HomeMy WebLinkAbout11-12180 CITY OF ZEPHYRHILLS
, � 5335 - 8TH SfREET
(sis)�so-oozo 12180
BUILDING PERMIT
Permit Number: 12180 Address: 5632 GALL BLVD
Permit Type: COMMERCIAL ZEPHYRHILLS, FL.
Class of Work: ADD/ALT COMMERCIAL Township: Range: Book:
Proposed Use: COMMERCIAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 11-26-21-0010-05700-0254
Improv. Cost: 11,000.00
Date Issued: 11/22/2011 Name: BANK OF AMERICA
Total Fees: 135.00 Address: 6700 LAKEVIEW CTR DR
Amount Paid: 135.00 TAMPA, FL 33619
Date Paid: 11/22/2011 Phone: (813)225-8173
Work Desc: INSTALL DUMPSTER ENCLOSURE
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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.
"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."
Complete Plans, Specifications Must Accompany Application. All work shall be pertormed in acxordance with
i Codes and Ordinances. NO OCCUPANCY BEFO C.O.
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C N CTOR SIGNATURE PERMIT OFFI R
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PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOUR NOTICE REQUIRED
PROTECT CARD FROM WEATHER
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City of Zephyrhills
BUILDING PLAN REVIEW COMMENTS
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�ntrac omeowner: ^ �'�,��,�2 �a.�'1c� .��`�c�u�a-. �( � -�;� s ��1� -
Date Received: `�� ��-/�
Site: ��� ��Z ��t% ���a�
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Permit Type: ��o�c� �•71��� �� �� ?�SC��..�
Approved w/no comment . ' Approved w/the below comments: Denied w/the below comments: ❑
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This comment sheet shall be kept with the permit and/or plans.
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Kalvin witzer` - Pl aminer Date -'� Contractor or Homeowner
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CITY OF ZEPHYRHILLS PB 1 PG 54 COM NE COR BLOCK 58 TH N63DG
28' 30"E TO INTERSECTION OF ELY R/W LN US 301 & SLY R/W
LN 12TH AVE 60.00 FT FOR POB TH CONT ALG SLY R/W 12TH AVE
N63DG 28' 30"E 200.00 FT TO WLY R/W LN 7TH ST TH ALG WLY
R/W LN 7TH ST S26DG 25' 00"E 225.00 FT TH S63DG 28' 30"W
200.00 FT TO ELY R/W US 301 TH ALG ELY R/W LN US 301
N26DG 25' 00"W 225.00 FT TO POB
OR 1251 PG 320
I IIIIII IIIII IIIII IIIII (I�II IIIII IIIII (IIII IIIII IIIII IIII IIII
NOTICE OF CONIlViENCEMENT 2011181789
Rcpt:1400551 Ree: 10.00
Permit 1vo. DS : 0. 00 I T: 0. 00
Properry Identification No. $� 2(o � i i?C 1 1 C� (`� `� T G'v tSZ'S'#
il/22/11 K. Gareia, Dpty Clerk
THE UNDERSIGNED hereby give informs you that the improvement witl be made to certain real property, and 'ui accordance with
5ection 713.13 of the Florida Statutes, the following information is provided in this NOTICE OF COMMENCEMENT.
1.Description of property (legal descriptton:) S" Q t7d�i
a) StreetAddress: S(� l� �1 / '�'G � ZLP ) i L
2.Cleneral descriprion of improvements: ui 1 �WI P�� 2h ��'►'� f�� T�a (� Cd t �
3Awncr Information
a) Name and address: i�r�nlc. ^� � C�, iOl v."t ��, ST .''�_rl at� N C� 2�3 Z`>`�
b) Name and address of fee simple tiUeholder (if other hau owner)
c) Tnterest in property t�wYY..�/'
4.Con�actor Information � e� `
a) Name and address: �D7 G�,�!\ 3��.,�5 r `�stt'+ t�w ,��' ��4 _�n`� Gurn �� F(. 3-� �' ''� �i F. -o
b) Telephone No. �(r,`'i , C�f�t _�lS��� Fax No. (OpG) �`3 -`l Th5 v �.. D
S.Surety Information � N a
a) Name and address: N
b) Amount of Bond; � � �
c) Telephone No.: Fax No. (Opt.) � r. Z
6.Lender /y� ^�
V�l�"� ..
a) Name and address: /�� N �
Phone No. V �w s
7 Identity of person within the State of Florida desi�ated by owner upon whom norices or other doc�ents may be served: �� o
a) Name and address: 3�
b) Telephone No.• Fa�c No. (Opt.) � v
8.In addition to hunself, owner designates the following person to receive a copy of the Lienor's Notice es provided in Section ��... o
713.13(I)(b), Florida Statutes: � �
a) Nama and address: p m
b) ?elephone No.: � Fax No. (Opt.) �� �
9.Expiralion date of Notice of Commencemeut (the expiration date is one yeaz from the date of recording unless a differcnt date is w� F+ �^
specified): !V c�
N °
3
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WARIVING TO OWNER: ANY PAYMENTS MAl)E BY TAE OWNER AFI'ER THE EXPIRATION OF THE NOTICE OF �
0
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COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAP1'ER 713, PART I, SEC'ITON 713.13, r ;
FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. �
A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST
INSPECTIOl�i. IF YOU INTEND TO OBTAIN FINANCING, CONSULT YOUR LENDER O AN ATTORNEY BEFORE
CONIMENCING WORK OR RECORDING YOUR NOTICE OF COMME N[ENT.
STATE OF FLORiDA
COUNTY OF PASCO
Signaturo of Owner or Owner's Authoriud OfficedDirecWdPufier/Mensger
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Print Neroe
The foregoing insuvment was acknowledged before me this day of 20�' by �
as (ty e of authority, e.g. officer, trust�e, attomey
in fact) for (name of p on behalf of wh in ment wes e ecuted).
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Personally Known �OR Ptoduced Ideetification _ Notary Signa
� Nota� �ud'
� Y K Stak N FI�� •.1�
Type of Identiftcation Produced Name (print) `(Q N�eNe Glass
�missi�n EE0325��
Em3Z�'�' �« n � Expires 71/OS/Z�14
Verification pursuant to SecYion 92.525, Florida Statutes. Under penalties ofperjury, I declaze that I ha read the oregom
the facts stated in it aze true to the.best of my lmowledge and belief.
i ature o amrel rson Signing Above
FORMSINOC.rvsd2007
STATE OF FLORIDA, CE�'�'�� p�`���
THIS IS TQ GERYIFY� CQ� Q DC1GlJM��T
TRUE ANQ CQRR�Sr.
ON FILE pR �HAND �FOCI�AL S AST
WIT S� _2�
__�=.�-- AY OF MPTROL R
�AULA S O'N C�ERK &
pUTY CLERK
BY.____. � -
ais-�ao-oo2o City of Zephyrhdls Permit Application Fax-813-780-0021
Budding Department
Date Received '� p7� �— l� Phone Contactfor Perm �in � �r -7S va
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Owners Name Owner Phone Number �ti 3.?.� � � t��
Owners Address `G �� - A � �- Owner Phone Number
Fee Simple Titleholder Name Owner Phone Number
Fee Simple Titleholder Address
JOB ADDRESS �'JG� = ��Z ��� � 7� �:t� a LOT # �+�Z ��
SUBDIVISION �17v\� PARCELID# 11 fl!"i iZ� V�i�� � -• dZ
�OBTAINED FROM PROPERTY TAX NOTICE)
WORK PROPOSED B NEW CONSTR � ADO/ALT 0 SIGN Q � DEMOLISH
INSTALL REPAIR
PROPOSED USE Q SFR � COMM 0 OTHER
TYPE OF CONSTRUCTION � BLOCK Q FRAME 0 STEEL 0
DESCRIPTION OF WORK NL.I�� d l�l�M S� � C1G\ tJS���
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BUILDING SIZE �� SQ FOOTAGE � 1 HEIGHT �
BUILDING $ VALUATION OF TOTAL CONSTRUCTION ��3 �'� ���_ .
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QELECTRICAL $ AMP SERVICE � PROG SS�� W.R E.C. �J /l � E ����,��
\�� t/YIG'<' .°ts�u�-�,u�-��- 'i � '
QPLUMBING $
�MECHANICAL $ VALUATION OF MECHANICAL INSTALLATION � /Z/go
�GAS Q ROOFING Q SPECIALTY � OTHER I
FINISHED FLOOR ELEVATIONS FLOOD ZONE AREA �YES NO �,/
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BUILDER f COMPANY (70 SCaI\ '� ^, pr �
SIGNATURE •�/r� REGIS7ERED Y N FEE CURREM1 Y/ N
Address �+ yp �$r{ �i1�+1 License# C.A�.(�j�d�..Cpl� �
ELECTRICIAN � COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N
Add ress License #
PLUMBER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURREf. Y/ N
Address License #
MECHANICAL COMPANY
SIGNATURE REGIS7ERED Y! N FEE CURRE� Y/ N
Address License #
OTHER COMPANY
SIGNATURE REGISTERED Y/ N FEE CURRE� Y/ N
Address License #
1 111111111111111111111111111111111111111111111111111111111111111111
RESIDENTIAL Attach (2) Plot Plans; (2) sets of Building Plans; (t) set of Energy Forms; R-O-W Permit for new construction,
Mimmum ten (10) working days after submittal date. Reqwred onsde, ConstrucLon Plans, Stormwater Plans w/ Silt Fence mstalled,
Sanitary Facilities & 1 dumpster; Site Work Permit for subdiwsions/large projects
COMMERCIAL Attach (3) complete se[s of Bwld�ng Plans plus a Life Safety Page; (1) set of Energy Forms. R-O-W Permit for new construct�on
Minimum ten (10) working days after submittaf date. Required onsite, Construction Plans, Stormwater Plans w/ Silt Fence installed,
Sanitary FaGtities & 1 dumpster Site Work Permit for all new pro�ects. All commercial requirements must meet compliance
SIGN PERMIT Attach (2) sets of Engineered Plans
"'"PROPERTY SURVEY required for all NEW construction
Directions: •
Fill out application completely
Owner & Contracror sign back of application, notanzetl
If over 52500, a Notice of Commencemen[ is required. (A/C upgrades over 57500)
" Agent (for the contractor) or Power of Attomey (for the owner) would be someone with notarized letter from owner authonzing same
OVER THE COUNTER PERMITTING (Front of Application Only)
Reroofs if shingles Sewers Service Upgrades A/C Fences (PIOUSurvey/Footage)
Driveways-Not over Counter if on public roadways..needs ROW
, NOTICE OF DEED RESTRICTIONS: The undersigned understands that this permit may be subject to "deed" restrictions"
which may be more restrictive than County regulations. The undersigned assumes responsibility for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESPONSIBILITIES: If the owner has hired a contractor or
contractors to undertake work, they may be required to be licensed in accordance with state and local regulations. If the
contractor is not licensed as required by law, both the owner and contractor may be cited for a misdemeanor violation
under state law If the owner or intended contractor are uncertain as to what licensing requirements may apply for the
intended work, they are advised to contact the Pasco County Building Inspection Division--Licensing Section at 727-847-
8009 Furthermore, if the owner has hired a contractor or contractors, he is advised to have the contractor(s) sign
portions of the "contractor Block" of this application for which they will be responsible. If you, as the owner sign as the
contractor, that may be an indication that he is not properly licensed and is not entitled to permitting privileges in Pasco
County
TRANSPORTATION IMPACT/UTILITIES IMPACT AND RESOURCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees may apply to the construction of new buildings, change of
use in existing buildings, or expansion of existing buildings, as specified in Pasco County Ordinance number 89-07 and
90-07, as amended. The undersigned also understands, that such fees, as may be due, will be identified at the time of
permitting. It is further understood that Transportation Impact Fees and Resource Recovery Fees must be paid prior to
receiving a"certificate of occupancy" or final power release. If the project does not involve a certificate of occupancy or
final power release, the fees must be paid prior to permit issuance. Furthermore, if Pasco County Water/Sewer Impact
fees are due, they must be paid prior to permit issuance in accordance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW (Chapter 713, Florida Statutes, as amended): If valuation of work is $2,500.00 or more, I
certify that I, the applicant, have been provided with a copy of the "Florida Construction Lien Law—Homeowner's
Protection Guide" prepared by the Florida Department of Agriculture and Consumer Affairs. If the applicant is someone
other than the "owner", I certiTy that I have obtained a copy of the above described document and promise in good faith to
deliver it to the "owner" prior to commencement.
CONTRACTOR'S/OWNER'S AFFIDAVIT I certify that all the information in this application is accurate and that all work
will be done in compliance with all applicable laws regulating construction, zoning and land development. Application is
hereby made to obtain a permit to do work and installation as indicated. I certify that no work or installation has
commenced prior to issuance of a permit and that all work will be performed to meet standards of all laws regulating
construction, County and City codes, zoning regulations, and land development regulations in the jurisdiction. I also
certify that I understand that the regulations of other government agencies may apply to the intended work, and that it is
my responsibility to identify what actions I must take to be in compliance. Such agencies include but are not limited to:
- Department of Environmental Protection-Cypress Bayheads, Wetland Areas and Environmentally Sensitive
Lands, WaterlWastewater Treatment.
- Southwest Florida Water Management District-Wells, Cypress Bayheads, Wetland Areas, Altenng
Watercourses.
- Army Corps of Engineers-Seawalls, Docks, Navigable Waterways.
- Department of Health & Rehabilitative ServiceslEnvironmental Health Unit-Wells, Wastewater Treatment,
Septic Tanks.
- US Environmental Protection Agency-Asbestos abatement.
- Federal Aviation Authority-Runways
I understand that the following restrictions apply to the use of fill:
- Use of fill is not allowed in Flood Zone "V" unless expressly permitted.
- If the fill material is to be used in Flood Zone "A", it is understood that a drainage plan addressing a
"compensating volume" will be submitted at time of permitting which is prepared by a professional engineer
licensed by the State of Florida
- If the fill material is to be used in Flood Zone "A" in connection with a permitted building using stem wall
construction, 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 properties, 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
permit issued shall be construed to be a license to proceed with the work and not as authority to violate, cancel, alter, or
set aside any provisions of the technical codes, nor shall issuance of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans, construction or violations of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced within six months of permit issuance, or if work authorized by
the permit is suspended or abandoned for a period of six (6) months after the time the work is commenced. An extension
may be requested, in writing, from the Building Official for a period not to exceed ninety (90) days and will demonstrate
justifiable cause for the extension. If work ceases for ninety (90) consecutive days, the job is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMP VEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOU NDER O AN ATTORNEY BEFORE RECORDING YOUR N TICE OF COMMENCEMENT.
FLORID (F .117 )
x OWNE � CONTRACTOR
S �1�� b . s ,�! i ed and sworn to r affirmed) before me this Su scri ed and swor e be re me this
� � � �bY SS I1 / I by � ( ( �
Who is/are personall nown to me or has/have produced o s re personally known to e or has/have oduced
as identification as identification.
�Nct�ry Public '�.-��1� Notary Pub6c
Commission No. L�%�,�.� �� ommission No. �� �� ���
Name o ty e printed or stamped Name of Notary typed, pnnted or sta ,��a�� .� M ��
��+"'��.* N�tary PuWic State of Flpr{d� * * MY COMMIISS�tV e DD 9961lS
Nic�te Glass �, � EXPIRES: May 30, 2011
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GOLDEN SANDS
■
June 27, 2011
Building Department
City of Zephyrhills
5335 8`� Street
Zephyrhills, FL 33542
RE: Authorization for permit processing
I, Mary F. Maguire, as qualifier for GOLDEN SANDS GENERAL CONTRACTORS, with
State License Contractor No. CGC 062617 hereby designate the following persons to
obtain/pull permits on my behalf:
Claudio Pastore �
Micah Henry �
Matthew Garrett
Kin Chan �
Witness:
Witness:
Sincerely,
,.,_—�
SIG LICENSE HOLDER
Mary . aguire — President Signed this 27�' day of June, 2011
STATE OF FLORIDA
COUNTY OF POLK �
Sworn to and subscribed before me on the ��y of -� � � �
X�� Personally Known to me or ,
Produced as Identification �
�t';: SANURAAMMiDTT �I �
h47 COAIk11SSt0�i t DD 9961�
*�� * o Public State of Florida
�, �� e�aee��e�ci���� y Commission Expires OS/30/2014
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Bank of America �
January, 31 2011
Building Department
RE: Banlc of America Facilities within the State of Florida
To whom it may concern:
This letter is intended to notify interested officials of the local municipality, that Bank of America, NA
has appointed CB Richard Ellis, as its agent. As facility partner, CB Richard Ellis is the authorized
agent to represent Bank of America in connection with the development of renovation plans, including
withaut limitation in connection with obtaining existing drawing, landlord approval, applications for
plan review, development orders, site permits, building permits, and other goveinment peimits and
approvals. This authorization is valid tlu•ough December, 31 2011.
Accordingly, the interested officials are authorized to recognize Bob Henderson with CB Richard Ellis
as Bank of America's agent in connection with the above matters.
Sincerely,
� ._.�--- n ---
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hn Demo
r. Vice President
Coiporate Real Estate
The foregaing instf•a�ment tivas acknotii�ledged befor i�1e on this 31 d�ry of � by _
�ti,N t�-.��, tiv I70 IS C! SI'. V1CC PTCSICICI?/ O� BGi1IC Of A!?1B1'1CCl G/?G� 1V is personall noti��n to me.
��� �W. i�lotary Public Siate ot Florida
�h Gregory R Weiser
� 3 My Commisabn DD936822
�ofa� Expirest0129l20 "'-�--..,,�,,,�
Notcn y Public, State of Florida
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GOLDEN SANDS
�
Requested Contact Information
Golden Sands General Contractors, Inc.
2500 NW 39"' Street
Miami, FL 33142
Phone: 863.984.7500
Fax: 305.984.7550
If you have any questions or concerns, please feel free to contact us.
Claudio Pastore
Project Manager
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,' �'�C�f � o � ,^ � STATE OF FLORtDA
�' DEPARTMENT OF BUSINESS AND FROFE'SSI.ONAL REC,ULA:TION
I�;, I CONSTRUCTI'ON TNDUSTRY LICENSING BOARD
r , , S�Q#L1Q08020],1�.�
� ; �:I , LIGENSE NBR ,����� y,a '�',�' _�.
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' ���; I The G�NERP�.L CON.3'RACTOR� �:�,�,,� � , �,. "� ._ ....' .� ' ,"�'', �
'; ,,;'� Nazned below TS CERTIFTED ��"?,��. ,.`�, ' '�'�=''� �
z i � ��, �✓,
'+,' Un.der the provisions of 'Chapt��;E�$?�,;���� �.��,� „-��,'�}
Expiration date. AUC3 91, 2012 ��',-�+ �- �����%:;�;
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, MAGUIRE. MARY FRANCES � • ��� i` ;;,.�x�' � �
GC1LD N SANDS GENERAL CONTRAC� x `�"'"f �,�.��,
,� 2500�N W 39TH ST Q � ,-..:�., '�:��,
> MIAMI FI; 33142� , �`��
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{ CHAI2LxE CRIST CHA,�t�,�E LZEM
GOVERNO$ $�GRE'T'A;RY
'; ° DISPLAY AS REQUIRED BY LA1N
'
I MIAMI-DADE COUNTY 2010 LOCAL BUSINESS TA) '� 2011 FIRST-CLASS
t ` '` TAX COLLECTOR MIAMI-DADE COUNTY� ATE OF FIORIDA " U.S. POSTAGE
, 140 W. FLAGLER ST. EXPIRES S T. 30, 2017 tl PAID
'° 1st FLOt�R MUST BE DISPLAYED AT INESS � MIAMI, FL
'$„ , MIAMI, FL 33130 pURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9& 10 PERMIT NO 231
�� i i IIS !S f•!fl'1' A E31LL - UO NOT PAY
i,„ 463228-8 RENEWAL
� I � CiUSlNESS NAME / LOCATION RECEIPT NO. �/836Z5 1
GOLDEN SANDS 6ENERAL CONTRACTORS STATE# CGC062617
', '� I NC
�,� 2500 NW 39 ST
,,� 33142 UNIN DADE COUNTY
P;,`� OWNER
_,;;� GOLDEN SANDS GNRL CONTRACTORS IN
Ar; � Sec. Type ot Business WORKER/$
196 GENERAL BUILDIN� CONTRACTOR 3
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BUSIMlEuS TA% RECEIPT li
-.,^� DOES NOT PERMIT THE
HpLDEN T6 VIOLATF �1NV
„ E%1371NG RF_GULA70RY OH
'� t N L6NING LAWS C1F iF1F
�`�a cour+Tr or� cnies, no�� DO NOT FORWARD
�•;,.,,A ooes ir exrraNr rriF.
MOLpER FIIC)M At1Y OItILR
,;��,},: ¢ VEHMII ()P I ICCN:iE
� r REOUIRED BY LnVJ ,�,�� �ti GOLDEN SANDS 6ENERAL CONTRACTORS
NOT A CERTIFICAf10N OF
THE NOlOER'S OUAIIFICa� I NC
TIONS
i;,r� � MARY F MAGUIRE PRES
vavns�r�riaeceiveo 2500 NW 39 ST
' �t i �.� MIAMI-UAUf- CUUNTY TAk
.�:,� ����r�T��+ MIAMI FL 33142
i'r`°°' 07/09/2010
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ACORD CERTIFICATE OF LIABILITY INSURANCE odiiiizoii'
PHJDDUCER �305)822-7800 FAX (305) 558-4294 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Col l i nsworth, A1 ter, Fowl er & French LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
8000 Governors S uare Bl vd HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
q ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 301
Miami Lakes, FL 33016 INSURERS AFFORDING COVERAGE NAIC #
INSURED Golden Sands General Contractors, Inc INSURERA: /��p'lSUre I115Yr'dflGe Co 19488
2500 NW 39th Street iNSUaeaB: Amerisure Mutual Ins Co 23396
Miami, FL 33142 �n,suReRC: Federal Insurance Company 01295
INSURER D:
INSUREF E.
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTW ITHSTANDING
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY GL2066108 OZ�OZ�ZO11 OZ�OI�ZO12 EACH OCCURRENCE $ 1� OOO � OO
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ZOO � OO
CLAIMS MADE � OCCUR MED EXP (Any one person) $ ZO � OO
A X BLANKET ADDTL INSD PERSONAL & ADV INJURY $ 1, 000, 00
X BLANKET WOS GENERAL AGGREGATE $ Z� OOO � OO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Z� OOO � OO
POLICY X PR � LOC
JECT
AUTOMOBILE IIABILITY CA2071489 OZ�OZ�ZO11 OZ�OI�ZO12 COMBINED SINGLE LIMIT
X ANY AUTO (Ea accident) $ i 000 00
ALL OWNED AUTOS
BODILY INJURY $
A SCHEDULED AUTOS (Per person)
X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO EA ACC $
OTHERTHAN
AUTO ONLY� AGG $
EXCESS/UMBRELLA LIABILITY CU2066105 OZ�OI�ZO11 OZ�OI�ZO12 EACH OCCURRENCE $ S� OOO � OO
X OCCUR � CLAIMS MADE AGGREGATE $ S� OOO � OO
B $
DEDUCTIBLE g
RETENTION $ $
WORKERS COMPENSATION AND WC2066106 OZ�OI�ZO11 OZ�OI�ZO12 X WC STATU- OTH-
EMPLOYERS' LIABILfTY y
/� ANY PFiOPRIETOR/PARTNER/EXECUTIVE % E.L. EACH ACCIDENT $ 1� OOO � OO
OFFICEFVMEMBER EXCLUDED? v E.L. DISEASE - EA EMPLOYEE $ 1� OOO � OO
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 1� OOO � OO
RIME 82214761 02/O1/2011 02/O1/2012 EMPLOYEE TNEFT $1,500,000
� PREMISES $1,500,000
$50,000. DED. IN TRANSIT $1,500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
C7 ty of Zephyrh i 11 s 3O DAYS WRITTEN NOTICE 70 THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Bu i 1 di ng Department BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
533 5 8th St reet OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Zephyrhills, FL 33542 AUTHORREDREPRESENTATIVE �
Michael Nielson/SANDYS
ACORD 25 (2001/08) OOACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s)
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
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