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Home My WebLink AboutFolio 2024-2026 Permit - CR 7897 CR 7897 - 9/24/2024 ,) (rp,,k4 CONTRACTOR REGISTRATION 100 West Dania Beach Boulevard *Dania Beach,FL 33004 (954)924-6805*3651,3633 or 3652 Fax(954)922-2687 DANIA BEACH SEA R.LIVE V LOVE IT PLEASE PRINT LEGIBLY Type of Contractor Certified General Contractor Company: NameTEPDB OPCO, LLC Office Address 326 Tryon Rd City/State/Zip Raleigh, NC 27603 Office Phone# (919)661-6351 Qualifier:Name William H.Martin Office Address 326 Tryon Rd City/State/Zip Raleigh, NC 27603 Home Phone# (919)703-4157 Owner:Name TEP Holdings, LLC Office Address 326 Tryon Rd City/State/Zip Raleigh, NC 27603 Home Phone# (919)661-6351 PROVIDE PHOTOCOPIES OF THE FOLLOWING DOCUMENTS Qualifier's Driver's License 25559253 State: NC City Business Tax License City: County Business Tax License County: Palm Beach County State License CGC1523917 Certificate of Competency Certificates of Insurance must show the City of Dania Beach as the Certificate Holder General Liability Expiration Date: 06/01/2025 Workers Compensation Expiration Date: 06/01/2025 I hereby certify that the information contained herein is true and accurate to the best of my knowledge. ttit Qualifier's Signature Date }} The foregoing instrument was acknowledged before me this 1 44"day of jt h- 20,L By \..,i e`v'v V v- -'r who is personally known to me or has produced as identification and did(or did not)take an oath My Commission Expires: Q Q3 (� �al'9 1l Contractor Registration Rev. 09/26/2017 K Ron DeSantis,Governor Melanie S.Griffin,Secretary Art, a rry 1 STATE OF FLORIDA CbbE -0 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE GENERAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES MARTIN, WILLIAM HURLEY TEPDB OPCO, LLC 326 TRYON ROAD RALEIGH NC 27603 r- LICENSE NUMBER:CGC1523917 I EXPIRATION DATE: AUGUST 31,2026 Always verify licenses online at MyFloridaLicense.com 0i El ISSUED:06/14/2024 Mir L.Otre Do not alter this document in any form. This is your license. It is unlawful for anyone other than the licensee to use this document. ottt_�.r › '. A N N E M. CANNON P.O.Box 3353,West Palm Beach, FL 33402-3353 s•f .,= CONSTITUTIONAL TAX COLLECTOR www.pbctax.com Tel (561)355-2264 'LOC RO R Serving Palm Beach County 326 TYN (J Serving you. RALEIGH NC 27603 I TYPE OF BUSINESS I OWNER I GENERAL CONTRACTOR CERTIFICATION# I RECEIPT#/DATE PAID AMT PAID I MARTIN WILLIAM HURLEY BILL# CGC1523917 B24.641737 8/1/2024 27.50 B40158404 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2024/2025 LOCAL BUSINESS TAX RECEIPT TEPDB OPCO LLC LBTR Number: 2019119381 TEPDB OPCO LLC EXPIRES: 9/30/2025 326 TYRON RD RALEIGH NC 27603 This receipt MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. AC RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �/ 9/17/2024 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 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 endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NFP Corporate Services(SE), Inc. NAME: Janet Martin 1901 Roxborough Road Suite 300 talc No.Eat):704-523-4222 E-MAIL (aC,He):704-892-3266 Charlotte NC 28211 ADDRESS: Janel.martin@nfp.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Indian Harbor Insurance Company 36940 INSURED TOWENGP INSURER B:Allied World Surplus Lines Insurance Co 24319 TEPDB OpCo LLC,TEP Design Build Inc 326 Tryon Road INSURER C:National Union Fire Insurance Company of Pittsburg 19445 Raleigh NC 27603-3530 INSURER D:Starr Indemnity&Liability Company-AM BEST RATI INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1175439172 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 ADDL SUBR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLICY EXP (MMlDD1YYYY) (MMlDD/YYVYYY) UMITS B X COMMERCIAL GENERAL LIABILITY Y Y 6004-0343 6/1/2024 6/1/2025 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $100,000 X Contractual Liab MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY X EC LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: Deductible $50,000 C AUTOMOBILE LIABILITY Y Y CA 7107757 6/1/2024 6/1/2025 COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ y HIRED X AUTOS ONLY x AUTOS ONLY PROPERTY DAMAGE $(Per accident) $ D UMBRELLA LIAB X OCCUR Y Y 1000586344241 6/1/2024 6/1/2025 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED RETENTION$ C WORKERS COMPENSATION $ C AND EMPLOYERS'LIABILITY Y WC 11967648(AOS) 6/1/2024 6/1/2025 X ;MUTE WC11967649(CALIFORNIA) 6/1/2024 6/1/2025 STATUTE ER ANYPROPRI ETOR/PARTN ER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N N/A E.L.EACH ACCIDENT $1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Pollution Liability Y Y CE0744614605 6/1/2024 6/1/2025 Poll 25,000 Retention 5000000 per claim A Professional Liability CE0744614605 6/1/2024 6/1/2025 Prof 250,000 Retentio 5000000 Aggregate DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate holder is included as Additional Insured as respect General Liability for ongoing&completed operations,Auto Liability and Excess Liability when required by written contract.Per Project Aggregate applies to General Liability.Blanket Waiver of Subrogation applies in favor of Additional Insured on General Liability,Auto Liability,Workers Compensation and Excess liability when required by written contract.Primary and Noncontributory applies to General Liability and Auto Liability when required by written contract.Excess follows form over General Liability,Auto Liability,and Workers Compensation/Employers Liability policies.30-day notice of cancellation by insurer applies to Auto,General Liability,Work Comp and Umbrella,except for 10-day notice for nonpayment. Unmanned Aircraft is covered by endorsement under the General Liability policy#6004-0343 per attached form.Excess/Umbrella Liability is written as follow form when supplementing Aircraft Liability. Contractor:William H.Martin See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Dania Beach ACCORDANCE WITH THE POLICY PROVISIONS. 100 West Dania Beach Boulevard Dania Beach FL 33004 AUTHORIZED REPRESENTATIVE ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered ma ks of ACORD - - DRIVER LICENSE 000025559253 01/28/1985 • 49P 01/28/2026 MARTIN - WILLIAM HURLEY- F, r r 325 SPRINGTREE PUOUAY VAR1NA,N 27604 -L 9 CLASS C 9a END M ; ;=sy, 12 RESTR NONE 15 SEX M 18 EYES BRO io riGT IV-00"--1-p HAIR BRO E-L 2J-0-• 01/24/2018 002099I3379 01/28/85 • f •