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16-17987
Zephyrhills
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2016
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16-17987
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Last modified
7/20/2017 2:28:33 PM
Creation date
7/20/2017 2:28:32 PM
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Building Department
Company Name
CITY OF ZEPHYRHILLS
Building Department - Doc Type
Permit
Permit #
16-17987
Building Department - Name
CITY OF ZEPHYRHILLS
Address
38122 HENRY DR
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, <br /> bb4�� KERS COMP�NSATION ANO�MPL.OYERS LfABIE.RY INSURANCE POLICY WC 00 EF3 i3 <br /> {Ed.04-84) <br /> AtVER 4F OUR RtGH'T T� REC�VER FRC1M OTHERS ENLiC?RSEMENT <br /> We have the cight to recaver our paym�nts from anyane liahle far an inlury covered by Ihis poGcy. We will not <br /> enfa�Ce our right against Ihe person or orqanization named in the 5chedule. (1'his agreement applies onfy to the <br /> extent that you peKarm work under a wdtten contract that requfres you to abtain this agreement irom us.) <br /> 17ris� greemenl shall not operate�rectlyr or indt�ectiy to benetit�nyone not named in the Scheduie. <br /> Schedule <br /> AU. ERSONS AND/�R ORGANI7�ITIONS THAT ARE REQUIRED BY WRITTEN CONTAACT OA AGREE- <br /> M� WITH THE INSUR�D�EXECUTED PRiOR TO THE AGCIOENT QR LOSS�7HI0.T WAIVEH OF SUBRO- <br /> GA iON 8E PROVlDEO UNDER'fH15 FOLICY FOR W ORK PEHFORMED 8Y YOU FOft THAT PERSON <br /> AN /OR ORGANIZATION <br /> I <br />� endo�emeat changes Ihe poficy to whEch it!s altached and is eHecihre an the dale fssued unless athenkiae statecf <br />', he(ntormativn balow(a roquired oMy whan ihl�andaaaemeat is 18aued aubeaqucni tn preperatloa ot the poficy.) <br />' Endor�ement �ltective:4/20/15 �otiayNo. WC 0114356-00 <br /> �n6�� New Tech Construction Corp. Premium S <br /> �I u�ance campeay councecsigned byr I <br /> RICH AMERiCAN iNSURAPfCE COMPANY OF ILLINOIS <br />' WI"124(A-84) Page t a(7 <br /> WC o0 0313 Gopyrtght te63 Nsuana!Coundt on Compenaetlo�Inauranca�rnc uca►am Fomts"' <br />� <br /> i <br />
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