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Permit 750 Plaza (vault) Y OF ATLANTIC BEACH ��T 800 SEMINOLE ROA B ATLANTIC BEACH,FL 3 3 � 33 INSPECTION PHONE LINE 247-5826 09-00001270 Date 9/09/09 Application Number 750 PLAZA Property Address Application type description PLUMBING ONLY Zoning TO BE UPDATED Property 0 ------------- Application valuation . - Application desc -------------- replace sewer ------ Contractor Owner ______ ------------------------ ___ ------------- ROTO ROOTER-SERVICES C 2028 W. 21ST ST. FL 32209 JACKSONVILLE (904) 354-7321 Permit . . . . . . PLUMBING PERMIT Additional desc . Plan Check Fee . 00 Permit Fee . . . . 4 . 00 0 Valuation Issue Date 3 08/10 Expiration Date / ------- --------------- Due ----------------- --- Credited Fee summary Charged Paid ---------- ----- ---------- . 00 ---------- ------------ 42 . 00 42 . 00 . 00 Permit Fee Total 00 00 00 . 00 Plan Check Total 42 . 00 . 00 . 00 Grand Total 42 . 00 PERMIT IS APPROVED ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. �— CITY OF ATLANTIC BEACH I DEPARTMENT OF BUILDING 800 Seminole Road -Atlantic Beach, FL 32233 - Tel: 247-5826 - Fax: 247-5877 PLUMBING PERMIT PERMIT INFORMATION _ LOCATION INFORMATION— Permt Number: 20602 '— —-- — -J---- Address: 750 PLAZA DRIVE — Permit Type: PLUMBING ATLANTIC BEACH, FL 32233 Class of Work: ALTERATION Township: Range: Book: I Proposed Use: SINGLE FAMILY Lot(s): Block: Section: Square Feet: Subdivision: ROYAL PALMS Est. Value: ParcelNumber: Improv. Cost: — — --_-- OWNER INFORMATION —_— ---__-_- Date Issued: 9/07/2000 Name: GILLESPIE, GENE { Total Fees: 56.50 1 Address: 750 PLAZA DRIVE Amount Paid: 56.50 ATLANTIC BEACH, FL 32233 Date Paid 9,107/2000_ _ Phone: (00 000 0000 I Work Desc:REPIPE NINE FIXTURES _ _ — _—_—. CONTRACTORtSLAPPLICATION FEES —� STE—EG PLUMBING a I I i I I 4 Inspections, Re uired FINAL ------ -- i I j I � NOTICE - INSPECTIONS MUST BE REQUESTED AT LEAST 24 HOURS PRIOR TO INSPECTION BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE, AND MUST BE CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER "FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT IN THE PROPERTY , OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS" ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW. 1%.5814 9/17/0 11 Receipt: M038899 b ATLANTIC BEACH B ILDING DEPT. EM31pt1� CITY OF ATLANTIC BEACH APPLICATION FOR PLUMBING PERMIT JOB LOCATION : OWNER OF PROPERTY: I e 5,01 p TELEPHONE NO. PLUMBING CONTRACTOR At, / u', L CONTRACTOR' S ADDRESS : ZW r STATE LICENSE NUMBER: Cl FCU T71 TELEPHONE:; "/7 'j1 cl/ HOW MANY OF THE FOLLOWING FIXTURES INSTALLED SINKS SHOWERS LAVATORY WATER HEATERS BATH TUBS DISHWASHERS URINALS DISPOSALS CLOSETS WASHING MACHINE FLOOR DRAINS SHOWER PANS SEWER WATER REPIPE OTHER TOTAL FIXTURES : _ x $3 . 50 + $15 . 00 MINIMUM PERMIT FEE - $25 . 00 SIGNATURE OF OWNER: SIGNATURE OF CONTRACTOR: INSTALLATION OF PLUMBING AND FIXTURES MUST BE IN ACCORDANCE WITH THE MOST RECENT EDITION OF THE SOUTHERN STANDARD PLUMBING CODE. CALL A DAY AHEAD TO SCHEDULE INSPECTIONS - (904) 247-5826 SEWER CONNECTIONS MUST BE CALLED INTO PUBLIC WORKS FOR INSPECTION /' o \�\a1 Q o�aS eu �pq — gs /1 ' ofi Bu11d\n9 E� S FOa aEQ Permit No. n 2© F M. to uty Date v MECNAW\CA\- time Receive Gontracto N1B� O NeaCrng O Place Job P res ��\CA\- OUj / F1re PFare b toP A;;l oo9hWrrin9 � $ewer Yw Owner's CONC41 n temp Vote O Friday/ N � Footing O Fin FDa\NSPE�\pN b C\ tnurs vvaming C ��ntei READY M F SRa`to^9 es Wed P'M Flnair`cape of O c PancY to C� Gert C pate Mon tnsPe,f%on Made ,soector CITY OF ATLANTIC BEACH MECHANICAL PERMIT 800 SEMINOLE ROAD-ATLANTIC BEACH,FL 32233-TEL: 247-5826-FAX: 247-5877 PERMIT_INFORMATION _ LOCATION f*F MATION Permit Number: 20655_ Address: 750 PLAZA DRIVE { Permit Type: MECHANICAL ATLANTIC BEACH, FL 32233 I Class of Work: ALTERATION Township: Range: Book: Proposed Use: SINGLE FAMILY Lot(s): Block: Section: Square Feet: I Subdivision: ROYAL PALMS Est.Value: Parcel Number: Improv. Cost: OWNER INFORMATION Date Issued: 9/99/2000 Name: GILLESPIE, GENE — + Total Fees: 47.00 Address: 750 PLAZA DRIVE ` Amount Paid: 47.00 ATLANTIC BEACH, FL 32233 Date Paid: 9/99/2000 Phone: (000)000-0000 I Work Desc: REPLACE AIR HA_NOLER AN_D_ H_ EAT STRIP _ CONTRACTOR(S) _ _ T _APPLICA_t FEES S) FIRSTA COAST HEATING AND AIR PERMIT 47.00 I � a i In_sections Required ROUGH MECHANICAL CFINAL. f t I NOTICE- INSPECTIONS MUST BE REQUESTED AT LEAST 24 HOURS PRIOR TO INSPECTION BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER "FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT IN THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS" ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW. I $47.80 14 AT TIC BEACH BUILDING DEPT. Date; 9/26/x8 61 Receiot: 86963? CIIECtiS _ BUILDING AND ZONING INSPECTION DIVISION CITY OF ATLANTIC BEACH ATLANTIC asaCH,FLORIDA Sataa APPLICATION FOR MECHANICAL PERMIT CALL-IN NUMBER IMPORTANT—Applicant to complete all items in sections I, II, III, and IV. I. � e !f LOCATION Street Addr.al p OF lohrreeting stmotst Batrraan / L� And WILDING sob dWlaion w^ ` Q II. IDENTIFICATION—To be completed by all applicants. In consideration of permit given for doing the work as described In the abow statement we hereby agree to perform%aid work in sccordance with the stfach d plan, and specification which area put hereof and in accordance with the City of Jacksonville ordinances and standard, of good.prectice listed therain. Name of Meahaxieal Contractors Contractor I►rinf) iY C—oG S,< JLfG-c�1It � I @ Malo Nome of /n Property Owner C 2dk L�t�{cfP�t Signature of Owner ,*,' signefare of . w Aetherlsod Avant Arahitact or Engineer III. MERAL INFORMATION A. Type of heet)ng foell l3. ' IS OTHER CONSTRUCTION BEING DONE ON Elecfrie THIS BUILDING OR SITET ❑ 6u—❑, LP ❑ Natural ❑ Control UtRlty IF YES,GIVE NUMBER OF CONSTRUCTION CI Oq PERMIT ❑ Oliver—Specify IV.MOCNANICAL NOUIPMWT TO Ri INSTALLED NATURE OF WORK Illsoold•complete ILA ef componeetr era batt of this form) Residential or ❑ Commercial Neal ❑ Space ❑ Roeeesed *Contra) O poen ❑ New Building Nr CeodsfhnMgs ❑ }RResmn" �Existing Building Deaf Syst., Ms... tjCo riet "` km. , Replacement of existing system Maximum capacity �0 CARL ❑ New Installation(No system prerrlously Installed) ❑ Refrigeration ❑ Extension or add-on to exlsting system ❑ Other—Specify a Cooling lew.r=GpeeNy g.p,sm. 13 pre spdatlonr Nembw of h ss ❑ Boaster 0 MomRfl O 6alater IIIIIm►erl This SPACR bR OtFICi YSE ONLY ❑.00-111-pumps Inumber) IR«ellm Q,•Ue►a (Iwsnbor) Remarks ❑ LM osahi-� (mrmbor) ❑ Uafired ploaae weal ❑ MRen ►anvil Approved by DN- D Other—'Specify hrmit lee LI8T ALL SQUIPM$NT AQ CONDMONING AND REFRIGERATION EQUIPMENT ppm Approviling NmberUnih DoeripU- XodalNUmber wnmtaatuuwr (Meee� ASIBestir MATLNG•PURNACES,BOILERS,PMEPLACM dya�t�r Ayptv�0� NmberUsite D-asipti- Me"Number mmutaotu w (11ZV) ACOMY rr D-i0 W1n 1 V ouo U L TANKS New Ydnr Naeleei CaPeelt7 �yrpe tJquld Nsntse est( Serial AP L auA DtmeeBlBea CsntaiDed ]tannfaeturer No. Apecy c1-Tv OF ' �__;,OG Acta Official ice 0 FOR11NSpEc�TION REAVES permit No. -- Date Time Received V MECHANICAL r & C Job pd essPWMBING _ Air Oond. "eaEC(RICAI- RFire ough Fire p ace G Names CONCRETE Rough Wiring n Se Ort �' pfe Fab A O pOle C TemP gVILD C" � Footing ❑ Final m ntel Blab CREADy POR MSPEc(101'l Friday Re Roofing LiThurs. Insulation Wed, p M P.M ed'On❑ Tues. FinallnsP c OccuPan Mon _ Z, C Certificate of Y de pate . Inspection � - n 1l AUG-22-2000 09:45A FROM: 247-5945 TO:93533939 P: 1'1 CITY OF ATLANTIC BEACH, FLORIDA As� APPLICATION FOR ELECTRICAL PERMIT TO THE CHIEF ELIMICAL INSPECTOR: DATE., I! 1wOIiTANT NOTICEi IN CONSIDERATION OF PERMIT GIVEN FOR DOING THE WORK AS DESCRIBED IN THE FOLLOWING, WE HERESY AGREE TO PERFORM- SAID WORK IN ACCORDANCE WITH THE ATTACHED PLANS AND SPECIFICATIONS. WHICH ARE A PART HEREOF, AND IWACCORDANCE WITH THE ELECTRICAL REGULATIONS,CODES AND CRY OF ATLANTIC BEACH ORDINANCES. KUWM/T�=� lICAL FIR :: I C,� / NAME I ,L�P DL,{�_ ADDRESS: ��..x �C�!�Q- RFS WX n .' BLDG SIZE BETWEEN: K_rQjL(]s��Q��t�1!1 0-1)-c RES.M API.i ) COMM.11 PUBLIC I ) INDUS.( I NEW i I OLD( 1 REW.( I ADDITION i ) TRAILER I i TEMP.I I SIGNS I ) Sq.FT. SERVICE: NEW( ) INCREASE I ) REPAIR i ) FEE qmpqmRwzI! —AMPS COPPER T OR BREAKER I PH w LT -�RACCWAY Fxw r.SERV.SIZE PH W VOLT t kRACEWAY FEEDERS NO. SIZE I NO. $174 NO. SIZE LIGHTING OUTLETS CONCEALED Om TOTAL AECEATACLES CONCEALED OPEN TOTAL e.ad Pg. 1 a+_iocArri. SWITCHES INGANOESCENT FLUORESCENT A M.V. Plxaa O-IDG AMPS. OVA APPLIANCE') BELL TRANSF. AIR H.P.RATING H.P.RATING CONDIT"JIN r COMP.MOTOR OTHER MOTORS AMPS CEIL HEAT: KW-MEAT 0.1 OYER MOTORS H.P. i VOLTAGE PHS NO. 1 B.A VOLTAGE PHS MLRC ANSFORMERW UNDER 600 V. OVER NOV. NO. I KVA NO. KVA NO.NEON TRANSP. NO. VA. MA, MOTOR SIZE Sw19 CH I FL.ASIIE EACH SIGN. FORWARDED s \ TOTAL FEES c� } C1 s f OF A7L ANTSr. F CI�K I DEPARTMENT OF BUILDING � 0 Se�'Y"d3Y°de Roao...Ai a tic Beach, FL 2223 TSI: 2�7-5 26- Fax: 24l �$�7 ELECTRICAL'PERt,`T PERMIT INFORMATION LOCATION INFORMATION 'eri it I umber: 20526 Address®- 750 PLAZA DRIVE Permit Type: ELECTRICAL y ATLANTIC BEACH, FL 32233 s Class of Work: INCREASE j Township, Range: Rook, Proposed Use: SINGLE FAMILY Lot(s): Bloch: Section: ; Square f=eet: Subdivision- ROYAL PALMS Est.Value: Parcel Number Improv. Cost: ? O NER INFORMATION Date Issued* 8/23/2000 Name: GI LESPIE, GENE Total Fees: 50.00 ; Address: 750 PWA DRIVE Amount!Peed: 50.00 ATLANTIC BEACH, FL 32233 } _ Date Paid 8/2312000 -- - �_�, _ ; _ Phone: a00}fIUO-0000 Work Desc: ESS10OAMPS-200AMP5 1PH 3W 240V S8-(-AW,2.5"RW ALt1M _ -- �ONTRAT4RS) -...___ _ _-- r-__ _ -- APPLICATION FEES___ __ oLCEN MMES-ELEC.TMC I ER IT - 5fl.G0 i I i i i �OIIGIi ELECTRIC_ _ ___ _ ir eds 1 6 i w r NOTICE - INSPECTIONS MUST BE REQUESTED ATL- ST 24 HOURS PRIOR TO INSPECTION BUILDING MATERIAL, RUBBISH AND DEBRIS FROM TINS WORK MUST NOT BE PLACED IN PUBLIC SPACE,AND MUST BE CLEANED UP ANDHAULED AWAY BY EITHER CONTRACTOR OR OWNER "FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT IN THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS" ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF L.A:^9_ E i f i I ---- ---- __ _ Date: 8/24/00 01 Receipt: 00a3,23 ATLANTIC BEACH BIS LDING CHECRS __ CITY OF ATLANTIC BEACH DEPARTMENT OF BUILDING 800 SEMINOLE ROAD-ATLANTIC BEACH,FL 32233-TEL: 247-5826-FAX: 247-5877 PER __ R__MIT INFORMATION - - - LOCATION INFORMATION Permit Number...._ 20535 - - _ _ Address:- 750 - -PLAZA Permit Type: REMODELING .ATLANTIC BEACH, FL 32233 Class of Work: REMODEL i Township: Range: Book: Proposed Use: SINGLE FAMILY Log : Section: Lot(s): Block 1 Square Feet: {{ ! Subdivision: ROYAL PALMS Est.Value: Parcel Number: -- - --- ---- ---- -- Improv. Cost: 10,000.00 II - -- - - i Date Issued: 8!24/2000 k ___OWNER INFORMATION Nalme: GILLESPiE, GENE Total Fees: 180.00 Address: 750 PLAZA DRIVE ! Amount Paid: 180.00 ATLANTIC BEACH, FL 32233 I Date Paid 8/24/2000 Phone: -_--------- - - - - -- - - ----� - -_ - (000)000-0000 _-Work Desc INTERIOR RENOVATION / PERMIT FEE DOUBLED/WQRK COMMENCED PRIOR T4 REF - - ___--- CONTRACTOR S - __ _.- __ _APPLICATION FEES - GILLESPIE CONSTRUCTION INC. PERMIT 180.00 I i j C®VER UP -- ------ --- - yjApeections_Required FRAMING - - ,FINAL BUILDING --- - �� INSULATION r i NOTICE-INSPECTIONS MUST BE REQUESTED AT LEAST 24 HOURS PRIOR TO INSPECTION BUILDING MATERIAL, RUBBISH AND DEBRIS FROM THIS WORK MUST NOT BE PLACED IN PUBLIC SPACE, AND If i MUST BE CLEARED UP AND HAULED AWAY BY EITHER CONTRACTOR OR OWNER "FAILURE TO COMPLY WITH THE CONSTRUCTION LIEN LAW CAN RESULT IN THE PROPERTY OWNER PAYING TWICE FOR BUILDING IMPROVEMENTS" ISSUED ACCORDING TO APPROVED PLANS WHICH ARE PART OF THIS PERMIT AND SUBJECT TO REVOCATION FOR VIOLATION OF APPLICABLE PROVISIONS OF LAW. I I f f 5180.H0 1 -- )- —I LD -_. Date: 8;25/00 01 Receipt. W R€ LAATN IC BEACHING DEPT. HECK 0 22113e� c h1�M-:;k �lv e C-4 c � � •�L3M/8d� / ' (J�' 3 �jj 14 ® � o a 9 0 H a- m � � VN Z Vqg � VI �, 3 i w 3 L LIQ � CITY OF ATLANTIC BEACH PE IT CALCULATION SHEET Address-2 0 A -z A � 7-1 /Z.! a 41 x:Aj 0 U T10A) Date —e- 2— Y Heated Sauare Footage s,- t = Garage/Shed --r sq = S Carport/Porch to pe scr ft = D e per sa ft = Patiope-I: = s a f ft t ...... TOTAL VALUATION : 27 000 0 © 0 To'L',.a Val uati on t Remaining Value per thousand or portion thereof F(_--1Zf7(F Aq��x,-TOTAL BUILDING FEE K IZ(o. r Srl;,fff t/ E TO 0 + ' " Filing Fee Fireplaces @ $15 , 00 BUILDING PERMIT FEE WATER IMPACT FEE SEWER IMPACT FEF fi WATER METER/TAP CAPITAL IMPROVEMENT SEWER TAP s. RADON (HRS ) . 6050 SECTION H PAVING HYDRAULIC SHARES CROSS CONNECTION SURCHARGE 44`1 OTHER GRAND TOTAL DUE .77 ADDITIONAL PERMITS OR FEES : Mechan-iLcal. P J.UIDh Eiectric,'New Electric/Temp c,w 4 r7im J n cr P o o , Septic Tank Wel Sign__ Finish Floor Elevation Survey— Other CALCULATIONS and/or NOTES : CITY OF ATLANTIC BEALCH µ PERMIT APPLICATION RENoZZZ, ADDITIONS, OR ALTMAT.ZONS G, DEMOLITIONS Owner(s) : C`C'N� UL/f Job Address: 7�v Phone: Lot # 15"" Block or unit # U Subdivision: 411y& Contractor: I—UL-V/E 6A),57V/C776A, ..ZAJC-• state License # Address: ��}� ea�U� Phone No: C9oy City fACaOA)0660!�' State IC& Zip Code Describe work to be done: Nf w /4/7M/0x0 , / 14 f 0116A011V D� U�D� Dy�,P re,PD�IiT I�,4P 8X3 'PCl��ti�C73£w Present use of building: Valuation of .Proposed Construction P Proposed use: /'EMAL Is this an addition? AA) If yes, what are the dimensions of the added space: ft. X ft. Will the added area be heated and cooled? New electrical (or increase) ? 5 \/ New /w plumbing fixt es? l6 New fireplace? ND New Heat/AC? (�5 ( Jj0 A90,T(D&3A t SZMIT IMF= (C�tCZAZ) TWO (RESZ 1'ZAL) CCWTX2Z SETS OF PLANS, IIYMMING SX22 PIAN, SURVEY, MUMGY COLBC FCMW, N10TICX OF � AND . 0M9WVCONTRACT= VZT, ZF ZS L=22t8GTm. Signature OWNER: /7 Date: 6p —'1?/00 Signature CONTRACTOR: /7 Date: 40 ODI:BALEVRE AR o My Comm Exp.7/04 t)'s �¢� Frib before me this day of �0/• 2000. wk*Known U 06M 1.0. ' NOTARY UBLIC AS TO CONTRACTOR: Sworn to and subscribed before me this day of _ 2000. F Fto DEBORAH M.BALEVRE AR v My Comm Exp.7/004 PUBUC > NO.CC 98.7914 NOTARY PUBLIC [yPersoneuy Known t 1 Otho IA. 08-08-2000 STATE OF FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF EXEMPTION FROM FLORIDA WORKERS' COMPENSATION LAW This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation Law. EFFECTIVE DATE 08/05/2000 EXPIRATION DATE 08/05/2002 EXEMPTED INDIVIDUAL NAME GI LLESPI E GENE A S.S. 261-89-1014 BUSINESS NAME GILLESPIE CONSTRUCTION INC FEIN 593658936 BUSINESS ADDRESS 905 GROVE PARK BLVD JACKSONVILLE FL 32216 NOTE: Pursuant to Chapter 440.10(1),(g),2 F.S., a sole proprietor, partner, or an officer of a corporation who elects exemption from the Florida Workers' Compensation Law may not recover benefits or compensation under Chapter 440. PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA sL, DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY "A DIVISION OF WORKERS' COMPENSATION . CONSTRUCTION INDUSTRY CERTIFICATE OF EXEMPTIONicy+ F NOTE: Pursuant to chapter 440.10(l),(g),1, F.S., a sole FROM FLORIDA WORKERS' COMPENSATION LAW °v proprietor, partner, or officer of a corporation who EFFECTIVE DATE 08.105,42000 .ti 0 elects exemption from the Florida Workers' Compensation ��� L Law may not recover benefits or compensation under EXPIRATION DATE 08/05/2002 D Chapter 440. EXEMPTED PERSON LAST NAME11.iI 11 FCpIF FIRST NAME `FNF A SOCIAL SECURITY NUMBER 761-89-1014 H BUSINESS NAME rll_1 F_cPIF CONSTRUCTIOIM INC E R E FEDERAL IDENTIFICATION NUMBER 593658936, BUSINESS ADDRESS 905 GROVE PARK BLVD 1ACKSONVII 11: Fl- 32716 CUT HERE • Carry bottom portion on the job, keep upper portion for your records. 0R/i4MOY)ACORD„ CERTIFICATE OF LIABILITY INSURANCE PRODUCER n THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEIsurance Concepts of Florida , Inc . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND ORALTER THE COVERAGEAFFORDED BY THE 14181 slvd. , Suite #5 POLICIES BELOW. -Jacksonville , CL 32250 INSURERS AFFORDING COVERAGE INSURED INSURER A: Lloyds o f L o n d o n Gillespie COC1StrliCt1011, Inc. INSURERS 005 .rove Park Blvd. INSURER C: Jacksonville , FL 32216 INSURER D: COVERAGES INSURER E: THEPOLICIES 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 Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH INSR POLICIES.AGGREGATE LIMITS SHOWN MA VE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER PDLICY EFFECTIVE POLICY EXPIRATION LIMITS `GENERAL LIABILITY L �7EACH OCCURRENCE $500 ,000 • X COMMERCIAL GENERAL LIABILITY h7. IO 110`7 R/14/00 8/14/ 1 FIRE DAMAGE(Any one Me) X CLAIMS MADE 0 OCCUR 10-H-- MED EXP(Any one arson f 5 (l,o PERSONAL 6 ADV INJURY S 7 f^•`-" GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S (I-)vo 0nn PRO. LOC PRODUCTS•COMPlOP AGG ffl_ POLICY f ��' _,._a0_0 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT S (La accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY f (Par Person) HIRED AUTOS NONOWNEDAUIOS BODILY INJURY f (Per accident) PROPERTY DAMAGE f (Per accident) GARAGE LIABILITY ALIT 0ONLY-LAACCIDEN1 S ANY AUTO OIHER THAN EA ACC f AUTO ONLY: AGG S EXCESS LIABILITY EACH OCCURRENCE j OCCUR CLAIMS MADE AGGREGAI E j DEDUCTIBLE f RLI ENT ION S f S WORKERS COMPENSATION AND WC STATU- OIH- EMPLOYERS'LIABILITY ' E.L.EACH ACCIDENT j E.L.DIS SL-EA LMPLOYLL S OTHER E.L.DISEASE-POLICY LIMIT j DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESTEXCLUSIONS ADDED BY ENDORSE MENYISPECIAL PROVISIONS Constructs screeners additions for residential horses . General. home repairs . CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTH!/E D REPRWN!yTWfVE ' ACORD 25-S(7/97) a ACORD CORPORATION 1988 J'M � MARK FRANZONI OFFICE XPRESS 1511-B PENMAN RD. JACKSONVILLE BEACH, FL 32250 July 13 , 2000 Hon. Katherine Harris ATT: Corporate Records P.O. Box 6327 Tallahassee, F1 32314 RE: GILLESPIE CONSTRUCTION, INC. Dear Madam: Enclosed please find the original Articles of Incorporation for the above referenced corporation. Also, please find a check in the amount of $70 . 00 for filing of same . Your assistance in this matter is greatly appreciated. If you have any further questions, feel free to call me at (904) 249-9399 . Yours truly, C Mark Franzoni ARTICLES OF INCORPORATION OF GILLESPIE CONSTRUCTION, INC. I, the undersigned subscriber to these Articles of Incorporation, natural person competent to contract, hereby form a corporation under the Laws of the State of Florida. ARTICLE I - NAME The name of this corporation shall be: GILLESPIE CONSTRUCTION, INC. . ARTICLE II - PRINCIPAL PLACE OF BUSINESS The principal place of business of this corporation shall be : 905 GROVE PARK BLVD. , JACKSONVILLE, FL 32216 ARTICLE III - DURATION This corporation shall have perpetual existence commencing on the date of this filing of these Articles with the Department of State . ARTICLE IV - PURPOSE This corporation is organized for the purpose of transacting any and all lawful business for which corporations may be incorporated under Chapter 607, Florida Statutes, as now exists or may after be amended. ARTICLE V, - CAPITAL STOCK The maximum number of shares this corporation is authorized to issue is 100 shares of ONE DOLLAR ($1 . 00) par value common stock which will be designated as "Common Shares. " ARTICLE VI - PREEMPTIVE RIGHTS Every shareholder, upon the sale for cash of• any new stock of this Corporation of the same kind, class, or series as that which he already holds, shall have the right to purchase his pro rata share thereof at the price at which it is offered to others. ARTICLE VII - INITIAL REGISTERED FFICE AND AGENT be . The initial registered agent and office of this Corporation shall GENE A. GILLESPIE 905 GROVE PARK BLVD. JACKSONVILLE, FL 32216 ARTICLE VIII - BOARD OF DIRECTORS This Corporation shall have no directors, initially. The affairs of the Corporation will be managed by the shareholders until such time directors are designated as provided by the Bylaws. ARTICLE IX - INCORPORATORS is . The name and address of the Incorporator signing these Articles GENE A. GILLESPIE 905 GROVE PARK BLVD. JACKSONVILLE, FL 32216 ARTICLE X - INDEMNIFICATION The Corporation shall indemnify any Officer or Director to the full extent permitted by law. ARTICLE XI - AMENDMENT This Corporation reserves the right to amend or appeal any Provision contained in these Articles of Incorporation, or any amendment hereto, by a majority vote of the Board of Directors, and any right conferred upon the shareholders is subject to this reservation. N WITNE WHEREOF, the undersigned Incorporator has executed Ar ' c s of Incorporation on this r day of the 2000 . GENE A. GILLES E STATE OF FLORIDA COUNTY OF DUVAL BEFORE ME, a Notary Public authorized to take acknowledgements in the State and County set forth above, personallya A. GILLESPIE, known to be and known by me to be thpersonewhoENE executed the foregoing Articles of Incorporation, and he acknowledged before me that he executed those Articles of Incorporation. IN WITNESS WHEREOF, I have set my hand and seal in the State and County above, this day of 2000 . NOTARY PUBLIC, State of Florida at Large My Commission Expires : CERTIFICATE DESIGNATING REGISTERED AGENT AND PLACE OF BUSINESS OR DOMICILE FOR THE SERVICE OF PROCESS WITHIN FLORIDA, AND ACCEPTANCE OF AGENT UPON WHOM PROCESS MAY BE SERVED In compliance with Sections 48 . 091 and 607. 034 , Florida Statutes, the following is submitted: FIRST that GILLESPIE CONSTRUCTION, INC. , desiring to organize or qualify under the laws of the State of Florida, with its principal place of business at 905 GROVE PARK BLVD. , JACKS&MILLE, FL 32216, has named GENE A. GILLESPIE as its agent to accept service of process within lorida. D4ate : �3� r GENE A. GILLESPIE Having been named to accept service of process for the above named corporation, at the place designated in this certificate, I hereby/'agree to act in this capacity, and I further agree to comply with e prow' ions of all statutes relative to. the proper performance of dut 'es . r GENE A. GILLESP Registered Agent r Form SS-4 Application for Employer Identification Number (Rev.December 1995) (For use by employers,corporations,partnerships,trusts,estates,churches, EIN Department of IheTreasury 90vemment agencies,certain Individuals,and others.See Instructions.) Intern I Revenue service ► Kee a CO br OUr reCOrda. OMB No. 1646-0003 1 Name of applicant(Legal name)(See Ins n3.) GILLESPIE CONSTRUCTION, INC. 2 Trade name of business('d different from name on line 1) 3 Executor,trustee,"care of"name 4a Mailing address(street address)(room,apt.,or suite no.) 5a Business address(if different from address on lines 4a and 4b) 905 GROVE PARK BLVD. 4b City,state,and ZIP code 5b City,state,and ZIP code JACKSONVILLE FL 32216 8 County and state where principal business is located DUVAL COUNTY FLORIDA 7 Name of principal officer,general partner,grantor,owner,or Wstor-SSN required(See instructions.)► 2 61-89- 014 GENE A. GILLESPIE 8a Type of entity(Check only one box.)(See instructions.) ❑ Estate(SSN of decedent) ❑Sole proprietor(SSN) i ❑ Plan administrator-SSN — ❑ Partnership ❑ Personal service Corp. ® Other corporation(specify) ► S CORP ❑ REMIC ❑ Limited liability co. ❑ Trust ❑ Farmer's cooperative ❑ State/local government ❑ National Guard ❑ Federal Govemment/milita ry .❑ Church or church-controlled organization [I Other nonprofit organization(specify)Do- (] ❑ Other(specify) it. (enter GEN If applicable) 8b If a corporation,name the state or foreign country State 71 Foreign country Of applicable)where incorporated FLORIDA 8 Reason for applying(Check only one box.) ❑ Banking purpose(specify) ► ® Started new business(specify) ► ❑ Changed type of organization(specify) ► ❑ Hired employees ❑ Purchased going business ❑ Created a trust(specify)it.[3 Created a ension plan(specify e) ► ❑ Other(specify)► 10 Date business started or acquired(Mo. day,year)(See instructions.) 11 Closingmonth of accounting 07/1 3/00 9 year(See instructions.) 12 First date paid p ( DECEMBER wages or annuities were d or will be aid Mo.,day,year). Note: If applicant is a withholding agent,enter date income will first be paid to nonresident alien.(Mo.,day,year) , . ► 08/15/00 13 Highest number of employees expected in the next 12 months. Note: If the applicant does Nonagricultural Agricultural =Householdnot expect to have any employees during the period,enter-0-.(See instructions.) ► 1 0 14 Principal activity(See instructions.) P. CONSTRUCTION 15 Is the principal business activity manufacturing? If"Yes".principal product and raw material used ► ❑ Yes ® No 18 To whom are most of the products or services sold?Please check the appropriate box. ® Public(retain ❑ Other(specify) ► Business(wholesale) 17a Has the applicant ever applied for an Identification number for this or any other business?, ❑ N/A Note: If"Yes",please complete lines 17b and 17c. L1 Y03 ® No 17b If you checked"Yes"on line 17a,give applicant's legal name and trade name shown on prior application,if different from line 1 or 2 above. Legal name ► Trade name ► 17C Approximate date when and city and state where the application was filed.Enter previous employer identification number if known. Approximate date when}fled(Mo.,day�yow) City and state where filed Previous EIN Under penalties of perjury,I declare that I have examined this application,and to the best of my knowiedps and belief,it la true,correct,and complet Business telephone n imber(include area code) (904) 721-7054 GENE A. GILLESPIE Fax telephone number(include area code) Name and tttle(PI a ype or print earl ES I DENT r Sltlnaturs► `/�_O� Date 111. i Do not write below this line. For official use on . please leave Oso. Ind. Claw blank mo Size Reason for applying For Paperwork Reduction Act Notice,see page 4. DXA Cat.No.16055N Form SS-4 (Rev.12-W :Form 2553 Election by a Small Business Corporation (Rev.September IWO) (Under section 1362 of the Internal Revenue Code) OMB No.1545.0146 Department of the Treasury ► For Paperwork Reduction Act Notice,see page 1 of Instructions. Internal Revenue Service ► See separate Instructions. Notes: 1.This election to be an S corporation can be accepted only if all the tests are met under Who May Elect In Part I and 111 are originals(no photocopies);and the exact name and address of the.corporatlon and other required form Information are provided. 2.Do not file Form 1120S, U.S Income Tax Return for an S Corporation,for any tax year before the year the election takes effect, 3.If the corporation was in existence before the effective date of this election,see Taxes an S Corporation May Owe on page 1 of the instructions. Election Information Name of corporation(see Instructions) A Employer identification number(EIN) PleaseJ:Num:b�ar, GILLESPIE CONSTRUCTION INC. APPLIED FOR street,and room or suite no.(If a P.O.box,see instructions.) B Date Incorporated Type or PrintLVD. 07 13 00y or town,state,and ZIP code C State of Inco JACKSONV I LLE FL 32216 Incorporation RIDA D Election Is to be effective for tax year bealrining(month.day,year). FLO E Name and title of officer or legal representative who the IRS may call for more information h 07 13 00 F Telephone number of officer or legal representative GENE A. GILLESPIE 0 If the corporation ch (9 04 721-7054 rp changed Its name or address atter applying for the EIN shown in A,check this box H If this election takes effect for the first tax year the corporation exists,enter month,day,and year of the earliest of the following:(1)date the b. [] corporation first had shareholders,(2)date the corporation first had assets,or(3)date the corporation began doing business. ► 07/13/00 1 Selected tax year:Annual return will be filed for tax year ending(month and day) ► 7 2/31 If the tax year ends on any date other than December 31,except for an automatic 52-53-week tax year ending with reference to the month of December,you must complete Part II on the back.If the date you enter is the ending date of an automatic 52-53 week tax year,write"52-53-week . year"to the right of the date.See Temporary Regulations section 1.441-2T(ex3). Name and address of each shareholder, K Shareholders'consent Statement. shareholder's Under penaltlea of perjury,we declare that we consent L spouse having a community to the election ofthe above-named corporation to be Stock owned N Share- property Interest in the corporation's stock, an S corporation under section 1362(x)and that we M Social security number holder's and each tenant a common,joint tenant, have examined this consent statement,Including or employer identification tax year and tenant their the entirety.(A husband and have schedules and statements,and to the number(see Instructions) ends wife(and their estates)ars counted as one best of our knowledge and belief,it is true,correct,and Number of (month shareholder In determining the number of complete.we understand our consent la binding and gates and day) shareholders without regard to the manner y D shares acquired M which the stock is owned.) a not be withdrawn after the corporation has made a valid tlon(Shareho ars sign and date below.) Slgnatur Date GENE A. GILLESPIE 5007/13760 261-89-1014 2/31 905 GROVE PARK BLVD, Lu JACKSONVLLE FL 32216 JULIE A. GILLESPIE - 5007/13/0 594-16-7908 2/31 905 GROVE PARK BLVD ^ JACKSONVLLE FL 32216 Under Penaof perjury,I declare t t I have examin d thl action,Including axompar ng schedules and statements,and to the best of my knowledge and belief,it is true. correct,,and and complete. mpieb. J SIna - ture of officer lo, ^ Title b, PRESIDENT p ►d��3 See Parts 11 and 111 on ack DXA Form 2553 (Rev.g-s6) GILLESPIE CONSTRUCTION, INC. APPLIED FOR Fort 2653(Rev.9-96) I 1 i ! �,'I Selection of Fiscal Tax Year AU c Page 2 n i , ( orporatlons using this part must complete Item O and one of Items P,O, +!: or R C Check the applicable box below to Indicate whether the corporation is: 1•®A new corporation adopting the tax year entered In item I,Part I. 2.❑An existing corporation retaining the tax year entered in Item I,Part I. 3.❑An existing corporation changing to the tax year entered in item I,Part I. P Complete item P If the corporation is using the expeditious approval provisions of Revenue Procedure 87-32, 1987-2,C.B.396,to request:(1)a natural business year(as defined in section 4.01(1)of Rev.87-32),or(2)a year that satisfies the ownership tax year test in section 4.01(2) of Rev.Proc.87-32.Check the applicable box below to indicate the representation statement the corporation is making as required under section 4 of Rev.Proc.87-32. 1.Natural Business Year ► ❑ 1 represent that the corporation Is retaining or changing to a tax year that coincides with its natural business Yew as defined in section 4.01(1)or Rev.Proc.87-32 and as verified by its satisfecation of the requirements of section 4.02(1)of Rev.Proc. 87-32.In addition,If the corporation Is changing to a natural business year as defined in section 4.01(1),1 futher represent that such tax year results in less deferral of Income to the owners than the corporation's present tax year.I also represent that the corporation is not decribed in section 3.0111 of Rev.Proc.87-32.(See instructions for additional information that must be attached.) 2.Ownership Tax Year ►® 1 represent that shareholders holding more than half of the shares of the stock(as of the first day of the tax year to which the request relates)of the corporation have the same tax year or are concurrently changing to the tax year that the corporation adopts,retains, or changes to per item I,Part I.1 also represent that the corporation is not described in section 3.0111 of Rev.Proc.87-32. Note:If you do not use item P and the corporation wants a fiscal tax year,complete either item Q or R below.Item Q is used to request a fiscal tax year based on a business purpose and to make a back-up section 444 election.Item R is used to make a regular section 444 election. G Business Purpose-To request a fiscal year based on a business purpose,you must check box Q1 and pay a user fee. See instructions for details. You may also check box 02 and/or box 03. 1.Check here ► ❑ If the fiscal year entered in item I,Part I,is requested under the provisions of section 6.03 of Rev.Proc.87-32.Attach to Form 2553 a statement showing the business purpose for the requested fiscal year.See instructions for additional information that must be attached. 2.Check here No ❑ to show that the corporation intends to make a back-up section 444 election in the event the corporation's business purpose request is not approved by the IRS.(See Instructions for more information.) 3.Check here ► ❑ to show that the corporation agrees to adopt or change to a tax year ending December 31 it necessary for the IRS to accept this ac election for S corporation status in the event:(1)the corporation's business purpose request is not approved and the corporation makes a bk-up section 444 election,but is ultimately not qualified to make a section 444 election,or(2)the corporation's business purpose request is not approved and the corporation did not make a back-up section 444 election. R Section 444 Election-To make a section 444 election,you must check box R1 and you may also check box R2. 1.Check here ► ❑ to show the corporation will make,if qualified,a section 444 election to have the fiscal tax year shown in item I,Part I.To make the election,you must complete Form 8716,Election To Have a Tax Year Other Than a Required Tax Year,and either attach it to Form 2553 or file it separately. 2.Check here ► ❑ to show that the corporation agrees to adopt or change to a tax year ending December 31 if necessary for the IRS to accept this election for S corporation status In the event the corporation Is ultimately not qualified to make a section 444 election. 'Pat ;1� Ouallfied Subchapter S Trust(ASST) Election Under Section 1361(d)(2)e .,. .... Income beneficiary's name and address Social security number Trust's name and adress Employer indentifice on number Date on which stock of the corporation was ansferred to the trust(month,day,year) ► In order for the trust named above to be a OSST and thus a qualifying shareholder of the S corporation for which this Form 2563 is filed,I hereby make the election under section 1381(dX2).Under penalties of perjury,I certify that the trust meets the definitional requirements of section 1381 other information provided in Part III Is true,correct,and complete. (d)(3)and that all Signature of Income vensticiary or signature and title of legal representative or other Qualified person making the election Date a Use of Part III to make the ASST election may be made on d stock of the corporation has been transferred to the trust on or before the date on which the corporation makes Its election to an S corporation,The ASST election must be made and filed separatey if stock of the corporation is transferred i the trust after the date on which the corporation makes the S election. FLORIDA DEPARTMENT OF STATE Katherine Harris Secretary of State July 19, 2000 MARK FRANZONI OFFICE EXPRESS 1511-B PENMAN RD JACKSONVILLE BEACH, FL 32250 The Articles of Incorporation for GILLESPIE CONSTRUCTION, INC. were filed on July 14, 2000 and assigned document number P00000068612. Please refer to this number whenever corresponding with this office regarding the above corporation. PLEASE NOTE: COMPLIANCE WITH THE FOLLOWING PROCEDURES IS ESSENTIAL TO MAINTAINING YOUR CORPORATE STATUS. FAILURE TO DO SO MAY RESULT IN DISSOLUTION OF YOUR CORPORATION. A CORPORATION ANNUAL REPORT/UNIFORM BUSINESS REPORT MUST BE FILED WITH THIS OFFICE BETWEEN JANUARY 1 AND MAY 1 OF EACH YEAR BEGINNING WITH THE CALENDAR YEAR FOLLOWING THE YEAR OF THE FILING DATE NOTED ABOVE AND EACH YEAR THEREAFTER. FAILURE TO FILE THE ANNUAL REPORT/UNIFORM BUSINES REPORT ON TIME MAY RESULT IN ADMINISTRATIVE DISSOLUTION OF YOUR CORPORATION. A FEDERAL EMPLOYER IDENTIFICATION (FEI) NUMBER MUST BE SHOWN ON THE ANNUAL REPORT/UNIFORM BUSINESS REPORT FORM PRIOR TO ITS FILING WITH THIS OFFICE. CONTACT THE INTERNAL REVENUE SERVICE TO INSURE THAT YOU RECEIVE THE FEI NUMBER IN TIME TO FILE THE ANNUAL REPORT/UNIFORM BUSINESS REPORT. TO OBTAIN A FEI NUMBER, CONTACT THE IRS AT 1-800-829-3676 AND REQUEST FORM SS-4. SHOULD YOUR CORPORATE MAILING ADDRESS CHANGE, YOU MUST NOTIFY THIS OFFICE IN WRITING, TO INSURE IMPORTANT MAILINGS SUCH AS THE ANNUAL REPORT/UNIFORM BUSINESS REPORT NOTICES REACH YOU. Should you have any questions regarding corporations, please contact this office at the address given below. Pamela Hall, Document Specialist New Filings Section Letter Number: 40OA00039497 Division of Corporations - P.O. BOX 6327 -Tallahassee, Florida 32314 ri" NI IMO ER_ !*Vrr'I'RATED PAYMENT SYSTEMS INC. I ISSUER NOTICE Ol 02-824581188 Please refer to the v ,,,, 82.40/1021 ;t' 1 AGENT 3B 01 DATE 080400 �� �L VV Division of Workers Ca028245811880 LOCATION! 001180---Z vN *9 By filing this application, you ele( FAY EXACTLY FIFTY DOLLARS AND NO CENTS #ar >zttK#t< #K Florida Statutes and waive an H WC Administrative Trust Fund y g NOT 5500 the State of Florida should you bec, r{ with intent to iniure, defraud, oI / Y SIGNING YOU AGREE'.THErl/t�l'/� TERreS ONTHE�REVERSESi0insurance comnany or nurnoses prtDSU L CAUTH RI Eo EPRE5ENTATIVE _ .anv false or mislead1nt? informatin one/Order Is a se vice mark of astern Union hnanc,al Serms,nb./Payable at Norwest Bank Grand Junction-0ovrnto•wn.N P Grano Junction,Colorado documentation is required by law t sheet for more details. t: LO 2 1004001: 400 28 24 S8 11880118 I am applying for exemption as a(che CONSTRUCTION INDUSTRY(S 50.00 FEE REQUIRED) �N� ) ❑ Sole Proprietor E] Partner [A Corporate Officer(your corp. title: S -OR- NON-CONSTRUCTION INDUSTRY (NO FEE REQUIRED) ❑ Corporate Officer(your corp. title: ) CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations, Department of State's Office(NOTE:your partnership may not h ve one,but a l c orations must have one. If your partnership doesn't have one,state 'N/A"): � ��02 THIS EXEMPTION APPLICATION APPLIES ONLY TO THE PERSON SIGNING THE APPLICATION AND ONLY FOR THE BUSINESS ENTITY LISTED IN THE FOLLOWING SECTION Bus tne s Name: Trade Name;d/b/a;or a/k/a: is/UOP/E M1V57A)WCT1ON 1 ,7-NC Busine s Mailing.Address: City: State: Zi pS' &RD ve P19)fX County: P ne No.: Natu of iness' FEIN- D14 EIN: .cul/&C MY) 714-7os�/ � ��D�cem,6 _365 v936 Unemployment Compensation Date Business Esta'bbllished: No. of Employees: Tax No: AUL y /7 a 00 Are you required to be registered or certified pursuant to Chapter 489, F. S.? o ❑ Yes: list all certified or registered licenses issued to you pursuant to Chapter 489, Florida Statutes Are you or a qualifier for your business required by the county or the municipality in which your business mailing address is located to have an occupational license for the business which is the subject of this application? ❑No ®Yes: YOU NIUST ATTACH A COPY OF A CURRENT OCCUPATIONAL LICENSE Are you employed by any sole proprietorship,partnership,corporation or business entity other than the business to which this application applies?[A NO ❑ YES list the name of all other businesses in which you are employed: Has the above-referenced business entity been in operation long enough to have filed with or be required to file by the IRS, an annual Federal Income Tax Return? No ❑ Yes,You must attach tax records. See instruction sheet for details: AFFIDAVIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my knowledge and belief; that this election does not exceed exemption limits for corporate officers or partners as provided in§440.02 Florida Statutes; and that I will secure the payment of workers' compensation benefits, pursuant to Chapter 440,Florida Statutes, for any employee}now have or may hereinafter acquire, for which my business is required by Florida law to secure such benefits. TYPEIPRINT NIE O7— " N AP IN .F EXEINFTION SOCIAL SECURITY NO. mo. day )'r• ��J / DATE OF BIRTfi APPLICANT'S SIGNATUREEA n SIGNED NOTARY STATE OF FLORIDA,COUNTY OF f t t 1 CSX �/ � Sworn to and subscribed before me this day of atL^• - ^-� O�6 6 by z lJ C A � t ,,,rrr ' Personally Known O Produced Identification ✓ Type of Identification Produced �' ^ "1 3011 5,2002 NOTARY SIGNATURE Nly Commission Expiri x rf4nna.tnwF tt� cuRaNcEiN (SEE REVERS OR ADDITIONAL INFORMATION _ DEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE DATE OF THIS NOTICE: 07-27-2000 ATLANTA GA 39901 NUMBER OF THIS NOTICE: CP 575 A EMPLOYER IDENTIFICATION NUMBER: 59-3658936 FORM: SS-4 0716933151 B FOR ASSISTANCE CALL US AT: GILLESPIE CONSTRUCTION INC 1-800-829-1040 905 GROVE PARK BLVD JACKSONVILLE FL 32216 OR WRITE TO THE ADDRESS SHOWN AT THE TOP LEFT. IF YOU WRITE, ATTACH THE STUB OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER (EIN) Thank you for your Form SS-4, Application for Employer Identification Number (EIN) . We assigned you ETN 59-3658936 . This EIN will identify your business account, tax returns, and documents, even if you have no employees. Please keep this notice in Your permanent records. Use your complete name and EIN as shown above on all federal tax forms, payments, and related correspondence. If you use any variation in your name or EIN, it may cause a delay in processing, incorrect information in your account, or cause you to be assigned more than one EIN. Based on the information shown on your Form SS-4, you must file the following forms(s) by the date we show. Form 941 10/31/2000 Form 1120 03/15/2001 Form 940 01/31/2001 Please file your Form by the due date shown above. If the due date above has Passed and you have not yet filed, please file your Form by 08-11-2000. If we don't receive your form by that date, we will charge additional penalties and interest. We charge penalties and interest from the due date of the return until it is filed. Your assigned tax classification is based on information obtained from your Form SS-4. It is not a legal determination of your tax classification and is not binding on the Service. If you want a determination on your tax classification, you may seek a private letter ruling from the Service under the procedures set forth in Rev. Proc. 98-01, 1998-1 I .R.B. 7 (or the superceding revenue procedure for the year at issue) . If you need help in determining what your tax year is, you can get Publication 538, Accounting Periods and Methods, at your local IRS office. If you have any questions about the forms shown or the date they are due, you may call us at 1-800-829-1040 or write to us at the address shown above. If you're required to deposit for employment taxes (Forms 941, 943, 940, 945, CT-1, or 1042) , excise taxes (Form 720) , or income taxes (Form 1120) , we will send an initial supply of Federal Tax Deposit (FTD) coupon books within six weeks. You can use the enclosed coupons if you need to make a deposit before you receive your supply. Start your business off right - pay your taxes the easy way. Pay through the Electronic Federal Tax Payment System (EFTPS) . For information about EFTPS, call 1-800-829-3676 and request Publication 966, EFTPS Answers to the Most Commonly Asked Questions. (IRS USE ONLY) 575A 593658936 07-27-2000 GILL B 0716933151 SS-4 Please use the label IRS provided when filing tax documents and FTD coupons when makingents. If belowhat isn't to identifysyourep You accounthanddue YutosavoidrdelaysninEIN adc ee name procrocesssing. GILLESPIE CONSTRUCTION INC 905 GROVE PARK BLVD JACKSONVILLE FL 32216 If this information isn't correct, please correct it using the bottom part of this notice. Return it to us at the address shown so we can correct your account. Thank you for your cooperation. Keep this part for your records. CP 575 A (Rev. 1-1999,1 -------------------------------------------------- Return this part with any correspondence so we may identify your account. Please CP 575 A c ect any errors in your name or address. 0716933151 Yo r Telephone Number t Time to Call DATE THIS NOTICE: 07-27-2000 ( oy) 7�/ - 7�-+�(7f E YER IDENTIFICATION NUMBER: 59-3658936 RM. SS-4 INTERNAL REVENUE RVICE ATLANTA GA 901 GILLESPIE CONSTRUCTION INC 905 GROVE PARK BLVD JACKSONVILLE FL 32216 Florida Department of Business and Professional Regulation Construction Industry Licensing Board Amended Residential Contractor Gillespie, Gene Alan Candidate Number: 905 Grove Park Blvd 270043Date: Jacksonville, FL 32216 7/17/2000 Examination Date: 6/27/2000 Examination Part Minimum Passing Score Score Achieved Part Status Part II Contract Administration 70.00 91.11 Passed Overall Examination Status Passed This is an unofficial grade report. It becomes official when ratified by the board. Grades will be ratified on August 11, 2000. Please retain this grade report for your records as the Board does NOT mail "official" reports after ratification. Pass Candidates: This is not a license and may not be used for contracting or bidding purposes. You should submit the enclosed application for licensure immediately. It is NOT necessary to wait for the Board to ratify the grades. Notify the Board promptly of any change of name or address. DEPOSIT SYSTEM ONLINE ACCOUNT STATEMENT INQUIRY PAGE REQ: BANK: 329 ACCOUNT: 0000096680 CYCLE REQ: C AUTHORITY: 0 SEARCH PAGE: 000 NAME: GILLESPIE CONSTRUCTION LAST STMT: 07/31/00 THRU: 08/14/00 PRA LINE: LST STMT BAL: 100 . 00 PRA AVAIL: CURR DAL: 10, 047 . 08 PND EFT: . 00 TRANS POST TC - - DESCRIPTION -- -SERIAL NO- -- AMOUNT --- --- BALANCE --- 08/02 08/02 941 ACH WITHDRAWAL 52 . 92 47 . 08 08/14 PEND 750 DEPOSIT 10, 000 . 00 10, 047 . 08 THE GORDON BANK PAGE 001 - LAST PAGE 2BwCRT A 1 : 540pm2 CREDITED TO ACCOUNT Of WITION ,NAMED PAYEE AND ABSENCE OF ENDOiiSEMENT GUARANTEED BY THE .GORE)ON BANK Department of Business & Professional Regulation THIS SPACE RESERVED FOR BOARD USE AND/OR O� E S� VALIDATION BY REVENUE ONLY b Construction Industry Licensing Board For Telephone Inquiries: (904) 727-6530- c/o 1940 North Monroe Street Tallahassee, Florida 32399-0783 Attention: Revenue Unit 1. CERTIFICATION CHANCE OF STATUS THIS FORM MUST BE COMPLETED IF YOU WISH TO INITIATE OR CHANGE THE STATUS OF AN EXISTING LICENSE. READ ALL INSTRUCTIONS AND MAKE SURE YOU HAVE SIGNED WHERE INDICATED. TYPE OR PRINT IN INK. MAKE CHECKS PAYABLE TO THE DEPARTMENT OF BUSINESS & PROFESSIONAL REGULATION. ALL CHECKS MUST CLEARLY STATE APPLICANT'S NAME AND ADDRESS. PLEASE ALLOW 2-3 WEEKS FOR PROCESSING. UNTIL YOU FULLY RESPOND TO ALL REQUIREMENTS OF THE APPLICATION, INCLUDING PROVIDING ALL INFORMATION REQUESTED IN THE FINANCIAL RESPONSIBILITY SECTION, YOUR APPLICATION IS NOT COMPLETE AND WILL NOT BE PROCESSED. YOU MUST RETURN BOTH PORTIONS OF YOUR CURRENT ORIGINAL LICENSE. IF YOU DO NOT HAVE BOTH PORTIONS, SUBMIT A NOTARIZED STATEMENT. Check Request(s) Fee Schedule (`►'Passed state exam & applying for initial licensure $205.00 (If postmarked 5/1/00 - 4/30/01) (Check One) V Active Inactive ) $105.00 (if postmarked 5/1/01 - 4/30/02) ( ) From One-Business En Ity to Another $50.00 (Return both portions of original license) ( ) From Individual to Qualifying Business $50.00 (Return both portions of original license) ( ) From Qualifying Business to Individual $50.00 (Return both portions of original license) t ) From Active to Inactive 'Complete items 1,3,4 &SIGN BELOW $50.00 (Return both portions of original license) ( ) From Inactive to Active $350.00 — O Reinstating Delinquent License OVaries (Contact Board Office) 1 . Applicant's Name (Licensee): C E-N E /I /LLE:5p/,,r- 'For "INACTIVE STATUS ONLY" SIGN HERE: DATE EXAM PASSED:(when applying for initial licensure G ? , or LICENSE NUMBER: Under the Federal Privacy Act,disclosure of Social Security numbers is voluntary unless specifically required by Federal statute. In this instance,SOCIAL SECURITY NUMBERS ARE MANDATORY pursuant to Title 42 United States Code, Sections 653 and 654; and sections 455.203(9), 409.2577, and 409.2598, Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and will be used for licensee identification pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L.193, Sec. 317. 0?(0/ , ?'9, 10 y 07/ /'7l 0 woRFol-K UIRMI** 615 A $07r rs F1$ER —13 — ity tx SEX: x Male _ Female RACE: -x-(t)White_(2)African-American_(3)Hispanic_(4)Asian_(5)Indian_Mother 2. Name of Business To Be Qualified: �iC�QPiE (,6�tJU(TOti', �N� Mailing Address: JD�Uf ,wIK, QZU, ;7/jCj i1y1�1L /C� �7 ��o STREET OR PO BOX CRY STATE ZIP Street Address: �v�"C/�a ULP lwt Be v� J xsotiur )0q STREET CITY STATE zr Business Phone Number:(-5w) /bo Federal ID Number QB # DBPR/CILB/025/Rev.02/00 Page 1 CERTIFICATION CHANGE OF STATUS 7. CREDIT REPORT(S) REPORTS THAT DO NOT INCLUDE THE FOLLOWING INFORMATION WILL NOT BE ACCEPTABLE: A report on your credit rating (not more than six months old) from a nationally recognized credit-reporting agency must be submitted on the applicant/licensee before a license can be issued. If you are applying to qualify as an individual, the credit report must be on you. If you are applying to qualify a business organization, credit reports are required for the business organization AND the applicant/licensee. IF YOUR BUSINESS IS NEWLY ESTABLISHED (less than one year old) YOU WILL "ALSO" NEED TO SUBMIT CREDIT REPORTS ON THE FOLLOWING: The applicant/licensee, the newly formed business and the majority owners holding 25% or more interest PLUS letters from three construction related suppliers indicating that an account either exists or has been opened for the entity you are applying to qualify. Make sure you give written authorization to the credit agency so they can accurately check your credit references. Federal, State, County (including 'all counties within the state of Florida) public records pertaining to judgments, bankruptcies and tax liens must be searched and the results noted on the credit report. The credit report must include a public records check of the home counties and all other counties where 25% or more of the contractor's work has been done over the last three years. If public records reflect unsatisfied obligations, attach written explanation and legal documentation. The credit report shall Include the FEIN:for the business organization and Social Security numbers for all officers, partners and/or owners. ATTACH THE CREDIT REPORT(S) FROM A NATIONALLY RECOGNIZED CREDIT-REPORTING AGENCY TO THIS APPLICATION. If you are unable to receive the credit report(s), you may have the credit agency send the credit report(s) directly to: Florida Construction Industry Licensing Board, 7960 Arlington Expressway Suite 300, Jacksonville, Florida 32211-7467; and complete this statement: i I have requested a credit report on: &6e. 14- �u pry Date: D17';I%'Al APPLICANT/LICENSEE,BUSINESS ORGANIZATION AND/OR MAJORITY OWNERS to be sent directly from NAME OF CREDIT AGENCY NOTE: Construction Industry Licensing Board Rule 61G4-15.005 establishes minimum NET WORTH REQUIREMENTS for the following categories of contractors: $20,000 General, Building and Residential $10,000 Sheet Metal, Roofing, Class A Air Conditioning, Class B Air Conditioning, Class C Air Conditioning, Mechanical, Commercial Pool/Spa, Residential Pool/Spa, Plumbing, Underground Utility & Excavation, Specialty Structure, Pollutant Storage Systems Specialty, Solar, Gas Line Specialty $ 2,500 Residential Solar Water Heating Specialty, Gypsum Drywall Specialty, Registered Precision Tank Tester, Swimming Pool/Spa Servicing NOTE: Net worth shall be defined to require a showng,for all contractor licensure categories that the applicant has a m1nimum of 50;percent of the amount In ...cash. Cash's : hal! be defined to include a Ime of credit DBPR/CILB/025/Rev. 02/00 Page 3 CERTIFICATION CHANGE OF STATUS This form must be accompanied by either an Application for Qualified Business Organization License Number. (A QB License Number WILL NOT be required if the qualifying agent is the sole proprietor.) or a Qualified Business Organization Change of Status Application. 8. QUALIFIED BUSINESS ORGANIZATION (QB) - NOTE if you are applying as an individual, you do not need to complete this page. A. AUTHORITY/RESPONSIBILITIES - Everyone except a person doing business as an "individual" must fill out the below statement. The owner or partner must sign; or, if you are qualifying a corporation, have the corporate secretary sign below. At a meeting of (Name of Business Organization) , held on the day of , (Name of Qualifier) was legally appointed as the qualifier to act for the business organization in all matters connected with its contracting business, and was given authority to supervise all construction work performed by the business. B. FINANCIAL RESPONSIBILITY Signed by Secretary, Partner, or Owner I, , acknowledge that pursuant to Florida Statute 489, 1 am responsible for all of the financial affairs of the business I am applying to qualify. I realize that this includes "financial matters" both for the organization in general and for each specific job. Signature NOTE: IF THE ABOVE NAMED INDIVIDUAL IS NOT A LICENSED CONTRACTOR FOR THE STATED ENTITY AND HAS NOT SUBMITTED A "FINANCIAL RESPONSIBLE OFFICER APPLICATION", PLEASE CONTACT THE BOARD OFFICE FOR THIS APPLICATION. 10. QUALIFYING AGENT(S) PRIMARY/SECONDARY QUALIFYING AGENT DESIGNATION (THE APPLICANT AND ALL EXISTING QUALIFYING AGENTS MUST SIGN THE DESIGNATED PORTION BELOW. IF NECESSARY, DUPLICATE THIS PAGE) - In accordance with Florida Statute 489.1195(1)&(2), we, the undersigned, agree to the following primary/secondary qualifier designation for: A. PRIMARY QUALIFYING AGENT As the primary qualifying agent I/we attest that I/we have final approval authority on all checks, drafts, or payments, regardless of the form of payment, made by the entity, and that the applicant has final approval authority for all construction work performed by the entity. Be advised that the entity cannot engage in any work that exceeds the scope or geographical jurisdiction of the primary qualifier's license. Primary Qualifying Agent License Number Signature Primary Qualifying Agent License Number Signature B. SECONDARY QUALIFYING AGENT As secondary qualifying agent 1/we attest that I/we have the authority to supervise all construction work performed by the entity as provided in 489.1 195(2) F.S. Secondary Qualifying Agent License Number Signature Secondary Qualifying Agent License Number Signature BPR/CILB/025/Rev. 02/00 Page 5 CERTIFICATION CHANGE OF STATUS 15. FINANCIAL RESPONSIBILITY All applicants/licensees must answer the below questions. If you answer "yes" to any of the questions, a written explanation is required. Additional documentation is also required, as indicated. If you are applying to qualify a corporation, partnership or other legal business entity, ALL OFFICERS OF THAT ENTITY MUST ALSO EXPLAIN IF ANY OF THE BELOW WOULD PERTAIN TO THEM. This would Include the president, vice president, secretary, and/or partners or owner of the proprietorship. HAVE YOU, the business organization, or any of the above mentioned individuals in any capacity EVER: YES NO ❑ [" A. Undertaken construction contracts or work that a third party, such as a bonding or surety company, completed or made V�J financial settlements? ❑ ® B. Had claims or lawsuits filed for unpaid or past due accounts by your creditors as a result of construction operations? M C. Undertaken construction contracts or work which resulted in liens, suits or judgments being filed? � © D. Had a lien filed against you by the U.S. Internal Revenue Service or Florida Corporate Tax Division? If "yes", you must attach a copy of the Notice of Lien, and any payment agreement, satisfaction, Release of Lien or other proof of payment. ❑ (�f E. Made an assignment of assets in settlement of construction obligations for less than the debts outstanding? ❑ © F. Been charged with or convicted of acting as a contractor without a license, or if licensed as a contractor in this or any other state,'been "subject to" any disciplinary action by a state, county, or municipality? If "yes", you must attach a copy of any state, county, municipal or out-of-state disciplinary order or judgment. F-1 ® G. Filed for or been discharged in bankruptcy within the past five years? If "yes", you must attach a copy of the Discharge Order, Order Confirming Plan, or if a Corporate Chapter 7 case, a copy of the Notice of Commencement. F] H. Been convicted or found guilty of, or entered a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction within the past 10 years? NOTE: IF YOU,THE APPLICANT/LICENSEE, HAVE HAD A FELONY CONVICTION, PROOF THAT YOUR CIVIL RIGHTS HAVE BEEN RESTORED WILL BE REQUIRED PRIOR TO LICENSURE. NOTE: The Board requires any applicant/licensee who answers"yes"to any question contained in the Financial Responsibility Section of the Application to supply a complete explanation of the response, and include a statement detailing the steps taken by the licensee to prevent a recurrence of the circumstances leading to the conviction, discipline,judgment, bankruptcy, or other event leading to the response. You must include any proof of payment,satisfaction of liens, judgments and bankruptcy discharge papers in your submittal, if applicable. Applicants may be required to appear before the Application Review Committee to answer questions regarding such responses. AFFIRMATION 16. The undersigned hereby makes application for licensure through a qualifying agent under the provisions of the Florida Construction Industry Licensing Board Act (Chapter 489, Part I, Florida Statutes) and affirms that all statements and answers herein contained are true and correct. Any willful falsification of any information contained in this application or attached forms are grounds for disqualification. If you are qualifying as an individual, only you need sign below. If you arequalifying a proprietorship, you and the owner must sign. If a corporation is being qualified, the signatures of the president, vice-president, and secretary are also required. If it is a partnership, each partner must also attest that the information is correct. List license numbers held by these individuals in spaces provided below. APPLICANT/LICENSEE SIGNATURE Previous or Current License Held Date Signature of Partner or President or Proprietorship Owner Print Name Date Address(P.O. Box not acceptable) Social Security Number License Number Signature of Partner or Vice President Print Name Date Address(P.O. Box not acceptable) Social Security Number License Number Signature of Partner or Secretary Print Name Date Address(P.O. Box not acceptable) Social Security Number License Number BPR/CILB/025/Rev. 02/00 Page 7 CITY OF jV Office of Building Official REQUEST FOR INSPECTION�'`r,)ps'� Date I ,d l LC, Pe it No. Time 7 '} A.M. Received HI" �C� P.M. - � Job Address Locality Owner's j Name Contractor r BUILDING % CONCRETE C�`L'E` ICA PLUM IN ANICA Framing _ ❑ Footing ❑ pug Wir"� my Fi Rough Re Roofing ❑ Slab L] Temp Pole ❑ To Out ❑ Air & F1Insulation ❑ Lintel ❑ Final p E] Heattinging ❑ Sewer ❑ Fire Place ❑ READY FOR INSPECTION Pre Fab Mon. Tues. Wed. A.M. Thurs. Friday PM. fA.M. Inspection Made — c-? P.M. l Inspector Final Inspe Certificate of Occupancy ❑ a Date 31666 DEPARTMENT OF BUILDING pERMIT NO. � CITY OF ATiANTIC BEACH.� �'�D PERMIT T THIS PERMIT MUST BE POSTED ON JOB Da g631 197 Fee$ 3 .00 Valuation$ •0 fl Treasurer, and is ennit not 'slid until above fee has been Pud to City This P applicable Provisions of Lw• subject to invocation for violation of aPP I Qo1S This is to certify tha aB p e round s wimmin o01 i has permission to buil lone residence —�-- Classificatio P,/P Owned by -----Block__ loc S SSD Lo 5 750 Plaza Road House Not According to approved plana which are part of this permit NOTICE—ALL CONCRETE FORMS MUST APECTED BEFORE D FOOTINGS POURING. S I TE P AFTER DATE OF�ISSUS �t1 debris I p material, Building rubbish andlaced in Z from this work must not be placed BP /------� '� public sPgCei and must be tractor and hauled away by either -� or owner. R. C. Vogel Buildint�0ia1• CONTRACTOR FOR OFFICE PERMIT DATE USE ONLY NUMBER PLUMBING ELECTRICAL SEWER WATER ,7� ATLAS POOLS Division of Atlas, Inc. - General Contractors 725-4155 10023 BEACH BOULEVARD JACKSONVILLE, FLORIDA 32216 I! 1100 / I I c i r I I P i I I I � j� (5 O '. h r {,?� ;I i l BUILDING PERMIT APPLICATION JURISDICTION OF APPLICANT TO COMPLETE SECTION A ONLY SECTION A JOB ADDRESS AFA �NNppp 1 DESC LOT/ B�- TRACT 4.�'7 OWN � ( E ATTACHED SHEET) 2 MAIeLADDRESSd ' f ZIP Pb10NE 3 CONTAIL ADDRESS P "�4 ��°/"PHONE LICE SENO. 4 ARCHIGNER "° 38MAIL ADDRESS PHONELICENSE NO. 5ENGIMAIL ADDRESS PHONE LICENSE NO. G CLASS OF WORK: NEW ADDITION EJALTERATION DREPAIR OMOVE E]REMOVE 7 BUILDING CHARACTERISTICS A. PROPOSED USE GROUP C.PRINCIPAL TYPE OF FRAME G,DIMENSIONS -MASONRY NUMBER OF STORIES RESIDENTIAL NON-RESIDENTIAL -WOOD FRAME TOTAL FEET OF FL -STRUCTURAL STEEL AREA A LUFLOORS.BASED ARE O OR ❑ONE FAMILY DWELLINGASSEMBLY -.REINFORCED CONCRETE EXTERIOR DIMENSIONS E]TWOOR MORE FAMILY OWE LLING; BUSINESS (OFFICE) -OTHER -SPECIFY TOTAL LAND AREA,SQ. FT. NO.OF UNITS nHOTEL,MOTEL, DORMITORY, ❑EDUCATIONAL D.TYPE OF HEATING FUEL H PARKING SPACES ER OF STREET NO.OF UNITS FACTORY-INDUSTRIAL -GAS ENCLOSED _01 L OUTDOORS GARAGE HAZARDOUS _ELECTRICITY -COAL I. RESIDENTIAL BUILDINGS ONLY CARPORT �AINSTITUTIONAL -.OTHER -SPECIFY NUMBER OF BEDROOMS DTH R SPECIFY Ej MERCANTILE (( �� E.TYPE OF SEWAGE DISPOSAL NUMBER OF BATHROOMS G STORAGE _PUBLIC OR PRIVATE COMPANY FULL ❑OTHER-SPECIFY _PRIVATE (SEPTIC TANK,ETC.) PARTIAL F.TYPE OF WATER SUPPLY -PUBLIC OR PRIVATE COMPANY -PRIVATE (WELL,CISTERN) B. NON-RESIDENTIAL- DESCRIBE IN DETAIL THE PROPOSED USE OF THE BUILDING. 8 7A. ON OF WORK BUILDING$ B. PLUMBING$ VALUATION $ E. OTHER$ D. ELECTRICAL$ F. TOTAL VALUATION Zed, I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL PROVISIONS OF 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 GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER STATE OR LOCAL LAW REGULAT- ING C STRUCTION OR THPERFORMANCE OF NSTRUCTION. SIGNAT O ONTRACTOR OR A IZED AGENT DATE SIGNATURE OF OWNER (IF OWNE IL ER) 3 (D E) CITY CF ATL.`-N.TIC rZ.•C}i ;:< _ _ __ :.r:L'C=TiG:1• ivR rLi."•��i:�{r YER?'iI l __ __ _ -- - , ?03,LCCATION: OWNER OF Pno? ?L•J~'a \G CONTRACTOR:�,s�� - cc ;TJ&sa��4 ���� STATE Llms3 Nu,'G2z: � c>L& l `� ( TELE? GN E: 73o � v 07 i C 7 LC`n'iNG F-.Xluvs i:%S l.7•L=D 1✓ SI\:<S S.-ow7:RS LAVA T 0 1 S 'riAT:.R BEATERS =AT i :V3 s 3I5:-NA':SFEERS V-Ri\ALS JTStC±S11-L S CLOSETS 4AS:iI\ G ?-:C: