HomeMy WebLinkAbout11-11930 CITY OF ZEPHYRHILLS
5335 - 8TH STREET
. • �si3> �so-oo20 �1930
COMM EXHAUST HOOD/DUCT PERMIT
Permit Number: 11930 Address: 5963 GALL BLVD
Permit Type: FIRE COMM EXH HOOD/DUCT ZEPHYRHILLS, FL.
Class of Work: FIRE-COM EXH KITCHEN HOOD/ UC�ownship: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 10-26-21-0020-00000-0021
Improv. Cost: 11,300.00
Date Issued: 6/15/20 1 � Name: ABC PIZZA OF ZEPHYRHILLS INC
Total Fees: 1 0/�� °� Address: 5963 GALL BLVD
Amount Paid: 13 . 0 Q�rY1 _. �_ � ZEPHYRHILLS, FL. 33542
Date Paid: 6/15/20 1 / � S��'"� � Phone:
Work Desc: INSTALL HOOD SYSTEM- SUN EATERY
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"'�i(�yyja,f �`�� ��� ��� FIRE INSPECTION FEES 30.00 �(�C�(�.; L s��h 6-�5 t! � [�, �
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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
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."
� _ 4
CONTRACTOR S GNATURE P IT OFFICER
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT - Fire Marshal Office - 813-780-0041
.lacqueline Boges
From: Jacqueline Boges
Sent: Tuesday, June 28, 2011 11:27 AM
To: Kerry Barnett
Subject: HOOD INSTALLATION 5963 GALL
Hey Kerry upon inspection of the hood system for the sunrise eatery restaurant 5963 Gall, could you check the electrical
that the contractor Thomas lisnock did and let us know if ok .
Thank you
Jackie Boges
Code Support Specialist
ext. 35
i
813-780-0020 City of Zephyrhills Fire Fax-813-780-0021
Permit Application
Date Received � Phone Contact for Pertnit ��� �e�
� � {�rtj•l/S /n►E.
� � Lz � � � 0
Owner's Name �� .� �_... k t+' Owner's Phone Number
Owner's Address �p 3 � r�� � tI �
Fee Simple Titleholder Name TiUeholder Phone Number �� �
Fee Simple Titleholder Address
Job Address � [ lO � (y �-� ( � � � Lot # �
Sub Division Parcei # ��' ZF�' Z�� UUZU � �6�U� '�UL r
� Bio-Hazard Waste Storage - ANNUAL � Fumigation Tent
� Comm Exhaust Kitchen Hood/Duct � Hazardous Material (Tier II or RQ Facility) ANNUAL
� Controlled Bum �Hood Installation
� Emergency Generator < 30 kw � lP/Natural Gas-Installation
� Emergency Generator> 30 kw � LP/Natural Gas-ANNUAL Sale
� Fire Protecfion Maintenance - ANNUAL � Places of Assembly-ANNUAL o I , ,�
�y emi �n er � v�'
Sprinkler � ❑ ❑ ❑ � � Recreational Bum
Fire Alartn � ❑ ❑ ❑ � � Sparklers �y `��J 3�
�T � /
Hood Cleaning � ❑ ❑ ❑� � Sprinkler System Installations
Hood Suppression � ❑ � ❑� � Standpipes (Sprinkler Sys)
� Fire Alartn Installation � Torch RoofinglTar Kettle
� Fire Pumps � Waste Tire Storage ANNUAL
� Fire Works
� Flammable Application- ANNUAL Valuation of Project
� Fuel Tanks
Q Other:
Contractor 1 L / ' ��� „ CompanY ( t r- /7 c
Signature � � Registered Y/ N Fee Current Y/ N
Address License #
ELECTRICIAN Company ?' ryt/Q5 L.lSyt[aC1�C �/,Q�:-f,e(Ci9JL CD�-�j'
Signature � Registered Y N Fee Current Y/ N
Address License # G D � Z��j
PLUMBER Company
Signature Registered Y/ N Fee Current Y/ N
Address License #
MECHANICA Company
Signature Registered Y/ N Fee Current Y/ N
Address License #
OTHER Company
Signature Registered Y/ N Fee Current Y/ N
Address License #
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 woiic over $5000)
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:!/appraiser.pascogov.com)
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 asiy
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.
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 "owne�', 1 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.
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 authoriry 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 ninery (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. 117.03) �
OWNER OR AGENT CONTRACTOR � �/� � �
Subscribed and swom to (or affirmed) before me this Subscribed and swo r affirmed) b fore me this
b �-Z3— / I by •� �-
Who is/are personally known to me or hasJhave produced Who is/are pe rsona�l y cnow to me or has/have produced
as identlfication. as identification.
Notary Public Notary Public
s
r �` :� Commi # EE 040520
Commission No. Co ssio -
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~ ��„pi�r�,•`' B�ntled7MuTrayFalnlmuranc�80DJ�7018
Name of Notary typed, printed or stamped Name of Notary typed, printed or stamped
THOMAS LISNOCK
Etectrical Contractor
� ' 22917 Sterling Manor Loop �
LUTZ, FLORIDA 33549
� (813) 948-0272
FAX (813) 909-9006 DATE
TO: i l / -''� , - _+ t " / / - / y --r � / ORDER NO.
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From: FAXmaker To City Of Zephyrhills Page• 1/2 Date 5131/2011 1•OS•59 PM
� ' T�flHSMISSION
. . . ... . . . . .. . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . .. . . . . . . . . . . . . . . . .
To Wendle Sheet Metal Inc
From Employee Leasing Solutions Inc
Subject: COVERAGE Document request for City Of Zephyrhills
Message The attached pages contain the documents you requested
The following documents are included
* Certificate of Liability
Client
Wendle Sheet Metal Inc
335 N Buena Vista Dr
Lake Alfred, FL 33850
Certificate Holder�
City Of Zephyrhiils
5335 8th Street
Zephyrhills, FL 33540
Artex Risk Solutions, Inc.
8800 E Chaparral Suite #230
. � `�" Scottsdale, AZ 85250
�'
_ ' ' Tel: (480) 951-4177 Fax: (480) 951-4266
����,�,, Email: info�cedarhill.com Website: www.cedarhill.com
.. .. . . .. .. . . .. .. . . . . . .. . ... .. .. .. .. . . .. . .. . . .. .. . . . . . .. . ... .. .. .. .. . . .. . .. . . .. .. . . .. .. .. .. .. . . .. . .. ... . .. . . .. .. . . .. .. . . .. . .. . . .. .. .. .. . . . . . .. .. .. .... . . .. . .. . . ...... . .. .. .. .. .. . ... .. . . .. . . . .. . . . . ... .. . . . . .. . .. .. .. .. .. . . . .. . . .. .. .. .. .. . . .. .. . .. ... . .. .. . . .. ..
1'his fax was sent with GFI FAXmaker fax server For more information, visit: http://www gfi.com
From. FAXmaker To City Of Zephyrhills Page 2/2 Date. 5/31/2011 1�06�00 PM
��'� � CERTIFICATE OF LIABILITY INSURANCE 05/31/20�11�
THIS CERTIFlCATE IS ISSUED A5 A MATTER OF INFORMAl10N ONLY AND CONFERS NO RIGNTS UPON THE CER?1FICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFlRMAl1VELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S� AUTFIORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERIIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subJect to
the teims and condftions of the policy, certaln policies may require an endorsement A statement on this certHicate does not cor�fer rights to the
cer[Ificate holder in Ileu of such endorsement(s).
�woouc�
NAME:
Mark van Wert � N � 353-5304 ext. 239 F '�' X N :{$$$� ZZS-4049
c% Willis of Florida, Inc. ��
3000 Bayport Drive, Suite 300 '�E��
Tampa, FL 33607 IN3UREA(S) AFFORqNG COVERAGE NAIC #
iNSUr� n: Rmerican Zurich Insuranoe Company 40142
r+su�o
IN3URER B •
Employee Leasing Solutions, Inc. Aft. Emp: Wendle Sheet Metal Inc iNSUa�c:
1401 Manatee Avenue West Suite 600
Braderrton, FL 34205-6708 IN3URER D:
IN3URER E -
IN3URER F :
COVERAGES CERTIFICATE NUIIABER:10FL079807766 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANOING 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 IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR POLICY EFF POLICY D(P
LTA TYPE OF NSURANCE POLICY NUYBEH Y LYRS
GENERAL W161LI7Y EACH OC(XIRRENCE $
COMMERCIAL GENERAL LIABILRY PREMISES Ea occurrence $
CLAIMS-MADE [] OCCUR MED EXP (My me peraon) $
PERSONAL &ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMR APPLIES PER: PRODUCTS - COMP:OP AGG $
POLICY PRO- LOC $
AUTOAIOBILE LIABILRY
Ea acctlent
ANYAUTO BODLY INJURY (Per person) $
ALL OWNED SCFIEDULE�
q�7pg p�pg BODLY INJURY (Per accdenp $
HIRED AUTOS
NON-OMINED PROPERTY DAMAGE
A�T� Per eccbent $
$
UYBRELLA LIAB OCCUR
EAqiOCCURRENCE $
IX � uA CLAIMS-MADE
AGGREGATE $
DED RETENTION$ $
WORKERS COIAPENSA710N X
AND EMPLOYERS' LWBILITY Y/ N
ANYPROPRETOR�PARTNER;'EXEIXI'fIVE E.L.EACHACCIDENT $ 1,000,000
A OFFICERlMEMBER EXCLUDED? � N/ A WC 90-00-81 &00 12/31/2010 12/31 /2011
(Yardetory In NH) E.L. DSEASE - EA EMPLOYE $ 1,000,000
IF yea, descrlbe under
DESCRIPTION OF OPERATIONS below E.L DISEASE - POIICY LIMff $ 1,000,000
Locatlon Coverage PeHod: 12/31/2010 12/31/2011 Cllem#: 052712
DE3CRIPTION OF OPEFtAT10N3 / LOCATIONS/ VEHICLES (Attach ACORD 101, Addltiorrel Rerrrerks Sehedule, H mae space Is requlred)
Coverage is provided for Wendle Sheet Metal Inc
onythose employees 335 N Buena Vista Dr
leased to but not Lake Alfred, FL 33850
subcontractors ot:
CERTIFICATE HOLDER CANCELLATION
City Of Zephyrhills SHOULD ANY OF THE ABOVE DESCRIBED POLIpES BE CANCEL�ED BEFORE
5335 8th Street 7HE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Zephy�hllls, FL 33540 ACCORDANCE WITH THE POLICY PROYISIONS.
AUTHORI�D REPRE3ENiATNE
�������
� 1988-2010 ACORD CORPORATION. All rlghts reserved.
7his fax was sent with GFI FAXmaker fax server For more information, visit: http.//www gfi.com
2011-05-31 15:14 WENDLE SHEET METAL 8639565102 a> ' P ���
'�� ��' CERTIFICATE QF LIABILITY IN$URANCE o5r�zo1' '
..
TFNS CERTIFlCATE IS ISSUED AS A MATTER OF INFORIIM11pN ONLY AND CONFERS Np RIOHT$ UPpp 'T}1E CERIIFICATE HOLDEFi. THIS
CERTIFICATE DOES NOT AFFIFiMATIV��Y Oii NEOATIVELY AMEN4, EXTEND QR ALTEFi THE CON�RAGE A�FORDEO BY THE POLICIES
BEIOW. TFMS CEft'YIfICAT� OF INSUHANCE OOES NOT OONSTIlUTE A CdV'�RAGT BETWE�N THE ISSIJING INStJRER(Sx AUTHORIZED
REPRESENTATINE OR PRODUCER, AND THE CERT'IFICATE HOLDER
IMPORTA : H tha certHb�is holdar Is an ApDIT10NAL INSUF�D, ths polkp(Iss) must bs �ndors�d. If SUBROGA710N IS WAIVE lubJ�ct 10
tda Ia�ma ond oondltlone af ths pollcy, cert�ln poNclss m�y npuke an e�dors�ena�+t A sts�emMn on thls catMlc�ts does not con�er rlqhts ro the
eatqksts halder In Neu of 9uch efWOrs s.
I�ROOUI�ER
Mll!F;
a w iws oi Florida, i nc. 4 ��. ���: ��) �-5304 •x�. 238 . --- ��,,� r• �888� 225-�0�9
3000 Baypo�l Drive: Suila 300 �� ' �-- -_.
Tampa fL 33607 INBUlld11�)AFPOROM16 _ wucr
� �: Ameiican Zurich Insurenoe Comp�ny 40142
weu�o
�e:
Empbyee Leasing Solutions, Inc. Alt. Emp: Wendle Sheet AAetal Inc ���: �""
1401 Manatee Avenue Wesl Suite 600 . .. . . . . ...- -- -- - -
Eradenlo�, FL 34205•6708 � ° �
NISINIFR E :
, . . .. ._.., ._...._
I F;
COVERAGES CERT�ICATE NUMBER:10FL079607766 REVISION NUYBEp:
THIS IS TO CERTI Y THAT THE POLICIES OF INSURANCE LISTED BELOW MAVE BEEN ISSUED Tq 7FI INSUREp NAMEp A80 fOR TM� PDLICY PER100
INDICATE�. AIOTWITIiStANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W11'M RESPECT TO WMICN TNIS
GERTIFICA7E MAY 9E 155UED OFl �IAY PERTAIN, TNE INSURANCE AfFORDED BY THE POLICIES DESCRfBED MEREIN IS SUBJECT TO ALL TNE TERMS,
EXCLUSIONS AND CONDITIONS OF Sl1CH POLICIES, L�MITS SHOWN MAY HAVE BEEN REOUCED BV PAID CLAIMS.
LT�R TYPE OF NlINlANCE � � POLICY NIMIB91 �� � Y FXP LMRS
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Loutlon Covsngs PeHod: t 2J31 �2010 12�3t i2017 ���; 052712
oESCroi►non oF onoR�noNa � �.acanaws � veua.F� I��,ch 1►c�ao to�, Iwd�►on.1 R«rwk. seh.rul.. u n,a. ap.a 1. nqdwd�
����� � p �� � Wendle Sheel AAetal Inc
�, ��� ���� 335 N 6uona Viste� pr
leased to h�.n na l�a�ce Alired, Fl 33650
subaontracwra ot:
CERTIFICATE HOLDER CANCELLAI'ION
City Qi Z6phyrh1116 9F10ULD ANV OF TkE A80YE OESCRIBED POLIpES BE CANCELLED BEfORE
5335 8th Sueei m�� �TM��A �ERE O,��E YYII.� BE DEUVERED MI
Zephyrhills, FL 33540
AVrM01q� R�RE8p1TATNE
�'l� ��..� ���-
�i 1986-ZO10 ACORO CORPOiiATIC�N. All rlQhts ►e�s►vsd.
Zephyrhilis Fir•e I�escue
(itli)7 I):ury R���id_ /ephy�rhills. I�L �35�t?
I irc I��tar�;hal 13us (813) 7fiU-OU41
k�rr}� 13,�rnet�. I�a�, (81 �) 780-UU=��
L.-m�til. kbarnclt(u;;lire.�e�hyrhilis.fl.us
Plan Review #: 1 1-067 . � - J ��. .. . � �. .� �
Pro�ect: Hood/Duct Installation
Number of Pages: Packet
May 27, 201 1
1 have received and reviewed the plans for the hood/duct installation located at 5963 Gall Blvd
and will allow this pro�ect to move forward. Paying for permit, contractor acknowledges to the
comments listed below. Should anyone have any questions, please do not hesitate to contact the
Fire Marshal's office
1. Ensure installation is completed in accordance to NFPA 96, edition currently
adopted by Florida.
2. A third party test and balance will need to be completed and given to this
authority at time of building final.
Inspection Required:
1. Light test on all welds. Contractor shall furnish all equipment to perform
inspection.
2. Final
:�"�`i
d
�..% ,
KERR NETT, FIRE MARSHAL
***Please be advised this review of plans submitted is a cursory review to assist the contractor in
compliance with applicable fire safety codes. This review is not intended to be a final approval of the
submitted plans. It is the contractor's sole responsibility to ensure that the plans are in complete compliance
with all applicable NFPA codes and local ordmances. In the event that further examination or site
inspection reveals areas of non-compliance, it shall be the contractor's sole responsibility, at their sole
expense to bring those areas in compliance The City assumes no responsibility for the contractor's failure
to be in compliance with all applicable NFPA codes and local ordinances.
Z������'����LS FIR� �EPAf���VIEi��
6907 C7airy Road, Zephyrhills, FL 33542
Fere Chief Ke�rh Wifii�ms Bus (813)780-Oi�41 F�x (81:3)%80-OU�4
FIRE SERVICE USER FEES
Occupancy No.: a
Plan No.: �Gy ° Coniractor: /,� � ����= � �.� � ��� ft
Bus�ness Name. ' ,1L Billing Address: � -,�,�� � /���
Business Address. ,��' 3 E,r,�-ij -� Q �� �� ��,��
Business Phone No � Billing Phone No.:
Business Fax No.. Billing Fax No..
Contact Contact:
PLAN REVIEW FEES INSPECTION FEES PERMIT FEE FALSE ALARM FEE
8 Site Plan N/C Annual N/C Sprinkler 350 1 st Alarm N/C
Mulu-FamilylCommercial O6 sf 1 st Re-inspection N/C Standpipes $50 2nd Alarm N/C
(Minimum Charge $25.00 2nd Re-inspe�tion $100 Fire Pump $50 3rd Alarm N/C
� Plan Revisions DBl 3rd Re-inspection $250 'Hoods ( 4th Alarm $100
4th Re-Inspection $500 Fire Alarm 5th Alarm $� 50
SPRINKLER SYSTEMS (Business closed untif LP Gas $50 6th Alarm $2pp
0- 25 Heads $50 v�olations corrected) Natural Gas �50 NON COMPLIANCE $150
26 plus Heads $100 SPRINKIER SYSTEMS Fuel Tanks- �� ra�k $50
STANDPIPE SYSTEM Hydro Undergrounds a45 Sparklers $100
� Per Riser $50 Hydrostatic Test $65 per system Fire Works $SOp
FIRE PUMP Acceptance Test �S per system Camp Fire $25
� Per Pump $100 Hydrant Flow $75 Controlled Burn $100
FIRE ALARM SYSTEM Hood/Duct $5p
8 0- 25 Devices $50 FIRE ALARM SYSTEM Place of Assembly $50 A�nual
26 plus Devices $100 System Acceptance $50 Fire Protection $25
SUPPRESSION SYSTEMS Recall Acceptance $50 Flammable Application $50 nnnuai
Wet $50 OTHER Waste Tire Storage $50 Annual
Dry $50 Fire Wall/Smoke Wall $15 perwan Generator < KW $�pp
CO2 $50 LP Gas $25 Pere��k Generatw>30 KW 150
Other g50 Natural Gas $25 per system BiaHazard Waste �100 Annual
�KITCHEN EXHAUST Fumigation Tenting $50
HoodlDucts $50 Tent 10'x10' or greater $15 per tent Torch PoUApplied $50
OTHER Fire Pump $45 Haz. Materials $100 Annual
LP Installation per tank $50 Fire Suppression $30
Fuel Tank Installation $50 ystem Acceptance
(Per Tank) $50 Exhaust Hood/Duct
� Nalural Gas Installatioo $50 Re-inSpeCtion
(Per System} ' (other than annual)
� Spray Booth $50 � Inspection scheduled DBL 8
and cancelled less than
24 hours
Construction Insp. N!C
' Emergency Vehicle Aa $50 , r �� FALSE ALARM
P�ANS TOTAL �_� � WSPECTION TOTAL � PERMIT TOTAL l� � TOTAL I_ I
GRAND TOTAL [��.��
Comments
Date .j� � �
�
Insq��ctor� ��'✓ f' ���
From:Michelle Hall FaxID:86�967-7592 Page 2 of 3 Date:05/17/11 12:33 PM Page2 of 3
��''�� OP ID: MH
'`�� ° CERTIFICATE OF LIABILITY INSURANCE ° "'�`�"°°"Y'" ,
05H 7111
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N ONLY AND CONFERS NO WGHTS UPON THE CERTiFICATE HOLDER. THIS
CERTiFICATE DOES NOT AFFIRMATIVELY OR NEGAIIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TMS CERTIFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRA�CT BElWEEN THE ISSUING INSURER(S�, AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CER7IFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADOITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and corxlitions of the policy, certain policies may require an endorsemeM. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemeM s
PRODUCER 563-967�.5� CONTACT
NAME:
Mulling InsuranceAgency, Inc. 863-967-7592 P "c ° � Ert: AAC ,r,o:
P O Box 308 208 E Park Street e�a�� -
Aubumdale, FL 33823-0308 noo�ss:
W. Gene Permenter, L.U.T.C.F.
c�r��eR ior. WEND-01
INSURER�S� AFFORDING COVERAGE NAIC i
INSURED Wendle Sheet Metal, Inc. uasur�n United Fire 8� Casualty 13021
Deborah Roberts INSURER B
335 N. Buena Vista Dr.
Lake Alfred, FL 33650 INSURER C
�NSURER D
INSURER E
INSURER F .
COVERAGES CERTIFICATE NUMBER: 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 NOTWITHSTANDMG ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CON04 TIONS OF SUCH POLICIES. LIMffS SHOWN MAY HAVE BEEN REDUCED BY PAID CIAIMS.
INSR 7ypE OF INSURANCE POL�CN EFF POLICY XP -�- -
LTR POLICY NUMBER MMADNYYY MMADlYWY LIMfTS
GENERALLIABIUTY EACH V�CURRENCE $ 'I,OOO,O
A X rnMMER_ryAL�=ENERFd LIABILITi 60385534 �7f���� 07�2��� FREMISE� Eaorr.urren�� � �
CLAIMS-MAL�E [� r� ��.i IR MEG Exp �My pne person) $ r J,
_ PERSnNA18ADV INJURY $ �,OOO,OO
�ENEFALA�>RE��ATE $ Y,OOO�O
vEN'L A�uREtSATE LIMIT A�FUE� FEF' FRVGUCTS- �uMF/VPA�� �I�OOO�OO
� $
POLICY FR �� - �n�_
$
AUtOMO81LE LIABILITY
COMBWED SIN6LE LIMIT
A X ANY AUTU 60388534 07���� �7�28/�� (Ea acadenq g �
BODIIY IN.IIRY (Perp?r5nn) f
ALL OWNEGAi i7r�5
6�GIL i INJJk i(Fer acadent) $
�CHEDULEG AUT! �5 —
HIREDAUTOS PROPERTYDAMAGE �
(Feracuden[�
N i dJ -� � WhJED AI ITO : �
�
UMBRELLA LIA6 n � r � iR
EACH nCr�iRRENCE $ 1�0���
EXCESSUAB CLAIMS-MAL�E AG�RE�_ATE $ 'I,OOO,OO
A 60385534 07/28/10 07/28N 1
DEDUCTIBLE
$
X FeTer�nori g 10,000 $
WOPo(ERS COMPENSATION Wr gTATU- nTH-
APD EMPLOYERS' LIABILITY Y f N TORY LIMITS ER
ANY PRnpRIETORIPARTNER�EXECUTIVE E L EArH ACCtDENT
OFFICERRdEMBER ExCLUGE _'� ❑ N / A $
(M�ndttory In NH) E L DI �EASE - EA EMFL�_� r'EE $
if ves, dws!nbe under
GESCRIPTION JF OFERATIUNS below E L GISEASE - Fi�UC Y LIMIT $
DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHCLES (Att�ch ACORD 101, AdditlonN R�maMa SchedWa, It mon ap�ce ia roqulrsd)
Metal Goods NOC
CERTIFICATE HOLDER CANCELLATION
CITYOZE
SHOULD ANY OF TNE ABOVE DESCR�ED POLICIES BE CANCELLED BEFORE
TF� EXPIRATION DATE THEREOF, N0710E WILL BE DELNERED IN
City of Zephyrhills - Building ACCORDANCE WITH 7HE POLICY PROYISIONS.
Department
5335 8th St�eet A������$�ArnE
Zephyrhilis, FL 33542 /,!_ s,�-- /f ���
bYQi�W ��f
O 1968-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009lb9) The ACORD name and logo are registered marks of ACORD
POLK COUNTY LOCAL BUSINESS TAX RECEIPT "
ACCOUNT NO 13735 CLASS: B EXPIRES: 9/30/2011
OWNER NAME LOCATION
WENDLE, RAYMOND E JR 335 N BUENA VISTA DR
LAKE ALFRED - IN
BUSINESS NAME AND MAILING ADDRESS CODE ACTIVITY TYPE
230260 CONTRACTOR SHEET METAL
WENDLE SHEET METAL INC
RAYMOND E WENDLE JR
335 N BUENA VISTA DR
LAKE ALFRED, FL 33850-2005
PROFESSIONAL LICENSE (IF APPLICABLE)
DBPR CSCO56662
OFFICE OF JOE G. TEDDER CFC * TAX COLLECTOR THISPOLKCOUNTYLOCALBUSINESSTAXRECEIPTMUSTBE
_ CONSPICUOSLY DISPLAYED AT THE BUSINESS LOCATION
PAID-1203542•0001-0001 07/2�/2010 07/2�/2010 N6G 12 57.75
AC# _ ", `° - STATE OF FLORlDA
' DEPARTMENT OF BUSINES3 AND PROFESSIONAL REGULATION
; CONSTRUCTION INDUSTRY LICENSING BOARD SEQ# L10072101137
i - LICENSE NBR
�
� 07 21 2010 108012526 CSCO56662
� The SHEET METAL CONTRACTOR
� Named below IS CERTIFIED
� Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2012
� WENDLE, RAYMOND E JR
� WENDLE SHEET METAL INC
, 335 N BUENA VISTA DR
LARE ALFRED FL 33850
, CHARLIE CRIST CHARLIE LIEM
GOVERNO$ INTERIM SECRETARY
; DISPLAY AS REQUIRED BY LAW
W2�C�re Shee7� i'I�Ta � �r�
3 3 � �V c
13uen V, f� �►-
�� ���'" �1 �33 FsSa
�3 q5� �a ,-�
�S (03 q 5(o S � c� �. -�Y
SPECIAL POWER OF ATTORNEY
I, Raymond E. Wendle Jr., residing at 107 Sevilla Street, Auburndale, Florida
33823, and as a principal of Wendle Sheet Metal Inc., 335 N. Buena Vista Drive,
Lake Alfred Florida 33850, do hereby appoint Deborah K. Roberts of 145 Kinstle
Ave., Auburndale, Florida 33823, as my Attorney-in-Fact ("Agent").
My Agent shall have full power and authority to act on my behalf but only to the
eztent permitted by this Special Power of Attorney. My Agent's powers shall include
the power to:
Handle all circumstances in regards to my State Certification No CSC 056662
whetLer it is licensing, permitting, etc.
I hereby grant to my Agent the fnil rigitt, power, and anthority to do every act,
deed, and thing necessary or advisable to be done regarding the above powers, as
fully as I could do if personally present and acting.
This Power of Attorney shall become effective immediately, and shall not be affected
by my disability or lack of inentsl competence, eacept as may be prnvided otherwise
by an applicable state statate. This is a Durable Power of Attorney. This Power of
Attorney shall continue effective until my death. I may revoke this Power of
Attoraey at any time by providiwg written notice to my Agent
Date ��' 2010 at Lake Alfred, Florida.
X � � Gt/�.�.�- �c �
( RRuymond E Wendle Jr.
State of Florida
County of Polk
The foregoing instrument was acknowledged before m � day of
�,1 , 2010 by Raymond E Wendle Jr., who ' personally know to me or wbo
hav roduced s i entification.
Nota
��" •�;: �
(�NA M. KALFY
*: : = MY �oA�tul�ss�oW � DD etraoa
��•.•' ��� P t9,�012
�my ub�cUnMrwnt�r3
Wendle Sheet Metal Inc. Jobsite: /EB6-�Phlia i4rrrs� E
#CSCO56662 � 335 N Buena Vista Drive 5963 Gall Blvd
Lake Alfred, FL 33850 Zephyrhills FI
Phone 863-956-2217 - Fax 863-956-5102 Contact: John
863-521-8807
�UBMITTED PLAN(S) HAVE BEEN REVIEW�
SY ZEPHYRHILLS FIR MA HAL'S O ICE
Datc:
�vieww
MininuM 10 �t clearance 10' x 12'
16 ga
Two 2000 cfM externally I
upblast welded
xhaust fan stnck
3400 CFM grease QiZM for 40' 3/12
fittered cu 1500 f r, � pitched
repinceroe t duct p veloci y 18' roof
alr fan support Inged
flange m�neral curb
wool
duct
ase
per NFPA
96-4,2.3.2
9ft 4' lay in ceiUng
baffle
skirting
grease
Supply ftex filters
front supply
plenuM
grease
cup fire extingulshing system by
42' others
4 ft stainless 16ft stainless steel, t
steel backirn�. I ype i
Cooler 6. hood wlth front supply plenuM
78'
Cooking
equipMent Exhaust flow based on
bY MediuM teroperature coaking
others equipment per FBC 507.13.2
Note� Hood, grease reMOVaI devices, exhaut fan, and duct shall have a clenrance of 18' to coMbustible
Materlats, 3' to liMited combustible Mnterinl nnd 0' to non coMbustible Material per NFPA 96-4,2.1. Where not
possibte a clearance reduction systeM of 22 gage on 1' Mineral wool batts relnforced with wire Mesh spaced
out i' on non coMbustibte spncers is provided for a 3' clearance to coMbust(ble Mnterial per NFPA 96-4.2.3.2
Wendle Sheet Metal Inc. Jobsite: ABC Piva
#CSCO56662 � 335 N Buena Vista Drive 5963 Gall Blvd
Lake Alfred, FL 33850 Zephyrhills FI
Phone 863-956-2217 � Fax 863-956-5102 Contact: John
863-521-8807
HOOD SPECIFICATIONS
HOOD� 16 FT X 4' - 18 GA STAINLESS STEEL, 24 INCHES HIGH AS PER NFPA CODE 96-
5 1, 5.3 & 6.2. AND FMC 507.4 AND FMC 507 7, 507.12-13. DESIGNED TO
COMPLETELY COVER COOKING EQUIPMENT AND EXTEND MINIMUM 6" BEYOND
THE EDGE OF THE COOKING SURFACE ON ALL OPEN SIDES
FILTERS HIGH VELOCITY BAFFLE TYPE AS PER NFPA CODE 96-6.1, 6.2.3 AND FMC 507 11.
FILTERS INSTALLED AT A MINIMUM ANGLE OR 45 DEGREES TO THE
HORIZONTAL AND ARRANGED TO CAPTURE AND DRAIN GREASE TO GREASE
CUP
HOOD HEIGHT• APPROXIMATELY 6 FT 8 INCHES FROM THE FLOOR. CEILING CLEARANCE
MINIMUM 18" TO COMBUSTIBLES PER NFPA 96-4.2.1
EXHAUST STACK. EXHAUST DUCT SYSTEM IS AN INDEPENDENT SYSTEM DESIGNED FOR THE
REMOVAL OF KITCHEN EXHAUST WITHOUT ANY OBSTRUCTIONS THAT MAY
COLLECT GREASE/RESIDUE. CONSTRUCTED OF 16 GAGE METAL, EXTERNALLY
WELDED (CONTINUOUS, LIQUID-TIGH� SIZED FOR A MINIMUM OF1500 FPM
VELOCITY TERMINATES 18" ABOVE ROOF LINE WITH WELDED FLANGE FOR
SUPPORT AS PER NFPA CODE 96-7 5, 96-7 3, 96-7.8 AND FMC 506.3 3,506.3 4,
506.3.6 PROTECTED AS PER NFPA CODE 96-4.2.3 AND FMC 308.6. DUCT TO
HOOD CONNECTIONS TO BE WELDED LIQUID TIGHT
ACCESS DOOR: AN OPENING SHALL BE PROVIDED AT EACH CHANGE IN DIRECTION OF THE
DUCT FOR PURPOSES OF INSPECTION AND CLEANING THIS ACCESS DOOR
SHALL BE MADE TO BE REMOVED WITHOUT THE USE OF TOOLS PER FMC
506 3.10 AND NFPA 96-7.3
EXHAUST OUTLET• IOCATED AT LEAST 10 FT FROM AIR INTAKE AS PER FMC 506 3.14, 507 16 AND
NFPA CODE 96-7 8
EXHAUST FAN Two-2000 CFM @ 1/2" S.P , EXHAUST AIR FLOWS AWAY FROM THE SURFACE OF
ROOF AS PER NFPA CODE 96-7.8.2, 96-8 AND FMC 507.13 1- 4
EXHAUST DISCHARGE. ROOF TERMINATION TO BE 40 INCHES ABOVE THE ROOF �INE AS PER FMC
506.3 14 1 AND NFPA CODE 96-5-8.2.
REPLACEMENT AIR. 3400 CFM FILTERED AIR INTO A SUPPLY PLENUM AT THE FRONT OF THE HOOD
AS PER NFPA CODE 96-8.3, AND FMC 508 1
Note: Hood, grease removal devices, exhaust fan and duct shall have a clearance of 18" to combustible
material, 3" to limited combustible material and 0" to non combustible material per NFPA 96-4.2.1. Where not
possible a clearance reduction system of 22 gage on 1" mineral wool bats reinforced with wire mesh spaced
out 1" on non combustible spaces is provided for a 3" clearance to combustible material per NFPA 96-
4.2.3.2.
- � ':*"'-` " -- ` r.,. - . . -,_ - �:^''- -,.. . � g _, ;
_ .�_ ��_. . ..-i � � - �r� �9 ,-'�io' c .. .+[y;F. .!?�ti...
� N.i.'•' .. .~:r�� s;� :b! i �.. .
ri'. � ` �,✓�_`:'Y t' r^ �"°_�. >� ;�._-.: .
�� _ '" ' .
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L � n ��. .
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F; y -%- ��'^�' f �,'W.s,"".,- ,:'.4a ' v� x �=y !�j' � .i;� - � �`f
.-.' y. ^?y is*i:`;�" o r+ w° -"..'�--�'_�� ,'�" -+ '" f '
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.+ - j � : Q _ .� — " ,
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W
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d':. ��<.€i� ; 3� �i� _�� ; r
�i .f�e�?'v� �
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_ - :r��@ - -_
• -r y. �i ^i ..
_ _:'e � ..:-.�- Ff '_'� =_ B
# -. .� - Measurements �
- �� � .. . .
..
. ___._.___e_. __ _._.__ _... _ ____... .. _�._. _. . ,_.... _.. __ . _ . . ....... . . .. .. _. .
� - DUBFA 13 1/2 19 3/4 1 1/2 19 9 3/4 13 20
:? DU9FA 13 1/2 19 3/4 1 1/2 19 9 3/4 13 20
�= DU76FA 151/2 24 1112 19 115/8 �3 35
DU25L/HFA 23 3/4 24 1/2 1 1!2 21 20 3f4 16 50
:i,: :;- : -
DU30LfHFA 23 3/4 24 1/2 1 1!2 21 20 3/4 16 50
�''- � DU33UHFA 23 3/4 24 1/2 1 1!2 21 20 3/4 16 50
E. .
�� '_ � DU50L/NFA 251/2 28 1/4 1 1/2 21 23 16 55
a: �:
''' � `+ DU75LIHFA ; 28 114 31 1/2 2 24 3/4 23 20 60
" ��- ,,.,.�-� DU85UHFA , 28 1/4 31 1/2 2 24 3/4 23 20 BO
��-+� ._- _ _ _ �='F_
F' _ .. "" ' "�£-
Motor Availability
�=�a�tc.�;•�,�s � �t:�a����E4�
Com�lt:tely enclosed drive �c mpartment
pratect:� motor from airborre ocntaminates
.. . , . . . . . � . ..
Force J fresh air cools the rio:o compartment. �-_-_..__.- -__...,.. _�__ ... .. ._..__._ ....__ � ._. . _ _ . __. _. _.
ensur��5 long motor life DU8FA na na �a
Vanab�e speed control is stard3rr: on DUBFAthru DU9FA na �a �,a
DU75,`=,�a, ailows up to 50% ret uction in speed DW 6FA na na ^a
Non o n:�rloading backward ir�;li �ed wheels, blades DU25UHFA na * r,a na
and �n f,ts fabricated from 3JC3-H14 aluminum DU30UNFA na * �
All sizes can be wall mount�c na na
Quick release latches allow fc r easy access to DU33UNFA na * �
motor compartment DUSOLlHFA na * na
Stand:a�d emergency discor,n�c� switch DU75L/HFA na * „
DUBSL/HFA na consult na
�C' �ltilOi":y
' Speed contro� can be �,vired for either low or High speec
Bird acreen �• rn�ee PnaSe r*o,crs are open tlnp proof
Grease Col�ection Bo� �uu;:5�!arger
Back tDraft Damper Certifications
Roof (:urbs
Epoxqr Coating U Models DU8FA *r�_ DU16FA are Listed under UL705 (Elecfical) Modets DU25FA tnr�
�� DU85FA are UL752 L�sted (Restaurant Exhaust Apphance).
Performance shown is for installatio^'ype A. Free Inlet. Free Outiet. Performance includes effect oi bird
�� trl�ll ; Pre.,sure lo� inehe:s �GV .�7. screen in the air stream. Speed �RPo.1i shown is nominal and performance is based on adual speed of test.
. � � ��� � � � � � �� ��� �
, � . _.. __... ._. _ �_ ___...___.___.______�_�_____._M__.�.�..�.....��_.�_...__.�,�_r..._,.________.______.______..._-��
[�lDBI'A 1/±3 169C 3485 365 320 275 185 70 - _ _ _
[IU9t°p 7f3 1725 4064 385 515 440 360 250 140 - _ _
C�U�IiFL� I/3 1620 4665 1�10 900 815 690 580 410 230 - _
C��U2:iLFA 1/ - 1000 3077 T83 654 520 389 237 - _
Ci�J25Hf'A 11' 1150 3538 900 825 746 651 542 233 - _
DdJ3[ILFA "!�� 1500 4614 1182 1127 1072 1013 954 884 810 636
GU3pHFA 11�� 1600 492? 1261 1202 1143 1081 1017 943 864 679 -
DIJ3i�LFA 1l;. +°�� 4999 1281 1221 1161 1098 1033 958 878 690 -
DU3�Hi'A ,.., 1700 5229 1342 1290 1238 1179 1115 1051 985 831 -
DU5C�LF�. 3 1/:? 1450 5220 1934 1859 1780 1694 1604 151'I 1403 1164 909
: ��DUS!'..�FFA ! 1Y' 1670 6012 2181 2'117 2p52 1g$g 1g22 1855 1787 1616 1419
1
D'J73LPp 3i�1 1125 4639 2497 2372 2246 2089 1946 1785 1609 - . �
DU75HFA 3/� 1150 4742 2596 2475 2352 2218 2084 1932 1773 134g
DU85LF.4 3/� 1400 5040 3205 3039 29os 2763 �sos 2nds 2aog �gg� ��
DU85HPA 3!4 1550 5580 3337 3212 3108 2994 2882 2774 2657 2381 2124
-��.
..� � �.
� I GALVANIZED SUPPLY FAN
FILTER �
0
� AIR INT�iCE TNROU(3-I F'IL TER �
SUPR.Y FAN
ELECTRICAL DROP --" ` � '"
-CURB �i?TH 20 GA CONSTRUCTI�N
� 3' GONTINIOUS �LASHING
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(x) WARNING. Maor overload wili resuK if blower is operated at SUUC preswre belw+ pertormance shovm. ('`) Orive package consists W appropnace motor, be14 and sheaves m o6tain the pertormance
listed.
3972 ��a ✓= Extended Warranty Availabie grainger
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B-LINE SPANS TWO ROOF JOIST
3' CLEARANCE REDUCTIOPI
METHOD PER NFPA 96
16 GA. VELDED EXHAUST DUCT
1' NON-C�MBUSTIBLE SPACER
� 8 � COMHUSTIHLE MATERIAL
— 3/8' A�LTHREAD
18' 8 , wIRE MESH �R SHEET METAL
1' MINERAL WO�L HAT
MIN. 22 GA. SHEET METAL
HANGER VELDED TO HUOD I 3' �-DUCT-� 3 �I
HOOD � �
SECTION VIEW
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3/8' ST CK WELDED EXHAUST
coupting
1' AIR SPACE
3/8' 1' THICK MINERA� WppL
PANELS ON
allthread NON-COMHUSTIBLE
SPACERS
CaMBUSTIHLE MATERIAL
hanger wetded
o hood
hood (3' I—DUCT--�3'�
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�This card is non- S=� YOUR �p�p
I transferable a�id is revocable for cause
�f �The contractor listed hereon will be held responsible
or all permits issued under this card. If this card is
� �lost or stolen, notify the Hil]sborou h Co.
Licensing Team immediatel at 81 g Contractor
�Your card mu t e renewed r'or � 635- 7308/7309
�shown on th P�t� the expiratio� date �
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I
CERTIFICATE OF COI�ETENCY---------------I
� HII.I.SHOROUGH COUNTY I
I Type:CERTIFIED ELECTRICAL CONTRACTOR ��DA I
I NO PERMIT UNTIL STATE REGISTERED, IF APPLICABLE I
� EC0002996 I
� Certificate No. 1 0/3b/2p12 I
� Issued To: Expiration Date I
i LISNOCK THOMAS G �
� DBA:THOMAS G LSSNOCK ELECT COiNT TNC
� Workers'Comp EI�.t�T 08/li/2011 �
"`C]" �
� .
I Issuing Officer I
� STATE OF FLORIDA -- � ~ � � �
DEPARTMENT OF FINANCIqL gERVICES D
DNISION OF WORKERS' COMPENSATION
CONS7RUCTION INpUSTRY
CERTIFICATE OF ELECTIpN TO BE FJ(EMPT FROM FLORIpq
WORKERS' C OMPENSqT�ON Lqyy
EFFECTIVE pg���� 4
PERSON: THpMpS G LISNOq�PI�TION DqTE: 08/��/20
FEIN: 651217256
BUSINESS NAME AND ADDRE5S:
THOMqS G LISNOCK ELECTRICAL CONTRqCTING INC
22917 STERLING MqNOR LOOP
LUT2, FL 33549
SCOPE OF BUSINESS OR TRqpE
�- ELECTRICq� CON7RAC70R
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�°� CERTIFICATE OF LIABILITY INSURANCE 6 j27i2a�
TN13 CERTfFICATE IS 159UED AS A MATTER OF INFGRMATION ONLY AND CpkF�RS NO RIGHTS UPON TNE CERTIFICATE (idLOER. TFNS
CERi1FICAT� OpES NOT AFFIRMATNELY OR N�C+IITIVELY AMEND, �XTEND 012 ALTER THE COYERAG� AFFORDED BY THE POUCIES
BE�OW. THl8 CERTIFICA7E OF INSURANCE DOES NOT CON3TIME A CONTRAC7 B�1'VYEEN THE ISSUING IN8URER(S), AUTHORIZED
REPR�SQVTATNE OR PRODUC�R, AND THE CERTIFICA7'� MCLDER.
IN�ORTANT: If the ce cabe holtlar 1s an ADDI1'IpNAL RED, ths policy(les) must be endorled, If SUBROGATIQN f$ WAIV�O. SubjeCt to
Nte terms and condltlonc of !he ppliCy. certsin poReles may rpquire 8n e�do�semenL A sfalement on thi9 certificabe does not eoMor nghfs to the
�art�GG�be holdor in Ilsu of sueh endQrgeime s.
PROGYCER NA � T 111 HaID�i'Ox'�
Hamero�� Ineurarice Ageacy .. PKbN� (813) 870-628� .. .. �.F"�
tN.�'n.NO, E7etj:. I (A1C� No�: f 613 ) 075-3x�0
PO Hox 270127 ��eai@tam�bey.��e.com .
PRODUCER paoo03ox ..- - - --- - ...
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Tampa _._.....__ FI� _ 33668 _ ... . IN9UREq{S) AFFOrmI�ICiCWEAAOE _ . .. .. MAIC
IN9URE0 _� F . �
,INSURERA:�eXa.CBlJ 3��@9 ... .. ...... . . .. 9'704,
INSIIRER B :
TE�O�A,S G LI3NOCEC SI,EC'��I� CO � .,._......___.. ... .__._._.._... ..... .. .....� _..
INSURE�I C ;
22917 BTERLIIQG L�,t�FOR LOOP ..._._.._ ... _.._......_.. _ . ..._.. ._._
INBUREp D :
INBttREft E : � - _ _ . _.1. . -.
�UTZ FL 33549 � u F: . . ,
COVERAG�S CERTiFICA7'� NUMBER:cs.iosa000991 REVISION NUMBER;
YNIS 15 TO CERTIFY THA7 71iE POIICIES OF INSURANCE LISTED B6LOW HAVE BEEN ISSUED TO THE INSURED NAMED AepV� FOR THE POLICY PERIOD
1N�IGATEO� NOTWlTHSTMDING ANY REQUIREMENt, T�RM GR COMDITION OF ANY CONTRACT OR 01'HER DQCUMENT 1MTH RESPECT Tp WHICH THIS
ceRn�ICATE MAY BE issuEO pR MAY pERTAIN THE INSURANC6 AFFORDED BY THE PdCICIES DESCRIBEO HEREIN IS $UBJECT TQ qLf. TNE TERMS
EXCLU310NS AND CONDITIONS OF SUCW POIICtES, LIMITS 3HOWN MAY HAVE BEEN REDUCED BY PAID CI�AIMS.
__ ...._ _.__ .. . ...._ . ...._._._., .. .
�L� TYPEOFINBURANC� P061CrNUNBER M�p ��PSLJCY�KR .�..._ .. _. LIMITS _ -. .. .
g ������ E!1CM OCCURRENCE 5 1 w 000, OD4
X COMMERCIAI, QEN@RAL LIABILRY � - ". .'- `. .
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...--� -°--_ --. ,--_ � PERSOWLL 8 ADV INJURY S 1� OOO , OOO
-- � GENF.RAL AGGREGAtE S 2, 000, 000
c�nr� AGOREOntE uMrc pa�.iES aER; � PROOUCTS - COMP� aGG a 2, 000 , 000
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M�OIiKERB COMPEW�A710N YYC 9TATU. ' � TH.
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ANY PROPRIETOWPARINERI�XEpJTfVE YIq ._. _ .. .
OFFICER�IAEM�ER E%CLU08D9 a N I A E.L EACH ACCID�Nr s
fNaneNe+Y 1n NH) • .. �� . . ..
N�e dNixlbB IMtler E.L DISEAS6 •�A EMPLOYE i ...__. ..
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E.L.DIS8A8E-POLICY�IM�T �
O�RIP1r10N OF OPERA'ItONSI LOCA7�ON9! VEMICLEB (�Shch ACORD 101. Ad�tlenY R•marks 9eMAule, M mon sp�q b
10 Days writtpn liOC i'os �fpn-pay��ti,
G�63�ock Tho�e G
LiCeaeaM �C000299b
�a�F�cA� Ho�o�R CANCEI.LATION
;813)780-002i
SMpULD ANY OF TF1E ABOVE OESCRIBED Pp�ICIEB SE GqNCELLED B�FdRE
THE EXP�RATION DATE THEREOF, NO?ICE NIILI, BE DELNEitED IN
City Of Z6phy�C�hi119 ACCORDANCE WITH TNE POLICY PROV1310NS.
k3uf.lding Aepartment
5338 @th 3t, �utrioRrzeon��eseHTanv{
Z�phy��sills, FZ, 335�2^-4312
141 Ham�ro�f/bE�7TT� � �
►CORp 25 (2008l09) � 9988.�009 ACORD CORPORATION, All right� �=erved�
VSp25 �oosos� The ACOIta nante and logo are registerad marks pf ACORO