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FIRE PERMIT APPLICATION 31 ROYAL PALMS DR 2011 MECHANICAL PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Rd Atlantic Beach, FL 32233 Ph (904) 247 -5826 Fax (904) 247 -5845 JOB ADDRESS: 2 i . 0 G\ CO be • PERMIT # //- Z(2 v PROJECT VALUE $ 3000!** NEW AIR CONDITIONING & HEATING SYSTEM INSTALLATION Air Conditioning: Unit Quantity Tons Per Unit Heat: Unit Quantity BTU's Per Unit Seer Rating Duct Systems: Total CFM REQUIRED REPLACEMENT AIR CONDITIONING & HEATING SYSTEM INSTALLATION Unit Quantity ARt # Air Conditioning: Quanti Tons Per Unit REQUIRED Heat: Unit Quantity BTU's Per Unit Seer Rating Duct Systems: Total CFM REQUIRED FIRE PREVENTION Fire Sprinkler System Quantity (Requires 3 sets of plans) Fire Standpipe Quantity (Requires 3 sets of plans) Underground Fire Main Value (Requires 3 sets of plans) Fire Hose Cabinets Quantity (Requires 3 sets of plans) Commercial Hoods Quantity (Requires 3 sets of plans) Fire Suppression Systems Quantity I (Requires 3 sets of plans) FIRE PLACES MISCELLANEOUS: Prefabricated Fireplace Qty Automobile Lifts Gas Piping Outlets Boilers BTU' s Elevators /Escalators ALL OTHER GAS PIPING Heat Exchanger Quantity of Outlets Pumps # Vented Wall Furnaces Refrigerator Condenser BTU's # Water Heaters Solar Collection Systems Tanks (gallons) Wells OTHER: Permit becomes void if work does not commence within a six month period or work is suspended or abandoned for six months. I hereby certify that I have read this application and know the same to be true and correct. All provisions of laws and ordinances governing this work will be complied with whether specified or not. The permit does not give authority to violate the provisions of any other state or local law regulation construction or the performance of construction. Property Owners Name Phone Number Mechanical Company - ").9 - 11 11 echanical Com p y Co C0 yy'+MfP C, ►a r , rf G i Office Phone Fax I- Ti .3 i3 Co. Address: u 4 CO City .Sc c gm a aZ State F 1, Zip _DAN License Holder (Print): 'c4,re -- / ,,,. ��S State Certification/Registration # DAR/0001V /cRe9g u��wuau Notariz�kdV[���f'License Holder – 4•'.**NN :(9.0 � 28 )& Sworn and subscribed before e this ■ r N : * Z n day of 20 /U * • Sig na ture of Notary Public �.- 7 • NEE 0380 : ¢` I — i ••.,�,, bonded ; • q . "4n PubAc • n'� °R°® CERTIFICATE OF LIABILITY INSURANCE OP ID .i DATE(MMIDDIVYYY) 05 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. IM - 9 - TIT: If the cert . cate 0 • er 15 an ' , I 0 A 1 R *II, t e po cy es must be en • orse • . I S B - e A • ` S "AIMED, sub ect 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 Iieu of such endorsement(s). PRODUCER LUNI ALA GM Insurance PHONE ONE A Division of Sihle Ins Groupm Eh I jac, No): 751 Oak St. Suite 100 ADDRESS: Jacksonville FL 32204 PNUUUCEN CUSTOMER ID 1!: CSIFI -1 Phone:904- 421 -8600 Fax:904- 421 -8601 INSURER(S) AFFORDING COVERAGE NAICA INSURED INSURER A: Liberty Surplus Insurance Comp Commercial Fire Inc. INSURER old Dominion Insurance Company 40231 y 402 2465 St. Johns Bluff Road S Jacksonville FL 32246 INSURERC: INSURER D : INSURER E : INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO AU. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AUUL suns i YUULY t - YUULY MAY LTR INSR WVD POLICY NUMBER iMMIDOIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 51,000,000 A X COMMECIALGENERAL LIABIUTY DGLAT0967651 01/01/11 01/01/12 PR E EM MISE S (E a occurrrence) 550,000 I MAMS-MADE © OCCUR MED EXP (Any one person) s Excluded — PERSONAL It ADV INJURY S 1,000,000 GENERAL AGGREGATE S _ 2,000,Q00 G GE Cy GE RI PRODUCTS 5 2,000,00 7 0 ) ou1� 1JEC n LOC 5 AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT 5 1,000,000 (Ea accident) B X ANY AUTO B1369672 01 /01 /11 01/01/12 BODILY INJURY (Par parson) 5 AU -OWNED AUTOS BODILY INJURY (Per accident) S SCHEDULED AUTOS X HIRED AUTOS PROPERTY DAMAGE 5 _ (Par accident) X NON-OWNED AUTOS S 5 UMBRELLA LUIS OCCUR EACH OCCURRENCE _ 5 EXCESS UAB CLAIMS -MADE AGGREGATE 5 DEDUCTIBLE $ — RETENTION 5 5 WORKERS COMPENSATION 1 W TA 5 1 I O T R AND EMPLOYERS' LIABILITY Y i N ANY PROPRIETOR /PARTNER/EXECUT1Vr; —, V f A EL EACH AC OFFICER/MEMBER EXCLUDED? U ACCIDENT 5 (Mandatory In NH) EL DISEASE - EA EMPLOYEE S If yes, desaibe under DESCRIPTION OF OPERATIONS below EL DISEASE - POUCY UMIT 5 DESCRIPTION OF OPERATIONS / LOCATIONS !VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) • CERTIFICATE HOLDER CANCELLATION CITOATL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. City of Atlantic Beach AUTHORIZED REPRESENTATIVE 800 Seminole Rd Atlantic Beach FL 32233 I R '6040I- / - I , (a , ORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD • ACORCT CERTIFICATE OF LIABILITY INSURANCE DATE sI " 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 (les) 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 endorse= nt(s}. COMIC= PRODUCER Wines " WC " No, Hs* 1 -800- 277 -1820 x4800 Ir c#e# 727797 -0704 FRANKCRUM INSURANCE AGENCY, INC. AM MO: 100 S. MISSOURI AVE. INSURER(S) AFFORDING COVERAGE NALCO CLEARWATER FL 33756 INSURER A: FRANK WINSTON CRUM INSURANCE, INC. 11600 INSURED INSURER B: • INSURER C FrankCrum 1 -80D- 277 -1620 INSURER Di 100 S MISSOURI AVENUE INSURER E CLEARWATER FL 33758 INSURER k COVERAGES CERTIFICATE NUMBER: 890 7 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMIT8 SHOWN MAY HAVE BEEN REDUCED BY PAID CUUMS. inaR TYPE OF INSURANCE ADD_ SUER POUCY NUMBER POLICY EFF POUOY ESP LAIR LTR INIIR WUD (MMVOClYYYY) IlE NDONYYY) OENERAL UAMUIY if OCCURRENCE S - DAMAGE TO RENTED COMMERCIAL GENERALDAHERY PREMBSEIL (Fa samaratm) S I CLAMINAADE =OCCUR MED ESP (Am one parson{ s • PERSONAL ACV INJURY S • GENERAL AGGREGATE S GENI.AGGREGATE DIET APPLIES PEIC PRODUCTS - COAWTOPAGa S 1POUCY nPROIEO, ETWC $ COLIGNED SINGLE OMIT AVTOMRLB LIABILITY (Es amldndl 5 SOOILYINJURY O'a Penn) S • ANY AUTO ALL OWNED SCHEDULED • BCOILYWIIIRY(Par nodding AUTOS AUTO5 NON -OWNED PROPERTY DAMAGE • FIRED AUTOS Arras • (Par aaddudl 5 • S UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 • . EXCESS LIAO CLAM -MADE AGGREGATE S CEOI I_ RETENTION S , A mums COUPENIOXIONANG WC2D1I00000 11112011 1/1/2012 X I NEI 1 ER EMPLOYERS' UAB8.ITY y/N ANYPAOPRIETOWPARTINEAIERECUOVE ILL EACH ACCIDENT 51,000,000 OFFICERIMEMEER OCCLUDED? NIA pl., datoty NHI EL MEAN -EA EMPLOYEE 51,000.000 II ye, demist nadir DESCRIPnoH OF OPERATIONS below B.L. DISEASE- POLICY war 51,000,000 • • • • • • • DESCRIPTION OF OPERATIONS N LOCATIONS N VEHICLES (Alath ACORD Tat, Additional Rsssnrbs aehadula, N morn space b raquIad) EFFECTIVE 11/10/2003, COVERAGE IS FOR 100% OF THE EMPLOYEES OF FRANKCRUM LEASED TO COMMERCIAL FIRE, INC. ( CUENT) FOR WHOM THE CUENT IS REPORTING HOURS TO FRANKCRUM. COVERAGE iS NOT EXTENDED TO STATUTORY EMPLOYEES. • • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. CiTY OF ATLANTIC BEACH 800 SEMINOLE RD AVIHDRELD REPRESENTATIVE ATLANTIC BEACH FL. 32233 Im 1008 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010108) The ACORD =no and logo are registered marks or ACORD • • ir- C/D 1, . = '1" .,” :•,-4 ,-,. ;:.:. V .„,„ •-■ ,:....". 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