HomeMy WebLinkAbout1604 William Clark Avel
CITY OF SANFORD
BUILDING & FIRE PREVENTION
AUG i 1 205 PERMIT APPLICATION BY: _ ------
Application No: Documented
Construction Value: $ 2,200,00 Job
Address: 1604 William Clark Avenue Historic District: Yes No Parcel
ID: 38-19-30-514-0000-0070 Residential Commercial Type
of Work: New Addition Alteration Repair Eq Demo Change of Use Move Description
of Work: Permit the as built work that has been done. Plan
Review Contact Person: Mark Orman _ Title: Contractor Phone:
321-945-2500 Fax: 407-209-3560 Email: markiorman@yahoo. corn Property Owner
Inf mation Name Investor
Trustee Services LLC Tr FBO hone: 407-367-8676 Street: 151
Southhall Lane #230 Re • ent of property? • No City, State '
Lip: Maitland, FL 32751 Contr ct
r Info mation Name Mark
Orman one: 321-945-2500 Street: 117
Georgetown Dr. Suite A Fax: 407-209-3560 City, State
Zip: Casselberry, FL 32707 State License No.: CGC 1506674 ch'tec
Engineer Information N e:
Phone: treet: Fax:
CI , St
ip: IN. E-mail: Bo g
Company. Mortgage Lender: Addres Address:
WARNI T
OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWI
E 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: 51" Edition (2014) Florida Building Code Rcvji ed:
June 30, 2015 Permit Application
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 lederal 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 at the time ol' permit submittal. A copy of the executed contract is required
in order to calculate a plan review charge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with,local ordinance. Should calculated charges 'Figured off the executed contract exceed the actual construction value,
credit will be applied to your permit fees when the permit is issued.
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.
8/11 /16
signature o1 Owner/Agent Date Signature of Contractor/Agent Date
Mark Orman
Print Owner/Agent's Nano Print Contractor/Agents Name
Signature ol' Notary -State of Florida Date
Owner/Agent is Personally Known to Me or
Produced ID Type of ID
Signature of Notary -State of Florida Date
Contractor/Agent is Personally Known to Me or
Produced ID 'Type of ID
BELOW IS FOR OFFICE USE ONLY
Permits Required: Building Electrical Mechanical Plumbing[] Gas Roof
Construction Type:
Total Sq Ft of Bldg:
New Construction: Electric - # of Amp
Occupancy Use:
Min. Occupancy Load:
Fire Sprinkler Permit: Yes No # of Heads
APPROVALS: ZONING:
ENGINEERING:
COMMENTS:
UTILITIES:
FIRE:
Flood Zone:
of Stories:
Plumbing - # of Fixtu
Fire Alarm Permit: Yes No
WASTE WATER:
BUILDING:
Revi.sed: June 30, 2015 Permit Application
CITY OF SANFORD
BUILDING AND FIRE PREVENTION DIVISION
300 N. PARK AVENUE
SANFORDj, FLORIDA 32772
PHONE: 407.688.5150
FAX: 407.688.5152
PLAN REVIEW COMMENTS
Application Number: 16-874
Date: August 18, 2016
Contact Person:
Contact Fax Number:
Contact E-mail Address: markiorman(&Yahoo.com
Project Description: Residential Addition/Alteration
Job Address: 1604 William Clark Ave
The following is a list of the areas of the submitted plans that contained violations of the codes adopted
by the City of Sanford and enforced by the Building Division. The violations noted must be addressed
before the plans can be approved. Changes to plans shall be submitted on the same size format as the
original submittal. Changes to construction documents that require an Architect or Engineer's seal must
be submitted with the appropriate seal. Provide two copies of affected plan sheets and/or supplemental
information as requested.
2"d Plan Review COMMENTS:
1. Please submit two (2) copies of a Sanford Product Approval Specification Form including the
following components that will be installed on the project: exterior doors, windows, siding, soffit, roof
underlayment, shingles, flat roof.
FBC 107
2. Please submit two (2) copies of Florida Product Approval and corresponding Installation Instructions
for the products listed in comment #1. **Cut sheets from the manufacturer webs ite are not permitted** FBC 107 Z e-oP1&S
3. Please submit two (2) copies of a plumbing riser for the new and reconfigured bathrooms and laundry. Riser to include pipe sizes and venting method.
FBC 107
4. Please submit two (2) copies of an HVAC duct layout for the new conditioned spaced. Duct sizes,
register locations must be shown.
FBC 107
5. Please specify the "SP" structural connector required at the top and bottom of studs on Sheet S4
FBC 107 rim
6. Please specify the type of insulation and R-value that will be installed in the exterior framed walls.
FBC 107
1-
7. Please provide infill framing details that address the interior 2x4 and 2x6 walls. Specify bearing or
non -load bearing.
FBC 107
8. The headers are not marked on the plans for reference to the Header Schedule. Please revise
FBC 107
9. Please provide the sheathing nail pattern for the roof and walls.
FBC 107
Please note: All areas of work must be accessible for inspection. Any areas that are covered or
completed will require a signed and sealed letter from the engineer of record certifying that the areas were
personally inspected and approved.
Any error or omission in this plan review shall not be construed to grant approval of any violation of any
of the adopted codes or municipal ordinances of this jurisdiction.
Please direct any questions you may have to Steve Morey at 407-688-5065 or by E-mail at
steve.fiorey(2sanfordfl.gov .
Respectfully,
Steve Fiorey
Residential Plans Examiner
2-
Revision
Response to Comments
City of Sanford
Building & Fire Prevention Division
Ph: 407.688.5150 Fax: 407.688.5152
Email: building@sanfordfl.gov
Permit # / (,o — 9 7 L Submittal Date 0 4 O 4•
Project Address: Ao O 9-
Contact:
Ph:
Email:
Trades encompassed in revision:
Building
Plumbing
Electrical
Mechanical
Life Safety
Waste Water
Fax:
General description of revision:
ROUTING INFORMATION
Department 'Approvals
Utilities
Waste Water
Planning
Engineering
Fire Prevention
Building 6PW AlAI)S
CITY OF SANFORD
BUILDING AND FIRE PREVENTION DIVISION
300 N. PARK AVENUE
SANFORDj, FLORIDA 32772
PHONE: 407.688.5150
FAX: 407.688.5152
PLAN REVIEW COMMENTS
Application Number: 16-874
Date: April 19, 2016
Contact Person:
Contact Fax Number:
Contact E-mail Address: jpturcio(a gmail.com
Project Description: Residential Addition/Alteration
Job Address: 1604 William Clark Ave
The following is a list of the areas of the submitted plans that contained violations of the codes adopted by the City ofSanfordandenforcedbytheBuildingDivision. The violations noted must be addressed before the plans can be approved.
Changes to plans shall be submitted on the same size format as the original submittal. Changes to construction documents
that require an Architect or Engineer's seal must be submitted with the appropriate seal. Provide two copies of affected
plan sheets and/or supplemental information as requested.
COMMENTS:
1. A licensed contractor (general, building, or residential) is required to pull the permit. The person listed on the permitapplicationdoesnotmeetalloftherequirementstoactasanowner/builder, in accordance with 489.103 Florida Statute.
The permit will not be acted upon until a licensed contractor is added to the permit. FBC 107
2. The Residential Alteration Submittal Guidelines are required to be followed, in accordance with FBC Chapter 1
Sanford Ordinance 4350. The plans submitted are missing major information such as:
Signed and Sealed by a Florida Registered Design Professional
Wind Design Data, as required by FBC Chapter 16
The current Florida Building Codes in which the plans have been designed
Existing vs Proposed drawings
Florida Product Approval
Compliance with the 2014 Florida Energy Conservation Code
No Review has been conducted and will not be conducted until a licensed contractor is recorded and propersigned/sealed plans are submitted as well as all other required documentation listed on the Submittal Guidelines.
Any error or omission in this plan review shall not be construed to grant approval of any violation of any of the adoptedcodesormunicipalordinancesofthisjurisdiction.
Please direct any questions you may have to Steve Fiorey at 407-688-5065 or by E-mail at steve.fiorey(_sanfordfl ov .
Respectfully,
Steve Fiorey
Residential Plans Examiner
1-
CITY OF SANFORD
BUILDING & FIRE PREVENTION
PERMIT APPLICATIONFD;
Application No: /y(
p
pC.
Documented Constructionikalue: $ n D D
JobsAddress: // a 1101-4o r A;, .e S AJAP.9 r- . Historic District:' Yes No
Parcel ID: ,j,6 aL Residential Commercial
Xype of Work: New Addition Alteration 10 Repair Demo Change of Use Move
gDescription of Work: zwlk - -' - Ad di '-A'o n Aed.,'yOm 7" L'
PlaWiReview Contac Person: rC— -Xit e. eG, u'' 5 Phonr.'-
4 V )(v -rFax• email• Pro
ert Owner lnformation - rt% - .q M P-'--Y`- - Name
Q f c Phone: !`!f• 7"_ 7 Y6 ? Street:
UL4 1A L A A V C Resident of property? City,
State Zip:. <AR Contractor Information
Name Phone:
Street: Fax:
City, State
Zip: State License No.: Architect/Engineer
Information Name: Phone:
Street: Fax:
City, St,
Zip: E-mail: Bonding Company:
Mortgage Lender: Address: 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. t. FBC
105.
3 Shall be inscribed with the date of application and the code in effect as of that date: 5'" Edition (2014) Florida Building Code Revised June
30, 2015 Permit Application
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 at the time of permit submittal. A copy of the executed contract is required
in order to calculate a plan review char"ge and will be considered the estimated construction value of the job at the time of submittal.
The actual construction value will be figured based on the current ICC Valuation Table in effect at the time the permit is issued, in
accordance with local ordinance. Should calculated charges figured off the executed contract exceed the actual construction, value,-,*
credit will be applied to your permit fees when the permit is issued.
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.
00
3_2_
Signal of ner/ gent `' Date Si a'1ur fC ntractor/Agent Date p
Dc -
Po.r( ircA Print
Owner/Agent's Name Print Contractor/Age is Name, DC-
U_3--a1-IUD 3-a\-110 Sig
ure of Notar},S etP= Fk — A Signature oiN4tarvrState o F ides—= A t 1
r
y R4EnaJwn LIZMARIE
SANTANA ZMARIE BANYAN Notar
Public State of FloridaPublic - State of FloridaMy Comm. Expires Dec 10, 2016 m Expires Dec 10, 2016Commission # EE857431ission # EE 857431Owner/
AgentiseoaynowntoaorCoersonalynotoMeorProduced
ID _J Type of ID C QC >C 1A2L35 Produced ID Type of ID US ga'niA -'-kqq BELOW
IS FOR OFFICE USE ONLY Permits
Required: Building Electrical Mechanical Plumbing[] Gas[] Roof Construction
Type: Total
Sq Ft of Bldg: Occupancy
Use: Min.
Occupancy Load: New
Construction: Electric - # of Amps Fire
Sprinkler Permit: Yes No # of Heads APPROVALS
COMMENTS:
ZONING:
JL L4('7111—a UTILITIES: _ ENGINEERING:
1 bi
FIRE:
1 (
tn 1 14 "r)' p1 d r P'\
004 oA as
66S C63 Flood
Zone: of
Stories: Plumbing - #
of Fixtures Fire
Alarm Permit: Yes No WASTE
WATER: BUILDING:
QR."
74erb-(
440f ; -,'«fi'onS Revised:
June 30, 2015 Permit Application
L
Acceptance by Trustee
I hereby accept the foregoing Conditional Assignment subject to all of the provisions of the TrustAgreement.
Investor Trustee Services, LLC as Trustee
of the 1604 William Clark Land Trust Agreement dated
July 16, 2014
By: a ra Hope chards, Manager
and acting as Trustee
r
3
CONDITIONAL ASSIGN INIENT OF BENEFICIAL INTEREST
Dated: March 17, 2015
FOR VALUE RECEIVED the undersigned, being the 100% beneficiary ("Assignor") of the 1604WilliamClarkLandTrustdatedJuly16, 2014 hereby sells, assigns and t sfers unto Jose Pereira, Potential Assignee") whose tax identification number(s) is . 5-17 /7f1whose address is9132TelferRun, Orlando, FL 32817 100% of all rights, powers, privileges and beneficial interests in and to
that certain Trust Agreement including all interest to [lie property subject to said Trust Agreement upon
the occurrence and full satisfaction of each of the following terms and conditions:
1. On or before March 20, 2016 5:00 EST, potential assignee must pay to assignor a purchase priceofTwentyFourThousandDollarsandZeroCents (S24,000.00). Said payment is to made in the
form of certified funds made payable to Scott Wright at 1708 Garvin Street, Orlando, FL 32803. 2. There shall be no prepayment penalty nurred pot—enal agneefor prepayment of frillpurchasepricebeforeMarch20, 2016.
3. During such time as potential assignee is procuring funds to satisfy the purchase price, potential
assignee is required to pay assignor a monthly payment in the amount of Two Hundred FortyDollarsandZeroCents ($240.00). Said payment is due on or before the 15°i of every month. This payment is to be consded consideration for Assignor keeping the property off of themarketduringthetermofthisagreement.
4. 'Potential Assignee is required to carry a fire and hazard insurance policy for a value of no lessthan $ 120,000.00 through TAPCO. Said policy it to name the above referenced
land trust as the primary loss payee. Potential assignee is not be listed in any capacity nor have
any interest whatsoever in the insurance policy until such time as all conditions herein are met. 5. Potential Assignee hereby represents that he understands and agrees he is not entitled to anyinsuranceproceedsrealizedfromclaimsplacedunderfireorhazardinsurancepolicy. It shall be "
in Assignors sole and absolute discretion as to how insurance proceeds are to be disbursed, if atall.
6. Potential Assignee is responsible for the payment of all property taxes and governmentalassessmentsastheybecomedue.
7. Potential Assignee is responsible for any liens or encumbrances that may attach to the propertyduetotheactionorinactionofpotentialassignee. Potential Assignee must satisfy any such liens15daysfromreceiptofnoticeofsuchlienorencumbrance.
8. Potential Assignee is required to maintain the property, buildings, and equipment in a manner
that is -equivalent to their current condition or in a manner that would be considered to be animprovementthereupon.
9. Potential Assignee must obtain Assignor permission before undertaking any substantial change
to the property, buildings) or equipment. Such approval shall be unreasonably withheld if'
considered to be an improvement enhancing the value of the property.
10. In the event of default under any terms and conditions stated herein Potential Assignee herebyrepresentsthatheunderstandsandagreesthatheisnotentitledtothematerialusedforthose
improvements nor any potential or realized increase in value of the property due to potentialassigneesimprovementsmade.
11. in the event of default under any terms and conditions stated herein potential assignee herebyrepresentsheunderstandsandagreesthatanyinteresthemayhaveinthesubjectpropertyornamedtrustwhetherequitableoratlawwillimmediatelybeforfeitedandextinguished.
12. In the event of forfeiture or default under any ternis or conditions stated herein by potential
assignee or extinguishment and cancellation of conditions of assignment due the default or any
FLORIDA SHORT -FORM INDIVIDUAL ACKNOWLEDGMENT
F.S. 695.25
GC.L-(-;c<>,czc c`'.c=c`.cl..c.cs•4^si C.c`.e:`.c C'44`.G%s,'`.E Y''C:S•S Y S 7
State of Florida
County of Dr_ __ _
NICOLE BADLU
OY COMMISSION # EE090745
a' P`. EXPIRES May 05. 2015
14071393.01FloniallotaryServrce.com Place
Notary Seal Stamp Above The
foregoing instrument s acknowledged before
me this day Date
of _
0i QrC`ih _oll S Month
n,
Year
by
r Name
of Person Acknowledging who
is personally( known to me or who has
produced ' it ( V-ewh Name
of Notary Typed, Prin Notary
Public — State of Florida OPTIONAL
or
Srarnpeo Though
this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document. Description
of Attached Document d
k
Title
or Type of Document: _ _ Document
Date: MEOW Signer(
s) Other Than Named Above: — k-.,
l ASS tcn rnein Ilii[
n - S-t Number of
Pages: ____________ kA0,1I\
Jkq .r-,I(Z(A- 2013 National
Notary Association • www.NationaiNotary.org 9 1-800-US NOTARY (1-800-876-6827) Item #5181
temps herein Potential Assignee is not entitled to reimbursement for any monthly payments, deposits, tax payments, insurance premiums. full or partial prepayment of purchaser price,
money paid for maintenance, improvements or rehabilitation of property resulting in an increase
or potential increase to property value. Rather, these funds shall be considered liquidated
damages.
13. This agreement shall terminate if full purchase price is not received by Assignor on or before
March 20, 2016. It shall be in Assignors ti II absolute and complete discretion as to whether the
terms of this agreement shall be extended past March 20, 2016. Such consent may beunreasonablywithheld.
14. In the event Assignor chooses to terminate this agreement due to a default by potential assignee
under the terns of this agreement, Assignor shall give potential notice of such default by email atemailaddressspacefuels(cDgmail com . Potential Assignee shall have 10 days to cure
the default. If potential assignee fails to cure the default within the 10 day period this assignment
shall immediately be terminated and all revoked with all beneficial interest remaining inAssignorandnopossibilityofassignmenttopotentialassigneewillremain.
15. Upon satisfaction of all conditions of this conditional assignment certain regulatory and state
taxes, fees and or costs may be assessed upon the actual assignment of' beneficial interest
contemplated herein. Potential assignee shall be responsible for all such taxes, fees or costs.
16. Both Assignor and Potential Assignee hold Trustee harmless for any loss or damages as the
result of and terms or conditions stated herein and agree to indemnify trustee for same.
17. This agreement is not assignable by potential assignee.
Potential Assignee understands absolutely no interest of any kind or nature in the property or
trust shall vest in Potential Assignee until such time as all terms and conditions stated herein are
fully satisfied. The final determination of full satisfaction of all terms and conditions shall lie solelywithAssignor.
Current Beneficiary Signature
Assignor
Scott Wright
Current Beneficiary Printed Name
Witness S11-Inature
Witness Signature
Acceptance of Terms and Conditions by Potential Assignee
The undersigned hereby accept the foregoing Conditional Assignment subject to all ofthe termsandconditionsstatedherein.
F
Pot nti ew eneficiary Signature itness Signature
Potential Assignee e ru L q7j
Jose Pereira
Potential New Beneficiary Printed Name
Potential Assignee
Vitness Signature
4 HJLD DOCVMENT UP TQ THE LICHT TO if
4 • ••• - - - - - ---
2e2111 f07 NI '(
rj ]r7 ate
E TER,.,PK
CASHIER'S Cl9lECK " " v ... - — - _ EW Ol/oa Wt---
HOLD DOCULIEW7 UP,fq $.,..•.X•.1._-li, "_T,1_R.
1-
1 1 v / V ' / VE 2 R1A.1,RIc 4IQ03/17/2015 voa,nR> 1o,rs aaoQtemittter. PEREIRA HOME REPAIR, INC. I
Pay To The SCOTT WRIGHT
Order of. -
Pay: FIVE THOUSAND DOLLARS AND 00 CENTSINTS
5,000.00
Do ool write oulr',de 1h!5 bax Drawer JPMORGAN CHASE SANK, NjL
Memo:_
Note: For lnforrnation only. Comme~ nt has no effect on banks- SeniorChasedent N.A. JPMo
Columbus, OH
II'bb676b5527n° 401j40000371.. 75866 13 2611°
w
4 tl
UNDERWRITERS, INC.
3060 South Church Street P.O. Box 286
Burlington, North Carolina 27216
Local) 336-584-8892
Toll -Free) 800-334-5579
FAX) 336-584-8880
Claims FAX) 336-538-0094
Binder Summary Sheet
Insured: Producer:
1604 William Clark Trust 930133
P O Box 950185 Insurance Group of Central FlaLakeMary, FL 32795 7523 Aloma Avenue
Suite 106
Winter Park, FL 32792
Producing Agent: Kimberly Mett
Insurer: Effective/Expiration Date: 3/19/2015 to 9/19/2015
Lloyd's of London
Term: Six Months
Binder ID: KSHPX-Z State: FL
Percent Earned: 50%
In accordance with your instructions, we have bound the following Vacant coverage; provided we receive a properlycompletedapplicationandapremiumpaymentwithin12daysoftheeffectivedateshownabove.
Comments: LMA3100 Sanction Limitation and Exclusion Clause will apply.
Glass breakage as a result of vandalism is excluded . Form TAP-3G-1 — Glass Exclusion — Vandalism applies.
General Liability:
500,000 General Aggregate
Excluded Products/Completed Operations Aggregate
Excluded Personal Injury/Advertising Injury
500,060 Each Occurrence Limit
Excluded, Damage to Premises Rented to You
Excluded Medical Payments
500 BI/PD Deductible Per Claimant
TAPCO'Claims Notice; TAP-CRF- Claim Reporting Information; TAPCO Flood Flood Insurance Notice; IL0017
Common Policy Conditions; MOLD EXCL Mold Exclusion; SVBW-01 Secured Vacant Building Warranty; NMA1256 Nuclear Incident Exclusion Clause; NMA2918 War and Terrorism Exclusion Endorsement; NMA2962BiologicalorChemicalMaterialsExclusion; LMA5020 Service of Suit Clause; LMA5021 Applicable LawU.S.A.); LMA5092 U.S. Terrorism Risk Insurance Act of 2002 as amended Not Purchased Clause;
TAP-BRGL-02 Exclusion -Construction Operations; TAP-SP-01 Swimming Pool Exclusion and Limitation;
SPGL-01 Additional Exclusions; CG0001 Commercial General Liability Coverage Form; CGO068 RecordingandDistributionofMaterialorInformationinViolationofLawExclusion; CG0220 Florida Changes -CancellationandNonrenewal; CG2104 Exclusion-Products/Completed Operations Hazard; CG2135 Exclusion -CoverageC-Medical Payments; CG2136 Exclusion -New Entities; CG2137 Exclusion -Employees and Volunteer Workers
as Insureds; CG2138 Exclusion -Personal and Advertising Injury; CG2139 Contractual Liability Limitation; CG2144 Limitation of Coverage to Designated Premises or Project; CG2145 Exclusion -Damage to PremisesRentedtoYou; CG2160 Exclusion -Year 2000 Computer -Related and Other Electronic Problems; LSW1135B
06/03 Privacy Notice; TAP128G Optional Provisions Endorsement This list is for informational purposes only anddoesnotintendtorepresenttheentirelistofformsand/or endorsements that may be attached to any policyissuedasaresultofthisquotation.
Location 1: 1604 William Clark Ave, Sanford, FL 32771
120,000 Building Valuation: ACV
Coverage Form:- Basic
Coinsurance: 80%
Wind & Hail Coverage: Included
Wind & Hail Deductible: 500
All Other Perils Deductible: 500
Secured Vacant Building Warranty endorsement applies
Location 1: 1604 William Clark Ave, Sanford, FL 32771
Code: 8998, Vacant, Ded: $500, Prot Class: 4, Constr: Frame, Cov. Form: Basic, Wind Ded: $500, Year Built: 1920, Sq Feet: 1397, ACV
Coverage Type Basis User Adj. Rate
Building Value $120,000 0.6000
Code: 68603, Vacant Building
Coverage Type
Liability
Basis User Adj. Rate
6 35.0000
We have bound Vacant coverage provided we receive a properly completed application and a premium payment within
12 days of the effective date shown above. Please return a copy of this binder with your net premium check to TAPCO.
Failure to remit the net premium within 12 days of the effective date shown above will nullify and void this binder.
Please note that this binder is for temporary insurance for a twelve -day period. This binder exists on its own terms and
expires on its own terms. When a binder expires on its own terms, no coverage exists thereafter. Requirements for
notice of cancellation to insureds do not apply to expired binder.
All applications to be completed have been attached to this account. Please note should any additionalinformation/application be needed, it will be requested at the time of issuance.
Any policy issued subsequent to this binder will be per the terms, coverages, limits and forms outlined in this binder.
Differences in terms, coverages, limits and forms received on any application will NOT revise, change or update the
policy at time of issuance. Any changes to this binder and any subsequent policy must be requested in writing by a
separate request and any changes must be made by endorsement.
THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS
LINES CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT
OF ANY RIGHT OF RECOVERY FOR THE OBLICATION OF AN INSOLVENT UNLICENSED INSURER.
ATTENTION: The FHCF (Florida Hurricane Catastrophe Fund Emergency Assessment) of 1.3%,the Citizens PropertyInsuranceCompanyassessmentof1.0%, the FSLSO service fee of .175%, and the applicable EMPA (EmergencyManagementPreparedness & Assistance) Surcharge are included in the above shown tax amount. For any quotes witheffectivedatesafter01/01/15, the FHCF will be removed.
Surplus Lines Licensee: 4 Virginia Clancy, License # A206695
Lloyd's of London, Dawson House 5 Jewry Street, London, England EC3N2EX
GL Premium: $210.00
Property Premium: $720.00
Premium: $930.00
Total Premium: $930.00
Policy Fee: $125.00
Tax: $67.15
Total: $1,122.15
Binder ID: KSHPX-Z
Page 1 of 1
ors,,
TYVek
HomeWrap
r a—
I
https://www2.citizenserve.com/Admin/WorkOrderpocuments?Action=ViewDocument&D... 4/ 19/2016
Page 1 of 1
6+4*1 - WW
i '4. Y * "7 1 ?` e'y S •:fir •'
https://www2.citizenserve.com/Admin/WorkOrderpocuments?Action=V iewDocument&D... 4/ 19/2016
Page 1 of 1
https://www2.citizenserve.com/Admin/WorkOrderpocuments?Action=V iewDocument&D... 4/ 19/2016
Page 1 of 1
JA
r .'
cam•
lo
https://www2.citizenserve.com/Admin/WorkOrderpocuments?Action=V iewDocument&D... 4/ 19/2016
al `
I
VAIN
r.