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2321 MAYPORT RD TEMP POLE 'Ji- 11 ts CITY OF ATLANTIC BEACH 800 SEMINOLE ROAD fj ATLANTIC BEACH, FL 32233 -5814 INSPECTION PHONE LINE 247 9 ELECTRICAL PERMIT MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814 JOB INFORMATION: Job ID: 15-ELEC-942 Job Type: ELECTRIC ONLY Description: TEMP POLE 60 AMPS FOR DOLLAR TREE Estimated Value: Issue Date: 4/22/2015 Expiration Date: 10/19/2015 PROPERTY ADDRESS: Address: 2321 MAYPORT RD RE Number: 169398-0410 PROPERTY OWN :.R: Name: AMERADA HESS CORP. Address: PO BOX 696419 PO BOX 696419 GENERAL CONTRACTOR INFORMATION: Name: RAINBOLT TECH SERVICES Address: P.O. BOX 773 LAKE CITY, FL 32056 Phone: FEES: State Elec DBPR Surcharge $2.00 State Elec DCA Surcharge $2.00 Temporary Electrical Service $35.00 Trade Permit Base Fee $55.00 Total Payments: $94.00 PERMIT IS APPRON'LD ONLY IN ACCORDANCE WITH ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA BUILDING CODES. ELECTRICAL PERMIT APPLICATION CITY OF ATLANTIC 13EACH 800 Seminole Rd, Atlantic Beach, Fl, 32233 Ph(904) 247-5826 Fax (904) 247-5845 JOB ADDRESS: 2321 MAYPoRT ROAD PERMIT# JEA INFORMATION REQUIRED ON ALL PERMITS 400 AMPS 208/120 VOLTS 3 PHASE VALUE OF WORK S38,000.00 NEW SERVICE 0 Overhead M Underground D Underground up Pole Residential (Main) Service 1 10-100 amps 11 101-150amps I I 151-200amps Ll amps of Meters --]Commercial(Main) Service LIO-100 amps L-1 10 1-15 Oamps Ll 151-200amps 11 400 amps LICT Service amps Conductor Type_Copper Size 3/0 'Multi-Family(Main)Service 11 0-100 amps E 10 1-1 50amps II 51-200amps i i amps # of Unit Meters U Tempww7 Poto 11_60—amps SERVICE UPGRADE � —amps I I CT Service amps NEW FEEDER(ADDITIONS,ACCESSORY STRUCTURES,ETC.) 11100amps E-450amps F.1200amps [J—amps 11CT Service amps ADDITIONS,REMODELS,REPAIRS,BUILD-OUTS,ACCESSORY STRUCTURES,ETC. Outlets/Switches: 51 0-30amps 3 1-1 00amps 101-200amps Appliances: 0-30amps 3 1-1 00amps 101-200amps A/C Circuits: 5 0-60amps 61-100amps Heat Circuits: # circuits @ ......�kw Number of Lighting Outlets, Including Fixtures: 160 OTHER ELECTRICAL PROJECTS -1 Motors : Swimming Pool I I Sign 1-1 Smoke Detectors_Qty I I Transformers KVA F hp FIRE ALARM SYSTEM (Requires 3 sets of plans) Qty_volts/amps VALUE OF WORKS REPAIRS/MISCELLANEOUS 0 Replace Burnt/Damaged Meter Can ESafety Inspection El Panel Change LJ OH to UG Ll 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. E,PJAI 4. - LIN 0 0 Al 6 RAI tv 00 L.7'_rt.r 25'OM Property Owners Name Phone Number Electrical Company RAJAI&e'Lj!� 7izq �mu� Office Phone3T6.-7 9 C.i5��Fax Co. Address: 9 0 . 0 6?,)r -7-7 :� — City Ltlfe rj r V State,,�J_,Zip 32a.!� License Holder(Print): j�/4-/42,i,/ 1-4,1 n,7 —7 State C='fication/Re gistration# &C 13 t7,0 I Notarized Signature of License Holder CIENNFER WALKER re meAis of OMM SSION F 114 1 y .......... MJENNIFER WALKER my OMMISSION#FF 011,41 i�vvorn and Ubscribed bef6 2 EXPIR S 0 7 XP IRES:Apdl 24�,201,7 E.�T r, P, ublic Vt�;.. Bonded Thru Notary POW Undow4k nature of Notary P ig I=L- Rus(L4 451- ADP 4/22/2015 1 : 58 : 39 PM PAGE 2/002 Fax Server DATE(NMMYYYY) CERTIFICATE OF LIABILITY INSURANCE 04/22/2015 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: It 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 enclorsement(s). PR"CER I Automatic Data Processing Insurance Agency,Inc. Eg: IN.): 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Twin City Fire Insurance Company 29459 IN"ED INSURER B: LYNDON RAINBOLT INSURERC: PO BOX 773 INSURER D: Lake City,FL 32056 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 336114 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE 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, EXCLUSION!S AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRT— ADULSUBR PO myzay L "UCYIFF _M TYPE OF INSURANCE INSO WVQ POLICY NUMBER yyyy)��(NUDDIYYYYI LIMITS COMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ LVONVUL I U HLN i CLAMS-MADE OCCUR PREMISES(Ea occurrmos) $ NED EXP(ft one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE UMITAPPUES PER: GENERALAGGRUGATE $ POUCY LOC PRDDUCTS-CCMP/OP AGG $ OTHER: $ AUTOWBILE LIAEMILITY r--11-1T-LV INGLE LFAl 1 $ ANY AUTO BODILY INJURY(Per pwson) $ ALLCMED SCHEDULED BODILY MURY(Per accidart) $ AUTOS AUTOS NON-OWNED ff)WIIE E $ HIREDAUTOS AUTOS rF r UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAKIIS-MDE AGGREGATE $ DED I I RETENTION$ $ VVORKERS CONFENSA-noN X I SMATUTE I T7 AM BFLOYERS'LIABILITY Y/N 1,000,000 ANY PRCPRlF70R/PAR7NER/EXECU7lVE NIA N /15/2015 E.L.EACH ACCIDENT $ A - EXCLUDED? EY 76WEGLY7525 09/15/2014 09 1,000,000 �Q=AF�4" E L DISEASE-EA BAP $ 6W- IA�be unzle-r 1,ODO,000 NOFOPERATIONS below EL DISEASE-PO ICY JUT $ L DESCF31PTION OF OPERAMONS/LOCATIONS/VEHICLES(ACORD 101,Additional Reffiarks ScheduLe-may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The cIty Of Atlantic Beach ACCORDANCE WITH THE POLICY PROVISIONS. 800 Seminole Rd Atlantic Beach, FL 32233 ALM-10RIZED REPRESENTATIVE 2014-15 COLUMBIA COUNTY BUSINESS TAX RECEIPT RONNIE BRANNON, TAX COLLECTOR RECEIPT NUMBER� RECEIPT EXPIRES 09/3012015 075163 MACHINES ROOMS SEATS EMPLOYEES 4 BUSINESS TYPE: 000104 SUPPLEMENTAL ELECTRICAL CONTRACTOR X RENEWAL 18.00 RAINBOLT TEC SVCS.IAIRSTREAM ELECTRICICABLE NEW RECEIPT -U ---I CD K7 C4 7) LYNDON RAINBOLT -0 m, r'J Z' PO BOX 773 TRANSFER ID ___4 0 2: 'n M N) LAKE CITY,FL 32056 m 0 X1 PENALTY 0 9 TOTAL rri r.,.15'80 In LOCATION 426 SW COMMERCE DR STE 245 ADDRESS: LAKE CITY,FL 32025 X 4za4 c:5�`T' SIGN AND RETURN WIT�PAYMENT JS*VARTHAT-HSAETlOR ORRECIEt—SWOEFORTHEBUSINLSSOR PROFE HEREON MO IS'�RUE�CORRECT 0000001800 0000001980 0000000000000521 1001 8 �EAPPLICA�O4�ST�UfMTHSTA�F�L�LORD�EINCLU�NGZW4o STATE OF FLORIDA DEPARTMENT OF 13USINESS AND PROFESSIONAL REGULATION EC13001835 ISSUED: 07/09/2014 CERTIFIED ELECTRICAL CONTRACTOR RAINBOLT,LYNDON JOHN RAINBOLT TECH SERVICES/AIR-STREAM IS CERTIFIED under the provisions of Ch.489 FS- Expiration date� AUG 31,2016 L1407090001448