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PL-16-1084 IM Miami Shores Village Tye Plum 1900 doi tilal 10050 N.E.2nd Avenue NE Miami Shores,FL 33138 0000 ttYi Cl #bfC 1�dditic 1V ratan Phone: (305)795 2204 a3x NOW �P��VE ioxivf' 'R gate 6� Expiration: 11/06/2016 Project Address Parcel Number Applicant 42 NE 96 Street 1132060130640 Miami Shores, FL 33138- Block: Lot: LUNI USA LLC Owner Information Address Phone Cell LUNI USA LLC 235 LINCOLN Road MIAMI BEACH FL 33139- 235 LINCOLN Road MIAMI BEACH FL 33139- Contractor(s) Phone Cell Phone Valuation: $ 4,850.00 NORTHWEST PLUMBING INC (786)586-5203 (305)986-1157 _. _.. .,.... .. _ _ Total Sq Feet: 0 Type of Work:REPLACE SOME EXISTING PLUMBING FIXT Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning: 1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.00 Invoice# PL-4-16-59499 DBPR Fee $3.38 04/21/2016 Credit Card $50.00 $417.76 DCA Fee $3.38 Education Surcharge $1.00 05/09/2016 Credit Card $417.76 $0.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $4.00 Work without Permit Fee $225.00 Total: $467.76 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 AFFID IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and oni g. Futhermore,I authorize the above-named contractor to do the work stated. 4, fV May 09, 2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy May 09,2016 1 Miami Shores Village 7BY R. 2 22016 Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 �, Q INSPECTION LINE PHONE NUMBER:(305)762-4949 �t FBC 20N BUILDING Master Permit No.RC-16-337 PERMIT APPLICATION Sub Permit No. — 109 F-IBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION EJ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 42 NE 96th Street City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-013-0640 Is the Building Historically Designated:Yes NO X Occupancy Type: R-3 Load: Construction Type: IIB Flood Zone: X BFE: N/A FFE: OWNER:Name(Fee Simple Titleholder):LUNI USA, LLC Phone#: Address:235 LINCOLN ROAD #310 City: MIAMI BEACH state: FL Zip: 33139 Tenant/Lessee Name: N/A Phone#: Email: CONTRACTOR:Company Name: NORTHWEST PLUMBING REPAIR SERVICE Phone#: 305-970-3500 Address: 15847 SW 68 TERRACE City: MIAMI State: FL Zip: 33193 Qualifier Name: EDUARDO SABINA Phone#: State Certification or Registration#: CFC#1428177 Certificate of Competency#: DESIGNER:Architect/Engineer: ROBERT KIRCHGESSNER Phone#: 954-980-4430 Address:1835 E HALLANDALE BEACH City: HALLANDALE BEACH State: FL Zip: 33009 Value of Work for this Permit:$4850.00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/Replace ❑ Demolition Description of Work: REPLACE SOME EXISTING PLUMBING FIXTURES. Specify color of colon thru tile: Submittal Fee$ �.J� Permit Fee$ r CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ :3*36 Notary$ Technology Fee$ 00 Training/Education Fee$ �' Double Fee$ el �� Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S 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 and zoning. "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." Notice to Applicant: As a condition to the issuance of a building permit with on estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature r �—�' �— Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrum nt was acknowledged before me this 10 day of 20 J.h by I Q day of ` 20 1 by r �, ,e,,r�.r Pj �, ,who is personally known to a �.� �(li�who is personally known to ,,.�s me or who has produced � � as me or who has produced_ L as identification and w o d take an oa . identification and who ' take an oath. NOTARY P'SUC: NOTARY PUBLI Sign:Sign: Y C M Print: •• Print: FF979492 rtrlp 16'ZUZ9 ' Maroh 48Seal: Seal: LKptB ,ZOZO v18q Imn APPROVED BY ®"/,/I� Plans Examiner Zoning Structural Review Clerk I (Revised02/24/2014) 0 • � nn1%.J Miami Shores Village -- ,���� Building Department rLEB 0 2016 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 J Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 F B C 20 I`j s� BUILDING Master Permit No. 0,C cJ�� PERMIT APPLICATION Sub Permit No. ®BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑'RENEWAL ❑X PLUMBING ® MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 42 NE 96th Street City: Miami Shores County: Miami Dade Zia: 33138 Folio/Parcel#: 11-3206-013-0640 Is the Building Historically Designated:Yes NO X Occupancy Type: R-3 Load: Construction Type: II B Flood Zone: X BFE: N/A FFE: 12.99 11.50 low OWNER:Name(Fee Simple Titleholder): LUNI USA, LLC Phone#: Address: 235 Llincoln Road#310 city. Miami Beach State: FL Zip: 33139 Tenant/Lessee Name: N/A Phone#: Email: CONTRACTOR:Company Name: Moonlight Editions, Inc. Phone#: (954)980-4430 Address: 1835 E Hallandale Beach Blvd#736 email: robfk@bellsouth.net city: Hallandale Beach State: FL zip: 33009 Qualifier Name: Robert Kirchgessner Phone#: (954)980-4430 State Certification or Registration#: CBC 060255 Certificate of Competency#: DESIGNER:Architect/Engineer: Robert Kirchgessner Phone#: (954) 980-4430 Address: 1835 E Hallandale Beach Blvd#736 city.Hallandale Bch State: FL Zip: 33009 Value of Work for this Permit:$ 56,100.00 Square/Linear Footage of Work: 2,564 sf Type of Work: El Addition ❑X Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Interior Renovation:Replase plumbing fixtures,-add-Fighting;partially remove a few non-load bearing walls, new floor&wall finishes, replace existing exterior windows and doors, new kitchen & bath cabinets and fixtures, Specify color/�of color thru tile: r;- _M Submittal Fee$ -M ' � Permit Fee$ I,6 83•M CCF$ 4 CO/CC$ �o r Scanning Fee$ 2-44 • n Radon Fee$ 2S• ZS DfB'PR$ 2 S• 2_ Notary$ �P" Technology Fee$ G 0 Training/Education Fee$ Double Fee$ G Structural Reviews$L2d•aj- (20.0i) k 2®•00 Bond$ TOTAL FEE NOW DUE$ :30 -4 44) " (Revised02/24/2014) i Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name((f applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the Issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S 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 and zoning. "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." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500,the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature —` Signature4 OWNER or AGENT "CONR The foregoing instruMent was acknowledged before me this The foregoing instrument was acknowledged before me this day of t��J�r. 20 ( f® by day of Q L—QC,—,Y- 20 �� .by lip `wm � who is personally known to Law �@ who is personally known to me or who has produced as me or who has produced 1 I��Z'L`$lnb" Z'O6�Oas Identification and who did take an oath. identification and who did take an oath. NOTARY PUB NOTARY PUBLIC: 1 1 -7)- Sign: Sign: i LWORM-gruan 4f Print: Print: ommissioF1 I n d EE t 75001 Seal: ; � IF Commission#EE 175001 Seal: '<• ., •' ''tv.Commission Expires My Commission Expires rt 1 4 2016 March 01. 2016 $� "' ."""''.. .,.. ^*• r*#s##r#s*#s**s#errs#*s*sr#asst * *# ##*r#*ss#s#ars*•s*#***ss*#s*#r*rasa*#**#**#####*###***#***#*****r**s# APPROVED BY Plans Examiner Zoning ! Structural Review Clerk (Rev1sed02/24/2014) ' Detail by Entity Name Page 1 of 2 v Detail Entity Blame Florida Limited Liability Company LUNI USA LLC Filing Information Document Number L15000090453 FEI/EIN Number NONE Date Filed 05/21/2015 Effective Date 05/21/2015 State FL Status ACTIVE Principal Address 235 LINCOLN RD STE 310 MIAMI BEACH, FL 33139 Mailing Address 235 LINCOLN RD STE 310 MIAMI BEACH, FL 33139 Registered Agent Name &Address CECCHINI, FRANCESCO 235 LINCOLN RD STE 310 MIAMI BEACH, FL 33139 Authorized Person(s) Detail Name &Address Title MGR SERAFINI, LIVIO 235 LINCOLN RD STE 310 MIAMI BEACH, FL 33139 Title P TONI, LORIS 235 LINCOLN RD STE 310 MIAMI BEACH, FL 33139 Title S SEMPRINI, GIOVANNI http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 2/5/2016 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850)X487-1395 1940 NORTH MONROE STREET ; TALLAHASSEE FL 32399-0783 IORCHGESSNER,ROBERT FRANCIS MOONLIGHT EDITIONS INC 1835 EAST HALLANDALE BEACH BLVD SUITE#736 HALLANDALE FL 33009 CongratulatWns! With this license you`F6coine`one`ofibe nearigr one rnitfion loddlans licensed by the Department of Business and Prot Regulation. Our professionals and businesses range STA71F QFLEtIDA'; from a to yacfit brokers,from boxers to bart�ue restaurants, DePARTME BUSINESS AN0 s and they ked Florida's economy strong. PR, F ULA'nON ' - serve we For improve am our ices please ler to s CB+C06f3255 �1}St 1i2Q1 a yflorkWi meow. Thein®you can more information � CERTIF#ED vnnm about our dI'utstorts and the reguiatlons that impact you,subscribe IC RC�HGE ; to department newsletters and learn more about the Department's initiatives. _ e w� Our mission at the Department is:License Efficlently,Regulate Fairly. x` ` We constantly strive to serve you better so that you can serve your customers.:'Thankyou for doing business in Florida, �rvv�alprta`ar s�rr;aas� and c ongrs*jl"ons'on your now license! ,,.cups?.;V16 fh 3 DETACH HERE RICK SCOTT,GOVERNOR (CEN LAWSON,SECRETARY _. r STATE OF FLORIDA WARIMENT OF BUSINESS AND PROFE�S$1 LtREQULATI0N C 3NSTRUC7'IEQ*INDUSTRY LICENSING BOARD Z" The BUI' NO CO C'OR N IS CERTIMED X Y E�goian AU631 �,....-•. J .tom � { xt ... � z ISSUED: OsMv2014 DISPLAY AS REQUIRED BY LAW SEct# L1408310003074 From:GFI FaxMaker To: 19546137224 Page:2/2 Date:1/20/2016 8:55:20 AM Client#:100502 MOOED DATE(MMIDD/YYYY) ACORD., CERTIFICATE OF LIABILITY INSURANCE 1/20/2016 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 pol)cy(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 endorsement(s). PRODUCER cT Certificate Department Advanced Insurance Underwriters,LLC 954 416 9780 FAX No): 954 963 9776 3250 N.29th Avenue ADDRESS: certificateofinsurance@advancedins.com Hollywood, FL 33020 INSURER(S)AFFORDING COVERAGE NMC# INSURERA:Essex Insurance Company 39020 INSURED INSURER B: Moonlight Editions,Inc. INSURERC: 1835 E.Hallandale Beach Blvd. INSURERD: #736 INSURERE: Hallandale Beach,FL 33009 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 CONTRACTOR 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. LTRR TYPE OF INSURANCE IN RL p POLICY NUMBER POLICY EFF MPN N)D� LIMITS A GENERALLIABILITY 3DX9829 2412015 02/2412016 EACH p�OECCCUUR�RENCE $1,000,000 NED X COMMERCIAL GENERAL LIABILITY PREMISES(EaEoccu.nce) $100,000 CLAIMS-MADE D OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded:500 PERSONALS ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2,000,000 X POLICY PEC LOC $ AUTOMOBILE LIABILITY Ee acciden SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I i RETENTION$ $ WORKERS COMPENSATION WC TCRY I IM11TU. ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N 1 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DE IPTION OF OPERATIONS LOC TIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more apace is required) CERTIFICATE HOLDER CANCELLATION City of Miami Shores SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE .� n1ot64G2lJetC¢ /�Su�auv+ i/--1-4./ ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #R133A57A/M19Q"fi9 AFI1 This fax was sent with GFI FaxMaker fax server. For more information,visit:http://wvwv.gfi.com JEFF ArWAlER CHIEF FINMICUL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be elempttom Florida Workers'Compensation law. EFFECTIVE DATE: 2/20=15 EXPIRATION DATE 2/19/2017 PERSON: MRCHGESSNER ROBERT F FEN: 650759480 BUS99W NAME AND ADDRESS: MOONLIGHT EDITIONS INC 1835 E HALLANDALE BEACH HALLANDALE BEACH FL 33009 SCOPES OF BUSINESS OR TRADE- LICENSED RADELICENSED BUILDING CONTRACTOR Parauara4 Cfmmter MQOS(14).F.S.,an a46ea d e carpare0im Wm deeffi mrenptlan tromtlda dmpta iw6Urig a eatl6ode of dectlan iaMer tlda aecHm mayrmtreawa ar carpematlon umler Oda d�t4a Piasuardto Chapter 44405{12),F.S.,CeA cffiea ofdec0an to heamrpt_ap{dY�Y WOdnOr aoapedOre hoi�reas artredellsted an 9a3 ro0ae afdeellan fo bem�pt.PuamnttaCh�p�440.05(13).F.S..NoOcea ofdac0on to be maertpt and ea00teGes oldee0antahe a eha0 besW�jeetm rewe�m If,at mryEme after Oreftlin9 ofOm'wtlee ar Ore isauarxe oT9re ceNOcate, Omparsonemmed an 6m ra�0aa ar eeOGcete rro larger meets Ore ragWremenm of Oda aec0on far ias�ranee ofa amUBcma The departrrcnt aha0 rewlm a ,1 DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEWT REVISED 08-13 QUESTIONS?(650)4131809 t .,.. Ulu Miami shores Village or� Building Department g01131Dg' 10050 N.E.2nd Avenue Miami Shores., Florida 33138 Tet: (305)795.2204 Fax: (305)756.8972 Notice to Owner — Workers' Com ensation Insurance Exemption i' w t M � i •, A_ 3 9 .r:,a- ,ttS�ra.,•� .�%.rr. ,�;�� tet.-. �5m�Z; -,3 >r,r�' ,.st., .3 .,, 'yF �.�. ;.s. ?"� ���;n r. FloridaLaw requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers'compensation coverage. Corporate officers or members of a limited liability company(LLC) in the construction industry may elect to be exempt if. 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor„part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors.. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature mer State of Florida County of Miami Dade The foregoing was acknowledge before me this_ day of ,20 [£. By IL"y(_t°1(Ae S C'W e;y- who is personally known to me or has produced tLA 1A 1 ,6— —D I-ti _0 as identification. No �o"" o a� VICTORIA ROSADO SEA 3• " Commission A EE 175001 yry�y'�Pan�"A My Commission Expires March 01, 2016 o n� Construction/Renovation Contractor Lic#CBC 060255 MOONLIGHT EDITIONS INC. Date: 2 ! .4 ( 1 � State Of County of Before me this day personally appeared iUe44 k i P.. (R6AsS-Wwho,being duly sworn,deposes and says: That he or she will be the only person working on the project located at::2 lj� �""e-- ���-e s , 1. 3 3 r<'3 g . �� I �'� � I l -3 Z o b _p Sworn to(or affirmed)and subscribed before me this day of -� tu-��f ,201A.,,by Personally know OR Produced Identification Type of Identification Produced- 6 A6 roduced 6A6 VICTORIA ROSADO commission#EE 175001 My Commission Expires .� 16 March 01, 20 Print,Typor Stamp Name of Notary r 1835 E. liallan&,le Reach Rlv d From: GFI FaxMaker To: 13057568972 Page: 2/2 Date:4/22/201611:35:15 AM Client#: 100502 MOOED DATE(MM/DD/YYYY) ACORD.: CERTIFICATE OF LIABILITY INSURANCE 04/22/2016 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 endomement(s). PRODUCER cT Certificates Department Advanced Insurance Underwriters,LLC 954 963-6666FAX 3250 N.29th Ave ac,No,Ext: (A/c,No): 954 964-1438 ADDRESS: certificates@advancedins.com Hollywood, VWL FL 33020 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Essex Insurance Company 39020 INSURED INSURER B: Moonlight Editions, Inc. INSURERC: dba RK Builders, Inc. INSURERD. 1835 E. Hallandale Beach Blvd.#736 Hallandale Beach,FL 33009 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 CONTRACTOR 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 ADDLSUBRPOLICY EXP LTR TYPE OF INSURANCE INSR D POLICY NUMBER M/DD MMMDIYM LIMITS A GENERALLIABILITY 3ED5485 2/24/2016 0212412017 EEAACCHp�OECCCUR��RENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ee oNTE1 nce $100 000 CLAIMS MADE I OCCUR MED EXP(Any one person) $5,000 X BI/PD Ded: PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,0001000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $1,000,000 X POLICY PELT LOC $ AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Persecident $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? El N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Contractor License#CBC060255 CERTIFICATE HOLDER CANCELLATION City of Miami Shores SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE A�riancacr!cy'ouuu�stcse aAa4VI-1 1 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #R1 AAARA1/M1 A&QAAA NAR This fax was sent with GFI FaxMaker fax server. For more information,visit: http://www.gfi.com Kc, 16 MUWAKI 00 1 FLA _r 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 ORA: Recelpt#:180-6508 MOONLIGHT EDITIONS INC GENERAL CONTRACTOR (GENER4 Business Name: Business Type:CONTRACTOR) Owner Name:ROBERT KIRCHGESSNER Business Opened:07/20/2000 Business Location:1734 WILEY ST B State/County/Cort/Rog:CBC060255 HOLLYWOOD Exemption Code; Business Phone:954-480-9257 Rooms seats Employees Machines Professionals 2 For Vending Business Only Number of Machines: Vending Type: tA Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 6.75 0.00 25.00 58.75 u4 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not Indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: ROBERT KIRCHGESSNER Receipt #05C-15-00002075 1835 E HALLANDALE BEACH BLVD Paid 02/09/2016 58.75 #736 HALLANDALE, FL 33009 2015 . 2016 all