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Permit Roof 747 Triton 2012 0.'-J' ti i � CITY OF ATLANTIC BEACH a � s s j 800 SEMINOLE ROAD J ATLANTIC BEACH, FL 32233 ......) `��' �' INSPECTION PHONE LINE 247 -5814 Application Number 12- 00000407 Date 4/10/12 Property Address 747 TRITON RD Application type description ROOF PERMIT Property Zoning TO BE UPDATED Application valuation . . . 4750 Application desc REROOF Owner Contractor NARKIEWICZ, BRENT J LEWIS WALKER ROOFING 130 POINSETTIA ST P 0 BOX 554 ATLANTIC BEACH FL 32233 LAKE BUTLER FL 32054 (866) 959 -7663 Permit ROOF PERMIT Additional desc . Permit Fee . . . 75.00 Plan Check Fee . . .00 Issue Date . . . Valuation . . . . 4750 Expiration Date . 10/07/12 Other Fees STATE DCA SURCHARGE 2.00 STATE DBPR SURCHARGE 2.00 Fee summary Charged Paid Credited Due Permit Fee Total 75.00 75.00 .00 .00 Plan Check Total .00 .00 .00 .00 Other Fee Total 4.00 4.00 .00 .00 Grand Total 79.00 79.00 .00 .00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. BUILDING PERMIT APPLICATION CITY OF ATLANTIC BEACH 800 Seminole Road, Atlantic Beach, FL 32233 Office (904) 247 -5826 Fax (904) 247 -5845 Job Address: 1 1 r 1 p . r � - 1 L\ lC 5 - a C " Permit Number: 31 I A !� 7 1� i > 1 t . Parcel #i Ft`s %O Legal Descri tion L U--M t S 1N li sq. r 2 g p �Oy © � F oor Area of ed /cooled (?J ( 'J n . on- heated /cooled 57 Valuation of Work $ 41 5 B Proposed Work heated/cooled of Work (circle one): New Addition Alteration Repair Move Demolition pool /spa window /door Use of existing /proposed structures) (circle one): Commercial Re If an existing structure, is a fire s Sy sprinkler system installed? (Circle one): es N o Florida Product Approval # � 1L i Lt. 1 For multiple products use product approval form Describe in detail the type of work to be performed: of COOf Si f e l ,E c 90 ique-e. fi Z- , _ M Coked XT 30 Property Owner Information: . Name ri; • as ACV . ' A \ _ Address: t Po t '( L'- 5i- cit - :tr'ri"Mer: 6 State _ ip ■ 0 - 'hone _.. -- - — E -Mail or Fax # (Optional) Contractor Information: Company Name - U3' c 1_ A . .' ■ .s AL 1 Aualifying Ate t: ' e• 1 r Address: • I,, City ! • * lt State Zip _ • lill Office Phone rise r� NAW /.. C Site/ Contact Number Fax # , - _eh blab State Certification/Registration # _ Architect Name & Phone # N,, / Engineer's Name & Phone # f\i /A Fee Simple Title Holder Name and Address 1., J A Bonding Company Name and Address (U / Mortgage Lender Name and Address N Pt 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 the standards of all laws regulating construction in this jurisdiction. This perntit becomes null and void if work is not commenced within six (6) months, or if construction or work is suspended or abandoned for aperiod of six (6) months at any time after work is commenced. 1 understand that separate permits must be secured for Electrical - Work, Plumbing, Signs, Wells, Pools, Furnaces, Boilers, Healers, Tanks and Air Conditioners, etc. 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. 1 hereby certify that 1 have read and examined this application and know the same to be true and correct. All provisions o'laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to gi e authority to violate or cancel the provisions of any other federal, s • i. al law re lating construction or the performance of construction. ( Signature of Owner' Signature of Contract. " -- b Print Name s illiraM Print Name Swor t ..and subscribed b f re me , n Swor t and subscribed. efore me this)d' 1 Day of 0 ren , 20 1 t� .'s Day of , '1 , 20 / Notary ublic Notary •::t:*' DEBORAH D ASBELL MY COMMISSION # EE113212 .44k" ;; DEBORAH D ASBELL • -': MY COMMISSION # tt713�� 01.26.10 ' �.` EXPIRES July 17, 2015 _, -t . EXPIRES July !7, 2015 ,,,, . DO NOT WRITE BELOW - OFFICE USE ONLY Applicable Codes: 2007 Florida Building Code w/ 2009 Revisions Review Result (circle one): Approved Disapproved Approved w/ Conditions Review Initials /Date: Development Size Habitable Space Non - Habitable Impervious area Miscellaneous Information Occupancy Group Type of Construction Number of Stories Zoning District Max. Occupancy Load Fire Sprinklers Required Flood Zone Conditions /Comments: 4 I � 800 Seminole Road '" Atlantic Beach, Florida 32233 r s i\ Telephone (904) 247 -5800 • �` FAX (904) 247 -5805 ,J Ji.1!) Construction Site Management Plan Compliance A construction site management plan conforming to Atlantic Beach City Code Sec 6 -18 has been approved as a part of this building permit. The Construction site management plan was approved based upon the following information. 1. Parking plan - parking plan showing how site will be accessed and all onsite and abutting street parking areas. 2. Location of construction trailers, loading /unloading area and material storage area. 3. Location of chemical toilet area - chemical toilets must be kept out of City right -of -way and not further than 15 feet from structure under construction. 4. Location of dumpster - dumpster must be from approved waste company (in accordance with Chapter 16 City Code). As of 2009, approved dumpster companies for Atl. Beach are Advanced Disposal, Realco Recycling, and Shappells. Dumpsters are to have tarp covers or rigid covers on windy days. Dumpsters must be removed prior to issuance of Certificate of Occupancy or Completion. 5. Traffic control plan, showing access with dimensions, area to be stabilized, narrative on phasing of construction with adequate parking and delivery of materials. 6. Site cleanliness. Contractor must have the entire construction site cleaned by Friday of each week. This means removal of scrap lumber, concrete remnants and other such construction debris including cans, metal, plastic and paper. 7. Erosion and Sediment Control. Contractor must maintain all elements of the approved Erosion & Sediment Control Plan (silt fence, catch basin filters, etc.) until sod or other stabilization has been placed and approved by Public Works. 8. Other activities, where special conditions are identified by the Building Official. Failure to comply with the Construction Site Management Ordinance may result in a Stop Work Order being issued in accordance with City Code Sec. 6 -17 (3) Revised 6/2009 Doc # 2012074517, OR BK 15903 Page 491, Number Pages: 1, Recorded 04/05/2012 at 12:31 PM, JIM FULLER CLERK CIRCUIT COURT DUVAL COUNTY RECORDING $10.00 NOTICE OF COMMENCEMENT Permit No. Tax Folio No. — *, 4 State of Florida, County of Duval THE UNDERSIGNED hereby give notice that the improvement will be made to certain real property in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Description of property (legal description of property and address if available): lln RjP 7T nF R r ALP/Al s`tlr LOT _�� (a ^ L3t_.1C I l 2. al Description of improvements:1 141 -' ' of '¥� Ai � c L�Cs j EL 3 2 ' 3 v 3 e'.X QC�f 3. Owner Information: a) Name and Address: M C .. 1k ► ► .S ■ / , &Me ras r_' it b) Interest in. property (lt„} c) Name and address of simple titleholder (if other than owner): 4. Contractor Information: a) Name and Address:. - S Y t ' ►i ft, , • 0 . _ t kL. b 1' b) Phone Number: o ► tl3t� / ( ' 5. Surety Information: a) Name and Address: b) Phone Number. \ c) Amount of Bond: $ \ 6. Lender Information: a) Name and Address: b) Phone Number. 7. Person within the State of Florida designated .y o . r upon whom notices or other documents may be served as provided by 713.13 (1)(a) 7, Florida Statutes: a) Name and Address: b) Phone Numbers of Designated Person: ' 8. In addition to himself/herself, Owner designates of to receive a copy of the Lienor's Notice as provided in Sectio . 3 (I.) b). rida Statutes. a) Name and Address: b) Phone Number of person or entity designated by owner 9 Expiration date of Notice of Commencement (The expiration date is one (1) year from the date of Recording unless a different date is specified: WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713:13, FLORIDA STATUTES, AND CAN 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 COMMENCING WORK OR RECORDLNG YOUR NOTICE OF COMMENCEMENT. • The foregoing instrument was acknowledged before me this , day of h: , 2019) 1111. th■ W DEBORAH D ASBEI.L NOTARY PUB C, STATE OF FL C }�(} MY COMMISSION # EE113212 Prntt Nam ^ e: t I iJ . 1 V j Q \ t EXPIRES July 17. 2015 1407 “0 Fla1e,NwnY9m.ice coal D P onally Knoun IV/Identification/Type: , Verification pursuant to Section 92.525, Florida Statutes. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowle. ;(4111 /1 Signature of Prop ; "Ai weer Revised 10/1/2009 U CA O O A 0O O b 4t O ,_ cu O O o 6 bp a U & .o a CU ( C -� .., U E J • 0 C H a E E w° 6) d a 44 a) ss 3 c.." 0 -d y O o i0 � - 0 -- al U ' / CA 0 1 W 1 '' n. E+ c•1 O a) a O A O v O ' Pro 3 1rU w W -o to 6 A / U .-' O � ( J A ? '. o w—, J .0 O 6 (1 ) V •S > o! - ,_, t1+ • Gz d � ' 6 `3 ,� , r w : iii 2 g 0* rsl r h - M E " ,n U A CL) 0 0 cA O Li) o � � c O o i. Z ^o 7 . E a W r° A z o Ed o o O' cd Q y cro x a. 6 W ., N M 4 ,n ■.O .--1 N M 4 00 O.. O; _ { , | it 1 7 } ° ___, , . , , it « i � I 4 0 = 2 1 } _ . . _ _ ( ■ ( 2 � a � ( 6 az • c / . — 1 ( | § . . u ( cet `� — ( \ « U . . f « o / \ m 1 \ / tO , CtJ 3 ® u/ q 0 2 0 / § k k / § / \ ° k j • U p k , ..• to ƒ % q « /•- 2 ƒ ƒ / -- » / / _ / • m § w u. t dƒ 3 \ f ms@ 4 ' ¥ 0 \ ' 2 / 0 0 ® 0 5 8 O o/ y c2 / 7 U 2 S S a »// m 2 cA c ƒ P- U m & t d¥ 4 a k a S - d w 4 G e 6 a"" G a s r. | . � . � - - Ta c) 0 a cs .4.• a rn w O 5 E a A O 'Co imi C t A U R O L L .=. V W C g it 0 t" cd o 1:1.0 8 a N E CA u v ! I 1 v o ' 1--: L : N M 4 0 -- N M 4 v1 \O r-4 00 O� O �-, N M - .-- .--, .--a U W F4 L7 ai c 0 co 0 0 O O N O 0 0 U 06 0 a V N 0 Q o En StL • rte+ 0. - 0 cl p i+ 0 _ d 4 ! ► 0 4D O 1 0 o,4 C 0 N 4 o tea' 0 - -� I al (46 E o 1 N .4 ai .dam - 0 - bb - iri 0 O 0 ` N i.4 45 a -o co En E.." 0 d A �° ,4-, Z 0 0= 1 4.4 w 0 a, . PI J — o 0 r E as - -0 4 + co }" = CI 0 0 0 0 a) o el ��� (1) 4 111 t . . .s ..c, H " a, Z 9 U , S o w a ,..... A do 0 `" �p v o 4 ,� l1 .— t W C O -� Z z Z 5 0 0 o d 0 0 . . to 0 O as W b ° `, a . 0 a N — 0 • W N 0 En En U En U U H U J U O cd ' N j /N_ 4111. 4. LEWIS WALKER ROOFING INC. - 11 -86 - w a.,w -FICoo Serving over 50 counties in North Florida & South Georgia RESIDENTIAL: Lake City, Live Oak, Branford, Lake Butler, Starke, Jacksonville, Green Cove Springs, St. Augustine, Williston, Valdosta COMMERCIAL: Serving the South Eastern United States Office: 14373 5. US 441 Lake City, FL 32024 Mailing: P.O. Box 554 Lake Butler, FL 32054 Fax: 386-496-0925 www.LewisWalkerRoofing.com I Proposal No. BL 030820121 I I DATE: 03/08/2012 I PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME: Brent Narkiewicz ADDRESS: ADDRESS: 747 Triton Rd. y Atlantic Beach, FL PHONE: (352)283 -3188 Lewis Walker Roofing, Inc. hereby proposes to furnish the materials and perform the labor necessary for the completion of: Lewis Walker Roofing, Inc. agrees to tear off entire roof down to wood deck, re -nail existing decking to meet your local building code, clean up and haul off all trash and debris. Guaranteed Best Service CertainTeed 30 yr. 3 -Tab shingle roof system as follows: Guaranteed Best Warranties • Install Two (2) layers of # 151b. felt over wood decking. Guaranteed Best Prices • Install a 30 yr. 3 -Tab shingle roof system over #151b. felt. (Color: CEt o. $11 ) • Install new Drip Edge to entire perimeter. (Color: I4rr ) • Install all flashings, fasteners sealants and accessories for a water tight roof system. • 5 yr. Workmanship Warranty from Lewis Walker Roofing, Inc. • 30 yr. Manufacturer materials warranty. ** *Any woodwork is additional labor plus materials. Woodwork is 25.00 per man hour. Grounds will be magnetized & yard cleaned daily. Comments: Four Thousand Seven Hundred Fifty & 00/100 Dollars ($ 4,750.00 ) Any alteration or deviation from above specifications involving extra costs Respectfully Submitted: Ben Liebtag will be executed only upon written order and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. THE TOTAL AMOUNT SHALL BE DUE UPON COMPLETION. 1 ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are borized to do the work as specified. Payments will be made as outlined above. (-`- ( - --- - j � Signature Date / Signature C,, Property Appraiser - Property Details Page 1 of 2 NARKIEWICZ BRENT 3 Primary Site Address Official Record Book /Page Tile # 130 POINSETTIA ST 747 TRITON RD 11214 -01335 9417 ATLANTIC BEACH, FL 32233 Atlantic Beach FL 32233 747 TRITON RD Property Detail Value — i : zo11 certified 120122012 inn P res.s RE # 1171443-0000 Value Method CAMA € CAMA Tax District ; USD3 ,.,, ____.. -I Total Building Value 8 251.00 1 $67 595.00 ` ProomtV Use i 0100 SINGLE FAMILY _ _ ____._____ Extra Feature Value $0.00 $0.00 # of Butldkps (1 __ _._ -_ Land Value (Market) $70,000.00 $70,000.00 Legal Desc. 1 31 -16 38- 2S-29E - - _ .___._ _...._____ I R/P OF PT OF ROYAL PALMS UNIT 2 A Land Value (A9ric.1 I $0.00 $0.00 1 Subdivision 1 03123 ROYAL PALMS UNIT 0213.00 3ust (Market) Value ' $138,251.00 $137,595.00 The sale of this property may result in higher property taxes. For more information go I Assessed Value $138,251.00 1 $137,595.00 to Save Our Homes and our Property Tax Estimator.Property values, exemptions and I Cap Diff /Portability Amt ' $0.00 / $ ? $0.00 / $0.00 other information listed as' In Progress' are subject to change. These numbers are °- ______ i See bebw 00 s tion ; $0 ! part of the 2012 working tax roll and will not be certified until October.Leam how the Exemptions i Property Appraiser's Office values property. 1 Taxable Value $138,251.00 ?See below Taxable Values and Exemptions — In Progress If there are no exemptions applicable to a taxing authority, the Taxable Value is the same as the Assessed Value listed above in the Value Summary box. County /Municipal Taxable Value SiRWMD /FIND Taxable Value School Taxable Value No applicable exemptions No applicable exemptions No applicable exemptions Sales History Book /Page ' Sale Date 1 Sale Price Qualifies[ teliif l Vacant /Improved 11214-01335 7/1/2003 $150,000.00 WD - Warranty Deed Qualified Improved 30980 -00467 3/14/2003 il $57,000.00 WD - Warranty Deed i Unqualified i Improved J0980 -00469 1 13/14/2003 1 $88,000.00 WD - Warranty Deed Unqualified Improved 278 00106 i 10/19/1971 ? $18,800.00 1 MS - Miscellaneous j Unqualified I 03278- 00106 Improved Extra Features No data found for this section Land & Legal Legal L Ni Code I Use Desc iptisn 7orri I Frart Dealr Category 1 Land Units Land Value 1 Lt. 1 Legal Description 1 t 0100 RES ID 3-7 UNITS PER AC I ARS-1 87.00 194.00 Common 1 1.00 I $70,000.00 1 131 -16 38- 2S-29E B/P OF PT OF ROYAL PALMS 2 1 um' 2A 3 LOT 26 BLJ( 11 Buildings Building 1 Building 1 Site Address Elect ( Code i Detail 1 747 TRITON RD _:,_, Atlantic Beach FL 32233 Exterior Wall 15 15 Concrete Bock Eiderior Wall 26 26 Alum/Vinyl Siding -_ usT Building Type 1 0101 - SFR 1 STORY SOH Roofing Structure 3 3 Gable or Hip r 111 ens Year Built 1971 L Roofing Cover 3 3 Aspl Shingle A" 1 Interior Wail 5 5 Drywall j ,L 1 Type I Gross Area Heated Area Id Hooting 11 11Cerandc Clay Tile Base Area 1104 1104 Heating Fuel 4 4 Electric Addition 209 209 Heating Type Ji 4 4 Forced - Ducted Unfinished Storage 77 0 Air Conditioning 1 3 3 Central Finished Open Porch 80 0 r Total 1470 131-3 -- 1 E Code Stories 1.000 Bedrooms 4.000 Baths 2.000 1 Rooms / Units 1.000 Traversing Data http: / /apps.coj . netlpao_property SearchBasi c/Detail . aspx ?RE= 1714430000 3/13/2012 Property Appraiser - Property Details Page 2 of 2 BAS( U24R46D24 ADT( R11U19 UST( UO7L11DO7R11) L11D19) L02 FOP( D04L20004R20) L44) . 2011 Notice of Proposed_ Property Taxes LTruth in Millage Notice) Taxing District I Assessed Value i Exemptions t Taxable Value 1 Last Year ! Proposed s Rolled back Gen Govt Beaches $138,251.00 $0.00 $138,251.00 $956.76 $932.45 $996.43 Public Schools: By State Law $138,251.00 $0.00 $138,251.00 $758.36 $733.42 E $790.31 By Local Board $138,251.00 $0.00 $138,251.00 $35436 1 $310.79 j $3 28 „ Fl Inland Navigation Dist. $1.38,251.00 $0.00 $138,251.00 $4.89 $4.77 1 $4.92 Atlantic Beach $138,251.00 $0.00 $138,251.00 $447.60 $460.17 I $460.17 Water Mgmt Dist. SJRWMD $138,251.00 $0.00 i $138,251.00 $5898 $45.80 $62.34 Gen Gov Voted $138,251.00 $0.00 $138,251.00 $0.00 $0.00 I $0.00 School Board Voted $138,251.00 $000 $138,25100 1 $0 00 I $0.00 $0.00 Urban Service Dlst3 $138,251.00 $0.00 1 $138,251.00 . $000 a $0.00 . $0.00 Totals 1 $2,580.95 $2,487.40 1 $2,683.45 3astValue Assessed Value Igoemptions { Taxable Value Last Year j #141,856.00 $141,856.00 i $0.00 $141,856.00 Current Year 1 $138,251.00 ( $138,251.00 1 $0.00 a $138,251.00 Property Record Card (PRC) The Property Appraiser's Office (PAO) provides historical property record cards (PRCs) online for 1995 -2005. The PAO no longer maintains a certified PRC file due to changes in appraisal software; therefore, there are no PRCs available online from 2006 forward. You may print this page which provides the current property record. (Sections not needed can be minimized.) To print the past -year cards below, set your browser's Page Set Up for printing to Landscape. 2005 1 2004 1 2003 1 2002 1 2001 1 2000 1 1999 1 1998 1 1997 1 1996 1 1995 More Information arcel Tax Record 1 GIS Map 1 Map this property on Google Maps 1 City Fees Record http: / /apps.coj . net/ pao_ propertySearchBasic /Detail.aspx ?RE= 1714430000 3/13/2012 POWER OF ATTORNEY y -5-I D ate � I hereby name and appoint B e n L }- -e b 6 to be my lawful attorney in fact to sign my documents pertaining to permits for the C ( T Or A ll, \V1 IC 66 H I; )u i l.OI V) to Dpt and complete one of the following.) 0 To sign for any and all documents until further notice. OR V To this specific job for work to be performed at: P� J v2 - 7 91 lyet70► -, Topic) A i uin itc_ OFAc Fl_ Alternate Key# 11 1 (-1 Li 3 - DOM Section Township Range Lot Block Subdivision License #9f OO(o1 -17 Lewis Walker Roofing, Inc. Lewis Walker N. a e of Contractor Sig . tune of Contractor State of Florida County of Union Th foregoing instrument was ac • , .: • ere me this ,, day of A pie' L , 201Z, by AO( who ' personally kno • to me or has produced as identification and who di. ; ... • t Make an oath. 1 (° #0 l"` (SEAL) % AIVAL 1 C ; ;4: DEBORAH D ASBELL + otary Public ( ignature) :' : ,...4 . 4k., '' * MY COMMISSION # EE113212 -, : '' ' ' EXPIRES July 17, 2015 •4071399-0153 KfdrfdaNda - rvice.com Client#: 26788 2LEWIWAL ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE . 31222/202 /20 DIYYYY) 12 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)- CONTACT PRODUCER NAME: Willis of Florida, Inc. PHONE (A/C, No, Exty (A/C 352 378 -2511 (A/C , No): 352 - 378 -9801 4880 Newberry Road, Ste. 100 E-MAIL ADDRESS: Gainesville, FL 32635 -7400 INSURER(S) AFFORDING COVERAGE NAIC # 352 378 -2511 INSURER A: First Mercury Ins. Co. 10657 INSURED INSURER B: Bridgefield Casualty Ins. Co. Lewis Walker Roofing, Inc. INSURER C: Post Office Box 554 INSURER D : Lake Butler, FL 32054 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACT OR 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. INSR ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MMIDDIYYYY) A GENERAL LIABILITY NJCGL000000795501 03/22/2012 03/22/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 50,000 CLAIMS -MADE [ X] OCCUR MED EXP (Any one person) $ O X BI /PD Ded:5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 — 1 POLICY JE0 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) _$ — ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Pe( accident) $ _ ,— — NON -OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR - -- EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ B WORKERS COMPENSATION 83036739 08/08/2011 08/08/2012 ORY iMITS 1 ° R " AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N E.L. EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION City of Atlantic Beach SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 800 Seminole Road ACCORDANCE WITH THE POLICY PROVISIONS. Atlantic Beach, FL 32233 AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S394803/M394797 BWEED , ...._ I 1 N I i CO I ■• I A rn 1 1 H 1 ... o 1 ! o I ' : co o H ! . 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