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HomeMy WebLinkAboutCEMEX PAPERWORK - LIABILITY INSURANCE,. Did lroD do ydur ggtgyr CCIIIC X 2 Did you Idendry hazard-awrds ? 3. Did you use Xour poggt¢s When at tho pump? 4. Did you use your sooty Gongs? S.Didyammmul�Imtekmndi9onsWdapatd�ofierdlNAs't .� , fL,�a7 q69_- 0197 55631318 SCANNED BY St. LucieCount/ .Plant- Begin Loading: To Job: Ardw Job: Start Unload: Finish Unload: Loa%%Job: _ Return Plant: Cumarm Cob 3173385 cumb NAmr COASTAL BUILDING CONTRACTORS Cufta Job Number. OrbrCudol DAM: 1257 01/15/19 f Prgod Coda 41146256 Ro}d NAna --- MAT —ALL JOBS PSL PIWw1P0 Number MUST HAVE ONwPO. NumM PO N 17274 Tldom om Vail"AamaQ .. _• bb0-PApo uarNo-calmm 01/15/19 'Dow"mdmtlb,c 16891 CAROLE NOON LANE FT PIERCE' - - - - - WEST ON MIDWAY — LEFT ON OKEECHOBEE — RIGHT ON (HEADER DbPMWW RdRcilmurray CANAL — RIGHT ON CAROLE NOON AND RIGHT AGAIN TCIM Number J 36179189 111.30 I 5.001 100696371 109263 I GEANA STEWART I CAL BLDNG: EXT SHE LOAD CUII"WE ORDERED NATEUALCODP E PRODUCTION DESCMnON DoN , uNrrPRICE ANouxT OUAI1IItY GUAgM OUANM 10.00 1.0.00 20.00 1152539 3000 REG YD3 $RRd 15 aM13: i� 1.00 1 1247818 FUEL SURCHARGE 1.00 1202749 ENVIRONMENTAL CHARGE 1.00 1586055 SERVpCONCRETE HANDLING FEE P Cwb ClrMa/AW,lbb• Sin of Dmer R®MO Cash' CM Reo.,wd TOLICOOCNer AmO Mlo CdMoe COA* C11eq , WMw2shindby Cbargm Cannnh , ' WATER ADDED: GAL YARDS IN DRUM• ' i WHEN ADDED. CURB LINE,CROSSED AT OWNER'SIAGENTS REQUEST. CONCRETE DISPOSAL FEE s Nnru� _ PARTIAL FULL LOAD YARDS t� LOAD WA TESTED BY: -a. Our brag Away Alfa[m pDaw rmbroM crow tl,A bwgrub.bt.aA SPECUIL TERN& Mrywaaradbder onmrora own rak rcwsmoAdbdmpb,-room menpl m{. w BONAeo IwOmsBUlyfa donpw 5, aoDorpopsy Me. AlprbIM wro la%wguannlmd WARNING Rodud Mmynun WmAMbrarembbon CAUnON ua n w of ade and dAMry Aro mm3 M eonas n w Du b mgorbw w1md am mA of aO may D. bATLbuA m yam AAfaSy wC baAyb PIawA MW m Dr betlwdo of Via bd* for ngaM �WWar am". On CarpuW WWM aawpl ry rAepmomtlyM do wmR Noaoddfa wdrybrdmg bmkmefOa Aro mme mamrW �,b anOraben bo dAnwtl waved UnIm" bw mwmeG AU IOXMD SIGMATURE 1 ' �v�o4addmdul,MamOGm.� SSUNIVERSAL ! PREV TRK: ORIGINAL LOAD NUM: 1 18-10-05: 2:10PMi # 1/ 1 ACORD„ CERTIFICATE OF LIABILITY INSURANCE OATE(13/20 10 / MMMBWM 5 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION A BETTER DEAL INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR -=1.026 SW BAYSHORE BLVD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ?ORT ST LUCIE 772-871;: 455 INSURERS AFFORDING COVERAGE NAIC# INSURED rBILL -& LYNN-'_�S-_GLASS -AND SHELV'I'NG YANOFF 6900 HERITAGE DR STE B INSURER, FIRST COMMERCIAL PORT ST LUCIE, FL 34952 NGuaERD INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. 0✓g1 LiR oov PP TYPEOFINSURANCE POLICY NUMBER POUCYEFFECTIVE DATEMMIDDMI POLICYEXPIRAPON DATEMMID UMTS GENERAL Maim EACH OCCURRENCE B1, 000, 000 A X COMMERCIAL GENERAL LABILITY CLAIMSMADE OOCCUR 289BOD2390 PREMISES Ea a� rence g O / O MEDEXP(Anyaee Person) S _..8-05 7-218-0 PERSONALBADVINJURY $1, 000, 000 GENCRAL AGGREGATE 9 r O 0 r 0 O GENL AGGREGATE LIMIT APPLIES PER: POLICY 2ECi El LOG PRODUCTS-COMP/OP AGG S , ,ub AUTOMOSILEUARUUTY ANYAUTO COMBINED widenoSINGLE LIMB (EaawiCo� $ X ECOILYINJURY (Pe1 P°f5O") g10, 000 ALLOWNEDAUTOS SCHEDULED AUTOS B HIRED AUTOS CA-018046471 8-3-05 8-3-06 BODILYINJURY NON-OWNEDAUTOS (Peraccidenq s20,000 PROPERTY DAMAGE 10 O 0 O ,,. (Pela=ident) S , GARAGE LKNUTY AUTOONLY-EAAOCIDENT $ OTHERTHAN EA ACC S ANYAUTO $ AUTOONLY: AGG FJICESSUMBRELLA MSILRY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMSMADE E q DEDUCTIBLE S-._•-.•-.— RETENTION 5-_-.-..� C WORI(ERSCOMPENSATXINAND EMPLOYERS MBILRV MY vmPRETaLPxITlmcertcuDm acyyrKm" - WCSTATU- OTH- RY MI EL EACH ACCIDENT g 1 O O , O EL. DISEASE -EAEMPLOYEE EI,000,OOO nbeEuavoEm SPEBPALSPROVISIONSW. 14707-6 .F id' a9'06 M - 6 E.L. DISEASE -POLICY LIMIT $1,000,uuu— OTHER DESCRIPMONOFOPERATONSILMATIONSIVEH LESIEXCLUSIONSADDEDBYENMRSEMENTISPECWLPROYIBIDNB CERTIFICATE - HOLDER---- CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED REFORETHE EEMRATION CERTIFIED BUILDING CONTRACTORS DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN 747 SW MACEDO BLVD NOTICE TO TH E CERTIRCATE HOLDER NAMED TO THE LEFT, BUT FAILU RE TO DO SO SMALL PORT ST LUCIE FL 34984 IMPOSE NO OBLWATION OR LIADBITY OF ANY HIND UPON THE INSURER, ITS AGENTS OR FAX' 772-879-0110 REPRESENTATIVES. 1 , I1.D' you doyoyrctlsleoTs�dyP z rd you Identity hererde? 3. 'you useydurgogpteswilm attloplmlp? DW you use your safely cone? DidyW mmouropleurosfesoftllYNdtod�SOddp91er6}'rra1� I , 55631320 0(.. Plant ;Begin Loading. To Job: AnWa Job: StartUnload: Flnleh Unload: Leave Job: Rolum Plant L092/1092 -- -- - - - -- -- - - I - - CuatrmrCodw Cummmr Name C� Job Numbs Wtlxcwo/Dam 3173385 COASTAL BUILDING CONTRACTORS 1257 01/15/19 'Prme;Coda• ' Prolel Name 'Rc"dpo N,mbar O,rbr P O. Numbm. 41146256 IMAT-ALL JOBS PSL MUST HAVE PO N 17274 01/13/19 :16891 CAROLE NOON LANE FT PIE1tCE � oalry I,�ams , . WEST ON MIDWAY - LEFT ON OKEECHOBEE - RIGHT ON'HEADER mdmcilmurray CANAL - RIGHT ON•CAROLE NOON AND RIGHT AGAIN Tr Number � d 36179302 Due'*bb. 12:03 SVm0. ; 5.00 Tmri Numbs. 10064589 Omar Nunes 109257 Dmm Nmm BILL KRICK aw Um CAL BLDNG: EXJ SHE lDIO WANTRT CUNLIUTNE WMITity ORDERED OWWTITy MTVCOOS PRODUCTM DESCRIPTION LION UNIT Place AYOLINT 10.00 20.00 20.00 1152539 3000 REG YD3 • � �A`ts�a�i1:4� 1.00 1247818 FUEL SURCHARGE 1.00 1202749 ENVIRONMENTAL CHARGE 1.00' i 1586055 SERV,CONCRETE HANDLING FEE P I I CONCRETE DISPOSAL FEE PARTS AL FULL LOAD mbma drama oO male emy awn m Pb= msmnam wawa ua CoMov aaurr m mAmobib tr damaps amda mpb a ,wetly, l mmN d WTI am dlnmy atl womb La,OaN a a DID to mpwam mMd ahr6tiay. Uaa Camp@,Wv a nd a®p1 am raapmmbNy tr VW WATER ADDED' i Tow coo omarAmwmmCofoef , 1Al1U,outere„dby cmrpea: I YARDS IN DRUM WHEN ADDED CURB LINE CROSSED AT OWNER-S/AGENT'S REQUEST: YARDS �� ❑ LOAIYWAS TESTED BY: ram daalPnal®, bul ma SPE C RYS: My addadme Owtrmoowm lol, ywetrmodaodmieb,mmBie aOegm p,tlo,mr .ame.m me ram euamnlCetl. MNUq Redud mar muse elan a,WarM u,mlm cnurfaa Mlm l nfi,N are aN ov may baa,do,m m ant heats Pmma mtr to am bad de of bI.ra b*d anpotwa easnd= Wllddofrot aamry emmma matrml aamtydem almam�mrelddnnal mmrmamn m n,Wamuamwdog aq SOUNIVERS& PREV TRK: 10069637 LOAD NUM: 2 ;3 ACORD CERTIFICATE OF LIABILITY INSURANCE OPID D DATE(MMIDDNYYY) .TAMES80 02 14 O5 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SIHLE INSURANCE GROUP, INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P. . O. BOX 160398 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _ACAMONTE SPRINGS FL 32716 tone:407-869-0962 Fax:407-774-0936 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Everest National IRS CO. INSURERB: Westfield Companies 24112 aIDOS-Bland COn V/Bre_Var _I_RO'. �11"NSLRER NSURER C: -2600—KIRBY—CIR" r5 NSURERD: PALM BAY FL 32905 E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER' DATE(MMDDTIVE PDATE MMD�/YVDN LIMITS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FXJ OCCUR CWP3428993 EZ09RG030326 03/26/04 03(26Z0� 03/26/05 3/`O-26/04_ EACH OCCURRENCE $2,000,000 PREMISES(Eaow=Emnce) $2,000,000 MED EXP (My one person) $ 5 , 000 PERSONAL SADV INJURY $2,000,000 GENERAL AGGREGATE s4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICYF_j PROECT LOC J PRODUCTS-COMP/OP AGG $4,000,000 f AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY ANY AUTO AUTO ONLY -EAACCIDENT $ OTHER THAN EA ACC AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILRY ANY PROPRIETOR/ EXCLUDED? OFFICER/MEMBEREXCLUDED9 SPECdescrile under IAL PROVISIONS bat. 2700009852031 02/17/04 ,--- U,/:L- 02/17/05 0.2/17�0�6 X TORY LIMITS ER E.L. EACH ACCIDENT $500,000 E.L DISEASE- EA EMPLOYEE $500,000 E.L. DISEASE -POLICY LIMIT $500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CERBUIL CERTIFIED BUILDING CONTRAC' FAX 772-879-0110 747 SW SOUTH MACEDO PORT ST LUCY FL 34986 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. ACORD 25 (2001108) - © ACORD CORPORATION 1988