HomeMy WebLinkAbout14-15505 CITY OF ZE HYRHILLS /
5335-8T STREET
F � �� (813)78�-oozo 15505
BUILDIN PERMIT
� .<,_�l:s='x=�,�x . `:; PE�RMIT INFORMATION` � � ��:��. : _..�� LOCATION�INFORMATION�. "`, "'��;_��`:°:�:�'.��
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Permit Number: 15505 Address: 7890 GALL BLVD
Permit Type: COMMERCIAL ZEPHYRHILLS, FL.
Class of Work: NEW CONST/COMM Township: Range: Book:
Proposed Use: NOT APPLICABLE Lot(s): Block: Section:
Square Feet: Subdivision: ZEPHYR COMMONS
Est. Value: Parcel Number: 35-25-21-0130-00000-0030
Improv. Cost: 85,088.00 _ ��:`�'OWNER INFORMATION". 's..���<:�:�°'��"'�� '���-���
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Date Issued: 7/28/2014 Name: SF ZEPHYR COMMONS LP _
Total Fees: 12,372.24 Address: 1-2851 JOHN ST
Amount Paid: � 5,477.04 MARKHAM ON L3R 5R7 CANADA
Date Paid: 7/29/2014 Phone:
Work Desc: INTERIOR B/OUT 1,600 SQ - JERSE MIKES
� CONTRACTOR S APPLICATION FEES
GENEVA CONSTRUCTION I BUILDING FEE 437.57 SEWER CONNECTION COMMERC 1,809.00
SAM'S ELECTRICAL CONTRACTOR.IN ELECTRICAL FEE 96.53 WATER CONNECTION COMMERC 576.90
JEFF'S ISLAND AIR PLUMBING FEE 64.35 TRAFFIC IMPACT FEE 99% 9,101.66
G&P PLUMBING OF ORLANDO INC. MECHANICAL FEE 45.05 TRAFFIC IMPACT FEE 1%, 91.94
FIRE PLAN REVIEW FEES 96.00 POLICE IMPACT FEE � ;``� 24.45
FIRE IMPACT FEE 2625 PUBLIC SAFETY 5%� � ,, �� 2.54
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�"�� °° � Ins ections Re uired � �
�FOOTER 2ND ROUGH PLUMB ISC INSULATION CEILING
FOOTER BOND DUCTS INSULATED S WER MISC.
ROUGH ELECTRIC LINTEL ISC • MISC.
1ST ROUGH PLUMB PRE-METER I SULATION WALL MISC.
DUCTS INSTALLED WATER ISC DRIVEWAY
PRE-SLAB SHEATHING ISC. MISC.
CONSTRUCTION POLE FRAME ISC. MISC.
REINSPECTION FEES: Reinspection fees will comply w th Florida Statute 553.80 (2)(c) when extra inspection
trips are necessary due to any one of the following re sons: a)wrong address b) condemned work resulting
from faulty construction c) repairs or corrections no made when inspections called d)work not ready for
inspection when called e) permit not posted on jo site f) plans not at job site g)work not accessible.
NOTICE: In addition to the requirements of this permit, ther 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 managemen , state agencies or federal agencies.
"Warning to owner: Your failure to record a notice f commencement may result in your paying twice for
improvements to your property. If you intend to ob in f nancing,consult with your lender or an attorney
before recording your n tice of commencement."
Complete Plans, Specifications Must Accompany Appl cation.All work shall be pertormed in accordance with
City Codes and Ordinances. NO OCCUPANCY BEFO C.O.
CONTRACTOR SIGNATURE PERMIT OFFI R
PERMIT EXPIRES IN 6 MONTHS ITHOUT APPROVED INSPECTION
CALL FOR INSPECTION - HOUR NOTICE REQUIRED
PROTECT CAR FROM WEATHER
NOTICE OF DEED RESTRICTIONS: The undersigned underst nds that this permit may be subject to"deed"restrictions"
f ' which may be more restrictive than County regulations. The un�ersigned assumes responsibility for compliance with any
applicable deed restrictions.
UNLICENSED CONTRACTORS AND CONTRACTOR RESP NSIBILITIES: If the owner has hired a contractor or
contractors to undertake work,they may be required to be licen ed in accordance with state and local regulations. If the
contractor is not licensed as required by law, both the owner nd contractor may be cited for a misdemeanor violation
under state law. If the owner or intended contractor are unce ain as to what licensing requirements may appty for the
intended work,they are advised to contact the Pasco County B ilding Inspection Division—Licensing Section at 727-847-
8009. Furthermore, if the owner has hired a contractor or c ntractors, he is advised to have the contractor(s) sign
portions of the"contractor Block"of this application for which t ey will be responsible. If you, as the owner sign as the
contractor,that may be an indication that he is not properly lic nsed and is not entitled to permitting privileges in Pasco
County
TRANSPORTATION IMPACT/UTILITIES IMPACTAND RESO RCE RECOVERY FEES: The undersigned understands
that Transportation Impact Fees and Recourse Recovery Fees ay apply to the construction of new buildings,change of
use in existing buildings, or expansion of existing buildings, as pecified in Pasco County Ordinance number 89-07 and
90-07,as amended. The undersigned also understands,that s ch fees, as may be due,will be identified at the time of
permitting. It is further understood that Transportation Impact ees and Resource Recovery Fees must be paid prior to
receiving a"certificate of occupancy"or final power release. If he project does not invoive a certificate of occupancy or
final power release,the fees must be paid prior to permit issu nce. Furthermore, if Pasco County Water/Sewer Impact
fees are due,they must be paid prior to permit issuance in acco ance with applicable Pasco County ordinances.
CONSTRUCTION LIEN LAW(Chapter 713,Florida Statutes, s amended): If valuation of work is$2,500.00 or more,I
certify that I, the applicant, have been provided with a cop of the "Florida Construction Lien Law—Homeowner's
Protection Guide"prepared by the Florida Department of Agric Iture and Consumer Affairs. If the applicant is someone
other than the"owner", I certify that I have obtained a copy of th 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 i formation in this application is accurate and that all work
will be done in compliance with all applicable laws regulating c nstruction,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 wi I 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 governme t agencies may apply to the intended work,and that it is
my responsibility to identify what actions I must take to be in co pliance. Such agencies include but are not limited to:
- Department of Environmental Protection-Cypress ayheads, Wetland Areas and Environmentally Sensitive
Lands,Water/Wastewater Treatment.
- Southwest Florida Water Management District Wells, Cypress Bayheads, Wetland Areas, Altering
Watercourses.
- Army Corps of Engineers-Seawalls,Docks,Naviga le Waterways.
- Department of Health & Rehabilitative Services/ nvironmental Health Unit-Wells, Wastewater Treatment,
Septic Tanks.
- US Environmental Protection Agency-Asbestos aba ement.
- 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 e pressly permitted.
- If the fill material is to be used in Flood Zone ' ", it is understood that a drainage plan addressing a
"compensating volume"will be submitted at time o 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 e area within the stem wall.
- If fill material is to be used in any area, I certi that use of such fill will not adversely affect adjacent
properties. If use of fill is found to adversely affec adjacent properties,the owner may be cited for violating
the conditions of the building permit issued under he attached permit application,for lots less than one (1)
acre which are elevated by fill,an engineered drain ge plan is required.
If I am the AGENT FOR THE OWNER, I promise in good faith o inform the owner`of the permitting conditions set forth in
this affidavit prior to commencing construction. I understand t at a separate permit may be required for electrical work,
plumbing, signs, wells, pools, air conditioning, gas, or other i stallations not specifically included in the application. A
permit issued shall be construed to be a license to proceed wit the work and not as authority to violate,cancel,alter,or
set aside any provisions of the technical codes,nor shall issua ce of a permit prevent the Building Official from thereafter
requiring a correction of errors in plans,construction or violatio s of any codes. Every permit issued shall become invalid
unless the work authorized by such permit is commenced with n six months of permit issuance, or if work authorized by
the permit is suspended or abandoned for a period of six(6)m nths after the time the work is commenced. An extension
may be requested, in writing,from the Building Official for a p riod not to exceed ninety(90)days and will demonstrate
justifiable cause for the extension. If work ceases for ninety(9 consecutive days,the job is considered abandoned.
WARNING TO OWNER: YOUR FAILURE TO RECORD A OTICE OF COM NC MENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPER . IF YOU INTE T OBT FINANCING,CONSULT
WITH YOUR LENDER R AN ATTO NEY BEFORE RECOR ING YOUR NO C C MENCEMENT.
FLORIDA JURAT(F.S.19 .0
OWNER OR AGENT� � CONT CTOR
Subscribed and swom to(or affirmed before me this Subscri e and swom to(or ffirmed before this
O�i'3O/ilby ,7�S� �//��i��//t/ � / by,iT�l.l���i1� � ����
Who is/are personaliy known to me or has/have produced Who is/ re personallv known to me or haslhave produced
identification. — as idenlification.
�j✓�r� ��j �✓ ?�(� Notary Public
Commissian Na. �� I��3�9 Cammi sion No. �� �v�� �f7 �'I
Name of Notary typed,printed or stamped Name f Notary typed,printed or stamped
o�''"Y.:'�e�.� RAYNA W.KOESTRING �pttY P�je
" * MY COMMISSION#FF 122369 .�;•••.,`� RAYNA W.KOESTRING
* * MY COMMISSION�FF 1?2369
;`��r 'o� EXPIRES:June 7,2018 EXPIRES:June 7,2018
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BUILDING PLAN VIEW COMMENTS /
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Contractor/Homeowner: j'l e i� , s'�j-��C`�
Date Received: � �—�--f
Site: � �C((� � � �v l ��
Permit Type: �� �Gl �C / � �� �V e'�:� ��(�'�
Approved w/no comments:❑ Approved w/the below omments: C�� Denied w/the below comments: ❑
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This commen sheet 1 be kept with the permit and/or pl s.
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Kalvin S,�it -Plans Examiner Date C actor and/or Homeovmer
� (Required when comments are present)
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SFZeplayr Commons LP Cityz City of zephyrhill�
DATE INVOICENO DESCRIPTION INVOICEAMOUNT DEDUCTION BALANCE
9-08-14 9/8/14 Jersey Mikes impact f 6895.20 6895.20
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DATEK 9-08-14 NUMBER 1080 TOTAL> 6895 .20 6895 .20
PLEASE DETACH AND RE IN FOR YOUR RECORDS
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SFZephyr Commons LP CityZ Ci��r of zephyrhills
DATE INVOICENO ' DESCRIPTION iNVOICEAMQUNT DEDUCTtON BALANCE
7-28-14 7/28/2014 Jersey Mike water/se 1192 . 95 1192 . 95
DATEK �-28-14 �yUMBER 2041 TOTAL> 1192 .95 1192.95
PLEASE DETACH AND RE AIN FOR YOUR RECORDS
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SFZep/iyr Commons LP Cityz City of zephyrhills
' DATE`� INVOICE NO DESCRIPTION INVOICE AMOUNT DEDUCTION BRLANCE
7-24-14 7890 Gall TIF 2298 .40 2298 .40
DATEK �-24-14 NUMBER 1034 TOTAL> 2298 .40 2298 .40
PLEASE DETACH AND RE IN FOR YOUR RECORDS
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Jersey Mikes-7890 Gall Blvd-Interior B/out-Restaurant-1,600 sq ft-
Geneva Construction Inc
oumn
SQ.FEET PRICE
MAIN OR LIVING: 1,600 $ 53.18
OTHER AREA UNDER ROOF: - $ 88.00
OTHER: - $ -
VALUATION $ 85,088.00
FEE SHEET $ 429.00
ADDRESS
DRIVEWAY
BUILDING: $ 437.58
ELECTRICAL: $ 96.53
PLUMBING: $ 64.35
MECHANICAL: $ 45.05
SUB-TOTAL $ 643.50
TOTAL $ 643.50
SEWER: $ 1,809.00
WATER: $ 576.90
IRRIGATION: S -
TOTAL: $ 2,385.90
WATER METER: nla
IRRIGATION METER $ - �a
FIRE DEPARTMENT FEES
PLANS TOTAL: $ 96.00
INSPECTION TOTAL:
PERMIT TOTAL
TOTAL: $ 96.00
PUBLIC SAFETY IMPACT FEES
POLICE $ 24.45
FIRE $ 26.25
5% $ 2.54
TOTAL: $ 53.24
SUB-TOTAL $ 3,178.64
PARKIMPACTFEES Na
SIF'S: Na
100.0% $
1.0% $ -
TOTAL: $ -
T 1 F'S: $ 9,193.60 ONLY TIF COULD YOU PA UP FRONT AND BALANCE UPON COMPLETION
99% $ 9,101.66 25%(SZ,Z9$•40)PAID WITH RMIT COST SEE ABOVE 75%PAID BEFORE PERMANENT POWER$6,895.20
1% $ 91.94
TOTAL: $ 12,372.24
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- P�► C0� COUNTY, FLORIDA
Permit No. (��Q`j
Date Permitted
Builder Name/Owner Name '��� , Sli�CG�Y� Control#
County Parcel No. ��- ZI-L�(3p^� ,��_���d SubDiv: Z���yr Lc3x.w.�y�
Address/Location �-// �j�I✓I�
ClassificationlType of Use Q�;i - (Z�S�-Eiu��c.,�!
TRANSPORTATION IMPAC FEE Rate: ��j .3,�f� Sq Ft Unit: �����a
Exempt � Yes � No How Determined
Impact Fee Amount $ � � ��•�� Zone No. TqZ;
SCHOOL IMPACT FEE
Account (056) Single-Fa ily Detached House Amount $ ,�
(057) Mobile H me
(058) Other Re idential
123) Collectio Fee
Exempt Yes � No How Determined
PARKS AND RECE2EATION EE
Land Account Land Credit Land Total �
Recreation Account Recreation Credit Recreation Total
Zone TO7AL AMOUNT $ ,�
Exempt � Yes � No How Determined
LIBRARY FEE
Land Account Land Credit Land Total
Facility Account Faciliry Credit Facility Total
Exempt � Yes � No How Determined Total Amount �.}��
RESOURCE FEE ERU
TOTALAMOUNT
Prepared By �, Checked By
NO CERTIFICATE O OCCUPANCY WILL BE ISSUED OR FINAL INSPECTION
PERFORM D UN71L THE TOTAL AMOUNTS LISTED HAVE
BEEN PAID AND
RECEIPTED FOR BY A CENTRAL PERMITTING OFFICE OF PASCO COUNTY
Acknowledgament below does not mply acceptance of concurrence,but simply receipt of a copy of this form,placing
the building permit owne on notice oi this assessment and the conditions of payment for same.
DATE RECEIVED BY
RECEIPT NO. DATE BY
� �
Jacqueline Boges
From: Eliezer Garcia [gnpplumbing@ho mail.com]
Sent: Monday, July 21, 2014 2:32 PM
To: Jacqueline Boges
Subject: RE: application
Attachments: zephrpaper.pdf
Hi Jackie,
Here is the application with our portion filled out. Let e know
if you received it and is what you needed.
Thanks
Yari Garcia
G & P Plumbing of Orlando, Inc.
9357 Spring Vale Drive
Orlando, FL 32825
Phone/Fax: 407-545-4670
�npplumbin�@hotmail.com
LIC #CFC 1427667
QB # 60221 _
From: ibo�es@ci.zephvrhills.fl.us
To: GNPPLUMBING@HOTMAIL.COM
Subject: application
Date: Mon, 21 Jul 201418:28:32+0000
Per our conversation I need your qualifier or agent sig ature on our building permit application. Fill in block
area and either fax 813-780-0021 or email back to me See attachment
Thank you
Jackie Boges-SCSS
813-780-0020 ext 3513
Faith makes things possible...Love makes all th ngs easy
Dwight L. Moody
, i
eas.�eaoozo CityoiZephyrh111sPef itAppllcat#an fax•e�s�7aoAOZ�
BaAsi�np Depaq �nt
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Ownola Nomo �M Servicea,LLC pwner Phane Numbef •B�d87 ����
Own�rs Add�eec 7870 Osli BMd„#405;ZoDhyrhOis,FL 33591 Ownar Phone Numdar Q7':�`�'�' ��!G`�� J y�y'"/'
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SUBOlVlSI4N ZeD�n Cammoas � PARGEI iDN 3g-2�•21-D130-0D4D4•0030 ���
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WpRK PROpQSE� � N[W CoNSiR 8 AADIALT SIGN Q � qEMOL16H
INS7r1tl REFAift
PRQPOSEO USH Q SFR Q CpMAi OTHER
TYPE OF COPIS7RUCTI4N � 6I.00K � FRAME STBEL [] �^�'"��
t DeSCRtPTiON OF WORK interior 8u�idwut far Jaracy hiika a Subs roelaura t
BU7403NGStZE tz•� � $AF007AtiE �.� H£It3HT 16tery
�BUILOlN4 S ��!� VALUATION Op 70T l,GONSTRUCTION
X�ELECTRICAL (S� AMR SERVICE Q PROGRESS ENERGY Q W.fi,E.C.
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�M�CHANICAI. (S VALUATION Of ME kilJVICAI INSTALLATIOM ( f J �(f�l• _~�
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QGAS C] ROOFINO [] SPECIALTY OTHER �,J� Z^ ��� �^���'�,
FIHISNED FL40R EtEVA710 FLOOD ZON� [A QYES NO ~�� � ^~
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8UICOER COMPJWY Geneva Construction.[�a, �
SIGNATURE' Ree�sYRneo Y 1 N FEE 9URREA Y!
AdCrosc PO 8ox 2'i858•4Jisda.FL 327ft2 Uc�nsa e � CBCOASCf48 � �, 't �
ELECTRICIAN COMPANY 5��� �� �'�(�y l�I U't,L P�' y '�I
SIGNATURE � r+ecisreReo Y'/N Fee cuqAen V 1 � �,�JF N�3'�b° `
�AaTresa �12. Wt5 'SCt ' Q.r C ' 3�ts� }n� �-
Licettaa M �. `�t��(� p �j
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y �� srGniaTUt�E 7� �Y.�-ir RECriSTERE Y/N oEH CU�RH� Y/
/��Q� Addr�a Liconao r ( � {� 2 ��ryt/m'r
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MEGNANICAL �:�i �(�- COMPAN ��C
SIC33NATURE RE�i1678RE Y! N POC CURREh Y/N ! ��,G�`
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Addroae Llconsa#
QTtiER GdMPAf1
SIGNATURE AEGiSTERE Y J N FEE WRRE7s Y I N
Adoress Liconae M � �
l21ilIIIIliIIIl1tIIII � ! l / tI � lIIt11IIliI1il! lII � tlF � tili`/ iltl � Itltl /
RESIDENTIAL Attsch(2)Plol Plens;(2)sets of BuOdinp Pluns;(1)set of Ener Forms;R-4W PormN tpt new constn�etion,"
Mintmum Wn(1q)workirip days oRer submNlal d»Ce. Required ncite,Conatruclian Plens,$tortm�mter Plana w!Sllt Fmce(nslolled,
9anitary Fac8ltles 8 7 dumpsta;Site Wark Perrnit for aubtllvls!nsllarpe prajacic
CONI�lERCIAt 1�ttactr{3)compiete sets ct 6uiiGinp Pibns plua a GiFe Saiaty t' ge,i1y aet of Ene:gy Fonns.R-O-W�em3t tat nsw eontWetion.
Minimum tan(10)working days efter aubmRtel Oate. Requlred nslto,ConsW ction Plena,Slormwaler Plaru w!SAt Pencs Installetl.
Sanitery FacUflleB d 1 Cumpater Site Work Permit for o9 new oJocls,Au commerGOl mqulromants must meet campl�anca
StGN PERMtS Atterh(2l��or Enpfneernd p�a�s.
•^•,PROPERiIf SURVEY toquiced tot oit NE4Y consFruelion. ' �
DfmcHont:
FiN a�rt a�iication cotnpietofy.
Owtte�&COntractnr stpn Gsdt tif appflcaiion,tmtarize2!
If ovor i2BOa.�N011cb ol COITIrtIerlcoflte0t Is Iequlrod, (AIC upgradas o ar STS00)
" A,�ent{!ot tho canlraao�or Pownr ot Ariomey(!w the owner}�wuld 6e so ne wilh naWriud Intter from awnw eulho�zing SOme
OVER THE CDl1NTER PERM�TTiNf3 (Fraa�t ot Appiicatinn Onty}
Remols H BNnptes Sewsrs Service Uppredes,A/C Fences(PIoUS rveylFon�nBe)
Orlveways-Tvbt over Cannter if on public roadvrays..needs ROW
s�3,�su-oQrs City.oE2epfiyrhillsP ronilAcptication �ezsi�-�so-oo2i
Buiiair�Q 0o ment
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Fcc S�mglr�Ttiluhn6der Name �9 O.mcr Phone Nt:mnv
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ELECTIt7I:1/�N COMF �
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Adtlrt�.: Liccti�c�
17 � IIIII�fllt � ] IDl"IIl� I � I�l11.19-Ll �1fl Ofl'1'7l�011t[� III7 �� YItl1llt.flJt1
RE51DEN7TAL P�d�(T�Plot AIm=:I2)xls a18u?d'i1�Fffict�.(�)s0!61 E �y fofms:lt-0-Y�'F'�E�m4 far ntw mutrsfan,
aununuRi sdn(laj eci1�8 dar aftc�st�itldial Ca}e.Reqiiu tl o�stte:CB(`•etntt7VO��?�F:$tOrmw�cs Plsns wf SY F.ennu inst�lkd,
Sanit�y.Facifitics&i dum�bcr,�Ic Wofli Peiim7 6or sum' iongAs�Qe pra)a�
ca�+n+€�e�ai- -amm{�}eo,i,qe�e sois cs auumiig nttara�us a�+teS�ro Paec:.i1}set ut.�nergy.FOmis.R-0=w�emiztor new canstacllon_
?Al�numlerl{19)Vlvf[cEngO�j'SBRCYS!�e►date.'Re a�sv�Ce.'GansWslfonPt�s.5lmiew�l�Ptaas'wt3tu�er+ce'r�s[a{I�I,
Scnitmy FodllUca'E 1 Gurnpsic�,Sil�Wrn'R Permittus�roe pro)ects.Atl�aiimesriai r�vu�crtiunts must m�et mr�i�rn
5lCn4 PERASIT AtCSdi(2)sels ua F_ngiieerod PIaRS, , .
•�"PRDPEftTY SURVEY rcquired toraa NEIN.00nsU�zll
DGociiov+s:. ' � - . . . -
�Itl a!aµpfko�on eomp�+�4oly.
Oxner g,-Cathx7o�sgn ho�1t af npFYiotinn:�a!i�1
�1!ovetS2500.�Nodeo a(Cai�vneacomept is reqe�inetl_ �rAlC upr�reD avBT i750G)
'� ,qQpr:�(for qia mrt:r��ar)n�Power o(lL'wmey(for�ihe aw�xr)wnuld 0e. mo0rve wilh mt�tcttcr irom an�cr a�ilhnising snnr�
OVER7HECDUR7TER PEt+iKfiY1NG [�mrn of Applloflm Ord�jy
fier'oot�•.'.�FUtigreg �5e��f5 ' f.e�vice UOG'+�dc�WC f-enxa IPd VSurv=y�Fomnge}
pm.cwaysNot o�Coufeter�,on p�6t{c ro�;v3yu.x�eods ROlA'
a�saeaoozo City ofZephyrhills P rmitApplication Fax-813-780-0021
Building Dep rtment
' , l�
I� Date Received �—`j�� Phone Contact for Per itting — _ I�
�---� n A�,;`TGI.
Owners Name ZHJM Services,LLC Owner Phone Number �=8 0-5 �897 �l��`
Owners Address 7810 Gall Blvd.,#405;Zephyrhills,FL 33541 Owner Phone Number ��7`�� ��/G� y�/
r�•�
Fee Simpie Titleholder Name ��a Owner Phone Number
Fee Simple Titleholder Address
JOB ADDRESS 7890 Gall Blvd.,Zephyrhills,FL 33541 LOT# �
SUBDIVISION Zephyr Commons PARCEL ID# 35-25-21-0130-00000-0030
� (OBTAINED FROM PROPERTY TAX NOTICE)
, WORK PROPOSED e NEW CoNSTR e ADD/ALT SIGN Q Q DEMOLISH
INSTALL REPAIR
�I PROPOSED USE Q SFR Q COMM OTHER
TYPE OF CONSTRUCTION � BLOCK Q FRAME STEEL Q
DESCRIPTION OF WORK Interior Build-out for Jersey Mike's Subs restau ant
BUILDING SIZE 11,000 SQ FOOTAGE 1,600 HEIGHT 1 story
OBUILDING $ �79 O VALUATION OF T AL CONSTRUCTION
ar
XQELECTRICAL $ AMP SERVICE Q PROGRESS ENERGY Q W.R.E.C.
XQPLUMBING $
QMECHANICAL $ VALUATION OF M CHANICAL INSTALLATION � ��� /����t
�
XQGAS Q ROOFING Q SPECIALTY OTHER � ���� �`.,,���-
FINISHED FLOOR ELEVATIO FLOOD ZONE AREA �YES NO � C„��
.Jl. G� l ���
,
i
BUILDER /. COMPAN Geneva Conslruction Inc.
SIGNATURE / REGISTER D Y/ N FEE CURREN Y/N
Address PO Box 621858;Oviedo,FL 32762 License# CBC045648 y �� �l��
ELECTRICIAN ��� � � COMPAN ��OC�u���u�2�
SIGNATURE REGISTER D Y/ N FEE CURREN Y/N �P�B�fL�1 3—
t����
` ATdress License# � l
n� ��\ PLUMBER ,bs,t,t� � � R OMP R o Y/ N FEE CURREN Y/N
v SIGNATURE ���- �
�� � �Q� Address License#
�� �j, ���
� MECHANICAL �,c� � � COMPA Y ����v'�^ �'
SIGNATURE REGISTER D Y/ N FEE CURREN Y/N a I OG��'e�"'^
Fll�n
Address License#
OTHER COMPA Y
SIGNATURE REGISTER D Y/ N FEE CURREN Y/N
Address License#
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIiillllltllllllllllllllllllllllllllllll
RESIDENTIAL Attach(2)Plot Plans;(2)sets of Building Plans;(1)set of En rgy Forms;R-O-W Permit for new construction,
Minimum ten(10)working days after submittal date. Require onsite,Construction Plans,Stormwater Pians w/Silt Fence installed,
Sanitary Facilities&1 dumpster;Site Work Permit for subdivi ionsAarge projects
i COMMERCIAL Altach(3)complete sets of Building Plans plus a Life Safety age;(1)set of Energy Forms.R-O-W Pertnit for new constructlon.
Minimum ten(10)worlcing days after submittal dale. Require onsite,Constniction Plans,Stormwater Plans w/Silt Fence installed,
Sanitary Facilities&1 dumpster Site Work Permit for all ne projecls.All commercial requirements must meet compiiance
SIGN PERMIT Attach(2)sets of Engineered Plans.
•"'PROPERTY SURVEY required for all NEW construction.
Directions:•
Fill out application completely
Owner 8 Contractor sign back of application,notarized
If over$2500,a Notice of Commencement is required. (AIC upgrades ver$7500)
•• Agent(for the contractor)or Power of Attomey(for the owner)would be so eone with notarized letter from owner authorizing same
OVER THE COUNTER PERMITTING (Front o(Application Only)
Reroofs if shingles Sewers Service Upgrades A/C Fences(Plo Survey/Footage)
Driveways-Not over Counter if on public roadways..needs ROW
��� � V � �t�� ��..R��CC� 1 t� �$`��Lt�
� ��...¢�,..�.t� � � "?��C� Ca'� �Lcs�.Q.
��.:�� �
�—
�- �� ��
1 �
Jersey Mlkes-7890 Gall Blvd-Interior B/out-Restaurant-1,600 sq ft-
Geneva Construction Inc
o n
SQ.FEET PRICE
MA1N OR�EVENG: 1,804 $ 53.18
OTHER AREA UNDER ROOF: - S 88•Oq
OTHER: - $
VALUATION $ 85,088.00
FEE SF{EET $ 429.04
ADDRESS \
DRIVEWAY
BUILDING: $ A37.58
�� � ELECTRICAL: $ 96.53 �(����
PLUMBING: $ 64.35 fl�
,,, , /yJ�t�
��MECHANiCAL: $ 45.05 �tj.
SUB•TOTAL $ &43.50
TOTAL $ fi43 � '
/
SEWER: $ 9;809.00 �
WA7ER: $ % 576.90
IRRIGATION: $ -
TOTAL: $ 2,385.90
WATER METER: Na
IRRIGATION METER $ - �e
FIRE DEPARTMENT FEES ���,.fj�
PLANS TOTAL: $ 96.00 ��U
INSPEGTfON SOTAI: � *
PERMR TOTAL �
TOTAL: $ 96.Op
PUBIEC SAFETY 1MPACT FEES /
POLICE $ 24.45 `�,��7�
FIRE $ 2625 S y�W
5°l0 $ 2..54 ��jt
70TA1:: S . 4 ,�""
SUB-TC�TAL $ � 3,'i78.64 .
PARK IMPACT PEES -- �e
� SIF'S: Na � �r w'' �
,,......, �oo.o�io $ G�� oCl 2��
,.... 1.0°l0 ,$ �� ��� �I �
TpTAL: $
T I F'S: $ 9,193.64 fl TtF C lD YOU PA UP FRONT AND BAt.RNCE I.IPON GOMPLET]ON
g9^/ $ 9,101.66 25 ($2,298.40)PAID WITH P RMIT COST SEE ABOVE 75%PAID BEFORE PERMA ENT PO EFf n6,895.20
1% $ 91.94 - � �V�
TOTAL: $ 12,372.24 �'�����
�
,. �
City of Z phyrhills
Water and Sewer Im act Fee Calculation
Land Use Type:
Rest urant
(A) Conventional
No. of Seats ��� � ,
Impact Fee For Type A
Within City Limits Outside City Limits
Water Distribution System $ - $ -
Wastewater Collection System $ - $ -
Wastewater Treatment Plant Ca acit $ - $ -
TOTAL $ - $ -
(B)Fast Food/Drive Through
No. of Seats f---_,------_-_-..�___�.`
Impact Fee For Type B
Within City Limits Outside City Limits
Water Distribution System $ - $ -
Wastewater Collection System $ - $ -
Wastewater Treatment Plant Ca acit $ - $ -
TOTAL $ - $ -
(C) Deli/Sandwich Shop with no dishwas er and disposable dinnerware-only
No. of Seats � � 30 � M
Impact Fee For Type � �
Withi: Ci y Limits O tside City Limits
Water Distribution System � r 576.90 $ 721.13
W astewater Collection System $ 1,159.57 $ 1,449.46
Wastewater Treatment Plant Ca aci 649.43 $ 811.79
TOTAL $ 2,385.90 $ 2,982.38
(D)Bakery
No. of Square Feet ��� ��
Impact Fe s For Type D
Within City Limits Outside City Limits
Water Distribution System $ - $ -
Wastewater Collection System $ - - $ -
Wastewater Treatment Plant Ca acit $ - $ -
TOTAL $ J - $ -
+�=� ` r
, :. •
Shell 7890 Gall Blvd- 1450 sq ft-tot I sq 9601
o umn
I
SQ. FEET PRICE
i MAIN OR LIVING: 1, 50 $ 53.18 106.36 valuation only half
OTHER AREA UNDER ROOF: - $ 88.00
OTHER: - -
$
VALUATION $ 77,11 .00
FEE SHEET $ 39 .00
ADDRESS $ 3 .00
DRIVEWAY $ 3 .00
BUILDING: $ 46 .94
ELECTRICAL: $ 8 .33
PLUMBING: $ 5 .55
MECHANICAL: $ 4 .69
SUB-TOTAL $ 65 .50
TOTAL $ 65 .50
SEW ER: will pay at build out
WATER: will pay at build out
IRRIGATION: $ -
TOTAL: $
WATER METER: $ 34 .09 3/4 meter-
IRRIGATION METER $ -
FIRE DEPARTMENT FEES
PLANS TOTAL: $ 11 .21 ('
INSPECTION TOTAL: n/a JN
PERMIT TOTAL n/a �� �
TOTAL: $ 11 .21
�
PUBLIC SAFETY IMPACT FEES
POLICE $ 26 .35 $163 per 1000 sq
FIRE $ 25 .75 $175 per 1000 sq
5% $ 2 .86
TOTAL: $ 54 .96 f�
.• � l
r }
SUB-TOTAL $ 1,661. 6 ��
PARK IMPACT FEES n/a
SIF'S: n/a
100.0% $ -
1.0% $ -
TOTAL:
T I F'S: $5746 per 1000 sqft per Developer
99% $ - tifs will be paid at buildout
1% $ -
TOTAL: $ 1,661. 6
y,- � -�
'�� �
y Sub Shop e{���C l' ( `
� � � �
o umn
SQ. FEET PRICE
MAIN OR LIVING: 1,694 $ Q'D 53.18 1/2 106.36 valuation
OTHER AREA UNDER ROOF: - $ 88.00
OTHER: - $ -
VALUATION $ 90,086.92
FEE SHEET $ 449.00
ADDRESS
DRIVEWAY
BUILDING: $ 457.98
ELECTRICAL: $ 101.03
PLUMBING: $ 67.35
MECHANICAL: $ 47.15
SUB-TOTAL $ 673.50
TOTAL $ 673.50
SEWER: $ 603.00
WATER: $ 192.30
IRRIGATION: $ - ���
TOTAL: $ 795.30 For every 10 seats
WATER METER:
IRRIGATION METER $ -
FIRE DEPARTMENT FEES
PLANS TOTAL:
INSPECTION TOTAL:
PERMIT TOTAL
TOTAL: $ -
PUBLIC SAFETY IMPACT FEES
POLICE $ 39.77 Diffrence between 1694 and 1450 sqft
FIRE $ 42.70
5% $ 4.12
TOTAL: $ 86.59
SUB-TOTAL $ 1,555.39
PARK IMPACT FEES
SIF'S:
100.0% $ -
1.0% $ -
TOTAL: $ -
T I F'S: $ 9,733.73
99% $ 9,636.39
1% $ 97.34
TOTAL: $ 11,289.12
r
From: 07121l2014 13;23 �832 P,0011001
J �� tl
873-7B�-0D20 City of Zephyr�ill Permlf ApppCatlon Fewe�a.yeaoos+
8u1(dlnp Depar�ment
Octa Fjecolvad ��`j,.�� Phone ConmcL for rnnlWn + ��
� ���
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Fee Slaipte YlCahamer Adtlro�s
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SUgl1lY{610N zeDM1N�mmms pqppg�� 9525.21.019GOOOOA0030
�aeTA1NRqFROM PROPERTYTA7t�wAC1�
WORKPROPOSED ' � NEWmN5�R8X AGNpL,7 � BItiN 0 Q �EMOLISH
1NSTi1L1. REPAIR
PiipPO4�l�6E [� 8FR � COMM � OTHER
TYPEOFCONSiRUC710N � 8�K Q FPo4M1iE Q STEEL �
DESCWP'�QNOF1n10RK Int�rfor9ulW.autPorJeneyMfkea6ves urant
eUILOIHG6IZE T1.OQD SQP00'TIUSE ��� Nl9GHY T�
�BUILOIHO s ,�❑ VALUATIONO 767qL�ONSTRUCYION
T
�KK�EC7'AICA1. C6� AMF SERViCE Q PROGRESS F.�IERGY Q W,R•E�C.
��
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�i.
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S�GNATUAL NE6) FEECUPotCM fN
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EbECfiiIQIAN C4M nPN
8lONAiURE q4aia EpBP Y1 N F�CU� Y/N
Addiaca � �Ixnsa#
�� PLUM6ER � CoM ANY
��?/� SIONA7VFtE RGaB EREO Y/N NpECUtue�v 1
Marcss Llceneey (��jy�j�
�� MECNANICAL COM ANY � � �4 �/QaC��}�•�L�°�� ;
SIGNAT�1pL R E6�B.E�� Y N F�C U n n� / ��u���
A11d�ea9 � dJ�l� • '� q�s/.����jCjCWl7o$IK'tiGg7�� t'i��in �f .
OTHER COM ANY
• SIGNA'NRE �ksld /N FEEtURAEN Y!N
AGdreae liaanao� �
Ill������lllllllllllllllltllllr�ll �I�II � IIIIISI11111�11111111 �1111
RE81DEN1iAL iularh(z)pl0t PiB110i f�Se�B4t BulWets Plena;St)xl af �py�to�s�R�W PBmtllOYnew COAB@Lttbn,
Mlntmum oen(101 wonenp rtqe ertar a�hmttt,l dntc, retl onette,Coneauctlon Ptans,S�omnvacer pinna ve Su�Fence Inateuea,
Senitery Fe¢116ea 81 d�anpster,�1ee Wafi pa�Q�prsu Mstonella�pe projeds
CaMMERClAI. AtteC,H(�)e0mpkle xb of BuQdlflB P�Dlue B Uf9 Ba�e Ps�A;(1)e6!d Envgy Fa�mc,�aW Peryn��(p�ngW COlfe Wetion.
Mlnimum fen{]Ujwo�idng a■ya myravbmRtel dele.Nsq 0 onstte,ConchuNcn Plona,8lormweler PlenawJSm Fame L�st�Nad,
Seni(ory FqdIN195 Q�i tllQilyetef.51lA WoAc Pmnl!(or aU n w pto�e�h,,q�1 oDmmefdBl requfienbnl8 muo!m9et mmpllpqc�
81ON PLW�11Y af�ach(�aota aT Enpinesred Pla�a.
^"�PROPERTY SURVEY Rqufred Wr cll NEVVconawdl .
olrooGons:
Pll out eppFcaGrn campetoy,
ONnef$ConE'ecloradgn bact o!�D�����te117.e4
ffoverit.600,iNaaasottammaneamentietequt►ed. f��pp�d eavar3T6oD)
� ABont(iwihGCaAteCtorJaPawerofAttcmeY(folCwWm6qNOUIdDa roao�mwiusnwilmdl�ttvr0omormereuitierkingeame , , �
, av�n�catm�R PE�uACrnNo (Ftom ornapneeuon a�M � '
ftwooTe KeNU�gtea Smtiers Bervice Uppredea AIC Fenas UBurvay(�oote0e} �
nMVewaysNa�owr counter I►on puhtic�aad�eys,.neeaa ROw •
�EPHYR�flLL� F[i�E I3E��R�'f��[�7°
6907 Dairy Road, Zeph rhills, FL 33542 •
u •� 7 _
FIRE SERVICE SER FEES
Occupancy No.•
Plan No.: Contractor: � ��7�'t/�
Business Name: '�' � , Billing Address:
Business Address: J.fi y�3 �/ �fv�
Business Phone No.: Billing Phone No.:
Business Fax No.: Billing Fax No.: � �
Contact: Contact:
PLAN REVIEW FEES INSPECTION°FEES PERMIT FEE FALSE ALARM FEE
�Sfte Plan WC Mnual ' N/C Sprinkler �50 1st Alarm N/C
Multi-Fainity/Commercial .06`sf 1st Re-inspection WC Standpipes �50 2nd Alarm N/C
(Minimum Charge a25.00 2nd Re-inspection $100 Fire Pump S50 3rd Alarm N/C
�Plan Revisions DBL 3rd Re-inspection .a250 Hoods S50 4th A1arm $100
4th R�Inspedion �500 �ire Alartn �50 5th Alartn $�5p
SPRINKLER SYSTEMS (Business dosed untif LP Gas �50 6fh Alartn �Zpp
�0-25 Heads $50 violations coReded) Natural Gas a50 NON COMPLIANCE $150
26 plus Heads $100 SPRINKLER SYSTEMS Fue!Tanks- Perramc a50
ST/WDPIPE SYSTEM Hydro Undergrounds $45 8pariclers 5100
� Per Riser S50 Nydrostatic Test $65 per syn Fre Worlcs 5500
FIRE PUMP Aa:eptance Test $45 persyst m Camp Fire 525
�Per Pump $100 Hydrant Flow $75 Controlled Bum $100
FIRE ALARM SYSTEM Hood/Dud S50
0-25 Devices a50 FIRE ALARM SYSTEM Place of Assembly $50 nnnuai
26 plus Devices $100 System Acxeptance $50 Fre Protection S25
SUPPRESSION SYSTEMS Recall Acceptance $50 Flammabte Application $50 Annua�
Wet S50 OTNER Waste Tire Storage �50 �nnua�
Dry S50 Flre WalUSmoke Waq �15 �wan Generator<FCV1f 5100
CO2 $50 LP Gas $25 per�k Generator>30 KW 150
Other a50 Natural Gas $25 �sys� B'�o-Fiazard Waste• 5100 �
KITCHEN IXHAUST Fumigation Tenting S50
�Hood/Duds a50 Tent 10k10'o{greater $15 pertent Torch PoUApplied $50
OTHER Fire Pump . $45 Haz Matetiats 5100 Nx,ua�
8 I..Plnstallattonpertank �50 Fire Suppression �30
FueCTank Inshallation S50 System Acceptance •
(Per Tank) �50 E�►aust Hood/Duct �30
�Natural Gas�nstaqation S50 Re-inspection DBL
(Pe�System) (other than annual)
�Spray Booth �50 �Inspection scheduled DBL a
a�d cancelled less tha�
, 24 hours
Construcdon Insp. N/C
Emergency Vehicle A� $50 FALSE ALAFtM
---�b4i�1�Tt��.. a S�ECiiBN-�O��4t-�--- ---��RMi�-��� flfiAt-�----�--•-�---
. t
GRAND TOTAL
Comme�ts:
Date:
Inspector:
nin
Jersey Mikes-7890 Gall Blvd-Interior B/o t-Restaurant-1,600 sq ft-
; ;. : Geneva Constructio Inc
ou n
SQ. F ET PRICE
MAIN OR LIVING: 1,600 $ 53.18
OTHER AREA UNDER ROOF: - $ 88.00
OTHER: - $ -
VALUATION $ 5,088.00
FEE SHEET $ 429.00
ADDRESS
DRIVEWAY
BUILDING: $ 437.58
ELECTRICAL: $ 96.53
I PLUMBING: $ 64.35
MECHANICAL: $ 45.05
SUB-TOTAL $ 643.50
TOTAL $ 643.50
SEWER: $ 1,809.00
WATER: $ 576.90
IRRIGATION: $ -
TOTAL: $ 2,385.90
WATER METER: n/a
IRRIGATION METER $ - n/a
FIRE DEPARTMENT FEES
PLANS TOTAL: $ 96.00
INSPECTION TOTAL:
PERMIT TOTAL
TOTAL: $ 96.00
PUBLIC SAFETY IMPACT FEES
POLICE $ 24.45 -
FIRE $ 26.25
5% $ 2.54
TOTAL: $ 53.24
S U B-TOTAL $ 3,178.64
PARK IMPACT FEES n/a
SIF'S: n/a
100.0% $ -
1.0% $ -
TOTAL: $ -
T I F'S: $ 9,193.60
� 99% $ 9,101.66
1% $ 91.94
TOTAL: $ 12 372.24
� ,� � Sub Shop
ou
SQ. F ET PRICE
MAIN OR LIVING: 1,600 $ 53.18
OTHER AREA UNDER ROOF: - $ 88.00
OTHER: - $ -
VALUATION $ 5,088.00
FEE SHEET $ 429.00
ADDRESS
DRIVEWAY
BUILDING: $ 437.58
ELECTRICAL: $ 96.53
PLUMBING: $ 64.35
MECHANICAL: $ 45.05
SUB-TOTAL $ 643.50
TOTAL $ 643.50
SEWER: $ 1,809.00
WATER: -$ 576.90 --
IRRIGATION: $ -
TOTAL: $ 2,385.90
WATER METER:
IRRIGATION METER $ -
FIRE DEPARTMENT FEES
PLANS TOTAL:
INSPECTION TOTAL:
PERMIT TOTAL
TOTAL: $ -
PUBLIC SAFETY IMPACT FEES
POLICE $ 24.45
FIRE $ 26.25
5% $ 2.54
TOTAL: $ 53.24
SUB-TOTAL $ 3, 82.64
PARK IMPACT FEES
SIF'S:
� 100.0% $ -
' 1.0% $ -
TOTAL: $ -
T I F'S: $ 9,193.60
99% $ 9,101.66
1% $ 91.94
TOTAL: $ 12 276.24
I IIIIII IIIII IIIII IIIII Illll IIIII IIIII IIIiI IIIII IIIII IIII illl
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2014117794
PertnilNo. / � ��O�r p roeIIDNO 3&2521-073Q00000-0030
NOTICE OF CO MENCEMENT
State of FLORIDA un[y oi PASCO
mv�
THE UNDERSIGNED hereby gives noUce Ihal improvement will be made lo rtain real pmperty,end in accordance with Chapter 773,Florida Slatutas,
the follawing infartnaUon is provlded in thls NoUce of Commancement N�w
1. DescripUan of Property: Parcel Identlficatian No. 3S2S21-0 30-OD00Q0030 �+1 m••
�• ►+
� SUeet Address: 789D Gall Blvd.;ZephYrhills,FL 33541 ~��
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2. Generel Descriplion of Improvement Interlor buldout forJe e Mike's Subs restaurant 7C �
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3. Owner Infortnatlon or Lessee infortnation If the Lessee conVacted f r lhe improvament: � ►+
� Q -i.�
ZHJM Services LLC `� " �
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Name m•-
7870 Gall Blvd.,tl405 2ephyrhills FL 12s�� O B�
Address Ciry State '��
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Inlarest in Property: tenant eF .
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Name of Fee Simple TiUehoider: n/a n m
(I(diHerent fiom Ovmer listed ab ve) .�
10
Address City State �
4. CoNractor. Geneva ConsWctfon,Ins. �
Nama
PO Box fi2185B Oviedo FL
Address City Slate �
ConVaclor's 7elephone No.. 407•349-5904
i
i5. Surety: n/a
Mame m D
Address City State ��D
i Amount of Bond: $ Telephone Na.: �4l y
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6. Lender. Na �A o
Nama (/� m
�i/�..
Address City State W�
Lenders Talephone No.: ��7
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7, Persons w(lhin lhe Slate of Florida desipneted by the owner pon whom notices or other documents may be served as providad by w'� �
Sedian 713.13(1)(a)(7),Florida Statutes: �V N
[�
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Name � �
r
O m
Address Ciry State �~►x
Telephona Number of Designaled Person: �►+n°
n
B, In addltion to hlmself,the awner designates �f— � 3
to receive a cop of lhe Lienor's Notice as provided in Section 713.13(1)(b),Florida Statutes. � �
Telephone Number ol Person w Entity Deslgnated by Oxmer: °
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9. E�IraUan date of Nolice oi Commencement(the expireUon dete mey not be hefore the complellon o1 construction entl finel payment to lhe �
contredor,but will be one year(rom the date of recording unless difterent date is specified):
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OW ER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT
ARE CONSIDERED IMPROPER PAYMENTS UNDER CHA R 713, PART 1, SECTION 713.13, FLORIDA STATUTES, AND CAN
RESUIT IN YOUR PAYING TWICE FOR IMPROVEMENTS 0 YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE
i RECORDED AND POSTED ON THE JOB SITE BEFORE THE F RST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING,CONSULT
' WI7H YOUR LENDER OR AN ATTORNEY BEFORE COMMENC NG WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT
Under penalty of per�ury,I dedare lhal I have read the foregoing o ice cotn ence nt and thal tha facts stated therein are We to the best
of my knoHledge and belief.
STATE OF FLORIDA
COUNTY OF PASCO
Sign lure of er ar Lessee,or Ownels ar Lassee's Authorized
Oflic r/DiredorlPariner/Manager
. C� �
Sign torys itlelOt6ca
Tha foregoing insWment�ras acknowtedged befora me this��day o( l 20��'by,���5►'1 J 4 1 � � � ��'nCd��
• l..t�`ne es C (type af authority,e.g.,oflicer,wstee,attomey in iaa)tor
V t.. a (name on behal!of whom Inslrume s�axe utad).
Personelty Knovm�QB Produc^ed Identification�/+ Not Slgneture `
Type of ldenthcaGon Produced 1Jf �`� °L�� `�Ce�'1�-� Na e(Print) � �� � �
STEPHANIE SMITH
i NOTARY PUBLIC
�� STATE OF FLORIDA
, � � , , I . Comm#FF030184
' . � ' ' , Expires 6/232017
wpd ata/bcs/n ottcecor4imen cement�c053048
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�`A o ' • e �'i
��. ��G STATE OF FLORIDA, COUNTY OF PA�CO
� , � THIS IS TG�CERTIFY THAT THE FOREGOING IS A
° TRUE AND CORRECT COPY OF THE DOCUMENT
f��°`��¢r'�`� , �c ON FILE OR OF PUBLIC ORD IN THIS OFFICE
'� . `���"�°'_ ` WITNES MY AND AN 0 FICI SEAL T IS
�t � . �' � AY OF 2�!1—
• rBBr � PAULA S. O'NEIL, TROLLER
�A��QF F�,QK��� DEPUTY CLERK
BY
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Range Hood S:' stems Report
r �, SERVICE COMPANY DA OFSERVC TIME AM. P.M.
^`1�j�y�S. ,�.�._�-'9 �A/i� � ,O�°f3� �°"
_` � ' ANN ' SEMI=ANNUAL RECHARGE INSTALUTION RENOVATION
NITE 1, ( �
LOCA li OF SYSTEM CYLINDEHS
'fire protection r.: 1�.� � Aa. r
•� MAN FAGTURER MODELNUMBER WET DRVCHEMICAL
2900 Shader Road � Orl.ando, Florida-32808
407-299-0201 • Fax 407-296-3126 `"�' � '��' `� �
CYLI DER SIZE MASTER CYLINOER SIZE SLAVE CVLINDER SIZE SLAVE
Website:www.unitedfirepro.com f�� � � �
CUSTOMER FU E LINKS 360'F FUSE LINKS 450'F FUSE LINKS 500'F OTHER '
Name •---�r���F ��F�6�S FUELSHUT-0FF ELECTAIC GAS S
Address ��� ��'EI ��`��`�' Q
� s9'�5/� ,�c�'iw C[� �
ERIAL NUMBER LASTHYDRO TEST DATE U5T RECHAAGE DATE
City ��,,,a�. ��/{� �! °'� '3S'��1 � �{
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MAN FACTURER'S MANUALREFERENCE
Telephone Store No.
PAG NUMBER: DRAWING NUMBER:
Owner or Manager �
,
COOK/NG APPLIANCE LOCATIONS: LEFT TO RIGHT `
� � 6p��it���
1. All appliances properly covered w/correct noules �. 20. Replaced fuse links �r�c�
2. Duct and plenum covered w/correct noules P'' 21. Check travel of cable nuts/S-hooks rs
3. Check positioning of all noules. ^-� 22. Piping & conduit securely�bracketed .f'
4. System installed in accordance w/MFG UL listing � 23. Proper separation between fryers &flame ✓'
5. Hood/duct penetrations sealed w/weld or UL device � 24. Proper clearance-flame to filters a�''
6. Check if seals intact, evidence of tampering .�_ 25. Exhaust fan in operating order /
7. If systern has been;discharged, report same � '26. All filters replaced 1 �.%
S. Pressure gauge in'proper range(If gauged) � 27. Fuel shut-off in on position .r
9. Check cartridge weight (If applicable) '� 28. Manual & remote seUseals in place �
10. Hydro�tatic test date O �f� 29. Replace systems covers ...-
11. 6 year maintenance date � °�°° 30. System�operational & seals in place , �-
12. Inspect cylinder and mount p� 31. Slave system operational r �S
13. Operate system from terminal link �' 32. Clean cylinder& mount ��'
14. Test for proper operation from remote -.r�" 33. Fan warning sign on hood �,n
15: Check operation of micro switch �-° 34. Personnel instructed in manual operation of system _.�„�
16. Check operation of gas valve �-'' 35. Proper hand portable extinguishers ...-
17. Clean noutes �� 36. Portable extinguishers properly serviced
r
18. Proper noule covers in place ��' , 37. Service &Certification tag on system ./
19. Check fuse links and clean , .� NOTE DISCREPANICES OR DEFICIENCIES BELOW
COMMENTS: �� '��'�'•� '�° �'�'°�
' `
On this date, the above sysfem was tested and inspected in acco dance with procedures of the presently adopte�editions of _
NFPA 17, 17A, 96 and the manufacturer's manual and was oper ed according to these procedure with result�s�mdicated above.
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SER I� E TECHNICIAN . PERMIT NO. DATE: TIME: AM PM ' CUSTOMERS AUTHORIZED AGENT
The above service technician certifies that the system was person Ily inspected and:found conditions to be as indicated on this repoit. �
WHITE-CUSTOMER COPY VELLOW-DISTRIBUTOR PINK-AUTHORITY'HAVING JURISDICTION