HomeMy WebLinkAbout13-14729 � CITY OF ZEPHYRF�iLLS � �
5335-8TH STRF,�T ��
(si3)�so-oo�0 14729
FIRE WORKS�PERM
Permit Number: 14729 ddress: 70�" ALL BLVD
Permit Type: FIRE WORKS ------ �EPHYRHILLS, FL.
Class of Work: FIRE WORKS Township: Range: Book:
Proposed Use: MEDICAL Lot(s): Block: Section:
Square Feet: Subdivision: CITY OF ZEPHYRHILLS
Est. Value: Parcel Number: 35-25-21-0010-10500-0000
Improv. Cost:
Date Issued: 11/20/2013 Name: FL HOSPITAL OF ZEPHYRHILLS
Total Fees: 530.00 Address: 7050 GALL BLVD
Amount Paid: 530.00 ZEPHYRHILLS, FL. 33542
Date Paid: 11/20/2013 Phone: (813)783-6189
Work Desc: SPECIAL EVENT SHOW FOR CHRISTMQS TREE DISPLAY DECEMBER 8, 2013
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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.
"FIREWORKS" per Section 791.01, Florida Statutes are considered as any combustible or explosiv�
composition or substance or combination of substances or,except as hereinafter provided,any article
prepared for the purpose of producing visible or audible effect by combustion,explosion,deflagration, or
detonation.
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�..k-'`�- �- �1 S��,4�`�t>s`1
ONT TOR SIGNATURE PERMIT OFFICER '�
PERMIT EXPIRES IN 6 MONTHS WITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - 8 HOURS NOTICE REQUIRED
ZEPHYRHILLS FIRE RESCUE DEPT- 813-780-0041
NOV/15,/2007/THU 04: 59 PM ZEPHYAHILLS BUILDING FAK No, $13-780-0021 P, 002
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• �5335 8�'SEteet • .
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• � • � �PLone:•813=780-0420/�'�:913-'78d-0OZl ' . .
�Q�NT6 ' � ' . .
'�;_ .P1ot Plan shoa►ing s@tup of Iocation. • . • � ' .
� ' Notarized�lctter fromproperly ownex sta.ting their appxoval. � .
•A'f1a�.aretarda�.t cati�cats is'requircd7F a tent is�involved.�spection is require�onco tent . '
� is earected aild,pYtox to ogcning fos buainess, • • . , . •
. Apprdv'ed cerEified fire cxixnguishers per N�PA 10. �
• � � No SmQking signs must ba plaaed outside eatrances. ,' '
' • IF there�xs a wiro f.�ce or chain l�a�c fe,�cing musti 3ia�ze ati least�5 Ft setback�'i'om tent a�at least
. � a exits. � � � � � � �
• �tent has sides��sides sball be in tb,e up position unless thexe is inclem.Pnt wesLlur, ,
thes�2 sides must be.ia the up poaition.. � • ' , • y�7,� �lr�,
�.r ..r'� rie��r S7f�'l-wt EFi11.�'Y�'
/� �L��y \ I�l-S 7 7 ZTTr"i L L
1'li�L7�YQI�.LL QUJ.Lti'+1Y.4�31V1►7�'��I.1�.�WGili7�vPi/ '+ l�l-I-���
Pxoof of Stata Y,icense. ' pace. 3 �---���� •
� .� �roof of Liability insuraucc. '=c�"�v�: -4-►-�'��� -
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' Y,ist of itm�s�to be sold at szte. " • • , • .
�,/ Gopy of br3vers Y,ice�se and Social Security Number of all personnel dealing
• with thc sa],e of fireworks at the tent locauon. � •
FFEs • � ' • ' ' • .
• . �G_ �$30.00--Ciiy Registration.(7f R�gulat�l.by.D�PR-Fee�s W sived}
. ' X $500.00-'FireAVOrks fco-Fire Dapartm.ent f�e ' ' . •
� $ S.00�Temporazy Sales Fee fot 1``two days ' • . � . . .
$ i:00-'�'empararS'Sales�'ea�per day for eaah consecuti�e day theiea�er,aot to , .
• ' exc�cd d�atioa o�30 consocuti'va days arid�no more thsn on�occtRxenee • , .
. ' � per calen�ar year per ordfnance#408. � . •
. $50.00-�'e�nt Feo(35.00BD, 15.00*/FD)-{"'515.00 waivedfosFireworlcs)
. ' • $3S.OU-Electrical Fee('�£applicable) � ' • . . • .
ProperCy'O'ov�r: ' Florida Hosvtial Zephvrhills ' �
• App]icant; � ' Pyrotecnico ' : , '
Phone�ContaCt' • Marsha LeFebvre - 800-854-4705 • ' ' .
, AddresSStte: ' 7050• Ga11.Blvd. Zephyrhills, FL 33541 ' ' _ '
� Da�o£s�: � � 1 a.1�I I�� . . . .
• OrdinanceNo.408 dated.l/26/198?'(fbr additionat rcquirements) • • � . .
Federal Explosives �icense/t°�e mi�
U.S.Depa�iment of Justice (18 U.S G Chapter 40)
Bureau ofAlcohol,Tobacco,Fireamia nnd Bxplosives ii��wwu��oxNrnaauuwui
In accordance tuith tlie provisions of Titic XI,Organized Crime Coirtrol Act of 1970,and the ngulatione issued tlureunder(27 CFR Part 555),you may e��gage in
tl�e activity specificd in tlus lixnae or permit witl�in tue 1'unitations of Che}rter 44�Tit�a 18,Unitod States Code and tlie rogulatioua issued thcreunder,wtitil the
expiration date slirnvn. THIS LICE SB IS NOT T NSR 2 C .R�Ss See"WARNII�T(3S"aud°NOTTCES"on roversa.
Direct ATI' ATF-Clue�FELC Licra�saPermit� � �
Cor��espondence To 244 Needy Road Nuntbet � " � �
Mutinsb WV 25405-9431 .
Chief,Federal Ex losiaes Lieensing Center(FEI. � Expiration � ^
• / _ . �� ��„e,A Date • � �
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PYROTECNICO
Premises Address(C�umges7 NotiPy tbe FELC nt IeaR 10 da}s befae tlu n�o�•r.)
299 WILSON RD
NEW CASTLE PA 16101-
Type ofLieense orPermit
23-IMPORTER OF EXPLOSIVES
Purohasuig CaRiScation Statement Mailing Adc)ress(Cl�anges7 Notify the FELC of any changesJ
Tl�e licauea or pamiltee nemed above ahall uee a copy of this license c+r pamit to assiffi a
tre�isfera of explosivmtovvitj�the idmitiry and tl�a licensrd slaais aftba licnicea ar
permittee as providt�dby 27 CFRPert SSS. Iho si ature on each�row musf be m�oriainal S VITALE PYROTECHNIC INDUSTRIES iNC
sia�ature. A faxecif ed or eanailed eopy ofthe licensa or prnvit�cith a ugiature
urtendcd to he en orr iguature is ecxxptabla. 'lbe aigpalurt nwa bt that oftha Feduul PYROTECNI CO
Baplosives Lica�see L) e responsiblo pason of dio FEI,.. 1 rmifi�Ihat tl�is ie a true PO BOX 149
copy of a licaise oK i t i r.d to Uie lica�sea a'pamittae nemrd abo�•a to mgage di tl�e N E W CAS i LE, PA 1 61 03-01 49
busin �,.p,�er a se�� e under"'1)�e of Licaisa�P�e �it"
�fr ..-- ,�`i��s j A er��
Licciisee/Pcm»ttctR sponsiblcPerson Signature Poeition,�Title
���t��� J !��1-,L�., lo-z�I�
Printed Name Date ,a'[F Fcrm saoo.►�s+oo.i s ran t
PreviousfiditionieObwleta aMa�►r�m�cw����a+��u��'�+'n'u":i�i,miaa+�xeneearn�nea��
Revised Octobu ZOl 1
Federal Explostva Ilcense(FGL)G�estomev Service In4'orknation
Federal Fa:plosives Licensing Ceater(FELC) Toll-free TelephotteNumber. (87T}283-3352 ATF Iiomepage:�vww.atf.gov
1A4 Neody Road FaxNumber: (304)616-0401
Mertiusburg,WV 25405-9431 E-maii: FELC(c�at£gov
i�►ange of Addres9 (17 CFR 555.54(q)(1)J. Licensees or penuittu.s may during the tecm of the�it cwre�6aaue or permit remove their business or operations to a
new location at whicli they inteud regularly to carry on sucli busincss or oporations. Tlie licensw or pemaittee is required to give notification of the new location of the
business or op�rations not lesa than 10 days prior to sucl�removal with tha Clua�Fedaral F�cp]osives Licansing Center. T6e license or permit will be valid for the
remaindcr of tho tr.nn ofthe original licensn or permit, (11►e Chief,R$LC,�►all,ff tt►e dcensee or petnsittee is not qualE6ed,xefer the request for amended I�c�se
ar pern�it to the Dlrectoe of Tr+dustry Opea•■a�s Foz�d�ial in accordanca with§555.5�.)
R1gFc�of Successfos (2y CFR SS5.59). (a)Certain persons other fl�an the lieenea or permittee may sxun the rigl�t to carry oa the samo cxplosivc materinls
�usiness or operstions at ti�a same addreas shown ai,and for the remainder of tl�e term af,a ourrent liccnso or parcnit. Sucl�pasona ar�: (1)The survivu�g spousc
�r child,or exceutor,administrator,or other legel representative of e deceased Geensee or permittx',and(2)A re�eivcr or trustee in bankruptcl�,or an assignee for
�enefit of creditors. (b)In order to secure tl�e rigl�t providul by this section,the person or persons continuing tl�e business ar operatione shsll fumish the ticense or
�ennit for for that business or operations for ondorse�nw�t of such succession to tl�e Chief,FELC,within 30 days froin the date on which the sucaessor bcgins to
:arcy on the business or operations.
(�onBnued on re+�erse side)
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�'e�3ey�l L��lQSdv�s LirrtasalP3a�e9t(ia'EL)Inf�ima»+on�.'asu� �
Lieense/PermitName:S VITALE PYROTECHNIC INDUSTRIES INC I
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BusinessName: PYROTECNICO �
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LiceuseJPerniit Numbcr:8-PA-0T3-?3-5J-12122 �
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Liea�se/Permit Type:23-IMP.ORTER Ot'EXPLOSIVES �
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�.xpiration: September 1,2015 �
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Pleuse Note: Not Valid far tl�e Sale or Other Disp�ition of Explosives. I
.4co� CERTIFICATE OF LIABILITY INSURANCE °"�`""�°°""Y",
`,r,i 08l28/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BEL�IV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEENTHE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcate holder is an ADDITIONAL INSURED,the policy(fes)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of the pollry,certaln policies may require an endorsement. A statement on this certiHcate does not confer rights to the
certificate holder in lieu of such endoraement(s).
PRODUCER �E; Melanie Allen
MCGRIFF,SEIBELS&WILLIAMS,INC. PHONE 800„4��y22�� FAX
P.O.Bou 10265 p!C No:
Birmingham,AL 35202 E-MAI� maU m rdf com
ADDRE88: � � •
INSURE S AFFORDINO COVERA6E NAIC/!
INSURER A:RLI Insurence Com an 13056
INSURED iNSURER e:James River Insurance Com an 12203
S.Vitale Pyrotechnic Industrfes.Inc.dba Pyrotecnico
P.O.Box 149 INSURER C:Catlin S ecia lnsurance Com n 15989
New CasUe,PA 16103
INSURER D:See BelOw
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:7QNXBZT8 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
INDICATEO. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT 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.
IN8R POLICY EFF OLIC EXP
LTR TYPE OF INSURANCE POUCY NUMBER MWD MIDD LIM�TS
B ceNEw►�unsi�m 00292605 0111412013 01l14/2014 1,000,000
enctt occuaRer�cE s
X COMMERCIAL GENERAL LIABILITY PREMISES Ea ocarrence S 100,000
CIAIAAS�AADE �OCCUR MED EXP(My one person� $
PERSONAL 8 ADV IN.IURY $ 1,000,000
GENERAI AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPlOP AGG 5 2�000,000
POLICY X PR�' LOC POIi re ete: S 5,000,000
A nuroMOei�unsluTr LFT0012741 01/14/2013 a1H4/2014 SINGLE LIMIT
Ee acdden� S 1,000,000
X ppry pUTp BODILY INJURY(Per pereonj S
ALL OWNED SCHEDULED BODILY INJURY(Par accident) S
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY OAMAGE a
Trlr InlerChg �TOS Per accldent
X Stmil Comp.52500 deductible Coll.$2500 deductible
B UMBRELLA LIAB X pCCUR �292625 01114/2013 01/14/2014 EACH OCCURRENCE S 4,000,000
X EXCESSLIAe C�q�M&MADE AGGREGATE $ 4�000.000
DED RETENTION S t
D woRKERE CoNPENSATION 738720960102-CalHornia lns.Co p8/p7/y013 08/07f2016 X wC STA7U- OTH-
IANO EMPL.OYERS'LIABWTY y�N 38720960101-Contlnental Indmnity R
ANV PROPRIETORIP11ftINERIEXECUTNE �• E.L.EACH ACCIDENT j 1.000,000
OFFICERIMEMBER EXCLUDED9 � N�A (Blanket Waiver of Subrogation Incid)
(MandaWry In NH) E.L.DtSEASE-EA EMPLOYEE S �•����
Ifyaa desaibs under
DESCRIPTION OF OPERATION3 below E.L.DISEASE-POLICY UAAIT 5 �•��•�
C EXCESS UMBRELLA OVERAGE SA2002600114 01H4l2073 01H4/2014 XS Underlying 4,Mil 5,000,000
S
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DESCRIPTION OF OPERATIONS/LOCATION8 f VEHICLES (Atheh ACORD 101,AddHlonal Rsmark�Sch�dula,H more spsu is roquhed)
Fireworks Display Date: December 8,2013
Location Florida Hospital Zephyrhllls,south parking lot,7050 Gall Blvd.,Zephyrhiils
City of Zephyrhllls,FL
The above listed are Additionai Insured respects to Generel Liabflity policy as required by written contrect subjed to policy terms,conditions and exclusions.
The Cert�cate Holder is Additlonal insured with respect to General Liability as required by written contrect.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELtVERED IN
ACCORDANCE WITHTHE POLICY PROVISIONS.
Florida Hospital Zephyrhills AUTHORIZED REPRESENTATIVE �--""•�
7050 Gali B1vd.
Zephyrhills,FL 33541 \,�'p��y�1.,u,�s,.��
�
Page 1 of 1 p 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
��v;.w l�a�-° t 1 �, I � I I�
813'��'�Z� City of Zephyrhilis Permit Appiicalion Fax-813-760�0021 i�t ���^ ��
BWldinp DspaMwnl � � i
Dam Raca{vod phon�ConUCt fo�Pormlttin I � �/—�3
.- �`%
Ovmera Name FIOIlde HOSplt81 Zephyi'hIIIS Owmr Phons Numbar 8�3.783.6192
ormsrs nddrsss �050 Gell Blvd.,2ephytfiills,FL 33541 pym�r Phone Number
Fes Sfmplo TiUaholdor Nama Ownar Phona Mumbor�
Fee Simpio Titlehold�r Addnas
J08ADORESS 7050 Gall Blvd., Zephyrhilis, FL 33541 �ora �
SUBOIVlSION ���� PARCEL IDM
(OBTAINED FROM PROPENTY T�7(!lOi1CF.)
WORK AROPOSED e NEW CON3TR e AIN7IALT Q SIGN Q IAOVE Q DEhSOLISH
INSTALI RFPAIR
PHOPOSED USE Q 3FR Q CO�dM � OTHER
TYPE OF CONSTRUCTION Q BLOCK Q FFWAE Q STEEL Q OTHER�—�
OESCRIPTION OF WORK Fireworks dispiay for Holiday Tree Lighting
BUILDIN6 SIZE SQ FOOTAGH��� HEIOHi
���
Q BUILDING r VAIUATION OF TOTAI.CONSTRUCTION
�
Q ELECTRICAL $ AMP SERVICE Q PRO�R[SS ENERGY O NI.R.E.C.. �
Q PLUAtBING IS—� •�� 2-
� MECHHNICAL 'S VALUATION Of MECHANICAL INSTALLATION � (
��
Q GA3 Q ROOFING Q SPECIALTY Q OTHER
FINISNED FLOOR ELEVATIOMS FLOOD ZONE AfIEA QYES QNO
BUILhEIt COMPANY �
S16NA7URE � aeo�srEaeo Y/N FEEGUARENT Y!N
Addrecs �— I License R I �
ELECTRICIAN� � COMPANY �
SHiNATURE rtEasTeqEO Y J N FEE GURqEf1f Y 1 N
Add�ass �� lixnse 7 �~�_._.__...�
PLUMBGR � � COMPANY � '-----'J
SIGNATURE REGISiEREO Y/N �� FEE CURIiENT Y!N
Address �—' _ Ucensai r��
MECHANICAI� �� COMPANY �
SMaNA7URE � RE619TEf�0 Y I N �e cuar�T Y!N �
AJd�esc � License il
OTNER �� tin�'stop e COMPANY �— �
SI�NATURE � �e� �p/Yj Aea�sreaeo YI N FEECURPEf7T Y!N
Address PO Box !49 NeW Castle,PA 16103 Llanso� �
RESIDENTIAL Atte[h(2)Plol Plans:(2)sets ol8ulldN�p Wsnr,it)sal of Enerpy Fams;R-O-W Pemiit fw new eansHUCUon, 9
Mtnlmum kn(10)+vaking days aRer subn�itlai dale. Req�drad ons�e,Construedon Plans,Stortmveter Plana w/Shc fenco ins�aucd,
Ser�ary f ac7itlet d 1 dumpslar,SI1e Work Psrmit tor su�dNiabnsAarpe projeUs
COAIMERCIAL Atlad�(7)oornpleto uls ol Bu�dinp Plsns yWs a life Safey Paye;(t)sel af Energy forms.R-O-W Pormfi lor now caia6uGion.
ktinimum ten(10}�voAcHg deyt eftet wbmiMa!dale. Requked onsNe,ConsWCdon Plans,Slomrv�ater Plans vd 31t Fence i�siaAeJ,
SanNsry FaciHfes 6 1 dvmpster.Ske WoAc Pmrnll Por all�aw proJed�.All oorm�erclal raquirnmeMs musl moet compNenw
SION PERMIT AuaWf�2)sab ol EngheerOd Plens.
'••'PROPERTY SURVEY requked for s1 NEW consUucgon.
Olroclions:
F�oW applcal{on aomplelely.
O�vner 6 Conlrada slpn beck of applitatlon,notaAzed
if ovar S2S00,e Nolice oi Commencen»nl ls r�qulred.�AIC upQrados ovor 55000)
" /�psnt(tw IAe conVeUOr)o�Power ot Atlomey(fa Ihe avner)vrould ba someone w1�h nola�ized letler trom m•mer au�horizinp sama
OVER THE COl1NTER PERMITTIM(i (Fronl of App�celton Only�
Remofa Sewere Servke Upgrodas NC fenceg(PbUSurvey/Footaqe)
DrivawsyuNot wer Gountet il on pubGc roadvtays..need�ROW
NOTICE OF DEED RES7RICTIONS: 'Iha undersfgned underslanda that ihis permlt may be subJect to"deed"restdcttons"
whlch may be more restrk�ive than County regulaUons. 7tre underslgned assumes responsibility for canpliance with arry
applicable dead reslriclbns.
UNIICENSED CONTRACTORS AND CON7RACTOR RE3PONSIBILITIES: If the owner has hked a contraGOr or
r,oniractors to undertake�vork,they may be requked to be Iicensed in accordence wiih stale and iocal regulaUo�s. If the
oontrector is not Ilcensed as requlted by law,both the amer and coMractor may be cHed for a misdemeanor violaUon
under state law. It the owner or Inlendad conUaclor are uncerialn as lo whel Ilcensing requiremenis may appy for the
Inhsnded work,U�ey are advtsed to�ntact the Pasco County Bufldtng InspecUon Divislon—Lkensing Sectlon at 727•847-
8009. Furihermore, it ihe owner has hired a coMractor or contradors, he is advfsed to have ihe conlraclor(s}sfgn
portiwis ot ihe'wntractor Block'of thie appNcaUon for wMch ihey wHl be responsibte. Ii you,as the owner sign as tha
c�nUector,that may be an trxilcafion that he ts not properly Ncenaed and Is not enUtied to permflGng prMleges in Pasco
County.
7RANSPORTATION IMPACT/UTILITIES IMPACT ANO RE80URCE RECOVHRY FEE9: Tha undersigned underslands
thet Transportalton Impad Fees and Recoutse Recovery Fees may appy to the constn�ction of new bulidings,change ot
use in extstlng buiklings,or expanglon of exlsling bufldtngs,as apedfled in Pasco Counly Ordinance number 89-07 arxi
90•07,as�nended. The undarsi9ned also undetstands,Ihat such(ees,as may ba due,wili be IdeMifled at the tlme of
permitUng. It is furlher understood that 7ransporlatlon Impact Fees and Resource Recovery Fees must be paid pdor lo
reCeiving a'ceNflcate of occupancy"or flnal power r�ease. It the proJect does not tnvdve a cariilicate o(occupancy or
flnal pmwer relsase,the fees mus!be pafd prbr to permit issuance. FurlAermore,It Pasco County WaterlSewet Impact
fees are due,they must be paid prbr to permit isauence In ac:wrdance wNh appilcable Pasca County ordinanc$s.
CONSTRUCTiON LIEN LAW{Chaptor 715.Florlde Stetutes,as amended): if valuetion of work is 52,500.06 or mora,1
certtiy ihal I, the applicant, have been provided with a copy of the "FlprWa Conetruction Lien Law�—HomQOwner's
HrotecUon 6ulde"prepared by the Flortda Depsrtment of Agrlcuilure and Consumer AHalrs. if the eppl�ant(s someone
oiher ihen ihe'ovme�',1 certity Uiat(have obtained a wpy ot the above decaibed document and prortdse in good failh io
deliver it to the'ovmer prior to commencement.
CONTRACTOR'SIOWNER'3 AFFtDAViT: I certlfy ihat atl the intormetlon tn this applicafton Is accurate and that ail wwk
wlll be done In comptlance with ak eppitcable lews reguleUng consiructton,zoning and land development. ApplicaUon is
hereby made to obtaln a permit lo do work snd (nstaNaqon as lndicated. I ce�iy Ihat no woric or instaqation has
commenced prior to issuance of a permit arW that all work wlll be perfwmed to meet standards ol ail iav�s regulaling
caulructlon, Counly aix! City cndes, zoning regulatlona, and larxl devebpmeM regulaUons in the Jurisdicllon. I aiso
certi(y that 1 understand lhal ihe regulatlons of olher govemment agencios may apply to the intended wwk,and that il is
my responsibiply to idenNfy what actlons I muet take lo be fn compltance. Such agencles include but are nol IimHed to:
- Department of Envlronmental Prolecttan-Cypress 8ayheads,Wetland Areas and FnvironmeMally Sensilive
Landa,WaterANssiewaler Treelment.
- Soulhwest Florida Water Managoment DlstAcl-Wells, Cypress Bayheads, WeUand Areas, Aitering
Watercourses.
- Army Corps o(Englneers-Seawalls,Docks,Navlgable VYaterways.
- Depertment o# tiealif� & Rehabltltatfve ServiceslEnvironmenlal Heallh Unit-Welis, Wastevrater Treatment,
SepUc Tanks.
- US Environmental ProtecUon AgencyAsbestos abatement.
- Federal Avfatlon Authaity-Rumvays.
I undersland ihet the tofloadng re�ldctions apply to the use of fill:
- Use of OII is not allo�ved fn Fbod Zone'V"unless expressiy permitled.
- If the 811 maiedel is lo be used fn Fbod Zone "A', it is understood lhal a dralnage plan addressing a
"compensatlng volume'wili be submltted at Hme of permitting vihich ts prepared by a professional en�ineer
Ilcensed by Ihe State of Florida.
- If the fill mate�lal Is to be used in Flood Zone'A'(n connecilon v�ith a permftted buildirx�using slem v�ali
cons[ruction,I cerlify that flll will be used only lo fill the area wilhin Ihe siem vrall,
- If ful material is to be used in eny area, I cedify thal use of such fill will noi edversely aHect adjacent
prope�t(es. if use of fill is tound to adversely atfect adJecent propeRies,the owner may be dfed tor violating
ihe condfitons ol the bulldirg permit iesued under Ihe atlached pem►It applicallon,tor lots less than one(1)
aae whlch are elevated by flll,an englneered dralnage plan is required.
if I am lhe AaHNT FOR THE OWNER,I promise in good falth to Inform Ihe owner of Uie permilting conditloiu sel forUi tn
this a�davit pdor to commencing consWclion. I understand Ihat a separate permit may be required Ior electr(cai�rork.
plumbing,signs,wells,pools,alr condtponing,gas,or other InstallaUons not spediicelly Induded in the applicatlon, A
permtt Issued shalf be construed(o be a Ilcense(o procesd wilh ihe work and not as authodty to vlolate,cancel,aiter,or
set aslde any provisfons of the technical c4dea,nor shaA issuance of a permit prevent lhe f3uiiding Offidal(rom therea�ter
requlrkig a corcecUon of errors fn pians,constructlon or vtdaUons of any codes. Every permit Issued shall become tnvaYd
unless tho vio►ic aulhorized by such permit Is conxnenced wfthin six monlhs of permit issuance,or it work authorized by
the permit Is suspended or abandoned for a perlod of six(B)months aNer Ihe time Ihe urork Is commenced. M extenslon
may be requasted,fn wriBng,from ihs Duilding OHida1 tor a period not fo exceecl ninety(9U)days and will demonstrate
justiflable cause for the extenslon. If work ceases for ninefy(90)consecutivo days,the Job is conaldered abandoned.
WARkiNG TO OWNER: YOUR FAILURE TO RECORD A NOTICH OF COMMENCEMENT MAY RESULT IN YOUR
PAYINCi NVICE FOR IMPROVEMENTS TO YOUR PRaPERTY. IF YOU INTEND TO OBTAIN FINANClNO,CONSULT
WITH YOUR LENDER OR AN ATTQRNEY BEFQRE RECORDINO YOUR NdTICE OF COMMENCEMENT
F�oRion,nu�T�F.s.,n.a�y
OWNERORAf3ENT�.�►Yl {,J �P CONTRACTOR
S�aabed and swom to(or before me Wa Subm�lbed end svwrn w(or aHGnw�beforo mo Wa
by py
MMelalar.,Mraenelk krwwn b r►ro of hsMiiave produced Who Is/are personaly knovm!o me ar hasfiavs producad
ac tdnntln¢aUan, as k1enWlcaBOn.
�!/(!/Id�.d�Ot�Q��.{�.(��p MotaryPublic NolaryP�blic
Commisston No. �" � —�CO Cmrnlsslon No.
�.l�l���} L�� /�F�b u v2-� ------
Name af Molary typod.Pd�ad w slamped Name o(Nolary lyped.P�fnled a stamped—_...---
COMMONWEALTH OF PkR�N5YLVANIA
Not�rlal Seai ��
Marsha Lee LeFebvre,yutary Public
Unlon Twp.,Lawrence County
Commisslon Explres Ma 1,20:6
MFMp��pENNSYLVANTA ASSOCIA't1ON OF MOTARIES
F«n, �■'9 Request for Taxpayer Give Form to the
���201� Identiflcation Number and Certificatton '�'"�r.°°"ot
DapartmeM ot the Treesury send to the IRS.
IMernal Revenua Service
Name(as ahown on your Income tax retum)
S. Vitale Pyrotechnic Ind. , Inc.
N 8usinesa neme/disregerded errtity name.if di(fereM from above
�, dba P rotecnico
� .
a Check appropriate box fa federel tax
ycles�flcation(requirecn: ❑ Indivfdual/sole proprletor �(] C Corporation ❑S Caporatbn ❑ Partnership ❑Tnat/estete
�� � LimRed ifaWlity company.Fr�ter the tax Gassificatlon(C=C corporation,S=S corporetion,P=pertnershlPl► ❑ExemPt PeYee
�
p -------------------------------
N y
a� ❑ on,er(see Inswct�orre)►
�� Address(rwmber�street�and ept.or suRe no.) Requeater's neme and address(optionall
y PO Bex 149
� cxy,�cat�,and ziP code
�' New Castle PA 16143
Ust eccourrt number(s)here(optionel)
Tax ayer ldentiftcation Number{TIN
EMer your TlN in the appropriate box.The TIN provided must match the name given on the"Name"Hne ���+�b number
to avofd backup withholding.For individuals,this is your.social sec�ity number(SSt�.However,for a � _m _�
resideM alien,sole proprietor,or disregarded entity,see the Part i instructions on page 3.For other
entitles,it is your�nployer identification number(EII�.If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines.on whose ��Oy°r�O"'"""b°'�
number to enter.
.I 2 1 7 D 0 7 7 2
• Cettification
Under penaRies of perJury,I certify that:
' 1. The number shown on this form is my correct taxpayer identffication number(or I am wafting for a number to be issued to me),and
2. I am not subject to backup withholding because:(a)I am exempt from backup withhoiding,or(b)!have not been notifled by the Intemal Reven�
Service(IRS)that I am subject to backup withholding as a result of a failure to report all int�est or dividends,or(c)the IRS has notiHed me ihat I am
no longer subject to backup withholding,and
3. I am a U.S.citizen or other U.S.person(deflned below).
CertHication instn�cttons.You must cross out kem 2 above if you have been notified by the IRS that you are currently subject to backup wkhhdding
because you have ta[led to report all Interest and dividends on your tax retum.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an indlvidual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certific:atlon,Lwt you must provide your correct TIN.See the
instrucdons on page 4.
Sign �„�,,,�,�
Here u.s.psnw,► uate►
General Instructions Note.H a request�gives you a form other than Form W-9 to request
your TIN,you must use the requester's form ff it is substantially similar
Section references are to the Intemal Revenue Code unless otherwise to this Form W-9.
n°ted' Deflnidon of a US.person.For federal tax purpose,s,you are
Purpose of Form consldered a U.S.person if you are:
A person who is required to file an infamation return with the IRS must •An individual who is a U.S.citizen or U.S.resfdent alien,
obtain your correct taxpayer klenUflcation number(i1N)to report,fw •A partnership,corporation,company,or association created or
exampie,irxome paid to you,real estate transactfons,mortgage interest organixed in the United States or under the laws of the Unked States,
you paid,acquisftion or abandonment of secured property,cancellation .qn esta;e(other than a foreign a4tate),w
of debt,or contributions you made to an IRR.
Use Form W-9 only if you are a U.S.person(induding a resident 'A domestic trust{as defined in Regulatlons section 301.7701-�.
alien),to provide your correct TIN to the person requesting ft(the Speclal rut�for parb�erships.Partnerships that conduct a trade or
requeste�and,when applicable,to: business in the Untted Stetes are generatly required to pay a wkhhdding
1.Cert that the TIN ou are ivi is correct or ou are waiti for a �°��y foreign part�ers'share of income from such business.
� Y 9 ^g � Y ^� Further,in certa(n cases where a Form W-9 has not been received,a
number to be issue�, partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,If you are a U.S.person that is a
3.Claim exemptfon from backup withhotding ff you are a U.S.exempt Pertner in a partnership conducting a trade or business in the Unked
payee.If applicable,you are also certifying that as a U.S.per�n,your States,provide Form W-9 to the partnership to estabOsh your U.S.
allocable share of any partnership income from a U.S.trade or bus(ness �atus and avo(d withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners'share of
eifectively connected income.
Cat.No.10231X Form W-9(Rev.i-2011)
HEADQUARTERS II.S.10I'Ai 1�)Nc
P.O.Box 149 ��x AtlanW,GA Mon[gpmery,AI.
New Castle,PA 16103 724.652.1288 Auburn,NY New Castle,PA
°F F i c t �°F s Del1a5,TX New Orlean5,LA
724.652.9555 www.pyrotecnico.com
for[Wuderdale,FL Saluda,SC
P�)I.I.IRI�[ fAlAll
P� �� � T�O'� B00.854.4705 info@pyrotecnico.com ]affrey,NH Tampa,FL
1 Las Vegas,NV Vineland,NJ
VI7AlE FAMILY fIREWORKS • 1889
November 5,2013
City of Zephyrhills
Attention: Jackie
This is a letter of authorization for Brenda Wetcher of Florida Hospital Zephyrhills
To pick up the permit for the December 8,2013 display.
Thank you in advance for your help.
Sincerely,
�
Marsha LeFebvre
800.854.4705 PH
724.652.1288 FX
mlefebvre@pyrotecnico.com
HEADCLUnRTERS 1i.1.IOC'n'iIUNS
P.O.Box 149 i�X Atlanta,GA Montgomery,At.
New CasUe,PA 16103 724.652.t288 Auburn,NY New Castle,PA
u���tt IYEB Dallas,TX New Orleans,LA
724.652.9555 www.pyrotecnico.com
Fort LauderCale,FL Saluda,SC
Mru«�Ri� �M��� Jaffre,P!H Tam F
Ptf 0��� j�O 800.854.4705 infoHDYrotecnico.com Y Pa, �
1 1 Ws Vegas,NV Vineland,N3
v1tA�E FAMILY FIREYJONKS • 1889
November 5,2013
City of Zephyrhills
Attention: Jackie
The show on December 8, 2013 will be shot electronically.
Thank you in advance for your help.
Sincerely,
�����
Marsha LeFebvre
800.854.4705 PH
724.652.1288 FX
mlefebvre@pyrotecnico.com
ZEPHYRHlLLS FIRE DEP/�RTl�[ENT°
6907 Dairy Road, Zephyrhills, FL 33542
FIRE SERVICE USER FEES
Occupancy No.:
Plan No.: Contractor:
8usiness Name: �C �1 G t o-� L . Billing Address:
Business Address:
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 $50 1st Alarm N/C
Multi-Family/Commercial .O6 sf 1st Re-inspection N/C Standpipes 550 2nd Alarm N/C
(Minimum Charge$25.00 2nd Re-inspection $100 Fire Pump $50 3rd Alarm N/C
� Plan Revisions DBL 3rd Re-inspection a250 Hoods $50 4th Alarm $100
4th Re-Inspection a500 Fire Alarm $50 5th Alann $150
SPRINKLER SYSTEMS (Business closed until LP Gas $50 6th Alartn $200
0-25 Heads $50 violations coRected) Natural Gas $50 NON COMPIIANCE $150
26 plus Heads a100 SPRINKIER SYSTEMS Fuel Tanks- per�a�k $50
STANDPIPE SYSTEM Hydro Undergrounds $45 Sparklers a100
� Per Riser $50 Hydrostatic Test $65 per system Fire Works $500
FIRE PUMP Acceptance Test $45 per system Camp Fire $25
� Per Pump a100 Hydrant Flow $75 Controlled Bum a100
FIRE ALARM SYSTEM Hood/Duct $50
0-25 Devices $50 FIRE ALARM SYSTEM Place of Assembly $50 Mnual
26 plus Devices $100 System Acceptance $50 Fire Protection $25
SUPPRESSION SYSTEMS Recall Acceptance $50 F�ammable nppiication S50 Mnual
Wet $50 OTHER Waste Tire Storage a50 nn�uai
Dry $50 Fire WalUSmoke Wall $15 Perwau Generator<KW a100
CO2 $50 LP Gas $25 per lank Generator>30 KW 150
Other $50 Natural Gas a25 per sysiem Bio-Hazarci Waste 5100 nnnuai
KITCHEN EXHAUST Fumigation Tenting $50
� Hood/Ducts $50 Tent 10k10'or greater $15 Per tent Torch PoUApplied a50
OTHER Fire Pump $45 Haz.Materials $1OO Mnual
LP Installation pertank $50 Fire Suppression $30
Fuel Tank Installation $50 System Acceptance
(Per Tank) S50 E�fiaust Hood/Duct a30
�Natural Gas Installation $50 Re-inspection DBL
(Per SyStem) (other than annual)
� Spray Booth $50 � Inspection scheduled DBL 8
and cancetled less than
24 hours
ConsVuction Insp. N/C
Emergency Vehicle A� $50 FALSE ALARM
PLANS TOTAL� INSPECTION TOTAL� PERMIT TOTAt i�� �,,, TOTAL�—
GRAND TOTAL
Comments:
Date: 1 1 � '�
Inspector� u�v►-�. �� � V, ��.,z � 1
/llh �!
t
11�'0712013 09:44 364E164401 ATF FELC PA�3E E11�'k�l
DEPARTIVIENT UF.�[JSTICE
�.`� Bureau of A.lcohol,Tobacco,
Fireatms and ExpIoQives
A4a+'N+w6mg,t�Y?5405
Nav�xnber. 7,2013
Fy1'O'��Ctl]CO O�F�,bF1CI3 L�C
9U 1090:CRlt/SAW
PO Box I49 �4�70
New Castle,PA 16103- �i�e Number: 1-FL-00886
k'z:emises Address:3q435 Commcrcc Ihive Unit 102 Suites J 8c L,San Antaniti,FL 3357'6-$b31
Deaz Sir/Madar�:
This letter ackndwledges receipt of your timely applicatidt�to reuew your Federal cxplasiv�s
Iicense/pezxnit.
�e Bureau of E1.leohol, Tob�.cco, k'axearms and Explasives (ATF} is nat able to pmcess your
applicataaz�priar to the ex�irstion date of your l�c�nse/per�nit. Hawever, Fedexal law allows yau
ta continue op�at�oz�s wnder ycrur current license/permXt ux�til such tun�c as ATF coxttpletes
proeessing your ap�licat�on. See S U.S.C. § 55$. This lette;r, ox as expiained belou�, a fo]low-up
letter,, w�il� serve as yaur licens�fpermit until we eomplet� action on ypur renewal. It is referred
ta as a Lctter of Authari.�.ation{LOA).
Since we k�ave nvt com�aleted process�ng your application,yau may supply a copy ofthis letter to
other licenseeslperrnitbees, e.g., your distributors, far the next six montb,s (or u.ntil we complete
a�tivn on your renewaa, if that occurs in ]ess thau six months) as �vidence of your
licensed/pezmitted status. �£ w� h�,ve not completed pxacessing yaur applicati�n far renewai
within six rn,oz�ths of the date of this �etter, we w�ill send you ax�v#her Ietter, which tiw-iii a.�so be
valzd for aix mvnths {or uutil we complete actiaa�ox.►your ren�ewal, if that occurs im l�ss than six
znomhs). This is a�'cflurse contingent upoz�pour remaining ent�tled to continue aperations u�der
yaur ctu�ent license/perrnit,
P1eASe direct questians ar caneerns regarding tlus Iettex to
Sincerely,
��.�""°'( .
� � ��
Christap�ez`R. Rceves
Chief,Fmd��a�Explasives�.iaensing Cent�r
A'i'F web addreas: www,s , nv