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PLC-16-1565 'L c ""CEI v D Miami Shores Village JUN 06 2 16 Building Department BY: 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 5+41 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20iq BUILDING Master Permit No. lie., PERMIT APPLICATION Sub Permit NO.Ar I6- I5� ❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL LUMBING ❑MECHANICAL ❑PUBLIC WORKS ❑CHANGE OF ❑CANCELLATION ❑ SHOWINGS r CONTRACTOR JOB ADDRESS: /" SU S+' d City: Miami Shores Coun : Miami Dade Zip: 331 3 O Folio/Parcel#: 11-32C(O_413—3r�J � Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(fee(�S im`ple Titleholder): (,Ci Phone#:.3,-5-7 51 -�Z�✓2 Address: SO I 'v � 7ip:33/3 City: State: C kt L Phone#3t-s-gtOS'0 Tenant/Lessee Name: VQ Qr�rn Email: I/e a✓ CONTRACTOR-Company Name: Phone#:����✓� State:_ — —Zip'-a:a Z222 City: Phone#: Qualifier Name: State Certification70rRegistration# Certificate of Competency#: DESIGNER:Architect/Engineer: V1(4Dr J �--R� Phone#: 05'"3 IO-S030 11 `- 3-3/.3 Address: 3�] �� 1c>1 ST• —City:91; r97r 5 State:�Zip Value of Work for this Permit:$ � �(� Square/Linear footage of Work: ❑ New ❑ Repair/Replace El Demolition Type of Work: ❑ Addition Alteration Description of Works Specify color of color thru tile: •� Permit Fee$ y�i CCF$ 3- (1", CO/CC$_ Submittal Fee$ 2 Scanning Fee$ 3 2L _Radon Fee S� 3�• _ DBPR$3• Notary$ Technology Fee$ T�1�!—Training/Education Fee$ / R1 _Double Fee$ Bond$ ,0Structural Reviews$7— TOTAL FEE NOW DUE$ IC1�-=.=J — (gcvmed02/24/2014) 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 ail 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 musr promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person i whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site j for the first inspection which occum-seven (7) days after the building permit is issued. In the absence of such posted notice, the t i inspection will not-be � and a reinspectn fee will be Charged. t wCe Si re f , WN R or AGENT CONTRACTOR The fora going instrument was acknowledged before me this The foregoing instrument was acknowledged before me this i 0 _day of20 1 (.O by day of_L"� 20 _,by y who is personal! known to �(A �JG7 i �J who is personally known to �� � ��r-r•`- me or who has produced as me or who has produced as identification and who,did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARI�P Sign: Sign. On _ Print: .: a4 BARBARA R MEDINA * 9 Print: r r=o ........:� ; '�4 ELIZABETH ELORRIAGA Seal: 1" MY COMMISSION#FF00162T Seal: a. ;ar My COMMISSION#FFM538 -.;'�aF�o!,` EXPIRES March 21,2017 ••• EXPIRES January 25.2020 (407)398.0153 Floridallota Service. 1.0/I.lAA�'�1 s. ssssssssrsssss sssss sssassssssssssssssasssss APPROVED BY Plans Examiner Zoning t Structural Review ae6 i €Rer2124/2614} Permit NO. PLC-6-16-1565 SNORES Miami Shores VillageM Permit Type:Plumbing-Commercial 10050 N.E.2nd Avenue NE ' Work Classification:Addition/Alteration Miami Shores,FL 33138-0000 Pen Phone: (305)795-2204 Perrr,it Status:APPROVED �LONut IOp' Issue Date: 1112912016 Expiration: 05/28/2017 Project Address Parcel Number Applicant 9501 NE 2 Avenue 1132060133920 Miami Shores, FL 33138- Block: Lot: DVS LLC Owner Information Address Phone Cell DVS LLC 9400 NE 2 Avenue (305)756-3711 MIAMI FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 4,100.00 RC PLUMBING CONTRACTOR LLC (754)235-3828 Total Sq Feet: 0 Type of Work:RELOCATE TOILET DRAIN;RUN WATER LI Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Classification:Commercial Re Pipe Scanning: 1 Main Drain Heater Water Service Final Water Main Lavatory Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.00 DBPR Fee Invoice# PLC-6-16-60079 $3.38 06/06/2016 Credit Card $50.00 $ 192.76 DCA Fee $3.38 Education Surcharge $1.00 11/29/2016 Credit Card $ 192.76 $0.00 Permit Fee $225.00 Scanning Fee $3.00 Technology Fee $4.00 Total: $242.76 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. November 29, 2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy November 29,2016 1 STATE OF FLORIDA _ DEPARTMENT CSF BUSINESS PROFE$Sl . REGULATION sY FC1429033 06/04/2014 CERTIFIED P w p CRESPORA .. RC PLUMBING Y a IS CERTIFIED under the provisions of Ch .. 89 FS . Expiration date : AUG 31 , 2016 LI 1587 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT ABILL-DO NOT PAY 7169753 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES RC PLUMBING CONTRACTOR RENEWAL SEPTEMBER 30, 2016 LLC 7448494 201 WEST PARK DR 206 Must he riiso1a�'P.V at rlar�+ ;f t,`fµsiness Pursuant to County Code MIAMI, FL .s�'l72 Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS RC PLUMBING CONTRACTOR LLC PAYMENT RECEIVED 196 PLUMBING BY TAX COLLECTOR CIO RAFAEL CRESPO CONTRACTOR 75.00 08/18/2015 Worker(s) 1 CFC1429033 FPPU06-15-016143 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holders qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 8e-276. 't a�DE For more information,visit .miamidade.govAugollector l A CERTIFICATE OF LIABILITY INSURANCE DAT05111/05/11/201166 DI 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(les)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 CONTACT NAME: GISELLE GONZALEZ Triumph Insurance Inc PHONE (786)362-6204 A/c No 7481 SW 8stE-MAIL ADDRESSR biumphinsurance@yahoo.com Miami,FL 33144 INSURE S AFFORDING COVERAGE NAIC# Phone (786)362-6204 Fax INSURER A: ASCENDANT INSURANCE COMPANY INSURED INSURER 6: RC PLUMBING CONTRACTOR LLC IN RER C: 201 W PARK DME APT206 INSURER 0: INSURER E MIAMI FL 33172 FL 33172" 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 CLAMS, INSR TYPE OF INSURANCE ADD UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMI M LIMITS © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000.00 ® CLAMS-MADE Q OCCUR DAMAGE TO RENTED 30O OOO.00 PREMISES Ea occurrence) $ X ❑ GL-47524-1 04/20/2016 04/20/2017 MED EXP(An one person $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 300,000.00 GEN'LAGGREGATE LMITAPPLIES PER: GENERAL AGGREGATE $ 300,000.00 ❑ POLICY ❑ JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 300,000.00 OTHER BVPD DEDUCTIBLE $ 500.00 AUTOMOBILE LIABILITY COMBINED SINGLE LMR Ea accident) ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ ALL AUTOS OWNED ❑ SSCOESULED BODILY INJURY(Per accident $ ❑ HIRED AUTOS ❑ NON-OWNED PROPERTY AGE $ATOSkent) ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ EXCESS LIAR ❑CLAMS-MADE AGGREGATE $ DED ❑ RETENTION $ WORKERS COMPENSATIONEl STA TEPER f EOR EMPLOYERS'LIABILITY Y/N TU t ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ A yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) COMMERCIAL&RESIDENTIAL PLUMBING. POLICY IS IN AN ACTIVE STATUS AND HAS BEEN PAID. INSURED CONTRACTOR LICENSE NUMBER:CFC 1429033-RAFAEL CRESPO. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2 AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE GG ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101)OF The ACORD name and logo are registered marks of ACORD 2SW6 Report Viewer JEFF ATWATER CHIEF FINANCIAL 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 cortifles that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 4/27/2016 EXPIRATION DATE: 4/27/2018 PERSON: CRESPO RAFAEL FEIN: 465026543 BUSINESS NAME AND ADDRESS: RC PLUMBING CONTRACTOR LLC 201 WEST PARK DR 11206 MIAMI FL 33172 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pur•uwt b cnevb►.�a o0I+4.F.�.�oAlo•r d a oarpar•Ion who a•p•arsnpran eom w.at+aprr��Ilnp•arlMero d aeetlon udr Ws•ecYan whinh•ocaaop•d h Oriwalro i a re0 Iird on tai•eoYw of a «a o•Cvs+b cri•Cp�M►aa06(d13a bHw°io••d ecYb b •�smp and o.►aeaM.d a•oran q a•MarnM•lal a aubl•or b r•rooalan H,at ary fm•aIr tlr Inp d IIr natio•ar dU Is•una d rr aalMlal•, CM VMaon named Crl fq ndu a o•r0110at•rp lenpor m••Ir ihs r•q�lr•m•nIt d Ha wotlon rot luwre d a oatlaca�•Th d•DaranarM•hell revdce a OFI'J-n-CWC-292 CaRTIFICATC OF ELECTION TO BE EXEMPT REVISED 0813 t]l,lE3TWNS?(E60)4131>ti ORES s� �- Miami shores Village "gs - Building Department artment "FN `S 10050 N.E.2nd Avenue IQRIDp' Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law 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— OU—AC-KNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. � Sign e: wn r V. S. C-4 c. State of Florida County of Miami-Dade The foregoing was acknowledge before me this ';;G1 day of 120_L_oo By ` kt:&tr 2 S Q YVI i S.P who is Personally known to me or has produced as identification. ,y�e'i" ELIZABETH ELORMAGA Notary: t'`�- a�— '= MY COMMISSION#FF953536 EXPIRES January 25.202o SEAL: i�o�i iai;-0 ,a Fk,;o,Na, RC PLUMBING CONTRACTOR LLC CFC 1429033 201 W Park Drive#206 Miami, FI 33172 Phone: 754-235-3828 Email: rcplumbinaccontractor&P-mail.com State of Florida DATE:6/1/2016 Miami Dade County Before me this date personally appeared Rafael Crespo who, being duly sworn, desposes and says: That Rafael Crespo will be the only person working on this project located at 211 NE 95St,Miami Shores. FL 33138 Rafael Crespo (Qualifier) Date v S!Fnlwi N FELDIYIAN MY SSION#FF902928 ,��, S July 23,2019 1(407)3gs.p+� ga oom )ddonat r Notary Stamp Date SNoREs �.qe J ,.in.?" Miami Shores Village Building Department ZOR 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. OPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: I ZZ d . BUSINESS ADDRESk, r- `� L�, .L�f��CITY T STATS_ZIP;� BUSINESS PHONE: �Z6S 3��� FAX NUMBER� ) CELL PHONE QUALIFIER'S NAME: a4cad e6 QUALIFIER'S LIC NUMBER: dAlz�a� �!) 6 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CFC1429033 ISSUED: 06/0712016 CERTIFIED PLUMBING CONTRACTOR CRESPO, RAFA RC PLUMBING CQjqTRACTofLUC IS CERTIFIED under the provisions of Ch 489 FS E-YPw ton fte AUG 31,201 THERE Local Business Tax Fbcei pt Miami Dade County, State of Florida THIS IS NOTA BILL DO NOT PA" 7169753 U t S-,S;StESS NA V r1LOCA TION RECEIPT NO EX PIR ES RC PLUMBING CONTRACTOR RENEWAL SEPTEMBER 30, 2017 LLC 7448494 201 WEST PARK DR 206 !� t be displayed ate of bus Hess pursuant to County Code MIAMI. FL 33172 Chapter 8A Art 9& 10 OF 51_STNESS P,ivM=_%- RECEIvE7- RC PLUMBING CONTRACTOR LLC 196 PLUMBING By Tax COLLEC-CR C/O RAFAEL CRESPO CONTRACTOR 75.00 09/13/2016 Worker(s) 1 CFC1429033 0201-16-002307 This Local Bus;ness Tax fteCei pt ON y con-rrrs payment of the Local Buri nesa Tax.The Recd pt is not a I icertse. perm t,or a cert;.,cation of the holder's qua;I..cations.to do business.Holder must corply with any govermrmtal or norKjovernrrental regulatory laws and requi rerents w Nch apply to the business The F Ce PT NO above rust be dl spl ayed on all corrrercial veh;cies-Miami-{lade lZbde Sec 8a-2/G For more information,vist v�vw mamdale TE(MMIDDIYYYY `SIO E® CERTIFICATE OF LIABILITY INSURANCE DA 05/11/2016 ) 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: H the certificate holder is an ADDITIONAL INSURED,the poiicy(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 CONTACT GISELLE GONZALEZ NAME, Triumph Insurance Inc PHONE E,tl; (786)362204 a/c No): 7481 SW 8st E-MAIL triumphinsurance@yahoo.com Miami,FL 33144 INSURERS AFFORDING COVERAGE NAIC s Phone (786)362-6204 Fax INSURER A: ASCENDANT INSURANCE COMPANY INSURED INSURER B: RC PLUMBING CONTRACTOR LLC INSURER C: 201 W PARK DRIVE APT206 INSURER D: INSURER E: MIAMI FL 33172 FL 33172- 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. INSR TYPE OF INSURANCE ADD UBR POLICY NUMBER POLICY YlYEFF MP POLICY EXP LIMITS LTR © COMMERCIAL GENERAL LLA BILI Y EACH OCCURRENCE $ 300,000.00 © CLAIMS-MADE © OCCUR DAMAGE TRENTED $ 300,000.00 PREMISESOEa occunence XElGL-47524-1 04/20/2016 04!20!2017 MED EXP(Any one person $ 5,000.00 PERSONAL&ADV INJURY $ 300,000.00 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 300,000.00 ❑ POLICY ❑ jEo- [:] LOC PRODUCTS-COMP/OP AGG $ 300,000.00 ❑ OTHER BVPD DEDUCTIBLE $ 500.00 AUTOMOBILE LIABILITY (Ea accident) GLE LIMB $ ❑ ANYAUTO BODILY INJURY(Per person) $ ❑ ALL AUTOS OWNED ❑ SCHEDULED BODILY INJURY(Per accident) $ AUTOS ❑ HIRED AUTOS ❑ NON-OWNED PROPERTY DAMAGE $ Per accident ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑PEARTUTE ❑OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIV4--1 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space is required) COMMERCIAL&RESIDENTIAL PLUMBING. POLICY IS IN AN ACTIVE STATUS AND HAS BEEN PAID. INSURED CONTRACTOR LICENSE NUMBER:CFC 1429033-RAFAEL CRESPO. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE GG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101)CIF The ACORD name and logo are registered marks of ACORD 29+Z018 Report Viewer i t 10096 JEFF ATWATER CHIEF FINANCIAL 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 exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 4/27/2016 EXPIRATION DATE: 4/27/2018 PERSON: CRESPO RAFAEL FEIN: 465028543 BUSINESS NAME AND ADDRESS: RC PLUMBING CONTRACTOR LLC 201 WEST PARK OR#208 MIAMI FL 33172 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR IIQ 11 F.tl.,Stn aflfoer d•aor0artttlon whod�OM wrrrrrlf7�ham tFN ofrprr_ Ey I�f�p rf oa111cr~d decYm udr 1hh wc11m fol-VORN d pt M rda d orlrtlflOrM ria lanplr mtNlr fb rgWrNnMb d Mwt anon AY hauM�a d a o�rtl0ala Ths cMprtrwi�trN r ra 0F8.p2.0WC-262 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED W13 WESTIONS7(E60y41313