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MC-18-1575Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Parcel Number Permit'N©. MC-6-18-1575 Permit Type: Mechanical - Residential Worts Classification: A/C Replacement Permit Status: APPROVED Expiration: 12/04/2018 Applicant 1135 NE 100 Street Miami Shores, FL 33138- 1132050340050 Block: Lot: THOMAS WENSJOE Owner Information Address Phone Cell THOMAS WENSJOE 1135 NE 100 Street MIAMI SHORES FL 33138 Contractor(s) Phone METROPOLITAN AIR CONDITIONING 305-264-4646 Cell Phone Valuation: Total Sq Feet: $ 2,480.00 0 Tons: 4 Additional Info: EQUAL REPLACEMENT OF A 4 TON Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.80 $2.00 $2.00 $0.60 $100.00 $9.00 $2.40 $117.80 Pay Date Pay Type Amt Paid Amt Due Invoice # MC-6-18-67848 06/07/2018 Check #: 7765 $ 50.00 $ 67.80 06/07/2018 Check #: 7766 $ 67.80 $ 0.00 Available Inspections: Inspection Type: Final Review Mechanical 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 will be done in compliance with all applicable laws regulating construction and zoning. Futherm authorize the above -named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent June 07, 2018 Date Building Department Copy June 07, 2018 1 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-306068 Permit Number: MC-6-18-1575 Scheduled Inspection Date: September 20, 2018 Inspector: Perez, JanPierre Owner: WENSJOE, THOMAS Job Address: 1135 NE 100 Street Miami Shores, FL 33138- Project: <NONE> Contractor: METROPOLITAN AIR CONDITIONING INC Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1132050340050 Phone: 305-264-4646 Building Department Comments EQUAL REPLACEMENT OF A 4 TON Infractio Passed Comments INSPECTOR COMMENTS False Cq °LI ?C ( Inspector Comments Passed ism Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. September 19, 2018 For Inspections please call: (305)762-4949 Page 9 of 38 BUILDING PERMIT APPLICATION El BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑PLUMBING MECHANICAL Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 Master Permit No. Sub Permit No. ❑ EXTENSION RECEIVED JUNOry22A b41 FBC 20 I1 ¥- 1 s15 ❑RENEWAL El PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR JOB ADDRESS: L I't _ . OO DRAWINGS City: Miami Shores ++ County: Miami Dade Zip: A.3�?5$ Folio/Parcel#: .1"Ja -O3I4-F)oSO Is the Building Historically Designated: Yes NO Occupancy Type: Load:. Construction Type: Flood Zone: BFE: ' FFE: OWNER: Name (Fee Simple Titleholder): \\\iOrryetc3 Lue Phone#:Z(Q 1 p- 0"I Address: ( (Y) City: R--0:16-�� U State: t Zip: 33'�$ Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Re_-Icti I' -11 Ale- tLrQ. Phone#: RS 2(04.44 *0 Address: %QQ ('l r\LL5 . f:) S'�. City: M1QrY\i State: 'P-,• Zip: 33� 1e Qualifier Name: R (*oer-f c) CCY12oJea_ Phone#:3O Qt- kQl4(O State Certification or Registration #: eACJD4 q (q Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 01�)i Le(r) .C.70 Square/Linear -ot Footage of Work: Type of Work: n Addition I I Alteration ❑ New ,' I� Repair/Replace ❑ Demolitioni Description of Work: Et4 LX d C Q 1 � k -Ccn 141C, , ('ll Kt.t'-j cl _r- Specify color of color thru tile ,' `� ` . d Submittal Fee $ *6 °°,' iPreit Fee $:' V1V N.V.V CCF $ CO/CC$ b . Scanning Fee $ Radon Fee $ DBPR $ Notary $ 4 Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (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 •r " 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 ee will be charged. Signat NER or AGENT Signature Thefffo��regoing instrum-nt was acknowl dged before me this The foregoing instrument was acknowledged before me this t_Ll day of (Sv` �-nie , 20 I % , by 1 day of , & fQ_, , 20 7t-vr1,01.._S W2v.J„!(7t , who is,p&rsdrially known o �� Q73,r�� _, who is me or who has produced as me or who has produced identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: by n to I Notary Public State 0E-Fbnida i' Beane Rodriguez y, I My Commission GG 080880 '�ja e' Expires 03/11/2021 1 to \ as laps APPROVED BY \ \ \J \ ' \` Examiner Zoning Structural Review (Revised02/24/2014) Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): City: Miami Shores Village • County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES NO ❑ ARHI Sheet Attached: YES 0 ❑ Contract Attached: YES E( UNIT BEING REPLACED DATA NEW UNIT CIAVeRiin MANUFACTURER "•-CCA-C1rle, NCOnetujQ AHU or PKG. UNIT MODEL # —CE Ku._'.C9Cy$ I,p,-ksap 48 COND. UNIT MODEL # 4 C-C (2...(20q% I O KW HEAT 1 0 (k-CorN NOM TONS Lk—COL1 AHU ;$CCU PKG 1) M.C.A AHU50 CU 2(J PKG — AHU (QOCU Ik PKG 2) M.O.P AHU 60 CU 40 PKG AHU CU PKG 7_045 (').3D 3) VOLTS AHU CU PKG - PKG UNIT / / ' PKG UNIT -1- --"/ 10 EER/SEER 0 (Q .aS) -2.O81a-3O YES REPLACING DUCTS YES I ) YES0 REPLACING THERMOSTAT dEr=> NO YES Cb NEW 4"CONCRETE SLAB YES CED YES 457 NEW ROOF STAND YES �I) YES 65) NEW RETURN PLENUM BOX YES 0 1. Minimum Circuit Ampacity (Wire Size): c 2. Maximum Overcurrent Protection (Fuse/Breaker Size): ' 3. Voltage of Circuit (208/240/480): 2c12�c> 4. Size Disconnecting Means:) qcr- Contractor's Company Name: i'- .*il.D""kCw.(\ State Certificate or Registratioi o.Q_Avcuzclq Certificate of Competency No. Signature Date: er's signature) Phone: 4-`-16(16 (Revised02/24/2014) *'* OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11-3205-034-0050 Property Address: 1135 NE 100 ST Miami Shores, FL 33138-2601 Owner MONICA E KULJICH THOMAS R WENSJOE Mailing Address 1135 NE 100 S i MIAMI SHORES, FL 33138 USA PA Primary Zone 0100 SINGLE FAMILY - GENERAL Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds!Baths/Half 4/3/0 Floors 2 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 3,661 Sq.Ft Lot Size 15,551 Sq.Ft Year Built 2005 Assessment Information Year 2018 2017 2016 Land Value $559,836 $558,237 $250,904 Building Value $402,710 $377,962 $382,208 XF Value $40,601 $41,063 $41,522 Market Value $1,003,147 $977,262 $674,634 Assessed Value $827,514 $808,928 $536,764 Benefits Information Benefit Type 2018 2017 2016 Save Our Homes Cap Assessment Reduction $175,633 $168,334 $137,870 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description 5 53 42 WEEKS SUB PB 71-91 LOTS E & D LOT SIZE 15551 SQ FT M/L OR 20846-4493 11 2002 1 Generated On : 6/6/2018 KENDALL-TAMIAMI EXECUTIVE Taxable Value Information 2018 2017 2016 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $777,514 $758,928 $486,764 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $802,514 $783,928 $511,764 City Exemption Value $50,000 $50,000 $50,000 Taxable Value $777,514 $758,928 $486,764 Regional Exemption Value $50,000 $50,000 $50,000 Taxable Value $777,514 $758,928 $486,764 Sales Information Previous Sale Price OR Book- Page Qualification Description 06/15/2016 $390,000 30117- 1607 Qual on DOS, but significant phy change since time of transfer 11/06/2013 $100 28946- 4780 Corrective, tax or QCD; min consideration 11/01/2002 $115,0000 93 Sales which are qualified 06/01/2002 $87,000 21- 48 Sales which are qualified The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.govfinfo/disclaimer.asp Version: 6917 NW 50'h St, Miami, Florida 33166 Phone: 305-2644646 Fax: 305-267-2525 1-800-749-KOOL Proposal Submitted To: AIM CONDIT/WM INC. PROPOSAL Job Info: Residential - Commercial - Industrial CAC043919 Date: 3-6-18 Name Thomas Wensjoe — Name 2nd. Floor Street Address 1135 NE. 100t. St. Street Address 1135 NE. 100t. St. City, State, Zip Miami Shores, Fl. 33138 City, State, Zip Miami Shores, Fl. 33138 Phone No. 786-478-1989 Phone No. mkuljichna gmail.com We hereby submit specifications and estimates for: The Supply and Installation of one 4 Ton Air Conditioning and Heating System. Make: Trane / S.E.E.R. 16.25 Model: 4TTR6048J 1000A / TEM6A0C48H41 SA Includes: Removal of the old Unit and Dispose of it, Installation of the New Unit, Thermostat and City Permit Warranty: 10-Years on Compressor 10-Year Parts 1-Year Labor We Propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: TWO THOUSAND FOUR HUNDRED EIGHTY 00/100 ($2,480.00) Payment to be made as follows: 50% at sign contract, and 50% upon equipment installation. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra cots will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strllces, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our workers are filly covered by Workmen's Compensation Insurance. Authorized Signature Note: This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal — The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature Signature CERTIFIED° www.ahrldirectory.org This combination qualifies for a Federal Energy Efficiency tax Credit when placed in service between Feb 17,2009 and Dec 31, 2016. Certficate of Product Ratings AHRI Certified Reference Number : 8936365 Date : 06-07-2018 AHRI Type : RCU-A-CB Series : XR16 Outdoor Unit Brand Name : TRANE Outdoor Unit Model Number (Condenser or Single Package) : 4TTR6048J1 Indoor Unit Model Number (Evaporator and/or Air Handler) : TEM6AOC48H41+TDR+UF/HRZ Region : Model Status : Active All (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, IA, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WV, WI, WY, U.S. Territories) Region Note : Central air conditioners manufactured prior to January 1, 2015 are eligible to be installed in all regions until June 30, 2016. Beginning July 1, 2016 central air conditioners can only be installed in region(s) for which they meet the regional efficiency requirement. The manufacturer of this TRANE product is responsible for the rating of this system combination. I 7 z Rated as follows in accordance with the latest edition of ANSI/AHRI 210/240 with Addenda 1 and 2, Performance Rating of Unitary Air -Conditioning & AirSource Heat Pump Equipment and subject to rating accuracy by'AHRI-sponsored, independent,+thifd party testing: T . Cooling Capacity (A2) -.Single or High Stage (95F), btuh : 47500 SEER : 16.25 EER (A2) - Single or High Stage (95F) : 13.50 r. rActive" Model Status are those that an AHRI Certification Program Participant is currently producing AND selling or offering for sale; OR new models that are being marketed but are not yet being produced.'Production Stopped' Model Status are those that an AHRI Certification Program Participant is no longer producing BUT is still selling or offering for sale. Ratings that are accompanied by WAS indicate an involuntary re -rate, The new published rating is shown along with the previous (i.e. WAS) rating. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www.ahrldlrectory.org. TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRI. This Certificate shall only be used for individual, personal and confidential reference purposes. The contents of this Certificate may not, In whole or In part, be reproduced; copied; disseminated; entered Into a computer database; or otherwise utilized, In any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The Information for the model cited on tills certificate can be verified at www.ah►idirectory.org, dick on "Verify Certificate' link and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which is listed above, and the Certificate No., which is listed at bottom right ©2018Air-Conditioning, Heating, and Refrigeration Institute AIR-CONDITIONING, HEATING, & REFRIGERATION INSTITUTE we make life better' CERTIFICATE NO.: 131728525124698210 n9riW 1 b 9iC' xst y:Jrtsiait33 left 7 Isl beR s zeii ts;.irp r;oitsnidmoo airtT ar Oj , i C os.C.S br de-i n9swi:3ca U^' a:v i7c3 rti baa6!!cc ovihbA . 2JtCta ltlboM 1 `!) .18‘. Sf nS-TO-0D • tF13 i'-.dtrniM :.Jnain i @frilitl i;) I51HA aC-A-tSt35t : l,ryT 151•HA arNX • aNie:; arrkSiT • otr+st•1 tar3cl€i tinld lard;.{ ri f M 1TT�• (-rs, . Sr! otgrlie. 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Er•,,ubm.'i y#tnei:tu 61 441ega9 ':n msi l9 rle! b O I2f*A r• ; tat 6cr 1 91:'.: uf:>a i,:1oM ",t v;i A't 1.t;Ja > l•T113 anU4.to'a 13t flhi on ei fnt tyi i^ 9 rislro.9 J:x±! 9sbrtJ by olerJ?. #6buM' "trrcg,:i: r!ra.3.4 o1R"-b-ctjbcic ,j,, : l:ty fan oir, f ld b'.',-::tlr.rr 3•nd5!. ii hW 9.i) euntvt-ra tail r'.ti,Y jx">11q rRN0ria t,d 9; 1-Nl voirpliovn, rCJ t44r,pgm x r. N's :Prif a lt:'4Y1 t3SA (4.ft.'-$t�3 't.;Ian, 09 P r'T ?f • 7 :� l9: tf 1,'; 10 ?^.,. i,., yv .>nn,_ 3,131 tsP f 4. 9S"-tilt:^' Witt hci�'i t-.' i " .:1 ltur J J::. , '4 t,. + ..C+�K'.1 .... ":.rfr'. ,F' t4.•i t' 9.1• ..J� •r�.i �.:tr . d ,'r 1, •lt.#:...r>:, 110.21'11t'i-.1 t. <t')tr94:1i • )J!2!t "-,ri: {'1. i .'` 1•,• . •, n .LI + )b 1a+.... ,, ^':11- ,>, "J.. r,. ,r- 't, , ...riQ+Tlu tri wino) tc "• , `J'1 t3- '.4• .3. '-'12-;9Lt '1093 t'rt „!" it t •,ritr •-1'•r :,,i14:1, i `11111' '+ $1 1'11 , eto - ri gt, Y_,.n lit' ... eid1 t 414,!:N).. 3.1' -'Q! 'C1 r 1.11 • r., •.Iv1ut : i f ! ) 3 ,r 2!7 ,r 1 i [ 1'•D i . "'tt *Y s ,tnl i , r 3 11";! 4 , vv:-tttc, t 1 tcts tilt) t#'#BS'31r :1ii31?tYN3 ) S+r• ; a';rl?- r :. ±_. t1 'YJ 921 1' f"' s Z-:r! !,•.� #e _..3 ::l;ilJo."'.1t`.'' ti �' 1r• Tl •9+'.. -i?i ;" 14, • et!•.'tihsad, ytir trl' r • K:.d 1,4, ' i9 ri' 334 `1,4J ..3<U P' 11 yy notIf `;:z1 Si1`v'9ea 8io 1 ^ CtS398=S.tvScestur ACORN® ��. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/Y YY) 06/07/2018 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 po icy, 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 The Miami Agency 688 South Drive MIAMI SPRINGS FL 33166 CONTACT CosetSosa NAME: PHONE (305) 885-2055 FAX (305)885-2005 (A/C, No, Ext): (A/C, No): E-MAIL coset@gdhins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: GRANADAINSURANCECOMPANY INSURED Metropolitan Air Conditioning, Inc. 6917 NW 50 Street Miami FL 33166 INSURER B: SUMMIT CONSULTING INSURER C : INSURER D : INSURER E : INSURERF: COVERAGES CERTIFICATE NUMBER: CL186702241 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-SUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 0185FL00064373-3 11/04/2017 11/04/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE RENTED PREMISESO(Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY EC PRO-2,000,000 ECT LOC OTHER: J GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMP/OPAGG $ HAUTL $ 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 LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ B 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 0521-09048-0 08/03/2017 08/03/2018 PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE - EA EMPLOYEE $ 100,000 E.L. DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CAC043919 CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2nd Avenue Miami Shores FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD