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EL-18-696Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO.. EL-3-18-696 Permit Type: Electrical - Residential Work Classification: Temp for Test Permit Status: APPROVED Issue Date: 3/20/2018 Expiration: 09/16/2018 Parcel Number Applicant 251 NE 98 Street Miami Shores, FL 33138- 1132060134410 Block: Lot: PANPER LLC Owner Information PANPER LLC Address 700 E DANIA BEACH Boulevard DANIA FL 33004- 700 E DANIA BEACH Boulevard DANIA FL 33004- Contractor(s) HI -TECH ELECTRIC & FIRE CORP Phone (786)326-0931 Cell Phone Phone Valuation: Total Sq Feet: Cell $ 300.00 0 Type of Work: TEMP FOR TEST Additional Info: TEMP FOR TEST Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Amount $0.60 $2.00 $2.00 $0.20 $100.00 $3.00 $0.80 Total: $108.60 Pay Date Pay Type Invoice # EL-3-18-66825 03/20/2018 Credit Card 03/16/2018 Credit Card Amt Paid Amt Due $ 58.60 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Review Electrical 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 fore construction and zoning. Futhermore, I aut Authorized Signature: Building Departme mati accurate and that all work will be done in compliance with all applicable laws regulating amed contractor to do the work stated. / Contractor / Agent March 20, 2018 Date March 20, 2018 1 "1 BUILDING PERMIT APPLICATION ❑ BUILDING 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 ❑ ELECTRIC ❑ ROOFING Master Permit No. Sub Permit No. ❑ REVISION \TED MAR 16018 FBC 2011 '+/1 (2c t - 32-? -� - t - - 1e4q Et`I8-696 ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP JOB ADDRESS: �S I 'i p City: Miami Shores Folio/Parcel#: I(-320 - 0(3 -4-(4tc, CONTRACTOR County: Miami Dade Occupancy Type: Load: Construction Type: DRAWINGS Zip: 3(3g Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Titleholder): PAN) 06!2- LLc_ Flood Zone: Address: 40(D — - Qc& -4Z 02— City: i z irA d-1 State: BFE: NO FFE: Phone#: Tenant/Lessee Name: Phone#: Email: Zip: 33 004 CONTRACTOR: Company Name: I'll ' 1 e.Ckrl c_ �� Z Address: f Soo 5:_(' / 0/ s f City: M -,w,: State: Qualifier Name: £Ins,, �d cv 1 Phone#: qK.-32,- o ( zip: 33 134 Phone#: ;86- 324, - 093 State Certification or Registration #: CC 1 `BOO 2.6:, 0 g Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ Q'"). ' Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work_: q-l., fit yt , .' ii.'' i#�. 7.. yeti •,.���x • Specify color of colorthru'tile Submittal Fee $ So { d Permit Fee $ `SQ. DD CCF $ CO/CC $ Scanning Fee $ Radon Fee $ a CP DBPR $ CA Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $S'' GO (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 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 af'the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted. notice, the inspection will not be approved and a reinspection fee will be charged. Signature /J Signature OWNER or AGENT The foregoing instrument was acknowledged before me this 1() day 'of Hi4/1✓ch , 20 / , by 'Da 1/i d i 6, 1 Cs , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC:• Sign: Print: Seal: *********************************** APPROVED BY CONTRACTOR The foregoing instrument was acknowledged before me this i 4 day of )1 dr , 20 18 , by EJ/-u.e{nG6,, who is personally known to as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: , Y EXPIRES February 23, 2020 No; ) &O b3 NondaNas rvko,000+ *******************9*************** Plans Examiner ************************* Zoning (Revised02/24/2014) Structural Review Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AFFIDAVIT FOR 30 DAY TEMPORARY -ELECTRIC SERVICE NOTE: ELECTRIC SERVICE WILL BE DISCONNECTED "WITHOUT NOTICE" UPON 30 DAY TERMINATION UNLESS APPLICATION IS RENEWED. It is understood that the temporary -electrical approval by the Miami Shores Village, Building Department given in connection with the building being constructed under: Building Permit N: \( - 3 32 g Electrical Permit N: EL-7-/ } - f 349 At Address: 2 S l IJt, q Miami Shores, FL 331'31e, For Owners: , and is being given only for construction purpose or for testing the following equipment in said structure: The owner does herby agree to assume the responsibility of maintaining the installation in such manner that there is no hazard to life or property. Such approval is in no event to be considered a RELEASE of said structure for the purpose of use and occupancy, and no occupancy shall be granted or permitted until further inspections have been called for and approved by the inspection divisions concerned, and/or a Certificate of Occupancy or Completion is obtained. The undersigned also understands that the temporary electric approval is subject to rescission and cancellation and electric power can be cut off at the discretion of the building official and will be disconcerted of le building concerned is occupied before final inspections are approved and/or obtained a Certificate of Occupancy or Completion. Note: Failure to comply with the provisions of this affidavit will result in your being unable to obtain future Temporary for Test permits. I, ✓AP, being first duly sworn, depose and say that I am the owner of the above described property, and that I agree that the structure covered in this agreement shall not be occupied until the building contractor has obtained approval of final inspections rpri,lrluohtainari a Cer ificate of Occupancy of Completion. Note: Failure to comply with the provisic ►T its afilenttcwtkborovit i 1 your being unable to obtain future Temporary for Test permits. _; _ MY COMM.;• • FF964004 ebruary 23, 2020 Signrerof Owner rySa+vico.com 1, ect.tiac2v , being duly sworn, depose and say that I am the Electrical Contractor for the above -described property and that the electrical installations as now j wi rip _ •- : - _ • : zard if temp ary s viceis connected. Signature of-Electcal Contractor Sig I, �r -€..l<\()e.- 0 2_r-z J , being first duly sworn, depose and say that I am the Building Contractor of the above described property and that I will not permit occupancy of this building until final inspections have been called for by the contractors and sub -contractors concerned and final approval by the inspection division obtained a r • that I have the authority insofar as the owner of said prop ert4.concoutgt}livcc pancy until suspections are obtained and/or a Certificate of Occupant . pjp � -"ON u .2 } (r"� '',;*tf'.' EXP ES'3.2020 L� -*1 *l: e!IJ ZS `% 1 J .40/; ]Sft-010 ! �wA,Senico. om gnature of : uilding Contractor 4 Signatur- „;+ -.►teary Signature of Inspector Signature of Notary \o\c(P Miami Shores Village v.)\ 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 BUILDING PERMIT APPLICATION dBUILDING ❑ ELECTRIC ❑ ROOFING ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS JOB ADDRESS: 2st NZ- c �� City: Miami Shores County: Master Permit No. Sub Permit No. ❑ REVISION ❑ EXTENSION [II RENEWAL RECEIVED OCT 1 0 2017 FBC 20NSoh 2c=1fo-3321 ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Miami Dade Zip: 3`31 3 Folio/Parcel#: ((, -3 2-Q‘, - D\•) ^'-c(Li d. 0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: _ Construction Type: ' Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):�'PA) E=2 l/ �L� Phone#: Address: Z d O Z.. —1 g Sr City: c\v`M. 1 State: Tenant/Lessee Name: Phone#: Email: Zip: % 3 t 3 e CONTRACTOR: Company Name: 4 ta.-.---mAiucc-, /Ll .-?2talc. Phone#: %(-63 (- 3S 33 Address: .3-2o s - S%-taC Jam' City: C 4 State: Qualifier Name: - ' LJ %- State'Certific`ation or Registration #: C t — t Sc431^ Zip:33( Phoneme ,S€t 4 74 'S`. i Certificate of Competency #: Ci3C IS 2- 31 DESIGNER: Architect/Engineer: Phone#: Address: City: Value of Work for this Permit: $ I�I Type of Work: ❑ Addition_� r I Alte ation ❑ New ❑ Repair/Replace (Description of_Work: Cc •-.�C2�. ter' , . i r t 3.. t, k.:. fi •z .U.3a •G ZIL *a. ,i, .'..ti 1 it,v 141'�i1J ...:Specify cabrfCdiortiiru the ..._ .... ^.� .., ..... State: Zip: Square/Linear Footage of Work: n Demolition 1v..sf ; ,",. pE i 4 )V. F ,1)4 o:1y. '^y, Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ CCF $ CO/CC $ Radon Fee $ DBPR $' Notary $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 5 • (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 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 commen must be posted at the job site for the first inspection which occurs sev ) days after the building permit is issued. In , - . such posted notice, the 4 inspection will not be approved and ./A ' -ction fee will be charged. Signature 0 NER or • GENT The foregoing instrume } ,„tjj . day:Qf .(111JA w�a Signature COAACTOR nowledged before me this The foregoing instrument was acknowledged beforemethis , 20 __ by `' CA day of d( 16 tt , 20 t i- , by , who is personally known to (L-e,(,,\e OW-7A , who is personally known to me or who has produced identification and who did take an oath... me or who has produced c as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: • ARTIN G TORRISI MY COMMISSION N FF9 4004 EXPIRES February 23.2020 rieeerace.yerviageop ********************************** APPROVED BY t**************************************************************** NOTARY PUBLIC: Seal: as A Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk Miafni Shores Village Building Department 10060 N.E2nd Avenue Miami Shores, Florida 331.3B Telt (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR ARCHITECT Permit N.C-t(a -n2 e Owner's Name (Fee Simple Tide Holder): (PA/0 PE-(2. (C- Owner's Addness: C bAdo h A 2_o2- City : bAni State : Et job Address (Of where work Is being tioney 2.s I OE 9g City: Miami Shores State: Florida Zip Code 8 Contractor's Company Name Address: 21 2-1 SW ros07-7 Goo City: V.\ State (F- L Qualifier's Name : LAJ is: Fel. o Phone - 952.8 zip c.d.00l phone* Zip Code '53 1161 Lic Number: CGC ()o)- 0 Architect/ EnOneer of Record Name: Phone #: Mdress: City: State: Zip Code Describe Work I hereby certify that the work has been abandoned and/or the contractoriarchitect is unable or unwilling complete the contract I hold Official and the Mi )Shores harmless of all legal in Signature Signature or The foregoin instrument was aknowledged before me, The foregoing instrument was aknowledged before me this (1—ctry of Oer 2044, y this OC day of 20(4-by Volo is personally known to me or who has pnoduced as indernifitation_ Notary Public Sol MARTIN 0 TORRISI F.. MY COMMISSION # FF964004 . .... .• EXPIRES February 23. 2020 140/) 3vis-tr Hnncialloisfyienolos com %%to is personality known, co ane or who has produced ,Or• 113 Notary Public Sign: Seal: MARTIN 0 TORRISI MY COMMISSION # FF984004 EXPIRES February 23. 2020 FionaiNotarySenoice cony tification. 01A1 c yr I-LUKIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 NARANJO, LUIS FELIPE APPEARANCE BUILDERS, LLC 1674 MERIDIAN AVE #320 SUITE 600 MIAMI BEACH FL 33139 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 i-sou, subscribe to department newsletters and learn more about e 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 ;/,`CGC1525037 , r , 'STATE'OF FLORIDA:: — - a, DEPARTMENT,.OF.FBUSINESS AND PROFESSIONALLREGULATION - CGC1625037 I SUED: 06%27/2017- CERTIFIED • GENERAL CONTRACTOR... NARANJO;;LUIS"FELIPEr1+-.*, APPEARANCE BUiLDERS.LLC`» IS CERTIFIED -under the. provisions of C6.'489 FS. t Expiration date : AUG 31; 2018 _ ..._--...o•U706270000277 DETACH HERE - MATILDE MILLER, INTERIM SECRETARY °- ---- -STATE OF FLORIDA ��� ` �1 � -, `� `, - DEPARTMENT.OF BUSINESS,AND PROFESSIONAL.REGUL•ATION� -CONSTRUCTION INDUSTRY LICENSING ' BOARD ` `r TIie'GENERALCONTRACTOR_-- -Waffled below IS CERTIFIED-- Undef the -provisions of.Chapter_489 FS." -- M Expiration `date:- AUG 31,72018 — - - " - • NARANJO;;LUTIS FELIPE /APPEARANCE'BUIL-DERS; LLC -1674,MERIDIAN'AVE 4320' �SUITE-600 . ,;=FwM1AMI;BEACl=1;�-• ISSUED: 06/27/2017 `- t `` L .N.-..-\`.- :. . ; , . • • DISPLAY AS REQUIRED BY LAW SEQ # L1706270000277 006664 Local Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7222703 BUSINESS NAME/LOCATION— APPEARANCE BUILDERS LLC 720 5 SHORE DR MIAMI BEACH FL 33141 RECEIPT NO. RENEWAL 7507202 EXPIRES SEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS APPEARANCE -BUILDERS LLC 196 GENERAL BUILDING CONTRACTOR LUISFELIPE.NARANJO, QUALIFIER: - Worker(s) 1 PAYMENT RECEIVED BY TAX COLLECTOR $45.00 07/30/2017- ECHECK-17-188489 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 holder's qualifications, to do business. Holder must comply 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. For more information, visit www.miamidade govitaxcollector ACC.7'� ORCERTIFICATE OF LIABILITY INSURANCE �„. OATE(MMIDD/YYVY) 08/22/2017 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 POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: tithe certificate holder is an ADDITIONAL INSURED, the pollcy(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(a). PRODUCER Occidental Risks Services, Inc 11890 SW 8st Suite 516 Miami, FL 33184 Phone (305) 433-4068 Fax (888) 678-2045 CONTACT VlckyFemandez NAME: PHONE 305 433-4068 FAX Ertl () mrc. Nol: (888) 678-2045 P ADD ESS: Ndty©occidentalnsks.com INSURERS) AFFORDING COVERAGE NAIC # INSURER A : Crum & Forster Specialty Insurance Company INSURED Appeearance Builder LLC 1674 Meridian Avenue Miami Beach FL 33139 INSURER B : INSURER C : INSURER D : INSURER E: INSURER F : n M/IR1Aa1 in1MQCQ- • L:U V CRALI O SOLI, , ., -"OM , r ,.v,.,.+.., .. THIS IS TO CERTIFY THAT THE POUCIES 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 TYPE OF INSURANCE ADDLBUBR INSR WVD POLICY NUMBER POUCY EFF IMMIDDIYYYY) POUCY EXP IMM/DDIYYYYI ORUMRS R A N BAK-25017-1 03/16/2017 03/16/2018 EACH OCCURRENCE $ 1,000,000.00 LM COMMERCIAL GENERAL LIABIUTY DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 NI CLAIMS -MADE 0 OCCUR MED EXP (Any one person) $ 5,000.00 III PERSONAL & ADV INJURY $ 1,000,000.00 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00 II POLICY III JPECOT m LOC PRODUCTS-COMP/OP AGG $ 2,000,000.00 $ IIIII OTHER AUTOMOBILE LIABILITY � (EaaccidentSINGLE LIMIT S BODILY INJURY (Per person) $ II ANY AUTO SCHEDULED INJURY (Per accident) S OWNED cm AUTOSBODILY • AUTOS ONLY (PeORTy accideMDAMAGE ) $ . HIRED AUTOS ONLYD AUTOS ONLY El IN UMBRELLA LAB • OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB II CLAIMS -MADE AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LABIUTY Y / N ANY PROPRIETORIPARTNERIEXECUTIVE� (MandaOFFICtoryIn N ER EXCLUDED? (Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑ FR - STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) General Contractor CERTIFICATE HOLDER CANCELLATION Miami Shores village Building Dept. 10050 NE 2nd Avenue Miami Shores, FI. 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 REPRESENTATNE i-� ACORD 25 (2016/03) QF OD 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACC RD® �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/5/2017 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 thls certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER SUNZ Insurance Solutions, LLC. ID: (Impact) c/o Impact Staff Leasing, LLC 1315 W Indiantown Road Second Floor Jupiter, FL 33458 NAMEACT Impact Staff Leasing PHONE FAX Extl: 561-743-0065 (A/C, No): 561-748-3235 IL E-MAIL ADDRESS: kimasignaturestaffinginc.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : SUNZ Insurance Company 34762 INSURED Impact Staff Leasing LLC. 1315 W. Indiantown Rd. Second Floor Jupiter FL 33458 INSURER B : INSURER C: INSURERD: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 38237350 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 MDWVD SUBR POLICY NUMBER POLICY EFF IMM/DDIYYYYI POLICY EXP (MM/DD/YYYYI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT accident $ _fEa BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N N NIA WCPE00000046 08 8/15/2017 8/15/2018 ,i STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Coverage provided for all leased employees but not subcontractors of: Apperance Builders LLC Client Effective: 4/7/2017 GENERAL CONTRACTOR SERVICES LICENSE # CGC 1525037 CERTIFICATE HOLDER CANCELLATION 1960 Miami Shores Village g SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE I'rJiy//GiJ.. '7 V. I Glen J Distefano ./ ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 38237350 I Impact Staff Leasing PEO 046 MASTER CERT I Marj Saathoff 110/5/2017 9:30:12 AM (PDT) I Page 1 of 1