9URED NAMED ABOVE FOR TME �OLICV PER100
IND�CAT�O. NOTW�TNSTqND�NO ANV FtEQU1REMENT TERM OH CONDITION OF ANY CONTRACT OR OTMER OOCUMENT WtTH RESPECT TO WHICH THI$
GERTIFICATE MAV BE 133UE0 OR MAV PERTAIN, TWE INSURANC� AFFOR�EO BY TNE POIICIES DEBCRIBED HERFIN R4 SUBJEGT TO ALL TNE TERM5,
EXCLUSIONS AND CONOYfION9 OK 3UCM POIICIE8. lIMR3 $MOWN MAV MAVE BEEN REDl10ED 6Y PAIO CLAIMS.
� r'PE OF INSURANCE�� I pOUCV NUMBER ��CY EFFECTNE � POLICV F�CP1R/1T�QN 1� LIbtIT3 �
LYR OATE (MM�ODlW) OATE (MM/DD/VV)
� GENERAL6�Ag��,m ' G�N�RALAGGREGA7F S 2000000
A J( I COMMERCIA�GENERALlIAB1UTV 062312-20680616-11 03/08/li 03��8�12 � PRODUCTS-COMP/OPAG('a S 1���0��
� CwMS M� CX J OccUR a�tsor� s ADV InuU�r S l OOOOOa
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' OWNER'S 8 CONTRAC?OR'S PRO7 i EACH OCCURRENCE S lOOOOOO _
X i Per Px'ojeCt_ FirtEOn�E�nnyo�efire) s 50000
' X waiver of 311Y�L0 . MED D(P (qnypne person� s 5000
aurOn�OBi�E �u�ei�m
COMBINE�SING��LIAAR E 1DOOOOO
A i X �VAUTO �46--'117-472-00 03/08/11 � 03/08/12
� ALl OWNED AUT03 i ^
.�— i BODILY INJURV E
SCHEDLILED qUTOS i (� �Sa
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� ANV AUTO I I OTNER THAN T N�/; I_ ,-- ��
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EA CH ACCIDENT i s
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�+OOR�GATE ! f
Exc�ss �wewTV i EACM OCCURRENCE S
i_ UMBRELLA FORM f AGGREGATE S
OTHER TNAN VMBRELLA FORM �
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; WORKERS COMP�NSATIpN qNp WC YTL�T �H- � � � � - �'� �' ` ,
�, EMPLOVERS' LIABI�ITV - ,
�' — I E� �cra ACCIp�NT S
, TME 7ROVfUETOR/ INCL FL OISEA3E - POUCY LIMIT j !
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OFFICER3 AFiE� , EKCL � EL D�SEASE •�q EAAP�OVEE S
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DESCRIPTION OF OVBRATIONSJIOCATIONSNEHICLE$ISPECI,04 IT'EMS
:C��.•T•.(F1"GA�TE�MdI,flCR�., , . . . . . . . , , , , �,�, , � , , , , �.�, ,. . : . . . .EANCCL•LA�TI�, ,� . � ".�,�, , . , , , ,�, ,. . . . . . - , , ,� , , '
Z.C� pI��H SHOUlO ANY OF THE ABOVE OESCR19E0 POUC�ES BE CANCELIED BEFORE THE
IXFIRATION DATE THEF�OF, TNE 193UING COMPANV WILL ENDEAVOR TO MA�I
3O �AYS WRfTTEN NOTICE TO TNE CERTIFICATE HOIDER NAMEO TO THE LEFT,
Cl t.y O.� Zephyrhi119 BUT FAIIURE TO MqIL SUCH NOTICE SHALL IMPOSE Np 06LIGATION OR UqBII�T�'
5335 8th 3treet
Zephyrhill s FL 33542 Of ANV KIND UPON THE COMPANV, ITS AGENTS OR f�Pf;ESENYATNE3.
AUTMORIZ�D REPRE3ENTA�
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May,'9. 2011 11;23AM AFFLE �IGN & AWNiNG No, 7�42 F. 1�'�2
B►ridgefzeld Employers
�Tnsurance Company�
Men'�bel' of �.�berty Mucv� Gro�p Ra�red A(Excellent) by A.M. 13est Company
summiiii nldi ng,e, cn���
CERTIFICATE OF INSURANCE
RE . 0830�44796 Producer , Brian C, Hunter
ISSUED TO ; City of Zephyrhilis Bldg Dept Company ; Autometic Data Processing
Insurance Agency
5335 Sth street Address 1 ADP BLVO
zephyrh�lls, FL 33542 ROSELAND, NJ 7066
Phone ; (600) 524�7024
This is to certify that Apple Sign & Awn�ng, LLC, 1635 N DALE MABRY HWY STE 7 LUTZ, FL 33548-
3000, being subject to the provisions o e ori a or erS ompensa ion aw, as secure e payment
o a workers' compensation benefits due by insuring their risk with the Bridgefield Employers Insurance
Company
POLICY NUMBER 0830-44796 Statutory Limits -- State of Florida
Employers Liability
�FF��71V� DATE: April 14, 2011 1,000,000 (Each Accident)
�,000,000 (Disease--Each Employee)
EXPIRA710N DATE. April 14, 2012 1,000,000 (Disease--Policy Limit)
This cerlificate is not a policy and of itself does not afford any insurance_ Nothing contained in this
certificate shall be construed as amending, extending, o� eltering coverage not afforded by the policy
shown above or affording insurance to any insured not named above.
The policy of insurance listed above has been issued to the named insured for the poliCy period
indicated Notwithstanding any requirement, term or condition of any contrect or Other document to which
this certi�cate may pertain, the �nsuranCe made available by the descnbed pollCy in this certificate is
subject to only the terms, exClusions and conditions of such policy, P2id Claims may have reduced the
shown limits.
If the policy described above is cancelled before the expiration date indicated, the �ssuing company
will ende2vor to mail 3p days' written notice to the certificate hplder named above, although if cancellation
is for nonpayment of premium, then the �5Suing company will endeavor to mail 30 days' written notice to
the certificate holder. In any event, the �ssuing company, its agents, and representatives accept no
obligation or liability of any kind for failure to mail such notice
���� Date March 25, 2011
Autho�•izcd S�g»ature
Suuthwesl Region CurNorate Otflce SouLh�asti Regioo
Alrilwnl�rr, �1r{.qi��cia. Ln�Lri.�n,a, ,Ni.cri.r.eip�n Flnrl�M Qe�•n;rrr. A'rnrYi kc, N��rili Curnhnn� Snwrt f'un fF�mn��rr
P,O, Box 8�439 • Hn�on Rpuge, LA 7D998-0439 P,O. Box 48S • Lukclund, FL 338U2-0988 P,O, 8ox 60I1 • G�ine"�,Ilc. G� 3n5G3•C1600
(225) 926•326� • I-B00-�'_1�29a� (y6_Z} 665-6060 • I-600-283-7G1N 1678� 45U-SB?5 � I-SUO-97 i�6b7
F,�x (?��) 936-11p2 Fax (Sb3) 666-i95R Fux 1770) 5,i-i339
I�Yld,�c'�Ir.ld Euipiny, n InSuimirr C'nni��r�y i.<nn uf,�lini� nf,+��4 i� iq�rnn�pd (+i� $unrn�i�
wC 97.G56 �Rev. 31081 iirnn irAChidv� SuMimif C�»�<oll���Y InC nruf il; suHciAim•r�Y
LDI C01 258152-� +2 � 0