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EL-14-2705 r Miami Shores Village Building Department ®rC 2014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 C 200 F BUILDING Master Permit No. !a— , i " PERMIT APP ATION Sub Permit NoZE/ ZZ /-� 2.�0� ❑BUILDING ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:] CHANGE OF ❑ CANCELLATION ❑ SHOP 9 CONTRACTOR DRAWINGS JOB ADDRESS: S� N-2- all r4 ' , City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): ro,jc-�` I c cf��°�l�c—, Phone#: -)?x, 3 Z,3 95. Address: go 0.E. 91 1 City: A),qr ; f State:_r'L- zip: 33 ) 3 E Tenant/Lessee Name: Phone#: Email: \ / CONTRACTOR:Com any Name: l�r �a. L l_A I oati, Phone#: Address: �l k! > C�t . J)Aw. «- City: A//PJL State: Zip: Qualifier Name: Vro, r Z.(nt., Phone#: 2 J -�State Certification or Registration#: -30 ( Certificate of Competency#: 0000 1 DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ �'O�>° Square/Linear Foot ge of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New '' Repair/Replace ❑ Demolition Description of Work: � �t, 4�iJ ✓�°�� a Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ IIII TOTAL FEE NOW DUE$� V (Revised02/24/2014) I i , 7 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: 1 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 beapproved and a reinspection fee will be char e Signature Signature OWNER or AGENT CONTRACTOR Theforegoinginstrument was acknowledged before me this The T ing instrument was acknowledged before me this 'l day of �0 Q c Ir 20 �� by � day of 20 1H , by F ✓1V L8M who is personally known to VO`SL'OD ` /q4who is personally known to 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: NOTARY PUBLIC: Sign: CG� Si n: g g Print: r('t,5) N Print: C Gr n S V) Seal: C.PARRISH Seal: ` o MY COMMISSION#EE15M EXPIRES:DEC 14,2015 , C.PARRISH Boded throughlst Site tmu=e : 'o MY COMMISSION#EE153394 Bonded through 1 et State Insurance APPROVED BY ' �' ?C./ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) A� CERTIFICATE OF LIABILITY INSURANCE °A�`MM,D°"Y"" 10/07/2014 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 policy may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NTACT NAME: ANA SAMY INSURANCE PHONE 5-559-6855 _ ta/c.No): 305-559-6856 3855 SOUTHWEST 137 AVE SUITE 2B E-MAIL aDOREss: 'nsuran�ceCaBDcosl' MIAMI,FL 33175 wsURER(S)AFFORDING COVERAGE NAIC it INSURER A: GRANADA INSURANCE INSURED INSURER B: FLORIDA ELECTRIC SOLUTION - - 9115 BROAD MANOR ROAD INSURER C; MIAMI,FL 33147 INSURER D: 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. rA TYPE OF INSURANCE ADDL SU POLICY NUMBER �M/IDDD MMOA DCDIYYYY- LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AGE TO X COMMERCIAL GENERAL LIABILITY PREMISES Ea oc ence S 100,000 CLAIMS-MADE X OCCUR I MED EXP(Arty one person) $ 5,000 0185FL00032758 01/09/2014 01/09/2015j PERSONAL&AIT/INJURY S 1,000 000 i_GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY 1 I COMBINED LE LI IT S ANY AUTO BODILY INJURY(Per person) $ 10,()00 ALL OWNEDX SCHEDULED BODILYINJURY(Par accident) $20,000 A AUTOSAUTOS 011FL00020766 01/14/2014 2015 NON-OWNED PROPERTY DAMAGE S 10,000 HIRED AUTOS AUTOS _{Peracddent S UMBRELLA UAB HOCCUR I I I EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE I AGGREGATE $ r_— DIED I RETENTION$ S WORKERS COMPENSATION TORY LIMI I O R AND EMPLOYERS UABILnY ANY PROPRIETORIPARTNERIEXECUTIVE YIN E L.EACH ACCIDENT $ OFFICE/MEMBER EXCLUDED? NIA I---- (Mandatory In NH) E.L DISEASE-EA EMPLOYE $ If yea'descrWe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATI NS below r� I f DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aitch ACORD 101,Addlttonal Remarks Schedule,If more apace Is required) Register Electric Contractor ER13014581 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2 AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED TATIVE -- j ©1=0 ACORD RPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are reg red meORD ,> 0 �ns4ru +ion Trades Quaff nr3 S Gtli1kd L=id_r thr:PrJV':GiMs G4 Chaptei 1,'1 of If tam:,"lade LOkin;�' .�r^�..-t .:?ge �-�l it .l•.f"v..���&kt!*� r' b I r.. ;o-.:.a J'.�iW�rl it4 � � . ' --- _---_ -_-___--- _--_- PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE , Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation STATE OF FLORIDA 0 elects exemption from this chapter by filing a cerfifiCale of Wh DEPARTMENT OF FINANCIAL SERVICES i election under this section may not recover benefits or CONSTRUCTION INDUSTRY EXEMPTION pursuant to Chapter 44(3.05(12),F.S.,Certificates of etection to 1 CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA be exempt...apply only vvithin the scope of the business or trade COMPF-%6ATn%LAW listed on Ibe m'6ce al dleaw ID be exempt. EFFECTIVE DATE: 3f412013 EXPIRATION DATE. 314f2015 PERSONt MARRERO YOISLANDY Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt E shall be FEIN: 274625762 subject to rev �R ocation if,at any firm after the finng of the notice BUSINESS NAME AND ADDRESS: i or the issuance of the certificate,the person named on the ELECTRIC SOLUTIONS INC E FLORIDA notice or certificate no longer meets the requirements of this 91 IS BROAD MANOR RD section for issuance of a certificate.The department shall revoke MIAMI FL 33147 a Gertificate at any time for failure of the person named on the certificate to meet the requirements of this section. SCOPES OF BUSINESS OR TRADE: E, LECTRICAL WIRING CERTIFICATE pFELECTION TOBEEXEMPT REVISED 07c12 QUESTIONS?(85%413-1609 i 004944 ®cel Business Tax Receipt Miami—Dade County' State of Florida BILL —THIS IS NOTA — DO NOT PAY I I 6807292 RECEIPT NO. EXPIRES BUSINESS NAME/LOCATION RENEWAL SEPTEMBER 30, 2016 FLORIDA ELECTRIC SOLUTIONS INC 7080807 Must be displayed at place of business 9115 BROAD MANOR RD Pursuant to County Code MIAMI FL 33147 Chapter 8A—Art.9&10 SEC.TYPE OF BUSINESS PAYMENT RECEIVED Oti NEN196 ELECTRICAL CONTRACTOR By TAX COLLECTOR FLORIDA ELECTRIC SOLUTIONS INC 11 E000018 $75.00 09/04/2014 i Worker(s) 1 CREDITCARD-14-035363 Iof the Local Business Tax.The Receipt is not a license, This Local Business Tax Receipt only confirms payment permit,or a certification of the bolder s qualihcataoms,to do business.Helder must comply with any 9oVernmelttass. or no regulatory laws and requirements which apply to the busine The RECEIPT NO.above must be displayed on ail commercial vehicles Miami—Dade Code Sec sa-276• For more information,Visit wvuw miasasd '-` '`` STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ER 13014581 ISSUED: 08/24/2014 REG ELECTRICAL CONTRACTOR MARRERO,YOISLANDY FLORIDA ELECTRIC SOLUTIONS,_INC. (INDIVIDUAL MUST PvIEETALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) HAS REGISTERED under the provisions of Ch.489 FS Expiration date: AUG 31.2016 L1408240004674 y8o SFS lose Miami shores V Building Department R1pA 10050 N.E.2nd Avenue 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.In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore,you may be personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Contractor Print Name: q0 Print Name: ( ,1,*•,�k Daa(z t-/- ey Signature: Signature: State of Florida) State o lorida) County of Miami-Dade) r, �` County of Miami-Dade) Sworn t subscribed before me this amu Sworn t and subscribed before me this day of i ' ,20 day of � � t' ,20_ By By SEAL l ``� (SEAL) / ll Typp..af ldenq duced T t d )r, n MY COMMISSMN AE153394 MY COM 1.rpivmn�EE15339 I EXPIRES:DEC 14,2015 p(pIt$$;DEC 14,2015 Bonded through tet Sin Insunwe Banded throughlot Site Insurance -. * iami Shores Village ilding Department 0 0 .E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 C7 Master Permit No. 9 c - /Y- 1 Sit S RMIT APPLICATION Sub Permit NO.E L- N-2-905 ❑BUILDING ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP L CONTRACTOR DRAWINGS JOB ADDRESS: S-0 PU C)I f`�Y`�f'/( City: Miami Shores County: Miami Dade Zip: 331360 Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: j� OWNER: Name(Fee Simple Titleholder): I' 08�,1'I/ilo ft Phone#: 26�- 3� 23 S9 Address: 5-0 fa z . oil f lc�e± 9 City: �` � , State: Zip: 32 69 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: C�(& �C R1G L aIJp� Phone#: 396-0� 6)—9 9IO Address: aoa izo G( a6 aj City: e4 Am') State: Zip: .3.3yLd Qualifier Name: ll m Phone#: State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ S22 Square/Linear Footage of Work: Type of Work: ❑ Addition ElAlteration EleNew r ❑ Repair/Replace ❑ Demolition V-L Description of Work: A EJ Specify color of color thru tile: Submittal Fee$ Permit Fee$ . � CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$U� (Revised02/24/2014) t 9 • w 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 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 approve and a reinspection fee will be charged. Signature Signature , /7 OWNER or AGENT a CONTRACTOR The foregoing instrument was acknowledged before me this The ft regoing instrument was acknowledged before me this �oday of a u c(r 20 16 by �o-tn day of J(i Vl I t V'` 20 by ® ���" ho is personally known to �'d� mj/3who is personally known to 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: NOTARY PUBLIC: } Sign: (/��i�QUI Sign: vliyi,. L/ Print: �, 0.s Print:Li aq-I'1 b Seal: C.PARM PARRISH Seal: r,��n WGcmi,•:3S1 M..#EE15394 EXPIRES.DEG 14,2015 EXPM:DEC 14,2015 Banded thionch tst state Ins"18 Bonded"b"100110MMO APPROVED BY V � �/ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ,eco CERTIFICATE OF LIABILITY INSURANCE �*�'M�DD>�YY"' `.� 02/17/2015 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 pollty(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: ONTA TNAME: ANA SAMYINSURANCE PHONE -- — -FAX 3855 SOUTHWEST 137 AVE SUITE 2B M,No Eat: 305-559-6855 -- --_._ - _1A�C,Nol 30r-559-,am E-MAIL MIAMI,FL 33175 ADOREss_samvinsuranceftrodigy,net INSURER(S)AFFORDING COVERAGE NAIC 6 INSURER A: UNITED STATES LIABILITY GROUP_ INSURED INSURER B: FLORIDA ELECTRIC SOLUTION -- - - --- ---- - --- i------ --- 9115 BROAD MANOR ROAD INsuRErtc ------- ----.-----_ MIAMI,FL 33147 iNSURERD_- ----_. - --- - ---- 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 REOUIREMENT,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. --- LTR TYPE OF INSURANCE POLICY NUMBER M�M/LID�EFF M�rA�D EXP LIMITS ------ GENERAL LIABILITY II EACH OCCURRENCE _ $ 1,000,OOU X I rDAwr. l u Kt:l t:u COMMERCIAL GENERAL LIABILITY �PReanlses(ea occurrence) _ $ 00-000 F I CLAIMS-MADE x]OCCUR ICL 1683110 12/22/2014 12/22/2015 MED EXP(Any one person) x_ 5,000_ A PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2000,000 !POLICY 1 PRO- !LOC �--- $ - AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT �Eaaccdent -- $------------_—___-- ANY AUTO i BODILY INJURY(Per parson) $ 1 - ALL OWNED SCHEDULED --- ----- - ---- - - - i ! BODILY INJURY(Per accident){5 iAUTOS AUTOS f NON-0WNED ( HIRED AUTOS AUTOS ;IPer sccdeM)_PROPERTY DAMAGE- !$ I UMBRELLA UAB OCCUR FEACH OCCURRENCE $ 1.000,000 A I x ;EXCESSLIAB i CLAIMS-MADE XL 1563729 12/22/2014 12/22/2015 AGGREGATE !s 1,000,000 -- - 1.- y--- --------------+ ---- --­­-- -r- - DED ! RETENTION$ iS WORKERS COMPENSATION WC STATU- OTH- TORV AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT S OFFICEWEMBER EXCLUDED? ❑ NIA -- ----------------- (Mandatory M NH) 1 E.L.DISEASE-EA EMPLOYE $ If yes,describe under ----- — _--- -- DESCRIPTION F QPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Register Electric Contractor ER13014581 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE VWLL BE DELIVERED IN 10050 NE 2 Ave ACCORDANC THE POLICY PR SI Miami Shores,FI 33138 AUTH .'E,ISEN 9 1988-20 CORD C RATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are regl#sred marcs of ACURD