1730 PARK TER E - ELECTRIC ADDITION r. L.i.\.,\Ty„„,
A �� IsCITY OF ATLANTIC BEACH
r _. l 800 SEMINOLE ROAD
i ' � ` ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
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ELECTRICAL PERMIT
MUST CALL BY 4PM FOR NEXT DAY INSPECTION: 247-5814
JOB INFORMATION:
Job ID: 17-ELEC-3839
Job Type: ELECTRIC ONLY
Description: 200 amps/240 volts/single phase - remodel 27
outlets/switches, 3 appliances, a/c circut, heat circuit, move meter can
Estimated Value:
Issue Date: 4/26/2017
Expiration Date: 10/23/20.1_7
PROPERTY ADDRESS:
Address: 1730 E PARK TER
RE Number: 172020-0394
PROPERTY OWNER:
Name: Moore, Paul
Address: 1730 Park TER
GENERAL CONTRACTOR INFORMATION:
Name: TRI COUNTY ELECTRICAL
Kevin Lee Weir, EC13005421
Address: 11637 E COLUMBIA PRK DR QA KEVIN LEE WEIR
Phone: - -
FEES:
AC Circuits $5.00
Electrical Heat $4.00
Lighting Outlets, Including $16.20
Fixtures
State Elec DBPR Surcharge $2.00
State Elec DCA Surcharge $2.00
Trade Permit Base Fee $55.00
Switch Outlets $16.20
PERMIT IS APPROVED ONLY IN ACCORDANCE will! ALL CITY OF ATLANTIC BEACH ORDINANCES AND THE FLORIDA
BUILDING CODES.
'burt�' CITY OF ATLANTIC BEACH
' 800 SEMINOLE ROAD
a- N� ATLANTIC BEACH, FL 32233
INSPECTION PHONE LINE 247-5814
Total Payments: $100.40
PERMIT IS APPROVED ONLY IN ACCORDANCE WI I II ALL CITY OF Al LAN'IC BEACH ORDINANCES AND 1111E FLORIDA
BUILDING CODES.
04/25/2017 12:42 9042609688 TRICOUNTY PAGE 01/01
--y) (C t. ELECTRICAL PERMIT APPLICATION ` —
-ve'17 CITY 01'ATLANTIC BEACH
800 Seminole Rd, Atlantic Beach, FL 32233
Ph (904) 247-5826 Fax (904) 247-5845 11-- .-6C-3 3'3 j
JOB ADDRESS: 1 7 3 O frc i k...e../A.Act.cpZ--,--;_t____________' PERNIIT# 17-f:(1•p i) ,36.
I____.-------,
JEA LNFORMA.TION REQUER. ;D ON ALL PERMITS 9'60 AMPS O VOLTS / PHASE
VALUE OF WORK$
NEW SERVICE E "Overllead 7 Underground OJ Underground up Pole
°Residential (Main) Service I�
00-100 amps 0101-150amps 0151-200amps 0 amps it of Meters
OCommercial (Main) Service
00-100 amps ❑101-150amps 01151-200amp.s 0 amps OCT Service__,amps
Conductor Type Size
❑M:ulti-Faaaaily(Main)Service •
D0-100 amps 0101.1,50amps 0151-200amps 0 amps ii of Unit Meters
OTrntporary Pole 0 amps
SERVICE UPGRADE 0 amps D CT Service amps
NEW FEEDER (ADDITIONS,ACCESSORY STRUCTURES,ETC.)
0100.amps 0150amps 0200amps 0 amps OCT Service amps
ADDT.TJONS +MOA LE S,i .0PAIRS, ILD-OUTS31-100,ACCESSORY STRUCTU 1 1 S,ETC.
-O tic s/S 'it hey ' -30ampBUs atnps 10 -200amps
Appliances: ' 0-30amps 31-100amps 1011.200amps•
A/C Circuits: t 0-60amps 61-100amps
Heat Circuits: ( 4 circuits @ kw
Number of Lighting Outlets, Including Fixtures:
OTHER ELECTRICAL PIC?OSECTS
C Swimining Pool 0 Sign OStnoke Detectors Qty OTransformers IKVA UMotors . lip
Fly ALARM SYSTEM. (Requires 3 sets of plans & Fire Alarm Checklist)
Qty volts/amps _ VALUE OF WORK$
REPAIRS'IMTSCJ LLANEOUS
OReplace Burnt/Damaged Meier``Can 0 Safetyff Inspection OPanel Chane 0011 to UG
COtfc "�0 r I+\, i ' D f U'1 'z 4-42.. /1 C� ^'L_ G/. /l /-MTIC 'TL7 G e !_.JL i -ecf�,
� �`,_� � 1 �. , ;
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 1 havo
read this application and know the same to be true and correct. All provisions of laws arid ordinances governin 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 rep.!akin construction or the performance of
construction.
Property Owners Name /11 2 ° 1 , _ Phone Number .
•,
.�.`
Electrical Company � r. Co,/,1‘7,1y. gle C., _ )ti ,01/c.,_„-Office Phone U- f Fax 4i1a,
.
Co, Address: 1l{o3_ L L . Ce.))1/11-16, c1 e___44.1C �,7 _ City r_� State-71_, lip
License Holder (?rfintt): i'-91..,vt 0'1 L . \-Q-r v"-- 7 _ Stdte'6ertificatioza/Registra.tio:a 4 �',.,�.,e,a6.5.. _4
Notarized 5ignat`u.re of License.folder -'v'/ '`J /�-' (4 .,./.-c-9 _ ______ �
— "/%,Z•i--- y TAMMY PALL Swore and stxbse ibed,before rrr this .r. / day o,f, _-/ 20 / 7
_r fir Notary Public•Stale of Florida?NCommission 0 FF 995425 Signature of Notary Public �0i.... .. /
',:,.-►�z,'-& My Comm,Expires Jul 6,2020 r e
',4� ,,,, 'landed through National Notary Assn. 0
04/25/2017 13: 18 9042609688 TRICOLINNTr PAGE 01/04
1�"AX D. %; e ° .
rw145 fir,,, } 20„I TRICOUN 15If f SIVI,I.0 1
Ate! CERTIFICATE OF LIABILITY INSURANCE 4/1312017
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 13Y 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 poIIcy(ies)must have ADDITIONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsomont. A statement on
this certificate does not Confer rights to the certificate holder In lieu of such endorsement($).,_
PRODUCER C NTACT IFA%
PHONE ( )(407)629-6378
Hub(Oran ttlonai Southeast Nodal):(407)594.5431 FAX--
(NC,No
1560 Orange AvenueI
Suite 750 kss•
Winter Park,FL 32789 IN5U.5R(S)AFFORDING CSWERAGE NAIC U
INsuRELA:American States Insurance Company 19704
INSURED 1 INSURER 3;American Economy_Insurance Company 19690 _
Trl County Electrical Contractors,Inc. iN uars c:BrldgefieldEmployers Insurance.Company 10701
11637 Columbia Park Drive East I INSURER o;
Jacksonville,FL 32258 ,SURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION.NUMBER: _
ITS IS TOND CATED, ONERTIFY THAT THE OTWTHSTAND NO AONY REQUIREMENLICIES OF T, TERMNCE I OR CONDITIONSTED W AOF NY CONTRACT OR OTHER DOCUVE SEEN ISSUED TO THE INSURED MENT WITH REESPECED ABOVE FOR THE TOL WHICH THIPOICY S
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.;ECT TO ALL THE TERMS,
EXCL14
USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,_
AWL SUER POLICY EFF POLICY F.Xpp.�.� Limn
�m _.Ir.ISl).yJy TYPE OF INSURANCE p POLICY NUMBER jitmai py,'L11I
, M,MLDDt1CLL'Y).
1,000 000
A X COMMERCIAL OENERAL LIABILITY EACH OCc,URRENCE b _
r 0411512017 04/15/2015 DAMAG K o R=NTED S 200,000
_. CLA'IAS.MADE OCCUR 010118945790 _P�31;6d1�.. lEP C4lr S',ft�_..._
h;EDf%P nv ole_pswion1 y 10,000
' 0ERSONAL as ADV INJURY -$ 1'000'900
e_rIE@ALAGCREGgiE g 2,000,000
,QFN,LAGGREGA LIMIT APPLIES PER. I 2,000,000 POLICY 1rl f ! X I LOC PRODUCTS-CON'POPASG I v_
OTHER. —
G_OMa NED SINa:F LIMIT'"'”' 1,000,000
8 AUTOMOBILE LIABILITY ( t113 t2 g
X ANY AUTO 020E23504E20 04/1512017 04/15/2018 EDD'LY.:JL5Y(Per person) $
OUWrNOESD ONLY —_ AHULED „ CDi.Y INJURY(5etrr
_den $
.— A0ONLY — A08O pgOd ?ynn _
f
$
A X UMBRELLA LIAR X I OCCUR EACH OCCUFjr,P E s ,. 2,000,000
EXCESSLIAB CLAIMS-WADE 01SU41293390 04/15/2017 04/1512018 _ C.C43FOA'- $ 2,000,000
DED X RETENTION:, 10,000 s
P23 Tht.
C WORKERS COMPENSATION X S'AT,-iSE R
AND EMPLOYERS'LIABILITY 83045055 04115/2017 0411512018 1,000,000
ANY PRO5RIETOR/PAR'NER/EXECUTIVE YEN Si.. EACj.P.CCICENT b
figN anal DED? _ NrA 1,000,000
l nn n ory�n _LLDISEASE-EA ENE,OYEE $
IDESCdPC L PgRATIONS below E.L.DISE5-°OLICY LIMIT $ 1,000,000
l
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORI 101,Additional Romerke$chndulo,may b0 ettnchnd If more'peep In roqulrodl
Certificate holder's interest is reflected as additional Insured as respects general liability,11 required by written contract,(or work performed by or on behalf of
the named Insured.Waiver of subrogation applies in favor of certificate holder if required by written contract,Certificate holder's interest is reflected as
additional insured as respects general liability on a primary and non-contributory bash;,If required by written contract,for work performed by or on behalf of
'the named Insured
CERTIFICATE HOLDER CA,(`10ELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Atlantic Beach Building Dept. ACCORDANCE WITH THE POLICY PROVISIONS,
800 Seminole Road
Atlantic Beach,FL 32233 -
AUTNORIZZEED REPRESENTATIVE
at2
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