ELC-18-392 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-297449 Permit Number: ELC-2-18-392
Scheduled Inspection Date: April 05, 2018 Permit Type: Electrical - Commercial
Inspector: Devaney, Michael Inspection Type: Final
Owner: , BARRY UNIVERSITY Work Classification: Low Voltage
Job Address:11300 NE 2 Avenue Health &Sports
Miami Shores, FL 33138-0000 Phone Number
Parcel Number 1121360010160-27
Project: BARRY UNIVERSITY
Contractor: CCS PRESENTATION SYSTEMS Phone{ (904)998-7227
Building Department Comments
UPGRADE TO AUDIO VISUAL EQUIPMENT AND LOW Infractio Passed Comments
VOLTAGE CABLING INSPECTOR COMMENTS False
Inspector Comments
Passed TODD FLAHERTY
I 954-923-5827
C
Failed
Correction
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
i
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April 04,2018 For Inspections please call: (305)762-4949 Page 8 of 31
a Permit No. ELC-2-18-392
�atjO1S°�� Miami Shores Village Permit Type:Electrical-Commercial
10050 N.E.2nd Avenue NE Work Classification.LOW Voltage
Miami Shores, FL 33138-0000 Per
Permit Status:APPROVED Phone: (305)795-2204
F�ORLDA
Issue Date:3/28/2018 Expiration: 09/25/2018
Project Address Parcel Number Applicant
11300 NE 2 Avenue Number: Health & Sport 1121360010160-27 BARRY UNIVERSITY INC
Miami Shores,.FL 33138-0000 Block: Lot:
Owner Information Address Phone Cell
BARRY UNIVERSITY INC 11300 NE 2 Avenue
d MIAMI SHORES FL 33161-6628
11300 NE 2 Avenue
MIAMI SHORES FL 33161-6628
Contractor(s) Phone Cell Phone
Valuation: $ 3,429.56
CCS PRESENTATION SYSTEMS
(904)998-7227 (904)607-2032
._. ._ __ _�..,H.._.,..�.. ... . ...._.. . ._. . Total Sq Feet: 0
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Type of Work:UPGRADE TO AUDIO VISUAL EQUIPMENT A Available Inspections:
Additional Info: Inspection Type:
Classification:Residential Final
Scanning:3 Review Electrical
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Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $2.40
DBPR Fee Invoice# ELC-2-18-66458
$2.25 03/29/2018 Credit Card $ 113.65 $50.00
DCA Fee $2.00
Education Surcharge $0.80 02/14/2018 Credit Card $50.00 $0.00
Permit Fee $150.00
Scanning Fee $3.00
Technology Fee $3.20 e
Total: $163.65
� k
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.
I
OWNERS AFFIDAVIT: I cera that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction=zonina or�Iauth e-above-named contractor to do the work stated.
March 29, 2018
A th z i Owner / Applicant / Contractor / Agent Date
Building Department Copy
March 29, 2018 1
r
f-s .• Miami Shores Village C
1 Building Department MAR o0 0�8
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 _
INSPECTION UNE PHONE NUMBER:(30S)M-4949
FBC 20 -T
� BUILDING ^ ' r'
Master Permit No. -7�
PERMIT APPLICATION Sub Permit No. —392-
BUILDING M ELECTRIC ROOFING REVISION EXTENSION [RENEWAL
G
[]PLUMBING [j MECHANICAL [-]PUBLIC WORKS [:]CHANGE OF CANCELLATION SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: Barry University- 11300 NE 2nd Aver HSC HOSPITALITY ROOM
City: Miami Shores County Miami Dade Zig:
Folio/pa W 11-2111011 050 Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):Barry University Phone#:303-899-3995
Address:11300 NE 2nd Ave.
City: Miami Shores State: FI Zlp: 33161
Tenant/Lessee Name: Phone#:305-899-3000
Email: Jyao@barry.edu
CONTRACTOR:Company Name: Visionworx LLC, DBA: CCS Presentation Systems phone#: 904-998-7227
Address: 5530 S. Florida Mining Blvd
city: Jacksonville state: FI np: 32257
Qualifier Name: Douglas Mann phone#: 904-998-7227
State Certification or Registration#: Florida Certificate of Competency#: ES 12001322
DESIGNER:Architect/Ensineer: Ray Ricoarango phones: 305-781-2071
a
Address:11470 Interchange Circle North City: Miramar state: FI 7Jp: 33025
1 value of Work for this Permit:$3429.56 Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New M Repair/Replace ❑ Demolition
Description of work: Upgrade audio visual equipment and low voltage cabling
Specify color of color thm tile:
Submltta!Fee$ Permit Fee$ CCF$ CO/Cc$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double fee$ i
Structural Reviews$ Bow$ !
TOTAL FEE NOW DUE$
(ReNseW2/24/W14)
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Bonding Company's Name(if applicable)
Bonding Company's Address
' City State Zip r
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
I 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
l 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.
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"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
1 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 faih that a copy of the notice of commencement and construction lien law brochure will be deliveried to the person
i whose property is subject to attachment Also,a certified copy of the recorded notice of commencement must be posted at the job site
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.
1
Signature,—' 4L, Signature Bt.44
OWNER or AGENT CO CTOR
I The folegoing instrument was acknowledged befqre
'Jme this The foregoing instrument was acknowledged before me this
day of-kUU _20 3 ,by .46 day of r 20 111K by
AA k�f5 NAU ,who is personally known to ()&oeraAs-N41�' 3
1 p Y _ :who is person known to
,>or who has produced as me or who has produced I as
Identification and who did take an oath. Y identification and who did take an oath. '
NOTARY PU UC: NOTARY PUBLIC:
Sign: Sign:
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` P t Print: A it S&rA
I Navy Punic State a Florida Seal: ��;���
Jeffry J Yao ;,ir ', KiRSTIN 0 IMMELL
j � � My Cammwron FF tsM4s1 =� ':MY COMMISSION N GG087854
V EM*M 11r12rio1s
EXPIRES March 211,2021
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APPROVED BY 1 /L Ath-&* Plans Examiner Zoning I
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Structural Review Clerk #
(RevisedO2/2412014) j
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Miami Shores Village Z/17 Ir
Building De artment
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(365)4624949' (14y
„ FBC 20 P
BUILDING Master PermitNo.r_kX� �
PERMIT APPLICATION Sub Permit No.
❑E3UILDING ,ELECTRIC ❑ ROOFING E3tREVISIQN, ❑'EXTENSION RENEWAL
a s •
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF: ❑CANCELLATION' ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County- k Miami Dade,; Zin
)K Folio/Parcel# 00D- MY-0 Is the Building Historica0y'Desigaated.Yes NO
Y Type;Occu an'c T e;
p y. Load: Construction Type: Flood Zone: BFE: FFE:
MER:Name(Fee Simple Titleholder): Phone#:�� '"_
.�^~� �'`���-3 �
Pty:, lAgt �Wd5 State:
U_
,K ..
..�il .1 _ _ yip.
Tenant/Lessee:Nime: ^j�c�ta
., Phone#: 105"'
Email: .i J C7L)
CONTRA&OR:Company'Name:V(x4)3"V GI.0 ,Q ; t±'(;` ____--`` �i�t x.•c.5
Address: : kJ90R 14 f `A)6- &vp
City: TAc.kS4V( State: L
�. Zip:-�•�.;�.'��
Qualifier Name: Di 64�� x4hdd e�
Phone#:�t)t!t" i� e �
State Certification orResistratian Certificate of Competency#: t Lp
DESIGNER:Architect/Engineer: L �, Ph
one ~3 ;Loll
Address A State: Zip:
Value of Work fo'r'this Permit:$ �.:57i M &
_. ,.,guar no �:_ age of Work: •: ,
°Type of Work: ❑ Addition ❑ Alteration
❑ NewRepair/Replace ❑ Demolition
Description of Work: DPG�rfiJ� cL IQt74tt> tld: 'jAG: E `ylP '1`
Speci)y'color of color thru tile:.. N
Submittal Fee$4c5O '()Q P D o
ermit Fee$,/✓T a o CCF$..__. ,. .d.. . . ..�,. CO/CC$,.
Scannint'Fee$ T �' Radon Fee
DBPR$- Notary$
Technalogy Fee$,'` Training/Education Fee$ Double Fee$.-
Structural Review`s$ .. a Bond
_. `�-
TOTAL FEE NOW DUE'$.-
(f evised02f24)2014)
L
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ZIP
Mone tenders Nim(if apDticeble)
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In thk� i wddrstwW that a e:�r*Oe .be secl�rgQ for n6
FWWACE4 BOLERS,,WATM4 TAMM AM CQWWtNEV ,ET_�.... , PLl1M$1ltG, . POOLS,
tkabie l� I8 and sorNrK, t +ire and that sq WC"t VAR be cone in campgolo with sY
I " UT MG TO �DWNER;: YOUR FAILURE
RESULT TO RECORD.A.NOTtM OF COMMENCEME
IN YOLM PAYIN
a G r lla FOR- OVEMENTS TO YOUR PROPERTY, IF YOU INTE#D
TO 08rtAIN HNANCII�
•CONSULT WrM YOUR LENDER OR AN ATTORNEY BEFORE
[OURECORDING
4 R NOTICE OF�p1� €MENT.'v
to APPAMft' As a=mown to the lbuonet�Q aft Oft w1d►an
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rruperty -)earcn application- Miami-Dade County Page 1 a 1
' E ""F "HE PROPEff"RTY APPRA�Shn,
OFFIG" U
Summary Report
4
Generated On:2/13/2018
Property information ,
Folio: 11-2136-000-0050
v
Property Address: 11300 NE 2 AVE
Miami Shores,FL 33161-6628
w •n . • '. ... "rt
Owner BARRY COLLEGEIrk
.
i''" `'° ,
Mailing Address 11300 NE 2 AVE �:• .� -
MIAMI SHORES,FL 33161-6628
PA Primary Zone 8200 SCHOOLS&CHURCHES - �1'��•�c�` � r ' ,�r, ,> � y�z ' ~ ';,�r
7241 EDUCATIONAUSCIENTIFIC
Primary Land Use3i4.
EX:EDUCATIONAL-PRIVATE
Beds I Baths/Half 0/0/0
'' - :.s r r , ` q;�"✓'
Floors 2
Living Units 66 s'fk 9 �• "`
Actual Area Sq.Ft
Living Area Sq.Ft " ``
�' 4.1
AdJusted Area 623,362 Sq.Ft
Lot Size1,740,400 Sq.Ft Taxable Value Information
Year Built 1954 2017 2016 2015
County
Assessment Information Exemption Value $48,008,208 $46,503,814 $43,013,559
Year 2017 2016 2015 Taxable Value $0 $0 $0
Land Value $6,961,600 $6,961,600 $6,961,600 School Board
Building Value $38,439,360 $36,913,434 $33,497,476 Exemption Value $48,008,208 $46,503,814 $43,013,559
XF Value $2,607,248 $2,628,780 $2,554,483 Taxable Value $0 $0 $0
Market Value $48,008,208 $46,503,814 $43,013,559 city
AssessedValue $48,008,208 $46,503,814 $43,013,559 Exemption Value $48,008,208 $46,503,814 $43,013,559
Taxable Value $0 $0 $0
Benefits InformaRlorr• Regional
Bement.•• Type•• • • l�017 2016 2015 Exemption Value $48,008,208 $46,503,814 $43,013,559
EcJypgal SScImption >F48,00 208 $46,503,814 $43,013,559 Taxable Value $0 $0 $0
Notg:•Not all benefiteare applicadigWATTaxable Values(i.e.County,
Sd b8l%Vbrd,City,Rt?of1al). ."." Sales Information
Previous SalePrice OR Book-Page teal Qualification Description
eal DeserilMIn •• ••
3ae 1 AC • ••.•.•
S6140F#4E1/4 LESS E15FT&tESS•• r
W40RT 00 •• • •.
LOe_E-1740400.80f1.l9RE FEET •
The Office of the Property Appraiser is continual) editing and updating the tax roll.This website May not reflect the most current information on record.The Property Appraiser
Y 9 Pd 9 Y P rty PP
and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at hfp://www.miamidade.gov/infotdisclaimer.asp
Version:
{
http://www.miamidade.gov/propertysearch/ 1 2/13001 R
1
?017 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT FILED
DOCUMENT#711458 Apr 27, 2017
Entity Name: BARRY UNIVERSITY, INC. Secretary of State
CC2519040112
Current Principal Place of Business:
11300 N.E.SECOND AVENUE
ROOM 105 FARRELL HALL
MIAMI, FL 33161
i
Current Mailing Address:
11300 N.E. SECOND AVENUE
ROOM 105, FARRELL HALL
MIAMI, FL 33161
FEI Number: 59-0624364 Certificate of Status Desired: No
Name and Address of Current Registered Agent:
DUDGEON,DAVID
11300 NE SECOND AVE
LAVOIE HALL#209
MIAMI,FL 33161 US
i
The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida.
SIGNATURE: ,
i
Electronic Signature of Registered Agent Date
'Officer/Director Detail :
I Title S Title T
Name DUDGEON,DAVID Name ROSENTHAL,'SUSAN
Address 11300 NE SECOND AVE Address 11300 N.E.SECOND AVENUE
City-State-Zip: MIAMI FL 33161 City-State-Zip: MIAMI FL 33161
Title D Title PD
Name BUSSEL,JOHN Name BEVILACQUA,SISTER LINDA
Address 11300 NE SECOND AVE Address 11300 NE SECOND AVE
1 City-State-Zip: MIAMI FL 33161 City-State-Zip: MIAMI FL 33161
Title VP
Name MURRAY,JOHN
Address . '41000 N.E.SECOND AVENUE
.pkState-Zip:' MIAAMI FL 330'.
•
•••••• •• • ••••••
I hereb ce '•vArmffon
oath;that 1�anaotAesr or dsactor�the Qo on this repot or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as it made under t
rporation or the receiver or trustee empowered to execute this report as required by Chapter 617,Fkxkta Statutes;and that my narrm appears
above,or on an attachment with all other like empowered.
,SIGNATURE:DAVID DUDGEON GENERAL 04/27/2017
1
COUNSEUSECRETARY
Electronic Signature of Signing Officer/Director Detail Date
R` J
Purchase Requisition
Please note special requ►remen s
JOB NUMBER: 30-17-PO58 such as need by dates requiring
JOB DESCRIPTION: BARRY HSC HOSPITALITY ROOM expedited shipping and special
DATE: 1/29/18 pricing instructions
Make Model Description Qtv Order Cost Ext.Cost Notes -Display -
CHIEF CMS006W PROJECTOR PIPE 1 10.03 10.03
CHIEF CMS440 UPPER CEILING PLATE 1 63.51 63.51
CHIEF RPAA1W LOWER PROJECTOR MOUNT 1 81.37 81.37
DALITE 40932 6"BRACKETS 1 10.65 10.65
DALITE 70293 MODEL C W/CSR HIGH CONTRAST MATTE 1 399.00 399.00
WHITE MANUAL SCREEN
EPSON V11 H871020 POWERLITE 2250U PROJECTOR 1 1,104.00 1,104.00
CRESTRON GLS-ODT-C-CN OCCUPANCY SENSOR 1 126.00 126.00
CRESTRON MP-610 ICONTROL KEYPAD 1 202.50 202.50
.. ... . . . . . ..
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INPUT I e
(OFE)CjPUTEROUTPUT AV PLATE
UBB HDMI HDMI 1 CRESTRON OMP319K-1500
INPUT OUTPUT
USB
UBB HDMI HDMI V002 — V002 HDMI HDMI-1
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COMPUTER AUDIO-1 DM OUT RJLS X01 ❑_ Dom RJU' DM 'HDMI � V17i�7 DMI
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FSR TS-BLK-CABLE CUBBY VOW HD11M VGA-2 HDMI TWISTED PAIR EXTENDER WUXGALCDPROJECTOR
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VGA VGA HD1SM 2004 Vans HDMI HDMI-3
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I ELMOTT-120 INPUT OUTPUT ,
OUTPUT AUDIO-1 PROGRAM 'PHX 101 — PNX CHANNEL 70V PHX SOm D
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PHX DDM USB 2 AV PLATE
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S AND ocOUL4j
This CAD drawing and specs are the exclusive REVISIONS DRAWING TITLE:
DRAWING INFO
property of CCS and were prepared exclusively for MARK i DATE NOTES AV FLOW
the use of CCS.These shall only be used for intended _
F purpose only. s a other use or reproduction of these I TBA TBA 2 O 18 'BARRY "U N 1 V E R S 1 TY
CCSwhether
CAD drawings and spec are permitted in arty form, ENG.: RAY• DATE: �I.29.18
by electronic,mechanical,photocopying
- photographed,recording other means,without MASTER CLASSROOM FLOW RAY
SHEET NO:
the prior written consent CCS,and any PM: RAY SCALE: N.T.S
unauthorized use or reproduction is strictly _ _ TA
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prohibited. �
SALES: GP SO No. VARIOUS
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STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395
W"N 2601 BLAIR STONE ROAD
TALLAHASSEE FL 32399-0783
i MANN, DOUGLAS N
CCS PRESENTATION SYSTEMS
2613 STONEGATE DR.
JACKSONVILLE FL 32223
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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 STATE OF FLORIDA,•�.
from architects to yacht brokers,from boxers to barbeque, DEPARTMENT_ BUSINESS AND
restaurants,and they keep Florida's economy strong. PROFESSIONAL REGULATION
�- .
ES12001322�- �s 8SUED�08/02/2016..
Every day we work to improve the waywe do business in order ��. .
to serve you better. For information about our services,please `r •-� (i,.,,.e. �, '' " '"
log onto www.myfli6ridalieense.com. There you can find more .CERT.'SPECIALTY-ELECfkiCAL�C'ONTR~
information about our divisions and the regulations that impact
---MANN,•DOUGLQS�N
you,subscribe to department newsletters and learn more about .-CCS,PRESENTATION SYSTEMS • _
the Department's initiatives. !�CERTIFIEDAS ;r,',, C'b�- ��e
''LIMITED ENERGY'SYSTEMS-SPEC. t
Our mission at the Department is: License Efficiently,Regulate _ - _
Fairly.We constantly strive to serve you better so that you can * .-'"�✓:.� i:r - --
serve your customers. Thank you for doing business in Florida, �S•CERTIFIED,under-the provisions or Ch.48 00019
and congratulations on our new license! Ex"pirMiondete':�AUG31.f2o19e ,T�lsoeoz000ls2s_
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DETACH HERE
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE,OF FLORIDA
DEPARTMENT OF-BUSINESS-AND PROFESSIONAL REGULATION'-.
`�.-- ~"' �� •- ELECTRICAL CONTRACTORS LICENSING BOARD
,:--ES12001322
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The.SPECIALTY-ELECTRICAL CONTRACTOR.'" +� '� �_ µ ~` •�~�,�+` '
Named below IS.CERTIFIED- w - - -.��`` ,. .., ,_ • .`
( Under the provisions of Chapter,489_FS. =" •+N°'�*"
i.Ex iratiori'date:�AUG31,-2018 -- _�.,,,�»�,�, ,� ,�, t
"As, LIMITED ENERGY SY'STEMS'SPECIIALIST ;>;� `�, ,r
,r« s�,,,y✓���I "'�,,,,�,eF fir„'"mr �..4 ��/:}P+'L"� +Z'1„�,'�Y."'4......,,� `, l� �. .. L} a � 'y \
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`. .✓IMANN'DOUGL-AS N ♦ '
I- f,/ s`CCS PRESENTATION SYSTEMS=
t :-� '5530_'FLORIDA MI N I N 6106
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ACKSONVILLE"" L°32257-- � ""` _ ""`'+ -;� ti..�- - •,�, � `' �`+�: '� I
Y°�' ,r^"`- I` jj.,.�"`',,`�+;'''y.����,t�—_,�,,a_,., wt�p�„ _#� '1'Q �``'`"' moi.. - + �.,,`'`�, y �'L� �.4 ■
ISSUED: 08/02/2016 DISPLAY AS REQUIRED BY LAW SEQ# L1608020001929
Local Bim'nes5 Tac Recel
Miami—Dade County,State of Florida
THIS IS NOTA BILL-DO NOT PAY
7130578 \�LBT
EXPIRES -
COPRESevTA7ION SYSTBVIS RENEWAL SEPTEMBER 30,2018-
3315 NW 167 ST 7407703 Must be displayed at place of business
MIAMI GARA MS R 33056 PunRNM to County Code
Chapter 8A-Art 9•&10
OWNER SEC.TYPE OF MUSINESS
11ISIONWORX LLC 220 TANGIBLE PERSONAL PROP DLR BATMEN RECEIVED
� BY TAX COLLECTOR -
f EMPICYee(s) 2 $45.00 09/25/2017
CHECK21-17-093778
t TbsLepi 8456145 TsoTNec d''�tt sallrs�su paYwsot of is Loch 8us(mns Taw TLe Reea�t is ast a 6pna,
pensst m a an es6w sf tbeiroblsfs�eell��eats is 6osntets Iislda shat s11"F Wn my Oswnsnsodd �
asyrsemmsaW ra/sVto�y laursaatra�a�nssealswbioh applpta tM busiest.
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A �t DATE(weuodrrvr)
CERTIFICATE OF LIABILITY INSURANCE 2/8/2018
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 have ADDITIONAL INSURED,provisions or 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 endorsemen s.
PRODUCER CONTACT
E: Missy Amos
GHG Insurance PHONE904421-8600 AfCFAX No):904-421-8801
1000 Riverside Ave
Suite 500 DDRE RESS: mamosdOoNins.corn
Jacksonville FL 32204 INSURER(3)AFFORDING COVERAGE NAICIF
INSURER A:FCCI Insurance Group 1 10178
INSURED CCSPR-1 INSURER B:
Visionworx LLC
'dba CCS Presentation Systems INsuRERc:
5530 S Florida Mining Blvd INSURERD:
Jacksonville FL 32257 INSURER E:
INSURER F:
'COVERAGES CERTIFICATE NUMBER:1218135495 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.
�TTRR TYPE OF INSURANCE L 8U8R POLICY NUMBER POLICY EFF POLICY EMO'
Lam
A X COMMERCLALOENERALLIABILIY GLOD169915 9112017 9/12018 EACH OCCURRENCE 51,000,000
_=—7DAMAGE TO RENTEff—
CLAIMS-MADE Fi1 OCCUR PREMISES Ea occurrence $100,000
MED EXP(Any one $5,000
PERSONAL s ADV INJURY $1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY 1:1 JPERCOT- F]LOC PRODUCTS-COMP/OP AGG $2.000,000
OTHER: $
A AUTOMO&LELIABILIY CAlOW05520 W12017 9112019 Eaa=nt INGLE LIMIT $1,000,000
IX ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per seddenq $
AUTOS ONLY AUTOS
X HIRED X NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY acdden
$
A X UMBRELLA LIAO X OCCUR UMB100017OW W12017 9112018 EACH OCCURRENCE $3,000000
EXCESS LIB CLAIMS-MADE AGGREGATE $3,OOD,000
DED I X I RETENTION s $
WORKERS COMPENSATIONPER
AND EMPI.OYERS� [ABILITY YIN STATUTE ER
ANYPROPRIETOFVPARTNER/EXECUTIVE I N/A E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(MandatoryM NH) E.L.DISEASE-EA EMPLOYEE S
I describe under
DESCRIPTION OF OPERATIONS below. E.L.DISEASE-POLICY LIMIT $
t
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddkWW Remarks SdrduN.may be seadwd I mon space Is required) I,
License B ES12001322 C
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
•THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Miami Shores Village Bldg Dept
10050 NE 2nd Ave AUTHORRDREPRESEINTATIVE
Miami Shores FL 33138
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®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
VISILLC-01 IMOS
RD DATE(MMM10812 )
CERTIFICATE OF LIABILITY INSURANCE o2ros�so18l6
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 endorse s.
PRODUCER W"Michelle B O'Steen
JP Perry Insurance,Inc "NE,,�: 904 482-1673 , ,No:(904)900-2222
3342 Kort Road
Jacksonville,FL 32257 mosteen@jppony.com
W AFFORDING COVERAGE NAIL 9
INSURER A:FFVA Mutual Insurance Co. 10385
INSURED INSURER S-
Vlslonworn,LLC dba CCS Presentation Systems INSURER C:
5530 Florida Mining Blvd S. WSURER D:
Jacksonville,FL 32257
- WSURER E
WSURERF: !-
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP umn's
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
CLAIMS-MADE 7 OCCUR DIMAA[aE TO RENTED
MED EXP one Person) $
PERSONAL&ADV INJURY
GEML AGGREGATE LIMIT.IAPPLIES PER GE AGGREGATE
POLICY 1:1JpECT F LOC PRODUCTS-COMPIOP AGG
OTHER:
AUTOMOBILE LL451UTY COMBINED SINGLE UMIT
ANYAUTO BODILY INJURY Wer
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY
BODIILEY INJURY Per accident
FAUTOS ONLY /UJTOS ONLY � E
UMBRELLA LIAR HOCCUR • EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED I I RETENTION$
A WORKERS COMPENSATION X PEROTH-
AND EMPLOYERS'LIABILITY TUTE
ANY PROPRti_TORIPARTNER&XECUTIVE YIN WC8400032206MIgA 01/01/2018 01/01/2019 E.L. ACCIDENT 1'000'000
Wd=LMW)EXCLUDED? El NIA 1'000'000
llMMyy���es� EL DISEASE-EA EMPLOYE
un
DESCPo OF PERATIONS below F-L DISEASE-POLICY LIMIT s 1'000'000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It nw a space is regitnmQ
License 6 ES12001322
I
E
r
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
e B De THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Miami Shores Village Bldg pt ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2nd Ave.
Miami Shores,FL 33138
AUTHORIZED REPRESENTATIVE
ACORD 25(2016103) 01988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
I
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