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RECEIVED
CITY OF SANFORU PERMIT APPLICATION DEC 0 5 Z006
Permit #: / 2 - Yne&
t
Date:
Job Address: `S %Qf,J/Q 07n-t/ C Ir
Description of Work: AAA Ar IRalbcA4e-S06Ar '4D k New (a-- 4-
Historic District: Zoning:
IF
Value of Work: S y(J
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm X Pool
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Polo
Mechanical: Residential Non -Residential Replacement New (Duct Layout & Energy Calc. Required)
Plumbing/ New Commercial: # of Fixtures # of Water & Sewer Lines # of Gas Lines
Plumbing/New Residential: # of Water Closets Plumbing Repair — Residential or Commercial
Occupancy Type: Residential Commercial X Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #:
Owners Name & Address:
Attach Proof of Ownership & Legal Description)
w PPhhoone: / I- " 1 /— Contractor Name & Address: T& j4dnaell 37cX m aikin Y wy 14twt orip,&I A -?,;,AO
State License Number; 66YA03-O I/Zo0 /
Phone & Fax: _A07-23S =" y67 2,?r-X-0 Contact Person: 1 t!oAo tiM Phone: ,321-7b
Bonding Company.
Address:
Mortgage Lender:
Address:
Architect/Engineer: Phone:
Address: Fax:
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 theissuanceofapermitandthatallworkwillbeperformedtomeetstandardsofalllawsregulatingconstructioninthisjurisdiction. 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, 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 regyjrowrcntsOf Pjorida LiCo.Law, FS 713.
Signature of Owner/Agent
Print Owner/Agent's Name
Date
Print
Signature of Notary -State of Florida Date Signature
Owner/Agent is _ Personally Known to Me or
Produced ID
J
APPLICATION APPROVED BY: Bldg; Zoning:
Initial A Date)
Special Conditions:
Z- yO&
Date
Date
MISAEI ALICEA
ColContractor/Agent is _ Pe ovally Known td
r'. DDOM405
Produced ID s ma2MV2 ?
as
a BorWerd Irh^,,u(t170 0-)_4-324254:
NFNM...y Assn.. Inc
Utilities: FD:A 0Wr2-
Initial & Dale) (Initial & ((initial • Date) Date) V / / %- --/
Two
Fire & Security 3701 North John Young Parkway
Suite 110
Orlando, FL 32804
SimplexGrinnell (407) 235-1100 Phone
407) 235-1 l 50 Fax
POWER OF ATTORNEY
MAY 15, 2006
I HEREBY AUTHORIZE JOSEPH J. NEMCEK & RYAN FUNK OF
SIMPLEX GRINNELL TO SIGN FOR, APPLY FOR AND PICK-UP FIRE
SUPPRESSION PERMITS IN THE STATE OF FLORIDA
GEORGE ILLER
BEFORE ME APPEARED GEORGE E MILLER TO ME WELL KNOWN
TO ME TO BE THE PERSON DESCRIBED IN AND WHO EXECUTED
THAT GEORGE E MILLER EXECUTED SAID INSTRUMENT FOR
THE PURPOSES "THEREIN EXPRESSED.
WITNESS MY HAND AND OFFICIAL SEAL, THIS 16 DAY OF MAY
NOTARY PUBLIC STATE OF .FLORI A
PAMELA A . MCELROY
Notary Public, StatO 0127l?p09MyCOMM. exp. Mal.
Comm. No. DD 411691
E
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF STATE FIRE MARSHAL
TALLAHASSEE, FLORIDA
CERTIFICATE OF COMPETENCY
THIS CERTIFIES THAT: GEORGE E MILLER
10255 FORTUNE PARKWAY BUILDTNG 500 SUITE 120
JACKSONVILLE, FL 32256-
BUSINESS ORGANIZATION: SIMPLEX GRINNELL LP
CONTRACTOR 11 IS LIMITED TO THE EXECUTION OF CONTRACTS REQUIRING THE ABILITY TO LAYOUT, FABRICATE, INSTALL, INSPECT,
ALTER, OR SERVICE WATER SPRINKLER SYSTEMS, WATER SPRAY SYSTEMS, FOAM -WATER SPRINKLER 4YSTEMS, FOAM -WATER
SPRAY SYSTEMS, STANDPIPES, COMBINATION STANDPIPES AND SPRINKLER RISERS, ALL PIPING THAT I§ AN INTEGRAL PART OF THE
SYSTEM BEGINNING AT THE POINT OF SERVICE, SPRINKLER TANK HEATERS, AIR LINES, THERMAL SYSMS USED IN CONNECTION
WITH SPRINKLERS, AND TANKS AND PUMPS CONNECTED THERETO, EXCLUDING PRE-ENGINEERED SYSTEMS.
I
01 2006 1 07 1 16 1 Duval
Issuc Datc ITypelclassl County
60476500012001
License/Permit Number
Chief Financial Officer
at, 9A SL
7626340001 150.00
Application # Taxes & Fa
06 30 2008
Expire Date
Earl'. K. Wood, Tax Collector Occupational License Orange County, Florid-
6hisdicense is In addition to and no( In of any other llcenso requiredjby law or+municipal orehr'iance. It is subject to ieyulation of -toning, hoalth and any othertawf
authority:1t is valid from October 1 through September 30 of license year: Delinquent penalty is added October 1:
ORIGINAL*** 2006 EXPIRES 9/30/2007 3121-0537842
3121 CERT ALARM/FIRE CONTR $225.00 100 EMPLOYEES;
T
TOTAL TAX $225:00 e SIM 11EX GRINNELL t"R ,
ATyJN l ICFNSING
PREVIOUSLY PAID $0.00
TOTAL DUE $225.00
y4J ys9'
t !`iais at
OIOX 3042'
A f2f'TON FL133431e11
3701 NJOHNYOUNGPY#11p F3RANTrJIfCHAE'COUALIFIfR
A ORLANDO 32804 y/21J2006.0':48 ?11Csh 0046 Regr 0024
T/Ref 0024006034 DBT: 9/21/2006
125,00 Val No: 0024-005542
kbThisformbecomesareceiptwhenvalidatedbytheTaxCollector.
Earl K. Wood, Tax Collector Occupational, se
This ItCehse is in addition to and not In liou of any other license required by law or municipal ordinance. It subject to h"eaith and any other lawauthority. It is valid from October 1' through September 30 of license year. Delinquent penalty is added October 1,
ORIGINAL' 2006 EXPIRES 9/30/2007 3502-0524870
3502 WHOLESALE-ELECTRONICSYSTEM$70 D0 40 EMPL.OYLI_.S!
TOTAL TAX $70.00
EX GRINNELL L:I,
F { X 3042
PREVIOUSLY PAID $0.00
TOTAL DUE $70,00
TON FL 33 31-094Lls
3701 N JOHN YOUNG PY #110 UCIIANAN MICAHEL PRESIDENT
9/19/2006 12:46 N! Csh 0046 Reg 0024AORLANDO, 32804 y a, •sFp, T/Ref 0024006V56 08I: 9/19/2006
D(Gt GvV l
L- I l f D(v
This form becomes a receipt when validated by the Tax Collector.
w
CERTIFICATE OF INSURANCE CERTIFICATE NUMBER
309622
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS
UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE POLICY. THISPRODUCER `
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
Marsh, Inc. POLICIES DESCRIBED HEREIN.
1166 Avenue of the Americas
New York, NY 10036
Telephone (212) 345-5000
COMPANIES AFFORDING COVERAGE
COMPANY A: Al South Insurance Co.
COMPANY B: American Home Assurance Co.
INSURED COMPANY C: Illinois National Insurance Co.
COMPANY D: Insurance Company of the State of PA
SimplexGrinnell, LP
3701 N. JOHN YOUNG PARKWAY
ORLANDO, FL 32804
COMPANY E: National Union Fire Insurance Co.
COMPANY F: New Hampshire Ins. Co.
COMPANY G: New York Marine & General Insurance Co. (Lead) United States
COMPANY H: Noetic S eclat Insurance Com an
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING+
ANY REOUIRMENTS, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE
AFFORDED BY THE POLICIES LISTED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
B GENERAL LIABILITY RMGL5759120 10/1/2006 10/1/2007 GENERAL AGGREGATE 15,000,000.00
X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG 15,000,000.00
CLAIMS MADE Fx I OCCUR PERSONAL & ADV INJURY 7,500,000.00
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE 7,600,000,00
FIRE DAMAGE (Any one fire) 1,000,000.00
MED EXP (Any one person) 10,000.00
B
AUTOMOBILE LIABILITY RMCA 5836480 (TX) 10/1/2006 10/1/2007 COMBINED SINGLE LIMIT 7,500,000.00
B X ANY AUTO RMCA 5836479 (VA) 10/1/2006 10/1/2007
B
B
ALLOWED AUTOS
RMCA 5836481 (MA)
RMCA 5836482 (AOS)
10/1/2006
10/1/2006
10/1/2007
10/1/2007
BODILY INJURY (Per person)
SCHEDULED AUTOS
X HIRED AUTOS BODILY INJURY (Per accident)
X NON -OWNED AUTOS
PROPERTY DAMAGE
PROPERTY
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
g
C
A
E
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/
PARTNERS/EXECUTIVE INCL
SEE PAGE TWO SEE PAGE TWO SEE PAGE TWO X LMnsAMORY OTHER
EL EACH ACCIDENT 2,000,000.00
EL DISEASE -POLICY LIMIT 2,000,000.00
EL DISEASE -EACH EMPLOYEE 2,000,000.00FOFFICERSARE: EXCL
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Please see page 2 for additional insureds and any additional language.
CERTIFICATE":HOLDER ; ` ' ` CANCELLATION
City Of Sanford Bldg. Dept.
300 N. Park Ave.
Sanford, Fl, 32771
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE
INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER
NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS CERTIFICATE.
MARSH USA INC. A
Katherine O'Leary, Casually Program J[JP4at1/I
Ca ewy 1
MM1(3/02)_ - VALID AS OF. 10/512006 .
ADDITIONAL INFORMATION 309622
CERTIFICATE NUMBER
09622
PRODUCER COMPANIES AFFORDING COVERAGE_.__
COMPANY I: White Mountain Insurance Co.
Marsh, Inc.
1166 Avenue of the Americas
New York, NY 10036 -
Telephone (212) 345-5000
INSURED
SimplexGrinnell, LP
3701 N. JOHN YOUNG PARKWAY
ORLANDO, FL 32804
United States
TEXT
WORKERS COMPENSATION POLICIES
Carrier Policy Number Eff. Date Exp. Date State
B) American Home Assurance Co. RMWC 2920280 10/1/2006 10/1/2007 CA
B) American Home Assurance Co. RMWC 2920292 10/l/2006 10/1/2007
AK,AL,AZ,CO,CT,DC,HI,IA,ID,IN,KS,KY,LA,MD,ME,MN,MO,MS,MT,NC,NE,NH,NM,OK,RI,SC,SD,TX,UT,VT
C) Illinois National Insurance Co. RMWC 2920289 10/1/2006 10/1/2007 MI
B) American Home Assurance Co. RMWC 2920287 10/1/2006 10/1/2007 FL
B) American Home Assurance Co. RMWC 2920290 10/l/2006 10/1/2007 NJ
A) AI South Insurance Co. RMWC 2920281 10/l/2006 10/1/2007 GA
E) National Union Fire Insurance Co. RMWC 2920283 10/1/2006 10/1/2007 NV
C) Illinois National Insurance Co. RMWC 2920286 10/l/2006 10/1/2007 IL
B) American Home Assurance Co. RMWC 2920291 10/1/2006 10/1/2007 PA
B) American Home Assurance Co. RMWC 2920285 10/1/2006 10/1/2007 DE
F) New Hampshire Ins. Co. RMWC 2920282 10/l/2006 10/l/2007 NY,WI
E) National Union Fire Insurance Co. RMWC 2920284 10/l/2006 10/1/2007 OR
D) Insurance Company of the State of PA RMWC 2920288 10/l/2006 10/1/2007 AR,MA,TN,VA
LIABILITY PROGRAM
Certificate holder is added as an additional insured for General Liability, but only to the extent of the Named
Insured's negligence.
Additional Insureds: City Of Sanford Bldg. Dept.
Project: All Projects
If there is a question regarding this certificate please contact Ellen Harris
Email: eharris@tycoint.com Phone: 407-235-1100)
CERTIFICATE HOLDER
City Of Sanford Bldg. Dept.
300 N. Park Ave.
Sanford, FI, 32771
CITY OF SANFORD FIRE DEPARTMENT
FEES FOR SERVICES
1
PHONE # 407-302-2516 - FAX # 407-302-2526
DATE: /2
BUSINESS NAME / PROJECT:
ADDRESS:
PERMIT C D 1 /
PHONE Nt73 .ZI) 2&AX NCC.-: 7) d, U
CONST. INSP. [ ] C / O INSP.:[ ] REINSPECTION [ ] . PLANS REVIEW/K
F. A. [ ] F.S. [r HOOD [ ] PAINT BOOTH [ ] BURN PERMIT [ ]
TENT PERMIT E ] TANK PERMIT [ ] OTHER [
TOTAL FEES: $ ' (PER UNIT SEE BELOW)
Address /Bldg. # /Unit # Square Footage Fees per Bldg / Unit
1.
2.
3.
4.
5.
6.
7.
8.
9.
W.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Fees must be paid to Sanford Building Department, 300 N. Park Ave., Sanford, FI. 32771 Phone N -407-
330-5656. Proof of Payment must be made to Fire Prevention division before any further services can take
place. I certify that the above is true and correct and that
will comply with all applicable codes and ordinances
of the City of Sanford, Florida.
TI,
S nford Fire Pre lion D' ision Applicant's Signature