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MC-17-1289Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Petit NO. lC-5-i 1- - yp k chaff ica!' Resideni 'ark aassi rcatrora. lC: l epl tcem+ Parcel Number 2017. APPR Expiration: 0 21/201 Applicant 265 NE 92 Street Miami Shores, FL 1132060133561 Block: Lot: MIAMI SHORES 265 NE 92 ST CC Owner Information Address Phone CeII MIAMI SHORES 265 NE 92 ST CORP 265 NE 92 Street MIAMI SHORES FL 33138- 265 NE 92 Street MIAMI SHORES FL 33138- Contractor(s) Phone C R MECHANICAL CONTRACTORS IN (954)540-7585 Cell Phone Valuation: Total Sq Feet: $ 4,000.00 0 Tons: 5 Additional Info: REPLACE EXISTING 5 TON SYSTEM C/U A Classification: Residential Approved: In Review Comments: Date Approved: : In Review Date Denied: Scanning: 3 Type of Work: REPLACE EXISTING 5 TON SYSTEM Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $2.40 $2.10 $2.10 $0.80 $140.00 $9.00 $3.20 $159.60 Pay Date Pay Type Invoice # MC -5-17-63980 08/25/2017 Credit Card 05/10/2017 Credit Card Amt Paid Amt Due $ 109.60 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Review Mechanical 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 cep.] all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning y+thermore) I autho ' e the above-named contractor to do the work stated. Authorized Si . 'ature: Owner _ A• • 'can / Contractor / Agent August 25, 2017 Building Department Copy Date August 25, 2017 1 4 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑PLUMBING MECHANICAL Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 ❑ ROOFING ❑ PUBLIC WORKS JOB ADDRESS: Co V RECEIVED ,.h1AY� 2017 �Y d� l l FBC 20 IL,1 Master Permit No. MC I - 1 ZcCI Sub Permit No. ❑ REVISION 0 EXTENSION RENEWAL ❑ CHANGE OF 0 CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS 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): j O R E Si L. &F -M.5 -tee •v Phone#: 48 -33- -9 09b Address: a to5 Me 6 9 ,T city: %/l1i�5M `r e/ZFS State: Zip: Tenant/Lessee Name: Phone Email: • /% -0333 CONTRACTOR: Company Name: @#la J" ecoAv,',,',\ ! ' Phone#: q _ sD-i5 BS Address: 1 61 1 3 qui City: 6wT State: Zip: 336 Qualifier Name: Of_72:, State Certification or Registration #: , 17J Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ '4 \ 009 Type of Work: ❑ Addition E Alteration ❑ New ❑ Repair/Replace ❑ Demolition P t Description of Work: C P ( � S s T� �� 1 /+ ,\ u A/M- VetA.) St --1 '1- S -7-0Y) oo il 1"?'")1 L( .gees/' � s . Phone# 954 --.-V:la`5 Square/Linear Footage of Work: 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$ 69 6)0 (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 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 hich occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be apl`\ov and a reinspection fee will be charged. Signature ..04/114� NER or AGENT The foregoing instrument was acknowledged before me this 4 day of P , 20 !9 , by S`&y / , who is personally known to me or who has produced✓& S//(0 C/?C W VItO qs identification and who did take an oath. NOTARY PUBLIC Sign: Print: Seal: t+i (.�� _____ `n c tae • nda o Elizabeth Yelin �}^r 47 My Expires 10/16/2017 ommission FF 063558 ************************************* APPROVED BY (Revised02/24/2014) *r‘ CONTRACTOR The foregoing instru ent was acknowledged before me this day of i(, , 20 , by o is personally known to dt � me or who has produced '(. 'letas identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: PI Exar>tiiner Structural Review MY COMMISSION FF208514 2 EXPIRES: March 5, 2019 ,8114,11%, Bonded Tho Notary Public Underwdtere Zoning Clerk • Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): 4 (o 5 PE 9g City: Miami Shores Village County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ 1. 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): (®8/? -3 ('7 UNIT BEING REPLACED DATA NEW UNIT EI -10f LI MANUFACTURER AHU or PKG. UNIT MODEL# _ED ea Q l-fC -?II ;s-// ltl Fb iik..7P (pi, a ,I. 7A kAle A..QcT/i X COND. UNIT MODEL# G gYF2 ( JKC JO KW HEAT I I 5 NOM TONS 5 AHU CU PKG 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3) VOLTS AHU 7,3/CUZ'DPKG PKG UNIT / / PKG UNIT / / EER/SEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4"CONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES NO Minimum Circuit Ampacity (Wire Size): e 612tr4K go 4. Size Disconnecting Means: .5O Contractor's Company Name: CR. 14,0(141 1U t GAL State Certificate or Registration No. Signature 64I- 1.© "Romig( er, g (Qualifier's signature) Phone: 18& 656-03 3 Certificate of Competency No. Date: 5- (6- .201 4 (Revised02/24/2014) /by: 1. , Suite 101 ,x138 Folio No. 11-32060133561 CFN: 20170055649 BOOK 30402 PAGE 3998 DATE:01/30/2017 04:43:48 PM DEED DOC 3,198.00 HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY SPACE Aeon THIS LDJE PON pilactilsDiG DATA SPACE AMMETERS MOM aECORDENC DATA PERSONAL REPRESENTATIVE'S DEED THIS INDENTURE, made this 21/ day ofJanuary, 2017 between LAURA DAIGLE, as Personal Representative of the Estate of Gloria F. Daatefano, Deceased, first party, and MIAMI SHORES 265 NE 92 ST CORP., a Florida corporation, whose post office address is: 5900 Collins Ave., #807, Miami Beach, FL 33140, seed party. WITNESSETH, that the said first party, acting in pursuance and by virtue of the powers vested in me under appoiatme,st of the Circuit Judge of the Circuit Covet, in and for Mahn County, Stuart, Florida, Probate Division, File No. 16- 000504 CP AXMX, and for and in consideration of the stun of Ten and 00/100 Dollars ($10.00), to him in hand paid by the second pasty, the receipt whereof is hereby acknowledged, has grafi, bargained, and sold to the second party, the following described land, situate and being in Miami -Dade County, State of Florida, to wit The East 30 feet of Lot 12, all of lot 13, in Block 26, an Amended Plat of Miami Shores Section No. 1, accon ng to the map or plat thereof, as recorded in Plat Book 10, Page 70, of the Public Records of Mlwni-Dade County, Florida SUBJECT 1'O: - Taxes for the current and all subsequent years. - Restrictions, reselrvations, easements, and ltmfations of record without hereby reimposing same. - Applicable zoning regulations and ordinances. GRANTOR COVENANTS with Grantee that Grantor has good right and iawf ul authority to sell and convey the property and warrants the title to the property for any acts of Grantor and wilt defend the title against the lawful claims of all persons claiming by, through, or under Grantor. And the party of the First Part does covenant to and with the Party of the Second Put, his heirs and assigns, that in all things preliminary to and about the sale and this conveyance the orders of the above-named Court and laws of Florida have been followed and glial with in alt respects. Wherever used Dein the terms "fast party" and "second party" shall include singular and plural, heirs, legal representatives, and assigns of individual, and the successors and assigins of c ospmatlons, and in the usage of personal pronouns, the masculine shall include the feminine and the neuter, wherever the context so admits or requires. IN WITNESS WHEREOF, the said party of the first part has hereunto set his hand and seal the day and year first above written. Signed, sealed, and delivered in tbe_presence of _,i______'._, . nt =IA 1/1.44.-Co`i dv 4Pritit STATE OF FLORIDA COUNTY OF MARTIN ) /.1.u4�- OLE, PersonafRepresentatiVe Estate of Gloria F. Destefano, Deceased 1404 N.W. Spruce Ridge Dr., Stuart, FL 34994 1 HEREBY CERTIFY that on this day before me, an officer duly authorized to administer oaths and take acknowledgments, perorally appeared, LAURA DAIGLE, as Personal Repmsemative of the Estee of Gloria 1:.Destefeno, Deceased, to nue wall Imosm to be the petson desctibedl in and whoeecuted the foregoing instrument and acknowledged belbre me that she executed the same freely and vehuttarily for the purposes therein expressed WITNESS my hand and official seal at the State and County last aforesaid on Page 1 of I 2/1, day of l 2017. NOT:.' 'r' LIC -STATE • •RIDA �::...rh...:.xiw..., yC-�.t^nm:i�.�$....e..J.?� JOANNE RAZZINO Notary Pubtic - State of Florlta .i 47My Comm. Emtiren May IL 2015 it°� Commission s° FF 099771 003784 Local Business Tax Receipt Miami—DadeIR�oA�_State AY Florida 5428172 BUSINESS ""Mo�AcroR INC C R MEECHANICAt 19133NW80Cf AAIAMI FL 33015 RECEIPT 140. RENEWAL 5667747 EXPIRES SEPTEMBER 30, 2017 Muet be displayed at Place of business Pursuant to CountY Code - Chapter lift - Art. 9&10 OWNER SEC. TYPE OP BUSINESS PAYMENT RECEIVED C R MECHANICAL CONTRACTOR INC 196 SPEC MECHANICAL CONTRACTOR BY TAX COLLECTOR CAMILO RODRIGUQ—MIRO, QUAURER CAC1813393 �n 210 /2016 5 Workeris) 1 atdp r firms payment of the Land Business Tex. The Reoeist Is nate license, t hn b, or Boe 1IThNTan tion of the �a to do business. Heider austenv* web any goverumental err mangolaws requirementswhish apply tothe business. The RECEIPI'I10. shove matt bedisplayed en all commeraiotvehicles _Wand-02da Coda Sao $a 278. For mare lafomrettao. vhdt STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 RODRIGUEZ- MIRO, CAMILO N C R MECHANICAL CONTRACTOR INC 19133 NW 80 COURT MIAMI FL 33015 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfioridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Departments initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! -_ - RICK SCOTT -GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC 1813393 ISSUED: 08/28/2016 CERTIFIED AIR COND CONTR RODRIGUEZ- MIRO, CAMILO N C R MECHANICAL CONTRACTOR INC IS CERTIFIED under the provisions of Ch.488 FS. Expiration date : AUG 31. 2018 L1608280002063 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD •LICENSE NUMBER The CLASS AAIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 RODRIGUEZ- MIRO, CAMILO N =` C R MECHANICAL CON _ RA` TOR INC 19133 NW 80 CT MIAMI FL 33013 i�CORO® `� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/09/2017 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 endorsement(s). PRODUCER A Quick & Easy Assurance Group,Inc. 7229 Coral Way Miami FL 33155 CONTACT Ray Guell (A/CC. No. Ext): (305) 662-7030 (A/C, No): (305) 267-1197 E-MAIL rayguell@aol.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ASCENDANT COMMERCIAL INSURANCE, INC COMMERCIAL GENERAL LIABILITY INSURED CR Mechanical Contractor Inc. 19133 NW 80 Ct Miami FL 33015 INSURER B : GL -38599-5 INSURER C : 11/13/2017 INSURER D : $ 1,000,000 INSURER E : INSURER F : X 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 LTR TYPE OF INSURANCE NSD I SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GL -38599-5 11/13/2016 11/13/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGETOREN IED PREEMIMI SES ( (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES jE�T PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) license number: CAC1813393 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVENUE MIAMI SHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE '1'1 4-k. ACORD 25 (2014/01) 01988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/08/2017 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 endorsement(s). PRODUCER Automatic Data Processing Insurance Agency, Inc. 1 Adp Boulevard Roseland, NJ 07068 CONTACT NAME: PHOE FAX (A/CNNo,Ext): (A/C, No): ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : NorGUARD Insurance Company 31470 INSURED CR MECHANICAL CONTRACTOR INC 19133 NW 80th CT Hialeah, FL 33015 INSURER B INSURER C INSURER D : $ INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 671867 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 LTR TYPE OF INSURANCE ADDL MSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N Y N / A N CRWC774031 12/04/2016 12/04/2017 XM STATUTE OTH- ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Contractor License: CAC1813393 CERTIFICATE HOLDER CANCELLATION 1 Miami Shores Village Bldg Dept. 10050 Ne 2nd Ave Miami, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD