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Permit # :.07- 90
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Job Address:
CITY OF SANFORD PERMIT APPLICATION
Date: P-- y—O G
SEP 1 g 7-006
Description of Work: A d-1 + KF `C)(Ck r9 SQ;,,1 KI Qr5 T -f 6 UeW la :: f
Historic District: Zoning: Value of Work: S , 9 00
J,
Permit Type: Building Electrical Mechanical Plumbing Fire Sprinkler/Alarm rl Pool
Electrical: New Service — # of AMPS Addition/Alteration Change of Service Temporary Pole
Mechanical: Residential Non -Residential Replacement New (Duct La out & Ener Cal R ; dygy — equtre )
Plumbing/ New Commercial: # of Fixtures # of Water & Sewer Lines # of Gas Lines
Plumbing/New Residential: # of Water Closets Plumbing Repair — Residential or Commercial
y
Occupancy Type: Residential Commercial /1 Industrial Total Square Footage:
Construction Type: # of Stories: # of Dwelling Units: Flood Zone: (FEMA form required for other than X)
Parcel #:
Owners Name & Address:
Contractor Name & Address: N.,
Attach Proof of Ownership & Legal Description)
Phone:
StaleLicense Number: t D 7& S—Odd1e00f
Phone &Fax: % S— 7 — Contact Person: ( 2 —/l Z Grh 1 k? 11 Phone:
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. 1 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. 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
Signature of Owner/Agent
Print Owner/Agent's Name
Date S,re oKCnnuaE
Print C tractor/Ape
Signature of Notary -State of Florida Date
Owner/Agent is _ Personally Known to Me or
Produced ID
HAPPLICATIONAPPROVEDBY: Bldg: lOZoning:
Initial V Date)
Special Conditions:
13.
Date
h G
Signature of Notary'State of Florida
t
Contractor/Agent is Personally Known M
Produced ID
I
Utilities: FD:
Initial & Date) (Initial & Date)
0001. 00
Wtattl0D11111
Yondrit! tittY Y00l4>til
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CITY OF SANFORD FIRE DEPARTMENT
FEES FOR SERVICES
PHONE # 407-302-2516 - FAX # 407-302-2526
DATE: —% 12—d
BUSINESS NAME /
I PROJECT:
ADDRESS: ed1 Y
PHONE NO.: FAX NO.:
CONST. INSP. [ ] C / O.INSP.:[ 1 REINSPECTION [ ] . PLANS REVIEW IoiL
F. A. [ ]. F.S. [ 1 HOOD [) PAINT BO TH [ ] BURN PERMIT [ J
TENT PERMIT J TANK PERT [ ] OTHER
TOTAL FEES: $ 0 (PER UNIT SEE BELOW)
COMMENTS:
I 1-%, . 2 Ci p ' 111...
Address / Blde. # / Unit # Square Footaee Fees ver Blda. / Unit
2.
3.
4.
5.
6.
7.
8.
9.
10.
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 # -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 1
will comply with all applicable codes and ordinances
of the City of Sanford, Florida.
J,
Sanford Fire Prev lion Division Applicant's Signature
CITE' OF SANFORD FIRE DEPARTMENT
FEES FOR SERVICES
PRONE # 407-302-2516 • FAX # 407-302-2526
DATE: - / C9 P RMIT #:
BUSINESS NAME / PROJECT:
F
i \ J et-o
ADDRESS: -P t_ iw,T. C'',
PHONE NO.: FAX NO.:
CONST. INSP. [ ] C / O INSP.:[ ] REINSPECTION [ ] PLANS REVIEW [t)
r
F. A. (]. F.S. [ ] HOOD [ ] PAINT BOOTH [ ] BURN PERMIT [ )
TENT PERMIT) ] TANK PERMIT[ ] OTHERIA[ oft
64TOTAL
FEES: $ (PER UNIT SEE BELOW) f .
COMMENTS:
r) J I Address /
Bld-g. # / Unit # Square Footage. Fees per Bldg. / Unit 1.
2.
3.
4.
5:
6.
7.
8.
9.
10. ..
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 # -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. Sanford
Fire Preve;tion Division Applicant's Signature
Tyco
Fire & Security
SimplexGrinnell
MAY 15, 2006
3701 North John Young Parkway
Suite 110
Orlando, FL 32804
407) 235-1100 Phone
407) 235-1150 Fax
POWER OF ATTORNEY
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
GEORGED LLER
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
2005.
a -
NOTARY PUBLIC STATE OF FLORIDA
PAMELA A . MCELROY
Notary Public, State of FloridaMy' comm. exp. Mar. 27, 2009Comm. No. DD 411691
r--
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 BUR DING 500 SUITE 120
JACKSONYILLF, FL 3225&
BUSINESS -ORGANIZATION: SIMPLEX GRMELL LP
CONTRACTOR 11 IS LIMITED To THE EXECUTION ()f CONTRACTS REQUIRING THE ABILITY To LAYOUT, FABRICATE, INSTALL, INSPECT, ALM, ORSERVICE WATER SPRINKLER - - -SPE
SPRAY SYSTEMS, SYSTEMS, WATER SPRAY SYSTEMS, FOAM -WATER SPRINKLER SYSTEMS, FOAM -WATERSTANDPIPES, COMBINATION STANDPIPES AND SPRINKLER RISERS, ALL PIPING THAT IS AN INTEGRAL PART OF
J,ER TANK HEATERS, AIR LINES, THERMAL SYSTEMS USED IN CONNECTIONSYSTEMBEGINNINGATTEMPOINTOFSERVICE, SPRINKLER AR THE
WITH SPRINKLERS, AND TANKS AND PUMPS CONNECTED THERETO, .EXCLUDING PRE-ENGINEERED SYSTEMS.
Cbief Fivandal Q'w , . Kgr
07 11112006 1 07 1 16 IDuval 6()4.7650()012001 7626340001 150.00 106130120091
Issue Type Claw'I COMV License/Permit Number Application # I Taxes & F= I Expire I)m
4 CIERTI:FICATE OFINSUR/N C
40
CERTIFICATE NUMBERE ,A
a fin. . , :
Z FTI 236827
PRODUCER 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. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
Marsh, Inc. POLICIES DESCRIBED HEREIN.
1166 Avenue of the Americas
COMPANIES AFFORDING COVERAGENewYork, NY 10036
COMPANY A: AI South Insurance Co. Telephone (212) 345-5000
COMPANY B: American Home Assurance Co.
INSURED COMPANY C: Illinois National Insurance Co.
COMPANY D: Insurance Company of the State of PA
SimplexGrinnell, LP COMPANY E: National Union Fire Insurance Co.
3701 N. JOHN YOUNG PARKWAY
ORLANDO, FL 32804 COMPANY F: New Hampshire Ins. Co.
United States COMPANY G: New York Marine & General Insurance Co. (Lead)
COMPANY H: Noetic Specialty Insurance Company
COVERAGES M
y
z '_ v.. a.. .kk ...... . .au«..,.u:
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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE (MM/DD/YY) DATE (MM/DD/YY)
g GENERAL LIABILITY RMGL5749708 10/1/2005 10/1/2006 GENERALAGGREGATE$15,000,000.00 X
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMPIOP AGG 15,000,000.00 PERSONAL &
ADV INJURY 7,500,000.00 CLAIMSMADE1XIOCCUROWNER'
S & CONTRACTOR'S PROT EACH OCCURRENCE 7,500,000.00 FIRE
DAMAGE (Any one fire) 1,000,000.00 MED
EXP (Any one person) 10,000.00 B
AUTOMOBILE LIABILITY RMCA3017798 (TX) 10/1/2005 10/1/2006 COMBINED SINGLE LIMIT 7,500,000.00 B
X ANY AUTO RMCA3017799 (AOS) 10/1/2005 10/1/2006 g
RMCA3017797(MA) 10/1/2005 10/1/2006 BODILY INJURY (Per person) B
ALLOWED
AUTOS RMCA3017796 (VA) 10/1/2005 10/1/2006 SCHEDULED
AUTOS BODILY
INJURY (Per accident) HIRED
AUTOS X
NON -OWNED AUTOS PROPERTY
DAMAGE PROPERTY
EXCESS
LIABILITY EACH OCCURRENCE AGGREGATE
UMBRELLA
FORM OTHER
THAN UMBRELLA FORM B
WORKERS COMPENSATION AND SEE PAGE TWO SEE PAGE TWO SEE PAGE TWO WC
XUNITSTORV OTHER LY.
IIT$ E
EMPLOYERS' LIABILITY EL EACH ACCIDENT 2,000,000.00 D
THE PROPRIETOR/ INCL
EL DISEASE -POLICY LIMIT 2,000,000.00 C
PARTNERS/EXECUTIVE EL
DISEASE -EACH EMPLOYEE 2,000,000.00 IFOFFICERSARE: EXCL OTHER
DESCRIPTION
OF OPERATIONS/LOCATIONS/VEHICLESISPECIAL ITEMS 1 Please
see page 2 for additional insureds and any additional language. CERTI,
FICAAA TEHOLDE>2 "CANCELLA'tION, SHOULD
ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE City
Of Sanford Bldg. Dept. Yg• P INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER 3OO
N. Park Ave. 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. Sanford,
327 MARSH
USA INC. BY: ^^ `` LL y QQ A4al _ KatherineO'Leary, Casualty Program e&Mk1?W_ MM1(
3/02)ALIDAS O 10%0/2"0 mow. , < .. ,,.
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