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HomeMy WebLinkAboutFolio 2024-2026 Permit - CR 7898 CR 7898 - 9/24/2024 q/11 24 CONTRACTOR REGISTRATION 100 West Dania Beach Boulevard*Dania Beach,FL 33004 (954)9246805*3651,3633 or 3652 Fax(954)922-2687 MAW. qg aV( PLEASE PRINT LEGIBLY Type of Contractor Electrical Contractor Company:NameTEPDB OPCO, LLC Office Address 326 Tryon Rd City/State/Zip Raleigh,NC 27603 Office Phone# (919)661-6351 Qualifier:Name Frederick T.Herb 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 20218312 State: NC City Business Tax License City: County Business Tax License County: Palm Beach County State License EC13010367 EC13010376 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 tha information ntained her s true and accurate to the best of my knowledge. Qualifie s S' nature Date The foregoing instrument was acknowledged before me this day of k''} 20011 BY 5' d QJ- c,(L T. N-*b who is personally known to me or has produced as identification and did(or did not)take an oath 031420a .' Commission Expires: DONNA LAYTON NOTARY PUBLIC JOHNSTON COUNTY,NC bly,pemmissien 6_ires 3-20-2027 • iit - A Ron DeSantis,Governor Melanie S.Griffin,Secretary , 1, _ Florida tr,n• :: Cf v. .":tea 2 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS' LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES I HERB, FREDERICK T TEPDB OPCO, LLC 326 TRYON ROAD '-' RALEIGH NC 27603 LICENSE NUMBER:EC13010376I EXPIR ATION DATE: AUGUST 31,2026 Always verify licenses online at MyFloridaLicense.com CIZW:1 ISSUED:06/21/2024 hi„:. ,• • -• Do not alter this document in any form. i . ,,,::�_r} b •. +',jo•. This is your license.It is unlawful for anyone other than the licensee to use this document. pt,• Q A N N E M. G AN NON P.O.Box 3353,West Palm Beach,FL 33402-3353 "*LOCATED AT** - CONSTITUTIONAL TAX COLLECTOR www.pbctax.com Tel (561)355-2264 326 TYRON RD Serving Palm Beach County RALEIGH NC 27603 Serving you. O TYPE HERB FREDERICK T BUSINESSOWNER ELECTRICALL CONTRACTORCER 11 01 37 ON# P3T 02 D A27.60 ID 640180770 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2023/2024 LOCAL BUSINESS TAX RECEIPT TEPDB OPCO LLC LBTR Number: 2022145711 TEPDB OPCO LLC EXPIRES: 9/30/2024 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. Is A ° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I 9L ER. /2024 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: Janel Martin 1901 Roxborough Road Suite 300 PHONE lac.No,Ext): 704-523-4222 I(A ,No);704-892-3266 Charlotte NC 28211 E-MAIL ADDRESS: Janel.martin@nfp.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Indian Harbor Insurance Company 36940 INSURED TOWENGP INSURERS: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 SUER LTR TYPE OF INSURANCE POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS 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 X Contractual Liab PREMISES(Ea occurrence) $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X JECOT I LOC GENERAL AGGREGATE $4,000,000 PRODUCTS-COMP/OP AGG $4,000,000 OTHER: C AUTOMOBILE LIABILITY Deductible $50,000 Y Y CA 7107757 6/1/2024 6/1/2025 COMBINED SINGLE LIMIT $1,000,000 X ANY AUTO (Ea accident) OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ONLY AUTOS X HIRED x NON-OWNED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ (Per accident) D UMBRELLA LIAR $ X OCCUR Y Y 1000586344241 6/1/2024 6/1/2025 EACH OCCURRENCE X EXCESS LIAB CLAIMS-MADE $5,000,000 AGGREGATE $5,000,000 DED RETENTION$ C WORKERS COMPENSATION $ C AND EMPLOYERS'LIABILITY Y WC 11967648(AOS) 6/1/2024 6/1/2025 X STATUTE EORTH- — ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N WC11967649(CALIFORNIA) 6/1/2024 6/1/2025 E.L. OFFICER/MEMBER EXCLUDED? N EACH ACCIDENT $1,000,000 (Mandatory in NH) N/A If yes,describe under E.L.DISEASE-EA EMPLOYEE $1,000,000 DESCRIPTION OF OPERATIONS below A Pollution E.L.DISEASE-POLICY LIMIT $1,000,000 A ProfessionalPollution Liabilitylability Y Y CE0744614605 6/1/2024 6/1/2025 Poll 25,000 Retention 5000000 per claim 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 I *7J ACORD 25 2016/03 ©1988-2015 ACORD CORPORATION. All rights reserved. ( ) The ACORD name and logo are registered marks of ACORD rL - - DRIVER UCE,CE •,r+,, 00002021'8312 , 3I1)0g s! }8l1974 125 HFREDEDEDERICK 1709 HIGH HRLU�Y RALEIGH.NC �y � C a«Enc NONE .:ur:9«,,NONE t.t,rt M }s-tt4 gLU 6'-01"+S}+,.a:r RED PncE u.= pfi.o rµ 03108i74 06184112647 i