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REV-17-338mis MUST BE OZ Ja3 9 motion (2O14)-? "�� Oviform PernpitApillatt_igflFvsfl O General +s T`Y PrSMONol. '-t >J to 4- Sr ROOF CATEGORY ma � oT .oShingles 0 New Roof Prenceipthrs SURRAS 150 ROOF TYPE -O RECEIVED FEB 0 81017 %> 4 0 N' set ;la�'91, �7 woad Are there Gas Vast UT Yeses Type:a LPGXa QRoRrooling 0 Recovering stspeirMaintenance ROOF SYSTEM INFORMATION Loi Stops RoolAres (S) Sisep.Slopsd o f /tea Total (SF) S&22 __' -;› Section B Moof Plan) Sketch Roof Purr fiats all l rnd s and sections, roof drains, =wpm, scuppers and ~Sow drains. kacinde dimensions ofsectionsand lavels,• .. idenlify dmensions of eisti_lsd mamma ZOOM and location at parapets. 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The documentation submitted has been reviewed and accepted by Miami -Dade County PERA - Product Control Section to be used in Miami Dade County and other areas where allowed by the Authority Having Jurisdiction (AHJ). This NOA shall not be valid after the expiration date stated below. The Miami -Dade County Product Control Section (In Miami Dade County) and/or the AHJ (in areas other than Miami Dade County) reserve the right to have this product or material tested for quality assurance purposes. If this product or material fails to perform in the accepted manner, the manufacturer will incur the expense of such testing and the AHJ may immediately revoke, modify, or suspend the use of such product or material within their jurisdiction. PERA reserves the right to revoke this acceptance, if it is determined by Miami -Dade County Product Control Section that this product or material fails to meet the requirements of the applicable building code. This product is approved as described herein, and has been designed to comply with the Florida Building Code including the High Velocity Hurricane Zone of the Florida Building Code. DESCRIPTION: : GACO WESTERN ROOF COATING SYSTEMS MIAMI-DADE COUNTY PRODUCT CONTROL SECTION 11805 SW 26 Street, Room 208 Miami, Florida 33175-2474 T (786)315-2590 F (786) 31525-99 www.miamidade.2ov/pera LABELING: Each unit shall bear a permanent label with the manufacturer's name or logo, city, state and following statement: "Miami -Dade County Product Control Approved", unless otherwise noted herein. RENEWAL of this NOA shall be considered after a renewal application has been filed and there has been no change in the applicable building code negatively affecting the performance of this product. TERMINATION of this NOA will occur after the expiration date or if there has been a revision or change in the materials, use, and/or manufacture of the product or process. Misuse of this NOA as an endorsement of any product, for sales, advertising or any other purposes shall automatically terminate this NOA. Failure to comply with any section of this NOA shall be cause for termination and removal of NOA. ADVERTISEMENT: The NOA number preceded by the words Miami -Dade County, Florida, and followed by the expiration date may be displayed in advertising literature. If any portion of the NOA is displayed, then it shall be done in its entirety. INSPECTION: A copy of this entire NOA shall be provided to the user by the manufacturer or its distributors and shall be available for inspection at the job site at the request of the Building Official. This NOA renews and revises NOA No. 09-1109.03 and consists of pages 1 through 4. The submitted documentation was reviewed by Jorge L. Acebo. NOA No.: 12-0426.06 Expiration Date: 05/31/17 Approval Date: 05/24/12 Page 1 of 4 ROOFING COMPONENT APPROVAL Cate2orv: Roofing Su b-Catezery : Cement -Adhesive -Coatings Material: Elastomeric SCOPE: This approves GACO WESTERN ROOF COATING SYSTEMS" as a roof maintenance coatings manufactured by Gaco Western LLC, as described in this Notice of Acceptance. This product has been designed to comply with the Florida Building Code, including the High Velocity Hurricane Zone of the Florida Building Code. EVIDENCE SUBMITTED: Test A2encv Test Identifier Test Name/Report Date PRI Construction Materials GWI-007-02-01 ASTM D 6083 08/14/09 Technologies Fed Spec TT -C -555B GWI-002-02-201 ASTM D 6083 01/09/07 Fed Spec TT -C -555B GWI-001-02-01 ASTM D 6694 04/10/07 Fed Spec TT -C -555B GWI-004-02-01 ASTM D 6694 05/13/08 Fed Spec TT -C -555B Underwriters Laboratories Project 04NK27341 UL 790 02/01/05 Project 07NK02171 UL 790 03/13/07 Project 08NB01503 UL 790 02/21/08 Factory Mutual Research Corp. 3023644 4470 02/02/07 MANUFACTURING LOCATION: 1. Waukesha, WI Trade names: Thickness: Specifications: Description: Container Size: Systems Approvals: PHYSICAL PROPERTIES OF COMPONENTS A3100R Acrylic Top Coat For application over spray polyurethane foam system apply a base coat at a minimum rate of 1.13 gall 100 ft2, an intermediate coat at a minimum rate of 1.13 gal/100 ft2, and a top coat at a minimum rate of 1.13 gaU100 ft2. For application of a recover coating over an existing acrylic roof apply a base coat at a minimum rate of 1 gal/100 ft2, and a top coat at a minimum rate of 1 gall 100 ft2. ASTM D 6083 An acrylic white elastomeric quick set coating membrane applied to; spray polyurethane foam roof systems and a recover of any existing acrylic roof. 5, 55 gallons. Note all precautions on container. Methods of application and quantities shall comply with specific Roof Assembly, Product Control Notice of Acceptance. NOA No.: 12-0426.06 Expiration Date: 05/31/17 Approval Date: 05/24/12 Page 2 of 4 Trade names: Thickness: Specifications: Description: Container Size: Systems Approvals: S 1000 Top Coat For application over spray polyurethane foam system apply a base coat at a minimum rate of 1.1 ga1/100 ft and a top coat at a minimum rate of 1.1 gal/100 ft2. For application of a recover coating over an existing silicone roof apply a base coat at a minimum rate of 1.1 gal/100 ft2, and a top coat at a minimum rate of 1.1 ga1/100 ft2. ASTM D 6694 A single component, air dried, silicone -based rubber elastomeric membrane coating that is brush, roller or spray -applied. To be applied to spray polyurethane foam roof systems and as a recover of any existing silicone roof coatings. 5 and 55 gallons. Note all precautions on container. Methods of application and quantities shall comply with specific Roof Assembly, Product Control Notice of Acceptance. Trade names: S-2000 Solventless Silicone Basecoat/Top Coat Thickness: For all applications apply 2 coats; a base coat at a minimum rate of .75 ga1/100 ft and a top coat at a minimum rate of .75 ga1/100 ft2. • Spray Polyurethane Foam Roof Systems • Acrylic Coatings • Galvanized Metal Roofs (in conjunction with E5320 2 part Epoxy Primer) • Smooth Built Up Roof Systems (in conjunction with E5320 2 part Epoxy Primer) • EPDM Single Ply Roof Systems (in conjunction with E5320 2 part Epoxy Primer) • PVC Single Ply Roof Systems (in conjunction with E5320 2 part Epoxy Primer) Specifications: ASTM D 6694 Description: A single component, moisture cured, silicone -based rubber elastomeric membrane coating that is brush, roller or spray -applied to the roof covers listed above. Container Size: 5 and 55 gallons. Note all precautions on container. Systems Approvals: Methods of application and quantities shall comply with specific Roof Assembly, Product Control Notice of Acceptance. NOA No.: 12-0426.06 Expiration Date: 05/31/17 Approval Date: 05/24/12 Page 3 of 4 Trade names: S 1600 Base Coat/Top Coat Thickness: For application over spray polyurethane foam system apply a base coat at a minimum rate of 1.1 gal/100 ft and a top coat at a minimum rate of 1 ga1/100 ft2. For application of a recover coating over an existing silicone roof apply a base coat ata minimum rate of 1 ga1/100 ft2, and a top coat at a minimum rate of 1 ga1/100 ft2. Specifications: ASTM D 6694 Description: A single component, moisture cured, silicone -based rubber elastomeric membrane coating that is brush, roller or spray -applied. To be applied to spray polyurethane foam roof systems, galvanized metal, smooth surfaced built-up (BUR) roofing, acrylic coating and any existing silicone roof coating.. Container Size: 1, 5 and 55 gallons. Note all precautions on container. Systems Approvals: Methods of application and quantities shall comply with specific Roof Assembly, Product Control Notice of Acceptance. LIMITATIONS: 1. Fire classification is not part of this acceptance; refer to a current Approved Roofing Materials Directory for fire rating of this product. 2. GACO WESTERN ROOF COATING SYSTEM shall not be applied in inclement weather conditions. 3. GACO WESTERN ROOF COATING SYSTEM shall not be applied over asphaltic shingles, metal shingles, fiber -cement shingles, quarry slate, cement or clay roofing tile, or wood shingles or shakes. 4. The products listed herein are components of roof assemblies and are approved for use with roof assemblies that list any of the products listed herein as part of their roof assemblies Notice of Acceptance. For applications over existing single ply, smooth or granulated BUR systems. Refer applicable building code for requirements. 5. All products listed herein shall have an unannounced follow-up quality control program from an approved listing agency. Follow up test results shall be made available to Miami -Dade County Product Control upon request. 6. All approved products listed herein shall be labeled in compliance with TAS 121 and shall bear the imprint or identifiable marking of the manufacturer's name or logo and following statement: "Miami -Dade County Product Control Approved" or the Miami -Dade County Product Control Seal as shown below. MIAMEDADE COUNTY APPROVED 7. Change in materials, use, or manufacture of any of the products listed herein shall be cause for termination of this Notice of Acceptance. 8. GACO WESTERN ROOF COATING SYSTEM shall only be applied by a factory trained and certified applicators. 9. GACO WESTERN ROOF COATING SYSTEM shall be applied in accordance with manufacturer's published application instructions. END OF THIS ACCEPTANCE NOA No.: 12-0426.06 Expiration Date: 05/31/17 Approval Date: 05/24/12 Page 4 of 4 _1 -3'01'1 a� Rt4 3 3� ' AVED Ba et,( ©,c kouse V1 - - goof 116" dVee ham or\\ 135N sties 1-6-611 .2.1'6// t.�b' 0uee.11 -1 pr bf CK o� -Roof ,26(6" 16M( i(V6t/ /o'3 ('x 3`' i S Levditu, 04- S ) clip oN bAcK S;je /Roo -f Y 6 s< 7S 'Pe'pfve SM Ari LeA) iN 00-F („t„:9L Xe ill/ ROUSE asNIW10t+.sfi M taMi 5hoejj F ! Ri c i4 3315® 305 9613- 808-- • • • • • • •• ..•. • • • • ••• • • • • •• • • • • • • • • G • • • • • • • • • • • • • • • • • • • O • • • • •• •• •• • • •• • • . • • • • •• • • • • • • • • • •• • ••• • • r • • •• • 1.4(`- Miami Shores Village RECEIVED vEo BUILDING Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 ONE'Nt BER?'(3D3)7bz 4949" RE PERMIT APPLICATION' ❑BUILDING ❑ ELECTRIC PLUMBING ❑ MECHANICAL ROOFING PUBLIC WORKS JOB ADDRESS: ,,PS i)z..) /C4c 87 FEB 0 8 2017 FBC20 tc P , No. �f =�f (.L - 237 Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Folio/Parcel#: 1/ - Z/36 — 0 /3 /Z O Is the Occupancy Type: Load: Construction Type: Miami Dade Zip: 33150 Building Historically Designated: Yes NO Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): /4 -/TN IA.)(C �• 2 L.tsF #: Phone 3oJ q8- &4:36-5 S Address: 2 A w 7 (w S7 - City: n/( IA -P4 ( S(r 61% :$ State: % Zip: 33 iS o Tenant/Lessee Name: Email: Sok Z. J?d. e.40 l• 00141 Phone#: CONTRACTOR: Company Name: iokeikki 4. Q 5jQ Address: //6s Ori- h s s, - Phone#: c S ! •90-(r •.? City: /i*t41,1 State: Qualifier Name: A./4s /6, 4' a Zip: ,706/ Phone#: 7-r ' fig- State Certification or Registration #: CCC )3L 12 J4' Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this .Permit: _$ Square/Line) ar Footage of,Workl da Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: iC.,44 i dye- ,¢; /Gym) ��� g y.tc a Specify color of color thru tile: ,:: Submittal Fee $ P it.Fee $ _ CCF $ Scanning Fee $" - Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) CO/CC$` ' • DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address i , r r F • L 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 Signature CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 19 day of CIQ-p(44.11 , 20 /I- , by /7- day of (2 W. ROUE , who// sonally knov "t:to me or who has produced _ - as identification and who did take an oath. NOTARY PUB C. Sign: Print: Seal: 41/l<oft2 ************* �u►' MICHAEL CRITCHLEY '' •: MY COMMISSION # FF221177 EXPIfjES April 15. 2019 �wr llun•i.* * ** *w�riu�lerlealleis ****** APPROVED BY (Revised02/24/2014) / 1-eee.4 ei J ,20 , by , who isj. rsonally kn wn to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ********************* Plans Examiner Structural Review .;. MICHAEL CRI?CHLEY ' i MY COMMISSION # FF221177 **eXPIRGE*440414:4 31*** t40 1)31(401131601b3` Flondalloto 9avico.cat Zoning Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 . 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 LEKAKOS, ILIAS PRAXIS INDUSTRIES INC 1065 NE 125TH STREET SUITE 321 NORTH MIAMI FL 33161 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.myfloridalicense.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 Department's 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 :At STATE OF FLORIDA PROFESSIONAL REGULATION AND CCC1328234 rt 1, ISSUED: 07/18/2016 CERTIFIED ROOFING_ CONTRACTOR LEKAKOS, ILIAS - : PRAXIS INDUSTRIES INC. `R IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31. 2018 11607180000694 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The ROOFING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 LEKAKOS, ILIAS PRAXIS INDUSTRIES INC% 1065 NE 125TH STREET SUITE 321 NORTH MIAMI FL 33161 ISSUED: 07/18/2016 ` • S 1- , _ t k.! DISPLAY AS REQUIRED BY LAW SEQ # L1607180000694 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A MI - DO NOT PAY 6077804 BUSINESS NAME/LOCATION PRAXIS INDUSTRIES INC 1065 NE 125 STSTE321 N MIAMI, FL 33161 OWNER PRAXIS INDUSTRIES INC CIO ILIAS LEKAKOS PRES Worker(s) 1 RECEIPT NO. RENEWAL 6340160 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC_ TYPE OF BUSINESS 196 SPECIALTY BUILDING CONTRACTOR CCC1328234 PAYMENT RECEIVED BY TAX COLLECTOR 45.00 09/19/2016 0229-16-008945 This local Business Tax Receipt only confines payment of the local Business Tax. The Receipt is not a license, permit, oracertification of the holders qualifications. to do business. Holder most comply with any goverameatal or nongovernmental regulatory bus and requirements which apply to the business. The RECEIPT N0. above meat be displayed on all commercial vehicles-1&ami-Dade Code See 8a-276. For more info nadou,visitwww.m"mmidade gov/utxcoJIeclar CERTIFICATE OF INSURANCE (MM/DD/YY) TE (MM/ DATE PRODUCER AND THE NAMED INSURED Transworld Building Trades and Contractors Liability Association, Inc. inc., A Risk Retention Purchasing Group qualified under the Risk Retention Act of 1986; Federal Law 97-05. P.O. Box 469 Sandy, UT 84091-0469 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OF INSURANCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE INSURANCE POLICIES BELOW. 800-851-8364 INSURERS AFFORDING COVERAGE INSURED Praxis Industries, Inc. 1065 Northeast 125 Street, #321 NSURER A NOTICE: Coverage is being provided as part of a Master Group INSURER B: Policy issued to members of the Transworld Building Trades and Contractors Liability Association, Inc. INSURER C: , a Risk Retention 'Purchasing Group' authorized under the Risk INSURER 0: Retention Act of 1986: Federal Law 97-45. North Miami , FL 33161 "LIMITS SHOWN ARE THOSE IN Prime Insurance Company COVERAGES EFFECT AS OF POLICY INCEPTION" The policies of insurance listed below have been issued to the insured named above for the policy 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. Aggregate limits shown may have been reduced by paid claims. POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DATE (MWIDD/YY) DATE (MM/DD/YY) LIMITS GENERAL COMMERCIAL U Li UABILITY GENERAL LIABLITY Claims Made Include Products PRC2660-17010004 01/11/2017 01/11/2018 EACH OCCURRENCE S $1,000,000.00 FIRE DAMAGE (Any e fire) an s N/A MED EXP (Any one person S N/A PERSONAL ADV INJURY S N/A j;ie Include Completed Operations GENERAL AGGREGATE $ $2,000,000.00 GEN'L nPOLICY AGGREGATE LIMIT APPLIES PER: I PECOT n LOC PRODUCTS - COMP/OP AG 1 S2,000,000.00 Per Person S $,100,000.00 AUTO D. n • n • J�.J_n LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS DRIVE AWAY ANNUAL AGGREGATE S BODILY INJURY (Per Person) S BODILY INJURY (Per Accident) S PROPERTY DAMAGE (Per Accident) S GARAGE SCHEDULE ■ E J J • • • UABRTTYIMANUSCRIPT FORM AUTO G.K.L.L O.T.R.P.D. D.O.C_ CARGO ON HOOK EMPLOYEE DISHONESTY WRONGFUL REPOSSESSIO PER PERSON S PER ACCIDENT S AGGREGATE S PROPERTY DAMAGE $ EXCESS ^- LIABILITY- OCCUR ❑ CLAIMS MADE RETENTION $ EACH OCCURRENCE S SO AGGREGATE S So S UMITATION OF COVERAGE FOR ADDITIONAL INSURED DESCRIPTION OF OPERATION/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISION Coverage is limited to only insured activities or operations on the Participant Member Declaration Certificate or as may be separately endorsed. Roofing - Commercial, Roofing - Residential., Painting - Residential & Commercial., Dry Wall or Wallboard Lrstallation., Floor Covering Installation., Concrete. k1 CERTIFICATE HOLDER LI ADDITIONAL INSURE LI LOSS PAYEE Miami Shoes Village Building Departement 10050 NE 2 Ave Miami Shoes Village, FL 33138 Fax Number: 3057568972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER MILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FALURE TO DO SO SHALL WIPOSE NO OBLIGATION OR LIABILITY OF ANY KND UPON THE INSURER, RS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENT 11�419kiiiiiirstrith6 CERTIFICATE OF LIABILITY INSURANCE I 2/1/ 017 per: Plymouth Insurance Agency 2739 U.S. Highway 19 N. Holiday, FL 34691 (727) 938-5562 This Certificate is issued as a matter of information only and confers no rights upon the certificate Howes This Certificate dols not amend, extend or alterthe coverage afforded by the polides below. Insurers Affording Coverage NAIL # Insured: South East Personnel Leasing, Inc. & Subsidiaries 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Lion Insurance Company - 11075 Insurer B: nsurer C: Insurer D: Insurer E: Coverages 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 terns, exclusions, and conditions of such policies_ Aggregate limits shown may have been reduced by paid claims_ INSR LTR ADDL INSRD Type of Insurance Policy Number Policy Effective Date (MM/DD/YY) Policy Expiration Date (MM/DD/YY) Limits GENERAL LIABILITY tCommercial General Liability Claims Made Occur Each Occurrence $ Damage to rented premises (EA occurrence) $ Med Exp $ Personal Adv Injury S General aggregate limit applies per. 3 Policy ❑ Project ❑ LOC General Aggregate $ Products - Corp/Op Agg $ AUTOMOBILE 11 LIABILITY Any Auto A0 Owned Autos Scheduled Autos Hired Autos Non-Owned Autos Combined Single Limit (EA Accident) $ Bodily Injury (Per Person) $ Bodily Injury (Per Accident) $ Property Damage (Per Accident) $ EXCESS/UMBRELLA LIABILITY Occur ❑ Claims Made 1 Deductible Eaar pence Aggregate A Workers Compensation and Employers' Liability Any proprietor/partner/executive officer/member exduded? NO If Yes, describe under special provisions below. WC 71949 01/01/2017 01/01/2018 x I WC Statu- I tory Limits I OTH- ER E.L. Each Accident $1.000.000 E.L. Disease - Ea Employee S1,000,000 E.L. Dicracr -Policy Limits S1,000,000 Other Lion Insurance Company is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of Operations/LocationsNehides/Exdusions added by Endorsement/Spedal Provisions: Client ID: 24-65-464 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company: Praxis Industries, Inc Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s), while working in: FL Coverage does not apply to statutory empbyee(s) or independent contractor(s) of the Client Company or any ottier entity. A list of the active employee(s) leased t0 the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name: ISSUE 02-01-17 (BP) Begin Dates 9/9/2016 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVENUE MIAMI SHORES VILLAGE, FL 33138 Should any of the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mad 30 days written notice to the certificate holder named to the lett, but failure to do so shall impose no odigation or liability of any kind upon the insurer, its agents or representatives. %%4: Q J Invoice Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 For Inspections please call: (305)762-4949 Return to: Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 r, Bill To KEITH ROUSE 25 NW 104 Street MIAMI SHORES, FL 33150-1237 Permit Number: REV -2-17-338 Invoice Date: February 09, 2017 Invoice Number: REV -2-17-62891 Bond Number: Comments: L Permit Type: Revision / Work Classification: Roofing Date 02/09/2017 02/09/2017 Fee Name Revision Fee Scanning Fee Fee Type Calculated Calculated Fee Amount $75.00 $9.00 Total Fees Due: $84.00 Payments Date Pay Type 02/09/2017 Credit Card 03/30/2017 Cash Check Number Amount Paid $50.00 $34.00 Change $0.00 $0.00 Total Paid: $84.00 is .3ti et\ Total Due: $0.00 II Thursday, March 30, 2017