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EL-16-1481Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 103 NE 99 Street Miami Shores, FL 33138- Owner Information Pei ■ Permit NO. EL -5-16-1481 Permit Type: Electrical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 12/27/2016 Expiration: 06/25/2017 Parcel Number Applicant Address 1132060132180 Block: Lot: 103 NE 99 Street MIAMI SHORES FL 33138-2340 GEORGE FISHMAN Phone CeII Contractor(s) Phone AP POWER ELECTRIC CORP (954)822-4496 CeII Phone Valuation: Total Sq Feet: $ 3,329.45 00 Type of Work: ADD ADDITIONAI OUTLETS AND RECEPTA Additional Info: Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $2.40 $3.38 $3.38 $0.80 $225.00 $9.00 $3.20 $247.16 Pay Date Pay Type Amt Paid Amt Due Invoice # EL -5-16-59966 05/27/2016 Credit Card $ 50.00 $ 197.16 12/27/2016 Credit Card $ 197.16 $ 0.00 Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W. W. 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 AFF constru tion an : I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating ng. Futhermore, I authorize the above-named contractor to do the work stated. Auth ignature:Owner / Applicant Contractor / Agent Building Department Copy December 27, 2016 Date December 27, 2016 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305)195-2204 Fax (305) 756.8972 INSPECTION UNE PI; ONE NUMBER: (305) 7E44949 FBC 20/x/ the BUILDING Master Permit No.X/6 - i 9y9 PERMIT APPLICATION Sub Permit No. E/ J - / 9a7 ' ❑BUILDING ('LE yCtRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL El PLUMBING ❑ MECHANICAL El PUBLIC WORKS D CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: (' 3P i s • f -r 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): an2.14A:;-- - 1-� C i-(—'44 4-4, Phone#: Address: / O '3 iij i -q . q t� K Sl/ City: ( 1 J i'"/' State: L - Tenant/Lessee Name:0/74- Email: zip: 3 3 Phone#: 32r= 7-1-1-14-69 CONTRACTOR: Company Name: )1 P 10 c>J E.4f 6' e -ti._ I C.:....!, Phi #:Rgi"'2-Z---415 res 27-')-- S ci tVl-.� (6 e -j City C—►�iv CI� `c L! i State: T-1...._yZip�' .3 3� Z, Qualifier Name. = C� C,�• Phone#: State Certification or Registration #•-e--D--10/ y4 3 • Certificate of Competency #: ( 0 -6-- cr--2:3%Z) DESIGNER: Architect/Engineer: Phone#: Address: — City: State: Zip: Value of Work for this Permit: $ - i .59- CliSquare/Linear Footage of Work Type of Work: ❑ Addition % Alteration ❑ New [1 Repair/Replace ❑ Demolition Description of Work: /4vaGy, 4 p 4‘1411.1710-1-44.. Cc. T L t �iB - J c- u.. it- A+tA.0- Specify color of color thru tile: �• Submittal Fee $ Permit Fee $ Z �' �'�' F` Y srCCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ -Bond $ TOTAL FEE NOW DUE $ IRswicnrin, he.hni e1 Bonding Company's Name (if applicable) Bonding Company's Address • P // 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. h 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. 1 understand that a separate permft 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 o building permit with an estimated value exceeding $1560, 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 abse4 e of such posted notice, the inspection will not be approved and a reinspection fee will be charged. OWNER or AGENT The foregoing instrument was acknowledged before me this 20 day of Co. .Lae' me or who has produced as identification and who did take an oath. NOTARY PUBLIC: s personally k by to APPROVED BY 111 AstAcaelill hd hM d L ,Signature �y- CONTRACTOR The foregoing instrument was acknowledged before me this Zo day of Itt4-? by e'C't 0k. 44.-"Z , w o is personal)ky,_nizarau�t me or who has produced identification and who did take an oath. NOTARY PUC: Sign: Print: Seal: f -,.."GI'// Plans Examiner as ################# Zoning Structural Review Clerk Local Business Tax Receipt ii,iliaini-Dade county, State of Florida 15NOTASRL- QONOTPAY NASIOLOCATbOtti AP PSR ELECTRIC CORP DOING BUSINESS 114 DADE couqlY OVaiffc POWERAP ElICTRIC CORP Ci9 tiacvoR /;R7Ci1 A K RECEIPT SR MEM - 711 ?YPC OF IsugligeSS 196 agcTRICAL Pi S SEPTEMBER n. art Matt be t!resip4Vad at #ii buiimrs. xt Coy/ay-OW. 4;40.4,10a, U - : S $1 le PAYMtv;i RECEIVED or wax S-[oi-OR 8,2 1 I}R+0112015, ampromopeaR' b>as > lOdliies lik0,0s** Ilatikem ThelIEIMPERE.ahaiam*/*-04.11:041:4111emenneWittegiciow-Mosti-DadetWeSecla-tX- harattflakirathaumiaRTEEPAWallARECIalMetaX JP Calmn s Tax Muni—Dade County,StateofRi -iinswworAssa km,NOTFY CCt : 1O i2i .4P MAIER ELECTRKC,01IP DOING 1r:55IN�TY ,4Y FLAMM 1 LF1.J1,X {AMP CfcJ Hi = M S RISCENIef 7473439 TIMEOf BUSINESS 10,0111101 UN:10MM EXPIRES SEPTEMBER 303 2016 ton 30 -rt 2C0.00 IQ/W/20'15 012'1-36ri3r-OJ44 nisfecepisagraikIhmekagoireitissimapatheesAvedwa.0021.SelestatrOisoort farzwimagetwa .t ® AC012Li CERTIFICATE OF LIABILITY INSURANCE . DATE (MM/DD/YYYY) 05/23/2016 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 art ADDITIONAL INSURED, the policy(ies) must be endorsed. U 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). a PRODUCER (786) 573-4485 (786) 573-4486 Insurance NOW Agency 12915 SW 132 Street suite 4-B N`"`T Mayleen Blandon Melo. (786) 573-4485 w , No): (786) 573-4486 aZH Ess: mayleen@insurancenowagency.com Miami, FL 33186 PRODUCER CUSTOMER ID X: INSURER(S) AFFORDING COVERAGE NAIC * INSURED AP Power Electric Corp. 10161 W Sunrise Blvd Apt 203 Plantation, FL 33322 INSURERA: Endurance American Specialty Ins Co INSURER B : 3/16/2016 INSURERC: EACH OCCURRENCE INSURER D : 1 INSURER E : $ 100, 000 INSURER F : CLAIMS -MADE 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 AODL INSR SUBR MM. POLICY NUMBER POLICY EFF JMMIDD/YYYY) POLICY EXP SMMIDD/YYYYL LIMITS A GEN ERALUABIUTY COMMERCIAL GENERAL LU181LrIY OCCUR CBC20001204500 3/16/2016 3/16/2017 EACH OCCURRENCE $ 1,000,000 1 PPRAEM GE SES Ea occuTO rrence) $ 100, 000 CLAIMS -MADE i MED EXP (Any one person) $ 5,000 $ 1.000.000 $ 2 000, 000 PERSONAL &Am/ INJURY GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER 1 POLICY n !Ira 17 IOC PRODUCTS - COMP/OP AGG $ 2,000,000 S 71 AUTOMOBILE LIABILITY ANY AUTO ALL 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) $ . $ — $ UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ — $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS YIN N/A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101 Additional Remarks Schedule, If more space is required) License #E000121 / ER 13014434 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building De artment g p 10050 NE 2nd Ave Miami Shores Villages, FL 33138 I 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 Mayleen Blandon \\e„ ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. AU rights reserved. The ACORD name and logo are registered marks of ACORD 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: 4/12/2016 EXPIRATION DATE: 4/12/2018 PERSON: ARZOLA FEIN: 271635909 BUSINESS NAME AND ADDRESS: AP POWER ELECTRIC CORP HECTOR 3758 SW 16TH ST FORT LAUDERDALE FL 33312 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR A SR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade fisted on the notice of election to be exempt. Pursuant to Chapter 440.05(13). F.S.. Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Miami Shores Village Building Department 10050 N.E2nd Avenue Miami Shores, Florida 33138 Tel: (305) 7952204 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 YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this 1-0 day of ,20J whq personally known tole or has produced \- as identification. SEAL: SEAL: Ap Power Electric Corp 3758 Sw 16th St Fort Lauderdale, FL 33312 Phone: (954) 822-4496 Date: 5/25/2016 State of: —FL—o 4 - County of:� 3:) Before me this day personalty appeared -i trG-r &.. 40-ZoL4- who, herein duly sworn, deposes and says: That he or she will be the only person working on the project at: (9? 11.) • V---7.4r/'-`]j ST Sworn to ( or affirmed) and subscribed before me this day of 20 12 , by 41e4G2L-kize,Lf c—PersonaUyjin OR Produced Identification Type of Identification Produced Print, Typ - or Stamp ARZOLA, HECTOR A AP POWER ELECTRIC CORP 8766 NW 140TH LANE MIAMI LAKES FL 33018 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 learn 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 41., STATE OF FLORIDA p: DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ER 13014434 ISSUED. 09/21/2016 REG ELECTRICAL CONTRACTOR ARZOLA, HECTOR A AP POWER ELECTRIC CORP (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) HAS REGISTERED under the provisions of Cn 489 FS Exr.'1:,Cfld.ITU AUG .. 2:.'18 1,62921-0c.s4e DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD LICENSE NUMBER The ELECTRICAL CONTRACTOR Named below HAS REGISTERED Under the provisions of Chapter 489 FS_ Expiration date: AUG 31, 2018 (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) ARZOLA, HECTOR A AP POWER ELECTRIC CORP 8766 NW 140TH LANE MIAMI LAKES FL 33018 ISSUED 09/21,2016 DISPLAY AS REQUIRED BY LAW SEQ # L1609210000648 '4C Rt7- CERTIFICATE OF LIABILITY INSURANCE OATE(MMAD/YYYY) 05/2312016 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 pollcy(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). ndor sement(s). PRODUC OD11C (786) 573-4485 (786) 573-4486 Insurance NOW Agency 12915 SW 132 Street suite 4-B NCT EA Mayleen Blandon MIL. Ext): (786) 5734485 w, No); (786) 573-4486 trpAfitligg, mayleen@insurancenowagency.com Miami, FL 33186 PRODUCER OMER ID N: , INSURER(S) AFFORIXINGCOMERAGE HNC5 INSURED AP Power Electric Corp. 10161 W Sunrise Blvd Apt 203 Plantation, FL 33322 INSURERA: Endurance American Specialty Ins Co INSURER B : 3/16/2016 INSURER C : EACH OCCURRENCE INSURER D : i INSURER E: $ 100,000 INSURER F : CLAIMS -MADE COVERAGES CERTIFICATE NUMBER: R THIS IS TO CERTIFY THAT THE POLICES 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_ LIR TYPE OF INSURANCE ADDL INSFI SMID POLICY NUMBER (MII t DR YrrYYYIJMEFF IMP MIODIYYY''Y LIMITS , A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR CBC20001204500 3/16/2016 3/16/2017 EACH OCCURRENCE $ 1 000,000 i CAIIMIGE ED PR g ERR ocolrrerxxr} $ 100,000 CLAIMS -MADE / MED EXP (Any one person} $ 5,000 $1,000,000 $ 2,000,000 $ 2,Q00 000 $ PERSONAL a ADV INJURY GENERAL AGGREGATE GEN'L AGGREGATE LIMIT POLICY n PF O- APPLIES PER: PRODUCTS - COMP/OP AGG 71 I I LOC AUTOMOBILE LIABILITY ANY AUTO ALL 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) $ —$ S UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ 5 WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory M NH) Rdescribe under DESCRIPTION OF OPERATIONS Y / N NIA WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) License #E000121 / ER 13014434 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building 10050 N.E. 2nd. Ave. Miami Shores, FI. 33138 ACORD 25 (2009/09) 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 Mayleen Blandon 01988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) r 72017 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 W.F. Roemer Insurance Agency, Inc. 3775 NW 124 Avenue Coral Springs FL 33065 NAMEACT Certificate Department PHONE 954-731-5566 (A/C Nn Ext). EooaELss: certificates@roemer-ins.com FAX. tet; 954-731-8438 INSURERS) AFFORDING COVERAGE NAIC 11 INSURER A :National Builders InSuranceCO. 16632 INSURED Star Construction Company, Inc 2155 NE 124 Street North Miami FL 33181 STARC-1 INSURER B : INSURER C : INSURER D : INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1472394111 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. iLTR TYPE OF INSURANCE INSD DDL BR WVD POLICY NUMBER POLICY EFF (MMlDDNWY) POLICY EXP (MMIDDIYYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY GLP 0021923 08 5/6/2017 5/6/2018 EACH OCCURRENCE 51,000.000 CLAIMS -MADE X OCCUR TO PRS{ RENTEDEaoccurrence} PREEMIMI ESES ( 1'00.000 MED EXP (Any one person) $b.000 PERSONAL & ADV INJURY 51,000.000 GEN'L X AGGREGATE POLICY OTHER. LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE 52.000.000 PRODUCTS -COMP lOPAGG $2.000,000 5 AUTOMOBILE LIABILITY ANY AUTO ALLL Ow NED HIRED AUTOS SCHEDULED TOS NON -OWNED AUTOS COMBINED SINGLE LIMB (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTIONS S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WCV 0071182 07 8/31/2016 8/31/2017 x PER STATUTE OTH- ER EL. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $100,000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Certified Residential Contractor, License #CRC010047 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building 10050 NE 2nd Ave 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 ACORD 25 (2014101) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 103 NE 99 Street Miami Shores, FL 33138- Owner Information Permit Permit NO. RC -5-16-1479 Permit Type: Residential Construction Work Classification: Garage Enclosure Permit Status: APPROVED Issue Date: 12/27/2016 Expiration: 06/25/2017 Parcel Number Applicant Address 1132060132180 Block: Lot: 103 NE 99 Street MIAMI SHORES FL 33138-2340 GEORGE FISHMAN Phone Cell Contractor(s) STAR CONSTRUCTION CO INC Phone (305)893-4101 CeII Phone Valuation: Total Sq Feet: $ 26,945.65 566 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: CONVERT Stories: 1 Front Setback: Left Setback: Bedrooms: 4 Plans Submitted: Yes Certificate Date: Bond Return : GARAGE INTO STUDIO Occupancy: Other Exterior: Rear Setback: Right Setback: Bathrooms: 2 Certificate Status: Additional Info: CONVERT GARAGE INTO STUDIO / Classification: Residential Fees Due CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Plan Review Fee (Engineer) Scanning Fee Technology Fee Total: Amount $16.20 $50.00 $12.13 $12.13 $5.40 $808.37 $160.00 $12.00 $21.60 $1,097.83 Pay Date Invoice # 05/27/2016 12/27/2016 Pay Type RC -5-16-59964 Credit Card Credit Card Anit Paid Amt Due $ 50.00 $ 1,047.83 $ 1,047.83 $ 0.00 Available Inspections: Inspection Type: Review Electrical Review Electrical Review Electrical Review Structural Review Mechanical Review Mechanical Review Mechanical Review Plumbing Review Plumbing Review Plumbing Review Planning Review Building Review Building Review Building Review Building Review Building 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 AFFIDAVr construction and z Autho certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating uthermore, I authorize the above-named contractor to do the work stated. Building ignature: Owner / Applicant epartment Copy December 27, 016 Contractor / Agent December 27, 2016 Date 1 DADE: (305) 893-4101 BROWARD: (954), 966-0051 FAX: (305) 893-9865 CELL: (305) 244-4101 Licensed & Insured State CC: #CRC010047. ACCREDITED 7BUSINESS B•• Rillp: STAR+ Constriwt[DYt CD./ jne. Additions • Remodeling • Custom Homes LEONARD C. FELDMAN 2155 N.E. 124th St. President N. Miami, Florida 33181 Email: starco@bellsouth.net • www.constructionbystar.com 3