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HomeMy WebLinkAboutFolio 2024-2026 Permit - CR 7879 CR 7879 - 9/24/2024 eit_d CONTRACTOR REGISTRATION 100 West Dania Beach Boulevard*Dania Beach, FL 33004 (954)924-6805*3651,3633 or 3652 Fax(954)922-2687 g 1 6( DANIA BEACH —---� Utu+r1kOtrt PLEASE PRINT LEGIBLY Type of Contractor Roofing Company:Name Priority Roofing of Lakeland LLC Office Address 4460 Florida National Dr City/State/Zp Lakeland,FL 33813 Office Phone# 863-701-4746 Qualifier:Name William Miller Office Address 4460 Florida National Dr City/State/Z]p Lakeland,FL 33813 Home Phone# 863-701-4746 Owner.Name William Miller Office Address 4460 Florida National Dr City/State/Zip Lakeland,FL 33813 Home Phone# 863-701-4746 PROVIDE PHOTOCOPIES OF THE FOLLOWING DOCUMENTS Qualifier's Driver's License 25918849 State: TX City Business Tax License 255257 City: Lakeland County Business Tax License County: Pak State License CCC1334967 Certificate of Competency Certificates of Insurance must show the City of Dania Beach as the Certificate Holder General Liability Expiration Date: 07/01/2025 Workers Compensation Expiration Date: 06/17/2025 I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Qualifiers Signature Date The foregoing instryment was acknowledged before me this 1L day of 20citf j[I Who is personally knowAr to me or has produced as identification and did(or did not)take an oath , My Commission Expires: no (ate; TERRI J.PHILLIPS •, ‘•‘ MYCOMMISSIONAHH194678 , 7. EXPIRES:November 3,2025 Contractor Registration Rev. ".r.R f, °�;' Bonded Thru Notary Puede Underwriters • _*' J 09/26/2017 ifichil 7:7 Limn ....0 c N co E 2 U N W C Q w w v cr; J 0 p E— cn .� CO a) 0 Z - p F— --IN o a)w '� w r O a V) to L.L. Q p > �O N `^ u Q V) Z I- Z M Os ci. W W w , Q p CO M c� � U. V U 0 `,} , Q w -J M M a r Y < M73 '51-N LL O per, >- oN r=, J u_ — N U = >. N a LL Z W } � i r L7 z :. w LLJ .0 v O i w ^ Z w CO F- 0 W a2 cc ~ w p H p Q 0 cn o _ W >, W � Z D € � o � :c Z U < li J 0 N Q Z Z ( _N cE) LLJ Z U ,4y e ; . > w Y to 4) 76 I ) F— w �' ¢,r . i_ 0 Q w H .—' +, 5 �. ce No o 3 Q L C o CO CO V 0 Z � X > 0 a v- D t. 0 ct W 0 oc 3 !— p > Q aito cnZZO > W CY ce o u o VH GC o >, CD Q Cl. •v) W ce CI I— off. ; � t t' >, 1at -F �' 0 i -2; '-Y' 1.1 14'. ,J 1 - �:rr POLK COUNTY LOCAL BUSINESS TAX APPLICATION FORM ACCOUNT NO. 255257 CLASS: B+ PAYMENT DUE BY: 09/30/2024 OWNER NAME LOCATION 4460 FLORIDA NATIONAL DR SUITE 4462-2 WILLIAM T MILLER LAKELAND BUSINESS NAME AND MAILING ADDRESS CODE ACTIVITY TYPE PRIORITY ROOFING OF LAKELAND LLC 230250 CONTRACTOR ROOFING PRIORITY ROOFING 12303 TECHNOLOGY BLVD STE 900 AUSTIN,TX 78727 SIGN HERE LAKELAND@PRIORITYROOFA.f SIGNATURE INDICATES APPLICANT READ AND UNDERSTANDS THE APPLICATION AFFIDAVIT ON THE BACK OF THE FORM AND AFFIRMS THE INFORMATION PROVIDED IS AMOUNT DUE: 57.75 TRUE AND CORRECT. PAID-2529670 07/31/2024 OPY OLP 57.75 PRIORITY ROOFING OF LAKELAND LLC For Your Information: What You Need To Know About Tangible Personal Property Every individual or firm doing business and located in Polk County is also subject to the tangible personal property requirement. An initial tangible personal property tax return is required to be filed with the Polk County Property Appraiser's Office by April 1st of the year after the business opens. The initial return is required if the business owns or leases any personal property, without regard to the value of that personal property. In subsequent years, however, no return is required unless the combined value of all business equipment is more than 25,000 dollars. To file an initial tangible personal property tax return or for additional information, visit Polk County Property Appraiser's Office website, polkpa.org. POLK COUNTY LOCAL BUSINESS TAX RECEIPT ACCOUNT NO. 255257 CLASS: B+ EXPIRES: 09/30/2025 OWNER NAME LOCATION WILLIAM T MILLER 4460 FLORIDA NATIONAL DR SUITE 4462-2 LAKELAND BUSINESS NAME AND MAILING ADDRESS CODE ACTIVITY TYPE PRIORITY ROOFING OF LAKELAND LLC 230250 CONTRACTOR ROOFING PRIORITY ROOFING 12303 TECHNOLOGY BLVD STE 900 AUSTIN,TX 78727 PROFESSIONAL LICENSE(IF APPLICABLE) DBPR CCC134967 OFFICE OF JOE G.TEDDER, CFC*TAX COLLECTOR THIS POLK COUNTY LOCAL BUSINESS TAX RECEIPT MUST BE CONSPICUOUSLY DISPLAYED AT THE BUSINESS LOCATION PAID -2529670 07/31/2024 OPY OLP 57.75 PRIORITY ROOFING OF LAKELAND LLC ACG'RD® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) IIkk...---- 8/12/2024 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 Roofers Choice Insurance NAME: David Clanton Bell Scott Insurance (a/c No,Ext):972-938-9676 FAX No):877-937-7521 PO Box 2567 A ADDREOREss: COI@RoofersChoicelnsurance.com Waxahachie TX 75168 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Summit Specialty Ins Co 16889 INSURED PRIOCON-01 INSURER B:OLD REPUBLIC SURETY CO 40444 Priority Roofing of Lakeland LLC 4460 Florida National Dr Suite 4462-2 INSURER C: Lakeland FL 33813 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1767391139 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTRINSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY SCGL004000014000 7/1/2024 7/1/2025 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURYaccident) AUTOS ONLY AUTOS (Per $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ A UMBRELLA LIAB X OCCUR SXCS004000006400 7/1/2024 7/1/2025 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$D PR/COMP OPS AGG $5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Business Services Bond W150435900 4/1/2024 4/1/2025 Employee Dishonesty $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Florida License CCC1334967 Qualifier: William Miller Coverage is valid in the State of Florida CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Dania Beach 100 West Dania Beach Boulevard Dania Beach FL 33004 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ALCM D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/12/2024 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 NAME: Employer Flexible Risk Management Department Employer Flexible Benefit Services, LLC PHONE FAX 7102 N.Sam Houston Parkway W., Suite 200 (A/C,No,Ext):E-MAIL 1-866-501-4942 (A/c,No): 281-377-7029 Houston,TX 77064 ADDRESS: certs@employerflexible.com INSURER(S)AFFORDING COVERAGE NAIC# www.employerflexible.com INSURER A: Texas Mutual Insurance Company 22945 INSURED INSURER B: Argonaut Insurance Company 19801 Employer Flexible HR Holdings LLC (PEO) 7102 N.Sam Houston Pkwy.W., Suite 200 INSURERC: Houston TX 77064 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 81381030 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 NUMBERPOLICY EFF POLICY EXP (MM/DD/YYYY) (MMlDD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL 8.ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION TSF-0001289521 (TX) 6/17/2024 6/17/2025 PER B AND EMPLOYERS'LIABILITY Y/N ✓ STATUTE EERH ANYPROPRIETOR/PARTNER/EXECUTIVE WC 92 929118716644 6/17/2024 6/17/2025 E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1.000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) PEO Client ID:ER198 PEO Client Address:Priority Roofing of Lakeland LLC 4460 Florida National Drive Suite 4462-2 Lakeland FL 33813 Coverage is provided for only those employees leased to,but not subcontractors of Priority Roofing of Lakeland LLC(A PEO Client). CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Dania Beach 100 Cit West Dania Beach Boulevard THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Dania Beach FL 33004 AUTHORIZED REPRESENTATIVE Wade Vielock ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 81381030 I EFHR (PEO) 24/25 WC 1 Zach Snider 1 8/12/2024 1:12:13 PM (CDT) I Page 1 of 1 This certificate cancels and supersedes ALL previously issued certificates. . _ `; - #.0 - `{ # may, s .. - , __ - '� �, -,-,„ N. ,'" ..„:„:„::,,,,..,.,,,-,- _ ,, ,, . '-:!.*,;-'s'''- e , ., .,,,,„ la- Aiti,,,,, ' ' Z mg4 .,,„,,,, - ..:', ' 0 LI * ,_,. 0 . , ' Z : : inin t * * a\ 0 41 y_miso 0 w at V) ,. a) 4 . , 'ii,-1 - a Cr ><-,- 4`.-" S, Y€'' ,( �- a o , Iv ,,,,, .,,. ... . 4 W'ki t?" , eke.rr vim, ., ..,,,_, < cu./ ru„,.....u.v).--- ',„,,.„..„, „ c...„,<N1 ...,..,,,.. ,... . ..,..;:„.._'%'81N4 ' : At a'--------'?. ..,,,:. th ....... it,x: . 0 ► 0) ve- III CTh we 2 . z . I to sn41 al * . cl . s ,,,c4 ,3crxo . a Li) u j 1, >i< 0 C'', . - ‘111.": ...„:7'14':-,,---. „- CD C r ^ ' - F