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PL-15-2391 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-258938 Permit Number: PL-9-15-2391 Scheduled Inspection Date: May 17,2016 Permit Type: Plumbing- Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: LAWSON,PETRONELLA Work Classification: Addition/Alteration Job Address:665 GRAND CONCOURSE Miami Shores, FL 33138- Phone Number (305)458-8621 Parcel Number 1132060172160 Project: <NONE> Contractor: GATOR PLUMBING OF SOUTH FLORIDA INC. Phone: (954)427-5882 Building Department Comments KITCHEN AND BATHROOM REMODEL In ractio Passed comments INSPECTOR COMMENTS False Inspector Comments Passed V1 Failed Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid Permit f to. PL-9-15-2391' �s+�ORES r, Miami Shores Village Permit Type:Plumbing-Residential 10050 N.E.2nd AvenuePerifil"t Work Classification:Addition/Alteration �• J- "�' Miami Shores,FL 33138-0000 Permit Status:APPROVED Phone: (305)795-2204 - °R`°PIssue Date:9/29/2015 Expiration: 03/2712016 Project Address Parcel Number Applicant 665 GRAND CONCOURSE 1132060172160 PETRONELLA LAWSON Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell PETRONELLA LAWSON 665 GRAND Concourse (305)458-8621 MIAMI SHORES FL 33138- 665 GRAND Concourse MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: L6,OOO.00 GATOR PLUMBING OF SOUTH FLORI (954)427-5882 Total Sq Feet: Type of Work:KITCHEN AND BATHROOM REMODEL Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Underground Fees Due AmoJOO Pay Date Pay Type Amt Paid Amt Due CCF Invoice# PL-9-15-57146 DBPR Fee DCA Fee 09/29/2015 Check#: 1738 $250.36 $0.00 Education Surcharge Permit Fee $ Scanning Fee Technology Fee Total: $25 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction andning. Futhermore,I authorize the above-named contractor to do the work stated. September 29, 2015 Authorized Si ature:Owner / Applicant / Contractor / Agent Date Building Department Copy September 29,2015 1 ri, Miami ores Village . :��rv�� SEP 21 015 J Building Department BY: � 30050 WEInd Areoua,/AibrWShores,Florida 33138. Tel.,(305)795-2204 Fay M)756-89727 1NSPSCI ON i_iNE PHOWf?#U1Vi1lit3t:") -4949 5+k FOG 2Q l q BUILDING Master PertrhNo. Z lS -woo PERMIT APPLICATION Sub Pemit No.2 L 15 — 2,3 9 � (ISUILDING ❑EUC'TRiC 0 ROOFING REVISION 0 D TTF I[ON rlRENEW j0:Pl, 9IN<; ®MkHANiM Pu LlCW0 KS CHANGE Of 0 Carnianom Q ori OOi•Ifitx WOR DRAWIN JOBA00RESS: 665 Grand Concourse C'Tttir iMlaml 3k►t`ras_.....,.. __._,. Cw�9"6: ._.jj.Wmd i2adc XIP' felfotPar�tl+f is the Building Ki9 adeallif DeskeWed:Yes�,„__Nf!_ Qctvrpwcy Type: Load, Construction TY4rt: Fbud Zor :�� f IFTL .,, OWNER:Name(Fee sir-pie TltiehoWerj: Marcus & Pea Lawson phoneii; LAg)-1&0� hddrels. 665 Grand Concourse C... Miami Shores Florida 33138 TenentAesw Narnet Frnaat: CO+ar MACmw.Cornpany lea :(7 ig. Ac6m,51 04�4! hddrrst: "i' i/ / ,v� sl�3 C� VlAr4dC�t�h y,/ �i,.� n� ( �.)h � 5. CL�. .1 faf`t City:9401 (� pry, 5tatC „ � __U0:-33_r,7 qualif#r tdarno: tlrftL� � ��>� Phanea: stat*C.e►�tf,14o +on or Aa81stmtson WC, 4�? t arcs lcara aE txnpa envy a: WSitiNER.Ardi3lerxAMirwen Pl'+onta Adldrets: City' St3ti*:, no: value o}Wor9t#or tills pemItt 3 W.,0?QQ, , s4varclunear Focifte of work- e iO WOrht ❑ Addefon F—* AIter&tico ❑wly ❑Repair/Replace ❑Demolitloo Dea6ptkut of work: Spelt color of color thrur tile:_ (3 fA1�� SuDratltlal Fee 3 _GDp r Permit Foe 2 25• ' _ CCF Caja S Scamlrgi Fee S Radon Fee 5 DOOR$ Notary S Tethnofogy Free$ Trainim/Educatloo Fee$ VoAk F*e S WuMral lte3rsews$ sand$. TOTAIL FEE NOW DUE f4vbed"0014► I flondint Compares three of aaptxat:el f l%d4 Corrpanws Addaess Glyn.. State xzp ttoftede terries Nsrr_(if'ap�lcabkl Mor%"Landot't Ad&*,.% etY SWti AF0101ton is ht reby mode to otta.n a permit to de illi work and kwACat!ons as Wkated t cerd&v tfia:roo wood or lnsttlbticn has c0mmerxad pNor t* th# fma.= of a permR and that all work wa be ptdorntad o «*et tf* standards of ad flaws w%&t* corstruction in Wn)ur:sdkC*n t utWentarW that a se"fatt rn+lt nwst bo sewrod fir ttwprR PLUM31fea, SiGvs. POOLS, FURNACES.C04M FEAMS.TAWS,AMC'0NWIONERS,ETC..... OWNER'S Ai fMAVVIT; i rtrtlfy that.atf thin Ettpotrg Irs/xrratlon fs acnnte and thAt ali work wAfif be done to oor.V.'ance Wth+eN tt-opM,able,taw%tWbtfn DoJYtl lion Ind xo.w.*. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE Of COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Abtke to Apr.-"zott; As o evne:tan to the user.#of rr bud&V Pertrf-r W-M to esttrr Wed vraW eve te, 2$2M th#aprJkvnt punt pmmfie rn Qood faith Oa*t a tipsy cf ril.e m*cv. nif carrn c+r�•Mt and constiwtim ton kw h vr.►str r. wO M dejoe►d to iho peru n whow property a srt*t to cnochr»mL Also o ceftljowd copy of the memw notroe of coir reca e"t trunt be pw.vd of the pb ire for the fnt .Mpettk-+ wwh o ws,so""11)di+lnc cjtw the bu�?"ny pev"O a rssmi 1K Me chwere of sash mfed nvtloi, the r!tsprcttxt bit 0,7mved erd a rtrL�sprc►�rr frc w�'Drs t Sytnatura,_ \" SkMatura . ._. ... .. a�%'KR or ACENN'T CONTRA`'fit The tore Inwjn nt was ackn&s*d;ed Were me ft The tareWn:incuurmrt yws acV*mv *ed before fee ft I� _.da!►of 5 11 P'� - _ _�.by S day of�5—c4vn6w io 15 W P C_ �v re l 1�ogV.cS7iYmwl+o k Vg1M N l F-'*.,n to i rt -O'A W*V N r a .wM a personacy ikat "to moor who ha s produced S. 'J as rwt of who has predated o f I�wtf:cattan and who dod tai!rt as with Jd#ntf:ratlon"who d:d take an oath, NMARY PU&UC NOYAitY PUWC: R:nt �t 0Z7� � f�rtsr'- C11"L 17r C«&-i tNo Stat A041 EVELYN ARTOLA Notary Public,State of Florida �� tit f1JLCLG ,� Commission#EE 167448 z •..,•....•.... .. .kyataatiexPi ,F.eb 7��016 ..•......... t°.q� .,i' .�, ..` �.....•.....•a. �QR ti�'f1.ht3'':FC.r�,�lfY.al''Zi1 APPROVED aY Pfana EXarra+ r lo>,ir�q StrwTursl Revkw Cerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION[ . .. CONSTRUCTION INDUSTRY LICENSING BOARD (880)487-1395 '1040 NORTH:MONROE ST-REE r TALLAHASSEE FL-82 1�'9�0783' MAGGARD, RICHARD A GATOR PLUMBING OF SOUTH FLORIDA INC 4911 LYONS TECH PKWY SUITE 96 COCONUT CREEK FL 33073 �.>':•.,---'.._',._ Marr,".„..•,' � I I •.r,:-,d;"..::._. ..y,"u:•+., s:•.M,d^:y:("o7!".'.4 1'-Y'vi},":+�'�'.k6r, Congra#ulatlonsf With this license you became one of the Hearty one million Floridlens llcenSed by the Department of Business and Professional Regulation. Our professlenals and businesses range from atchitecls to yacht brokers,from boxers to barbeque restaurants, ,s and they keep Florida's economy strong. DEI?; R7ME151 s.L�F�KI;ISINESS-AND PROFS, B N k� C.�.ULATION x. £r....,,.., Every day we work to improve the way we do business in order to CFC057457 r. serve you bettor. For irrforrnation about our services, lease too ants 4 uuwtw:I yf orid6f oense,aom. There you can find more information s CEI vi1=D P `' about our divisions and the regulations that impact you,subscribe ti. " to department newsletters sod.learn more about the Department's RA/�GGAR©,'Fl .,I''...11. „r,; ,gyp ;.:"; GATOR PLi)NM 91. : td4 ibi41N initiatives, ��.n• -: Our mliWorr at the Department is:License Efficiently,Regulate Fairly. r;- .:.` : :;.' ;,,y!: ..;, „',�L` `. • -,i We cbristant strive to serve you better so that you can serve your CG9tom'eTs. hank you for doing business In Florida, :PS'C RT0117 Und'�r':t'�i9.ptgd.l9rGrYli"[lP and congratulations on your new license) EvAilen0nte':,AUCIgi,-2016 i.fia2zscropia,na '!i!'.... ,�1•c�+rx:�a,;r'r�Mcy;c'&. .,:qr^,-�,.a`'xrgls"�p;'d+'n•,asaq:r'��'l:�p'i?T:9,.y7L1'.+T7a'�`'. DETACH HERE RICK SCOTT,GOVERNOR KEN L.AW5ON SECRETARY STATE OF FLORIDA 0E.0.AR�'liIIEN,,r Of R'IJSINESS ANIJ PROFtSSIONAL;REOULAi'iON ” •.,':' ITIS R1JCT1 i N iTrF4�<tS;TR LICENSING 130AR6 1;467457 i . Th6P UNISINOZONTRAC.TOR' ,. L;; yuridr'.I;hFt'o1s'it�rr '+aP' 'hapter'"YW,i+. 5?S x nr.5••i :'-Y'li '.rw 0 . £xprrIat,..d �er °AITO 3..1', �18 '� Q4 •4\ 4i - ��r+.'f I r" u IIt ■ w inrljakM -:14�01AR'D;.rA.`,�:' - _ •.~, ., `"�at''tq'���sY�"�Ni«'�'�; ,: "GAT PI I;th71'Bticlt��l.F�� :.,�.'',- � N• f F. "'45.11LYSMB";Ir r .4tr} c..:}`. ✓y �.d,+i d rovv ro„.'•y �,;'. `-�I”`I;�:: .,;:'air:7r,:,. .3'<�`' �.•.; �„`+: - M ° _,,.r, .,� w F•;itis:::,: ,.p''a,,, ,.. '�rt"�'��`l�i,tl"T',4vi1'E'�'IM�'+ •'I�t47, .�.r10,�„�y�J.. ;�y�,yl.: ,h•bl'yr^�Ma�•yQ1,� �. ,pw , � `�4; r •7 , r' .ra• irr ' I:•w..ia.., ISSUED: 07/n/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1407230001244 Fen—�-- ._....._ROWARD COUNTY LOCAL. BUS.I 1ESS TAX RECEIPT_-.-- S.Andrews Ave.,Rm.A-l00, Ft. Lauderdale, FL 33301-I835—954-831VALID OCTOBER 9,201.5 THROUGH SEPTEMBER30,Recelptg.-I 2-1115- GATOR FLLR�I3SidG OF SfliFI7i ?�LARIDA BuBICteSS E'lame: bn � EYP •(Plvc�irr;. v _ �:atne:RICHARD A r•AGGALRD Business Opened:101i7/19:i 4'zad=4911 LYONS TECH1JOLf5GY PICK 26 $ t��COI[n> IlCerklRe :�f?C 457E00OLTUT CREEK Exemption Code;95A-427-58 hone B2 '.v ;: .. Rooms Seats Employees fAa�hlnes Prd}Oa$fpii z. •:x .,.-_• 10 Fw Veering 6ss usk[eOn[y Z. Humt►er of Machines: Vend[ng Tali Art161ln1 TreRsfer Fee tdS .Penalty F�fiaf ' fS Cb Wi=Gojd?' 7otal:Fi:'i�_:.:.'.," THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF Bt7.61W86 THIS BECOMES A TAX RECEIPT This tax is levied for the privilege ot`doing business Wmn Brcr ;.:4:;::;:. non-regulatorynDn-regulatory in nature.You must meet.all County andfor Muftici and zoning requirements. This Business Tax Receipt musk be- WHEN VALIDATED Y a'•cv.a e, the business is sold, business Warne has changed or you' ave. ove _ r _ business iocation.This receipt does not indicate that the btisirissealrat, it is in compliance with State or local laws and regulations. Mal[Ing Address: GATOR PLumI3ING OF SOUTH FLORIDA IN Receipt fWW-14-00k . 4911 LYONS TECHNOLOGY PKY 25 #*aid 07/09/2015W. COCONUT CREEK, FL 33073 2015 - 2016 City Of Coconut Creek B USMESS TAX RE'CEZPT Nam@ of Business: GATOR PLUMSING OF SO FLORIDA Buslncss ID: 0.90000.010''6 BUST»ass Address: EXPIRES.9/30/201,6 4911 LYONS TECHNOLOGY PKWY STE 426 COCONUT CREEK,FL 33073 oevetopment Name: LYONS TECHNOLOGY IV Zoning CertlflcoCe.pn; 1J15/ Q04 CONTRACTORS':OPFICE IN CITY W./CERTIFICATE OF COMPETENCY PLUMBING'CD'NTRAGTCrR 052500• L0400077.'1':'.'..X.53:la IrkPrflpt Amt: .00 beJrrrquen.t tiMt: on "Ntl8fcr Ak: 00 TOTAL TAX: 153.14 BUS'INESS:TAX RSCBIPT AND 70NING.CERTIFICATE MUS7'bt _ GCJWSPICiICYtJSL,Y.WSPLA'YEb FOR PUBLIC VIEW AT BUSINESS LOCATION. 5Ust�in� a De�vel©peri. . Licslgned - CERTIFICATE OF LIABILI UNS;URANCE D9/i0920i5 TS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE IS ISSUED AS A MATTE - THIS R OF INFORMATION ONLY ANDSND NORF�ASLR RAE COVERAGE AFFORDED f3Y THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR DOES NOT C AMEND, AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTRUTE A CONTRACT BETWEEN THE ISSUINti INSURER(3}, REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IS IMPORTANT: M the certfficate holder Is an ADDITIONAL INSURED,the Policy(Ies)must be endoread. If SUBROGATION sit this certificate does noo WANED,subject to the terms and conditions of the Policy,certain policies may require an endorsement. A swemrnet confer rights to the certificate holder In Ileu of such endo s �RDDUCER N NNOVATIVE INSURANCE PHONE NO IONSULTANTS,INC. ai UNIVERSITY DRIVE,0103 ,ORAL SPRINGS,FL 33057 GATOR-2 IRIANJ.MAMO *aU 3AFPOROINOCsvERAGE Nass NSW" GATOR PLUMBING OF SOUTH INSURER A:ASSOCIATION INSURANCE CO. 11240 FLORIDA, INC. IN3UREto: 4911 LYONS TECHNOLOGY PKWY#26 uasURERc; COCONUT CREEK,FL 33073 INSURER 0: I INSURER E: I INIURER F COVERAGESCERTIFICATE NUMBER. REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAKED ABOVE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT UVI H RESPECT TO WHICH THIS C INDICATED. NOTWITHSTANDING iES,DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE AMY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POU EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLOVIS.EXP LIMnE am Su NSR1 TYPE OF INSURANCE vvOl ma POLICY NUMBER M 3 A30. LTREACH OCCURRENCE GENERAL LIAetLITY LP0144864-02 03920t20i 5 0392092015 M s t A ocwrm a' A X COMMERCIAL GENERAL LYIBILRY MEo Exp are ram SCLAIMSMIADE OCCUR X BKLT ADDL INSD PRIMARY S PERSONAL a ADN wxxtY a Id.CONTRIBUTORY GENERAL AGGREGATE a 2,000, X BLKT WAVER 2,000, PRODUCT8•COMP/OP AGG b GERL AGGREGATE LIWT APPLIES PER: S POLICY X PRo LOC COMBINED SINGLE LINT S AUTOMOBILE LIA NLITY (EaSC*ea�J ANY AUTO BODILY INJURY(Per PWSW)_l a ALL OWNED AUTOS BODILY INJURY(Per ialdenl) S SCHEDULED AUTOS PROPERTY DAMAGE S (PER ACCIDENT) HIRED AUTOS S NON-OWNED AUTOS tS X UMBRELLA LIAa X OCCUR EACH OCCURRENCE 3 1,0m, I EXCESS �pE 1,000, 000 A ESS UAa UMB0193158-00 OM1M2016 03/2092016 AGGREGATE � DEDUCTIBLE I RETENTION WORIOM COMPENSATION X Y;IC STATU X OER TR AND EMPLOYERV LIADILITY Y f N �05693-04 0GM312016 05913/2016 EL EACH ACCIDENT 3 1.000.00 A ANY1ICER�MBER E)CLUDED7 F-1NIAEL DISEASE.EA EMPLOYE a 1,x,00 1 ( dMvin ") below EL DISEASE.POLICY L.MtR a i,00,00 ' i r P WTION OF OPERATIONS I LOCATIONS I VEHMM(Ana ACORD 101,AdtatlorW Reaurle aa++duK K mon nf.o.in rwA*m ) 305-756.8972 C ICATE HOLDER CANCELLATION M1AMI22 SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER IN ACCORDANCE WITH THE POUCY PROVISIONS. CITY OF MIAMI SHORES BUILDING DEPARTMENT AUTVAXt M REPRE3ENTATNE 10060 NE 2ND AVENUE MIAMI SNORES,FL 33198 , 0 JM-IM ACORD CORPORATION All rights reserved. ACORD 25(2009/09) - The ACORD name and logo are registamd maNts of ACORD Da �'L !,� - Z��� �,,C5" OP ID: HP A1164 D CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDIYYYY) 04/12/2016 7 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 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 endorsemen s. PRODUCER CONTACT INNOVATIVE INSURANCE NAME: CONSULTANTS,INC. PHONE FAX 5461 UNIVERSITY DRIVE,#103 {E Mai Ext) -- ..... . — — CORAL SPRINGS,FL 33067 . AODREss...._..._._......__---.---.--------....__..........._......_...___. ... _ "............................._........... ._..---... PRODUCE .. R BRIAN J.MAMO GATOR-2 CUSTOMER lD n: -- _ INSURER(SLAFFORDING GOVERAGE i NAIL 8 INSURED GATOR PLUMBING OF SOUTH INSURER A:KINSALE INSURANCE COMPANY 38920 FLORIDA, INC. _ _ SUNCOAST AIR CONTRACTOR, INC INSURER 13:COMMERCE&INDUSTRY/CHARTIS 19410 4911 LYONS TECHNOLOGY PKWY#26 INSURERC:AMERICAN BUILDERS INS.CO. 111240 COCONUT CREEK,FL 33073 INSURER U� INSURER E: INSURER F: ---- COVERAGES CERTIFICATE NUMBER: 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. i4Stt ... ............_...__. f10bL SU R. _—__ . .. .. _..--------- _". LTR TYPE OF INSURANCE POLICY EFf PQLICY EXP; __ POLICY NUMBER M D/YYYY i MMJDDNYYY ' LIMITS A X <COMMERCIAL GENERAL LIABILITY ) € EACH OCCURRENCE is 1,000,00( GENERAL LIABILITY 10100036815.0 03/20/2016 03/2012017;„EAraaGE"ro R iJT€D"' — --' EACH OC occurcence) $ 100,00( CLAIMS-MADE X OCCUR — ` PERSONAL 8 ADV INJURY S EXCL MED EXP(Any one person) $ I X N BKLT ADDL INSD PRIMARY& 1,000,00 — — _. X BLKT WAIVER .__ _......_..............._ _._ ' NON-CONTRIBUTORY GENERAL AccRECATE $ 2 000 00- ..... . GF.N't.AGGREGATE LIMIT APPLIES PER j PRODUCTS-COMP/OP AGG $ 2,000,00 II PRO- �^ ............--.._................_...._.__...._.._..._.._..._...._...;...._........_................ _ —-- ;POLICY X " LOC ) I I is ( AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO _..... ALL OWNED AUTOS ; i BODILY INJURY(Per person) $ I BODILY INJURY(Per accrdent) $ SCHEDULED AUTOS I PROPERTY DAMAGE HIRED AUTOS $ER ACCIDENT} — , NON-OWNED AUTOS $ m I $ UMBRELLA UAB _X OCCUR EACHOC................ —. _... _ X i EXCESS LIAR CLAIMS MADE; AGGREGATE is 1,000,00B B -' -""- - BE026141466 03120/2016 03/20/2017` — DEDUCTIBLE $ RETENTION $ — — -----� ;$ WORKERS COMPENSATION X t WC STATU X OTH ANO EMPLOYERS'LIABILITY Y!N ! _...�.SZY_Llt+'tIIS LR i. ._ .._... -_ ..„ C 'ANY PROPRIETORIPARTNER/EXECUTIVE C 'WCV0106593-04 06/13/2015`06/13!2016 E.L encH ACCIDENT '$ 1,000,00 OFFICER/MEMBER EXCLUDED? N t A z —�_.__.._.... .... (Mand tory in NH) E,L DISEASE-EA EMPLOYEE[$ 11000,00 It yes,describe under E L.DISEASE-POLICY LIMIT ,$ 1,000,00 I DESCRIPTION OF OPERATIONS below i((I I I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CFC057457 CERTIFICATE HOLDER CANCELLATION MIAMI22 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF MIAMI SHORES ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT 10050 NE 2ND AVENUE AUTHORIZED REPRESENTATIVE MIAMI SHORES,FL 33138 fj' �7 O 1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD