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RC-18-505Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Per mit NO. RC-2-18-505 Permit Type: Residential Construction Work Classification: Alteration Permit Status: APPROVED Issue Date. 3130/2018 Expiration: 09/26/2018 Parcel Number Applicant 101 NW 99 Street Miami Shores, FL 33150- 1131010220380 Block: Lot: JOANNE LABOSSIERE Owner Information Address Phone Cell JOANNE LABOSSIERE 101 NW 99 Street MIAMI SHORES FL 33150- (305)235-7223 101 NW 99 Street MIAMI SHORES FL 33150- Contractor(s) Phone Cell Phone MONTENEGRO CONSTRUCTION INC (305)244-3624 Valuation: Total Sq Feet: $ 2,500.00 100 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Construction: REPAIR Stories: Front Setback: Left Setback: Bedrooms: Plans Submitted: Yes Certificate Date: Bond Return : FASCIA BOARDS. REMOV Occupancy: Single Family Exterior: Rear Setback: Right Setback: Bathrooms: Certificate Status: Additional Info: Classification: Residential Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Amount $1.80 $2.00 $2.00 $0.60 $5.00 $100.00 $9.00 $2.40 Total: $122.80 Pay Date Pay Type Invoice # RC-2-18-66597 02/27/2018 Check #: 1368 03/30/2018 Credit Card Amt Paid Amt Due $ 50.00 $ 72.80 $ 72.80 $ 0.00 Available Inspections: Inspection Type: Window Door Attachment Framing Insulation Drywall Screw Final PE Certification Window and Door Buck Fill Cells Columns Review Building Review Planning Review Electrical Review Plumbing Review Structural 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 certify that all the foregoing information is accurate and that all work .11 be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the abov ed contract r to do th work st March 30, 2018 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy March 30, 2018 1 BUILDING PERMIT APPLICATION 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 RRCETvgff BY �l l FBC 201 Master Permit No. C t' S Sub Permit No. BUILDING '❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP G� CONTRACTOR DRAWINGS ) JOB ADDRESS: / 0 / /� f�J ? -/ $- /1-'e 1 City: Miami Shores County: Miami Dade Zip: -3 3 / 3 P. Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): c.j '1 4e 4,418°S S r eft Address: / O ( j City: elirfivil / 5 t -' -- . State: Phone#: Zip: 3 3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: `"C�� ��� ��5 L-L7 '- - Phone#: Address: IC' � 4—, 1/4-k--) ° Vq_ Sic City: I P��-L\ S Alzyce free State:n 'c�-- Zip: 7 Qualifier Name: o..� C�6—l�S �`-'��"�-� E'M� Phone#: � ay-q 3 6Z 74, State Certification or Registration #: L G 6 / CI CY / Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 5c:'. Square/Linear Footage of Work: "n o �1 Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace n Demolition Description of Work: o ✓ e a e? I w cs vc=(. IGG wCv ✓� . �� / % :r i r•r S-- Specify color of color thru tle:. �� Submittal Fee $ 1� , Scanning Fee $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ —} Z • Pio s r c J --7.a,-,-r4) 41- 04- CCF $ Permit Fee $ \W • Radon Fee $ >t , 06 DBPR $ . CO/CC $ Notary $S • 00 (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 pereby 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 jurisdictiori ',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. a y•s'r .l 11 Signature �" `-1"``—Signature CONTRACTOR cs , le ' ' 44 1 ,The foregoing instrumen was acknowledged before me this , The foregoing instrument was acknowledged before me this 20 day of r ova r y , 20 �� , by -`` - � danny of cCb{ U(j it,, , 20 g , by �0�+'21G L„q.4olsre./ who is personally known to COT \CCS • fa-t • f o't"(1 rao is personally known to 3 me or who has produced i/ 2 (?— 112d 7 6 s`"o me or who has produced \ JY 1 1 C'`Q - identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: i r ****************** APPROVED BY OWNER or AGENT MY COta1MlS ON *i=t• 1 "" ' ES. is My y4 2018 a S t identification and who djd.sake an oath. NOTAR Sign: Print: Seal: YANADY PRIETO ' `+= MY MMISSION # FF 214031 as EXPt ES: March 25, 2019 Bonded Thor ► otary Pubic ►hdelw,Npra • as **1************************************************************** Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Montenegro Construction Inc Date:_ I 9:i )-" 1 State of: County of: I D M ip't NI0N N Before me this day personally appeared who, being field sworn, deposes and says: That he or she will be the only person working on the project located at : Contractor signature n Sworn to (or affirmed) and subscribed before me this L�' day of ` 2012 By 0.-15 -OS -ALB DOI ift ON I - J C, e-O Personally know Or Produced Identification Type Of Identification Produced t -1>24 2! LA-fNS t i Cam' �. Print, T pe or Stam'p`--hE of notary i`' i' dam"tie Notary Public State of Florida Sindia Alvarez } =t. 4 My Commission FF 156750 orA Expires'0910312018 Notice to Owner — Workers' Com p Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305), 756.8972 ensation 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. Signature: , Owner State of Florida County of Miami -Dade �^ The foregoing was acknowledge before me this 10 day of ("_ f/alLy , 20 /8 . By ✓ 0 4 n "� fa 6° s cle!fe- who is personally known to me or has produced L.I RCP (.0 -7-2 -LyV.0 Notary: SEAL: as identification. JORGE ROSSt:"•. MY COMMISSION *FT I ; 9046 EXPIRES M=Y a 2U 8 (407) 398 0153 F100031,1910 +fS^. L— STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD ; - (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 MONTENEGRO, CARLOS ALBERTO MONTENEGRO CONSTRUCTION INC 15366 S.W. 42ND LANE MIAMI FL 33185-4534 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 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 ►, 4,0,..BUSINESS-AND-- a s, IGUI=ATION- -- �. CERTIFIEDnG i_s T 4E,D aert e-p-r 4sia f Ch 489<F, Expirdtion-date?'Au 3 DETACH HERE J KEN LAWSON, SECRETARY �_�-- - DEPARTMENT OF-BUS1 ESS.AND PROFESSIONAL'REGUEATION�.�;`` �`:"°.•- ----'CONSTRUCTIO *INDUSTRYYLICENSItgq.BOARDs LICENSE NUMBER "-`' '" '`N.„..N*\\\....:� "-T lt`e.OENERAL CONT T IVam'edbetow ISCERTIF_IED � 'miler th 4V sions'ofCha to 489-FS. icct tFn _nRmann1A r ISPI AY AS REOUIRED BY LAW SEQ # L1608090001978 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6411953 BUSINESS NAME/LOCATION MONTENEGRO CONSTRUCTION INC 15366 SW 42 LA MIAMI FL 33185 OWNER MONTENEGRO CONSTRUCTION INC Worker(s) 1 RECEIPT NO. RENEWAL 6680152 EXPIRES SEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 GENERAL BUILDING CONTRACTOR CGC1515414 PAYMENT RECEIVED BY TAX COLLECTOR $82.50- _10/03/201-7:.-...._: ;_ • . CREDITCARD 48-000687 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holder must coayily with any governmental or nongovernmental regulatory laws and requirements which apply to the business. - The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. Ill II ill 11II : II For more information, visit www.miamidade.gov/taxcollector ACORN►® `�. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YVYY) 02/20/2018 '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 endorsement(s). PRODUCER Estrella Insurance #103 10973 SW 40 Street Miami FL 33165 CONTACT ADILEY NAME: (A/c. No. Ext): (305) 221-1911 FAX No): (305) 221-8144 E-MAIL ADDRESS: agency103@estrellainsurance.com a enc 103@estrellainsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: GRANADA INSURANCE CO INSURED MONTENEGRO CONSTRUCTION 15366 SW 4 Ln Miami FL 33185- INSURER B : INSURER C : INSURER D : INSURER E : INSURERF: 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 ADDL INSn SUBR wvn POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABIUTY 0185FL00093314-0 03/01/2017 03/01/2018 EACH OCCURRENCE $ 1 ,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS - COMP/OP AGG $ FIRE DAMAGE $ 100,000 AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS UAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENT ON $ WORKERS COMPENSATION AND EMPLOYERS' LIABIUTY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 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 it more space is required) GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION Miami Shores Village 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 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1 /3/2/2016 3 .,Repc41)Aewer • ' . CHIEF FINANCIAL OFFICESTATE OF FLORIDA R DEPARTMENT OF FINANCIAL SERVICES JEFF ATWATER DIVISION OF WORKERSCOMPENSATION * * CERTIRCATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW** CONSTRUCTION INDUSTRY EXENIPTICIN This certifies etatthe individual fisted below has elected to be exempt from Florida Workers' Compensation law. EffECTIVE DATE: 3/2/2016 EXPIRATION DATE: 3/22018 CARLOS A PERSON: MONTENEGRO FEIN: 205380705 BUSINESS NAME AND ADDRESS: MONTENEGRO CONSTRUCTION INC 15366 SW 42 LANE MIAMI FL 33165 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR p...u.d 646n;440X16(44), F.S, an ofacei rta ccrpastion who elects carnplicn tram tlis chapter= rstil.csge sr siscSai sneer this seem nctrefetatt IttlirsbigriessccmPT=cottr5-tirPureittriurntrt=44°424440.05r14.,Pict=tisticsitsaFrAY " cerillestenarefelZtotescortirt becstiiectlo revocaticn it, airy tim alti; toting alibi name' theissuerce d ctitli;:atr EvOrned.cnthernice sr arta:ate no lager meets *a requiremerts this seal fix Issuance at t! cenitcats.Thedepirtment age Mama DFS-F2431NC-252 CERTIFICATE OF ELECTION TO SE IDOSIIIPT REVISED 011:13 QUESTIONS? (850)413-1609 CORQ® ��: CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/30/2018 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(ies) 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 endorsement(s). PRODUCER Estrella Insurance #103 10973 SW 40 Street Miami FL 33165 CONTNAME: ACT Maray Varona INCD No Ext)• (305) 221-1911 FAX No): (305) 221-8144 E-MAIL ADDRESS: a103 enc estrellainsuranCe.com g Y C INSURER(S) AFFORDING COVERAGE NAIC p INSURER A: GRANADA INSURANCE CO - INSURED . MONTENEGRO CONSTRUCTION 15366 SW 4 Ln Miami FL 33185- INSURER 8 : INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF IMM/DO/YYYY) POLICY EXP (MM/DD/VYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY 0185FL00107175 02/27/2018 02/27/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO D PREMISES (EaENTEoccu occurrence) _ $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES JERT PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 FIRE DAMAGE $ 100,000 AUTOMOBILE LIABILITY ANY AUTO OWNED _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Si UMBRELLA LIAB EXCESS LIAB O 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 ER OTH- 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 mo a space Is required) GENERAL CONTRACTOR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES BUILDING DEPT 10050 NE 12 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 (2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ld3Q DNINOZ a3AOtiddV co v m a6ell!A saaous !wen/II 4 .. ... • • • • • • • • • • • • • • •• ••• •• • • • •• • ••• • ••• ••• • • • • • • • • • • • • • • • • • • • • • •• • • • •• •• • • • • • • • • • • • • • ••• • • • ••• • • • • ••• • • ••• • • • ••• • • • • • • • • • •• • •• •• • • . https://maikgoogle.coin/mail)%u/il:te bswmAi� box/15f35874cfccf222?projector=l https;//mail.google.com/mail/u/1/?tab= (0 1 tpu) `� .,J 1/1