HomeMy WebLinkAbout110 Oaks Ctr
T
Xxt'CEIVED
CITY OF SANFORD
FEB 16 2016 BUILDING & FIRE PREVENTION
BY. PERMIT APPLICATION
Application No: — 5
Documented Construction Value: $
Job Address: // o PA-1(.5 Historic District: Yes No [-
Parcel ID: 3:?:), —I % --30--ResidentialEl Commercial Type
of Work: New Addition Alteration Repair Demo Change of Use Move Description
of Work: Chamap a /> -L 2 i m 5USf-P.m !r GuJ-0vj-no EKi Plan
Review Contact Person: U U e- 60 Title: iy1aM42r- Phone: /-
y D2Fax: Id / ,;C qb Email: r_'uCO .6-3 6)41A;-ar'- J Property Owner
Information / Name Wl^!
1 '!/i 4- iC. UL,(:' C1V Phone: _ 707 —3 -3 . 6 V /2, Street: City,
State
Zip: Resident of
property? : L Contractor Information > `
r Name ,
ca &r Phone: UD ! d :3 Street: City,
State
Zip: Fax: State
License
No.: Architect/Engineer
Information Name: Phone:
Street: Fax:
City, St,
Zip: E-mail: Bonding Company:
Address: Mortgage
Lender:
Address: WARNING
TO
OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY 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 INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT
WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT. Application
is
hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior
to the issuance of a permit and that all work will be performed to meet standards of all laws regulating construction in this
jurisdiction. I understand that a separate permit must be secured for electrical work, plumbing, signs, wells, pools, furnaces, boilers,
heaters, tanks, and air conditioners, etc. FBC 105.
3 Shall be inscribed with the date of application and the code in effect as of that date: 51h Edition (2014) Florida Building Code Revised: June
30, 2015 Permit Application 1 L /i1
r „Q
1 uC
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no
work or installation has commenced prior to the issuance of a permit and that all work will be performed to
meet standards of all laws regulating construction in this jurisdiction. I understand that a separate permit
must be secured for electrical work, plumbing, signs, wells, pools, furnaces, boilers, heaters, tanks, and
air conditioners, etc.
OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
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 INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
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 districts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the requirements of Florida
Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee. A copy of the executed contract is required in order
to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the
plan review fee based on past permit activity levels. Should calculated charges exceed the documented
construction value when the executed contract is submitted, credit will be applied to your permit fees when the
permit is released.
CkL,6- z - 3 -Ito
SignatuA of Owner/Agent Date
Print
of
GEORGEANNEBLEDSOE
MY COMMISSION N FF94M
E7 HM: Jamxy 07, 2020
07/3 /020 /
Date
Owner/Agent is V Personally Known to Me or
Produced ID Type of ID
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
UTILITIES:
I 1'
Signature of Contractor/Agent Date
Zap/ 4
Print Contractor/Agent's Name
rI16
Notary Public - State of Florida
My Comm. Expires Jun 1, 2016
Commission # EE 194633
Bonded Through National Notary Assn.
Contractor/Agent is 1 Personally Known to Me or
Produced ID Type of ID
WASTE WATER:
BUILDING:
Shall be inscribed with the date of application and the code in effect as of that date (Code 2010 FBC) 731.135(5)(6) Florida Statutes.
REV 07.14
Application No:
Job Address:
Parcel ID•
Description of Work:
Plan Review Contact Person:
Phone:
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Documented Construction Value: $
Historic District: Yes ElNo ElZoning:
Fax: E-mail:
Property Owner Information
Title:
Name Phone:
Street: Resident of property?
City, State Zip:
Name
Street:
City, State Zip:
Name:
Street: . a
City, St, Zip:
Bonding Company:
Address:
Contractor Information
Phone:
Fax:
State License No.:
Architect/Engineer Information
Phone:
Fax:
E-mail:
PERMIT INFO
Building Permit `
c2
Square Footage: Construction Type:
No. of Dwelling Units: Flood Zone:
Electrical
New Service — No. of AMPS:
Mechanical (Duct layout required for new systems)
Mortgage Lender:
Address:
RMATION ttrawi t a x .tcT [}:'''SYM
No. of Stories:
Plumbing
New Construction - No. of Fixtures:
Fire Sprinkler/Alarm No. of heads:
Shall be inscribed with the date of application and the code in effect as of that date (Code 2010 FBC) 731.135(5)(6) Florida Statutes.
REV 07.14
Application No:
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATION
Documented Construction Value: $ G / 00 , v2-
Job Address: // O 4 q )CS Ov UIZ7' Historic District: Yes No Ik
Parcel ID: 3 - 30— YOY-o0DO-01'Po Zoning:
Description of Work: c'f,4W67e_vuT
Plan Review Contact Person: ocr- Title: 1WAnIA (h-'2
Phone: V07 - Y/0 cZ-aa-() ° Fax: V%d7-h-31,?- Siy E-mail: 4'3 Rl^dod -ed-O
Property Owner Information
Name Phone: Vd 7 - ? 02— 2
Street: // D a"41Je S rot//L 7 Resident of property? City,
State Zip: Contractor
Information Name
ljl_ S-s e'y s—
1'--
l ?n G Phone: Street:
5,rr 5/UUO 7 . /(JY/11V Fax: 7— 2 h " a- S20 City,
State Zip: State License No.: (f::' 60 .S6 70K Name:
Architect/
Engineer Information Phone:
Street:
4a Fax: City,
St, Zip: Bonding
Company: Address: ;
i1_7ABuilding
Permit Square
Footage: No.
of Dwelling Units: Electrical
New
Service — No. of AMPS: E-
mail: Mortgage
Lender: Address:
PERMIT
INFORMATION Construction
Type: Flood
Zone: Mechanical (
Duct layout required for new systems) Plumbing
No.
of Stories: New
Construction - No. of Fixtures: Fire
Sprinkler/Alarm No. of heads: Shall
be inscribed with the date of application and the code in effect as of that date (Code 2010 FBC) 731.135(5)(6) Florida Statutes. REV
07.14
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no
work or installation has commenced prior to the issuance of a permit and that all work will be performed to
meet standards of all laws regulating construction in this jurisdiction. I understand that a separate permit
must be secured for electrical work, plumbing, signs, wells, pools, furnaces, boilers, heaters, tanks, and
air conditioners, etc.
OWNER'S AFFIDAVIT: I certify that all of the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating construction and zoning.
WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
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 INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
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 districts, state agencies, or federal agencies.
Acceptance of permit is verification that I will notify the owner of the property of the requirements of Florida
Lien Law, FS 713.
The City of Sanford requires payment of a plan review fee. A copy of the executed contract is required in order
to calculate a plan review charge. If the executed contract is not submitted, we reserve the right to calculate the
plan review fee based on past permit activity levels. Should calculated charges exceed the documented
construction value when the executed contract is submitted, credit will be applied to your permit fees when the
permit is released.
Signature of Owner/Agent
Print Owner/Agent's Name
Date
Signature of Notary -State of Florida Date
Owner/Agent is Personally Known to Me or
Produced ID Type of ID
APPROVALS: ZONING: UTILITIES:
ENGINEERING:
COMMENTS:
FIRE:
Signature of Contractor/Agent Date
Print Contractor/Agent's Name
Signature of Notary -State of Florida Date
Contractor/Agent is Personally Known to Me or
Produced ID Type of ID
WASTE WATER:
BUILDING:
Shall be inscribed with the date of application and the code in effect as of that date (Code 2010 FBC) 731.135(5)(6) Florida Statutes.
REV 07.14
SCPA Parcel View: 33-19-30-503-0000-0180 Page I of 2
t wlcf Johnson. Cf=A Property Record Card
PROPERTY Parcel: 33-19-30-503-0000-0180
APPRAISER Owner: MC KIBBIN WILLIAM B & LINDA W
sErn. a COUN7Y, PLORIDn Property Address: 110 OAKS CT SANFORD, FL 32771
Parcel: 33-19-30-503-0000-0180 ry
Property Address: 110 OAKS CT 2016 Working 2015 Certified
Owner: MC KIBBIN WILLIAM B & LINDA W Values Values
Mailing: 110 OAKS CT Valuation Method Cost/Market Cost/Market
SANFORD, FL 32771-3647
Subdivision Name: OAKS OF SANFORD
Number of Buildings 1 1
Tax District: SI-SANFORD Depreciated Bldg Value $130,906 $124,135
Exemptions: 00-HOMESTEAD (1999) Depreciated EXFT Value $600 $600
DOR Use Code: 04-CONDOMINIUM
Land Value (Market)
Land Value Ag
jQ9- Just/Market Value
131,506 $124,735
c L
EFO u =
Portability Adj
I Save Our Homes Adj $33,223 $27,135
np hDri
Amendment 1 Adj
r,
4rVV LL JJ tt4+##JJl 4.1
F
Cam—
Assessed Value 98,283 $97,600
J a } Tax Amount without SOH: $1,717.18
2015 Tax Bill Amount $1,164.95
V Tax Estimator
Save Our Homes Savings: $552.23
III r.T Does NOT INCLUDE Non Ad Valorem Assessments
jLegal Description
LOT 18&512FTOFLOT 17 OAKS
OF SANFORD PB
19 PIGS 55 + 56 C-
Taxes Taxing
Authority Assessment Value Exempt Values Taxable Value County
General Fund I
98,
283 $50,000 $48,283 Schools
98,283 $25,000 $73,283 City
Sanford 98,283 $50,000 $48,283 S3WM(
SaintJohns Water Management) 98,283 $50,000 $48,283 County
Bonds 98,283 $50,000 $48,283 Sales
Description
Date Book Page Amount Qualified Vac/Imp I
WARRANTY DEED 12/1/1998 03563 1184 117,000 Yes Improved WARRANTY
DEED 3/1/1979 01214 0849 76,400 Yes Improved Find
Comparable Sales within this Subdivision Land -
Method
Frontage Depth Units Units Price Land Value j
LOT 0 0 1 Building
Information Description
Year
Built Fixtures
Base Area Total SF Living SF Ext Wall Actual/Effective 1
CONDOS 1979 8 1,044 2,825 1,999 SIDING GRADE
3 0.
10 Adj
Value Repl Value Appendages 124,
135 $124,135 Description
Area OPEN
PORCH FINISHED
64 http://
www.scpafl.org/PareelDetailInfo.aspx?PID=33193050300000180 2/2/2016
SCPA Parcel View: 33-19-30-503-0000-0180 Page 2 of 2
GARAGE 624
FINISHED
OPEN PORCH 96FINISHED
OPEN PORCH 42
FINISHED
UPPER STORY
955FINISHED
Permits
Permit # Type Agency Amount CO Date Permit Date
02025 Miscellaneous Sanford $5,293 4/23/2007
Extra Features
Description Year Built Units Value New Cost
FIREPLACE 1 12/1/1979 1 $600 $1,500
http://www.scpafl.org/ParcelDetaillnfo.aspx?PID=33193050300000180 2/2/2016
Page 1 of 1
arcel: Building # 1 I i Page # 1 j ' ram, 'a` Note:Chck on image to drag.
http://www.scpafl.org/footprint.aspx?PID=33193050300000180 2/2/2016
SEMINOLE COUNTY MuLT!%URISDICTIONAL
LIMITED POWER OF ATTORNEY
Altamonte Springs, Casselberry, Lake Mary, Longwood, Sanford,
Seminole County, Winter Springs
Date:
I hereby name and appoint:
an agent of: ___c
to be my lawful attorney -in -fact to act for me to apply for, receipt for, sign for and do all things necessary to thisappointmentfor (check only one option):
All permits and applications submitted by this contractor.
Or
The specific permit and application for work located at:
O
Street Address)
Expiration Date for This Limited Pow r of Attorney:
License Holder Name: G/21 !e-f%.
State License Number:
Signature of License He
STATE OF FLORIDA
COUNTY OF 5EM /,q d &
The foregoing instrument was acknowledged before me this day of
20_/C bywho i rsona nown to me or who
has produced and
who did (did not) take an oath. Signature
of Notary as
identification Print
or type Notary name Y'
p'a,, ANN JEANETTE BONACKI Notary Public - State of Notary
Public •State of Florida Commission No. oMyComm. Expires Jun 1, 2016 ary
8t911psion # EE 194633 My Commission Expires: S4.Cn ( 10 ga Bonded
Through National Notary Assn.
1 WESSON A INC.
Air Conditioning & beating
Page 3 of 3, McKibbion, Trane Weathertron XR 15 Heat Pump System, 2 ton 15 Seer
PROPER STARTUP:
After the mechanics have completed the installation work a courteous NATE certified Wesson Air
Inc. technician shall be dispatched to your home to perform proper start-up.
To assure that your new Wesson Comfort System operates at peak performance, your system is
dehydrated with nitrogen and suction, then tuned to your home by measuring the temperature split, sub
cooling, super heat in addition to just observing the operating pressures. These essential steps are over
looked in 90 % of installations nationally and results in less comfort, economy and reliability to you,
WARRANTY:
Wesson Air Inc. shall provide one-year part and labor coverage on installed system.
Wesson Air Inc. shall provide lifetime warranty on all of the new ductwork installed by Wesson Air Inc.
against defective material and workmanship.
Trane shall provide five-year part coverage on the compressor and five-year part coverage on all of the new
Trane components. Factory 10 year part warranty registration is included in your total investment.
PAYMENT SCHEDULE: Payment upon start-up.
TOTAL FINANCED INVESTMENT: $ 6.341.00
with Wells Fargo Visa, 36 Months 0 Interest with EQUAL monthly payments of $ 176.14
Trane consumer financing apply on line at wessonair.com. Click on Payment Options, Click on Finance.
With the balance to be paid prior to end of promotional interest period.
WESSON AIR
BY
John Bandur
NATUR
DATE 2 . 3 - I ,
Proposal valid for thirty days and is subject to equipment availability.
1• /
Equipment qualifies for the reinstated IRS income tax credit, consult your tax prepare about your eligibility.
OPTIONS:
108.00 High performance mery eight rated filters one case of twelve. Six filters included with installation.
169.95 Energy Saving Agreement, factory recommended precision preventive maintenance. Carry over.
Trane optional extended part & labor warranty through the installation date of 2026. $ 2,336.00
n
Florida homeowner's construction recovery fund. Payment may be available from the Florida homeowner's construction
recovery fund if you lose money on a project performed under contract, where the loss results from specified violation of
Florida law by a licensed contractor. For information about the recovery fund and filing a claim, contact the Florida
construction industry licensing board at the following telephone number and address:
1-850-487-1395
Florida homeowner's construction recovery fund. 1940 N. Monroe St., Tallahassee, FI.32399
Mc KI b b fn 0 a ks L LX R 15.wrd
mar-. ®/ andti99C7 8lY
Extreme Condition Mounting KitBAYECMTOES
13AY-ECMt004
MA pleases of this installation must comply withNMON.4LJ ffAjjgANDLaCAL CODES
RTANT—This Document is customer propertypackuponcompletionofwork. and is to remain with this unit. Please return to service informationpacku
KIT CONTENT - BAYECMT023:
Will mount 10 individual units.
Base Tab Bracket — Qty 40 (Height 2.1"
for Base 2 & 3)
Backup Clip — Qty 40
Self drilling 12.14 Screws — Qty 45
12.18 Screws — Qty 45
KIT CONTENT - SAYECNIT004:
Will mount 5 -10 individual units depending on
unit height. See Installation - BAYECMT004
UNITS greater to or equal to 51" verses 54".
Base Tab Bracket — Qty 40 (Height 2.5"
for Base 4)Backup Clip — Qty 4OSelf
drilling 12.14 Screws — Qty 45
12-18 Screws — Qty 45
INSPECTION - ALL KITS:
Check carefWly for any shipping damage.
This must be reported to and claims made
against the transportation company immedi-
ately. Any missing parts should be reported to
your supplier at once and replaced with au-
thorized parts only.
2008 Trane
O BASE TAB BRACKET
HEIGHT
o
This combination qualifies for a Federal Energy I
Efficiency Tax Credit when placed in service;
between Feb 17, 2009 and Dec 31 2016.'
Z -
v%
ate &
c:;hf Produd-,A Ranfinmertifik;
AHRI Certified Reference Number: 7699412 Date: 2/2/2016
Product: Split System: Heat Pump with Remote Outdoor Unit -Air -Source
Outdoor Unit Model Number: 4TWR5024G1
Indoor Unit Model Number: TEM6AOB24H21+TDR
Manufacturer: TRANE ; >y
Trade/Brand name: TRANE
Series name: XR15
Manufacturer responsible for the rating of this system combination is TRANE
Rated as follows in accordance with AHRI Standard 210/240-2008 for Unitary Air -Conditioning and Air -Source
Heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, independent, third
party testing:
Cooling Capacity (Btuh): 24000
EER Rating (Cooling): 12.50
SEER Rating (Cooling): 15.00
Heating Capacity(Btuh) @ 47 F: 21000
Region IV HSPF Rating (Heating): 9.50
Heating Capacity(Btuh) @ 17 F: 13300
Ratings followed by an asterisk (') indicate a voluntary rerate of previously published data, unless accompanied with a WAS, which indicates an involuntary rerale
DISCLAIMER
AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for,
the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the
unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the
directory at www.ahridirectory.org.
TERMS AND CONDITIONS
This Certificate and its contents are proprietary products of AHRI. This Certificate shall only be used for individual, personal and
confidential reference purposes. The contents of this Certificate may not, in whole or in part, be reproduced; copied; disseminated;
entered into a computer database; or otherwise utilized, in any form or manner or by any means, except for the user's individual,
personal and confidential reference.
CERTIFICATE VERIFICATION
The information for the model cited on this certificate can be verified at a :+:i.aliriclirectory.org, click on "Verify Certificate" link
and enter the AHRI Certified Reference Number and the date on which the certificate was issued, "
which is listed above, and the Certificate No., which is listed at bottom right.
2014 Air -Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 130989244629027725
a
WESSAIR-01 SULLIVANPA
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) F3127/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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).
PRODUCER
Insurance Office of America, Inc.
1865 West State Road 434
CONTACT
NAME:
PHONE FAXArcNoEzt : (407) 788-3000 AIC No): (407) 788-7933
Longwood, FL 32760 E-MAILADDRESS:
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: National Trust Insurance Company 20141
INSURED INSURER B:Bridgefield Employers Insurance Company 10701
INSURERC: Wesson Air, Inc.
156 Baywood Ave.
Longwood, FL 32750
INSURER D :
INSURER E :
INSURER F :
L.UVtKAUtS CERTIFICATE MHMRFR- oCVlCIMI Idl IMIZeo•
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTRR
TYPE OF INSURANCE INSD BR
POLICY
NUMBER MM/DDY MMIDDY LIMITS A
COMMERCIAL GENERAL LIABILITY CLAIMS -
MADE M OCCUR GL00105860 0410112015 0410112016 EACH
OCCURRENCE S 1,000,000 DAMAGE
TO PREMISES
RENTED
occurreoLel
100,00 MED
EXP (Any one person) S 5,000 PERSONAL
BADVINJURY S 1,000,000 GEN'
L AGGREGATE LIMIT APPLIES PER: X
POLICY a jEO El LOC OTHER:
GENERAL
AGGREGATE S 2,000,00 PRODUCTS-
COMP/OPAGG 2,000,00 S
A
AUTOMOBILE
X
X
LIABILITY
ANY
AUTO SULED
NEDSCHAUTOSAAUAUTOSNON -
OWNED HIRED
AUTOS X AUTOS CA00071990
04101/2015 04/01/2016 COMBINED
SINGLE LIMIT Ea
accident)$ 1,000,000 BODILY
INJURY (Per person) BODILY
INJURY (Per accident) PROPERTY
DAMAGE Per
accident S S
UMBRELLA
LIAB EXCESS
LIAB OCCUR
CLAIMS -
MADE EACH
OCCURRENCE AGGREGATE
S DED
I I RETENTION $ B
WORKERS
COMPENSATION AND
EMPLOYERS' LIABILITY ANY
PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/
MEMBER EXCLUDED? N Mandatory
in NH) If
yes, describe under DESCRIPTION
OF OPERATIONS below N
I A 83050428
04/0112015 0410112016 PER
OTH- XSTATUTEERE.
L. EACH ACCIDENT S 100,000 E
L. DISEASE - EA EMPLOYEE 100,000 E.
L. DISEASE - POLICY LIMIT S 500,000 DESCRIPTION
OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 1
G MiLUCR CITY
OF SANFORD BUILDING DEPARTMENT P
0 BOX 1788 SHOULD
ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE
WITH THE POLICY PROVISIONS. AUTHORIZED
RI,
DRREEP RESENTATIVE
u
1aut%-ZU14 ACORD CORPORATION. All rights reserved. ACORD
25 (2014/01) The ACORD name and logo are registered marks of ACORD