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Miami Shores Village
Building -Department T s '$
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ny" �.
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 20
BUILDING -Master Permit No. l/ PR 3 -9 -12
PERMITPPLICATION , Sub Permit No. �L 19-��3
]BUILDING ELECTRIC ❑ ROOFING, ❑ REVISION❑EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR • DRAWINGS
JOB ADDRESS: 14 loo N C— I O � SA–
City: ''Miami Shores _ 1 ` " "l -"County, s Miami Dade Zip:
Folio/Parcel#: ` w ' Is the Building'Historically Designated: Yes" NO
1x'A r�.•.. ,°'. jt �. �. y' A r i + ,.t�r, �
Occupancy Type: Loa7d: Construction Type: `" F Flood Zone: ' BFE: FFE': '
' '� �r •i AA � � � 't r, .p r
OWNER: Name (Fee Simple Titleholder): S,4
/,Phone#:
City: `/lila Aj 4
Tenant/Lessee Name:
Email:
�-State: TleW o ,�(
Phone#:
p:
r
CONTRACTOR: Company Name": 7` Phone#: '"
Address" �w
City: 9 .Statg: Zip:
Qualifier Name: Phone#:
State Certification or Registration #:0Certificate of Competency #: 00
DESIGNER: Architect/Engineer: Phone#: _
Address: v City: State:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace
Zip:
❑ Demolition
Specify colo' of rcoloi"Aru, ek:
Submittal Fee $ Permit Fee $* CCF $'' CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
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 •( ` T, »' ^' " ` = ! $
City
State II ` . ' _ `
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address''
Zip
City State Zip t • 1 • ,
Application is•hereby made to obtain a permit to do the work and installations as indicated. I certify Wk-rIo 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 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 FORIMPROVEMENTS 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.
Signatur Signature 4114111'
-•- OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day of L_n _ J t— 20 cam, by
who is personally known to
me or who has produced as -
identification and'who did take an oath.
The foregoing instrument pwas acknowledged before me this
yof `c SLS , 20by
who is personally known to
me orwho has produced . :0 b( " _ as
identification and who did take an oath.
19
NOTARY PUBLIC: `` t F `^ `' ' NOTARY PUBLIC:
Sign: Si n•
Print: Print: ,
Seal: r -p o r CHARAIN M UEz _ Seal:CHARLAINEMIGUEZ
:;•.;
` WY COMMISSION M GG 176551 YY COMMISSION N GG 111661
EXPIRES: January 17.2022 :� p(PIRES Janllan, 17, 2W, . • 1
5,,dad r" Notary Public Underwriters _
PubGcurldelrriihls 14r �, �; sc
s _
APPROVED BY - , '``Plans Examiner ' ' ` Zoning
(Revised02/24/2014)
Structural Review - • ' Clerk '
Q
Miami Shores Village
Building Department
-� 10050 N.E.2nd Avenue
�1 1 201 Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N.,,i�'/� /?/�?71 1 I ,L (8 -863
Owner's Name (Fee Simple Title Holder):.%�;Vcy%-f:.yf -S�Ial Phone #:
Owner's Address: /i � lv;Le- %l�zx,7-
City;j,✓l�s�i�� SzrS State Zip Code:3ff/-Xe
Job Address (Of where work is being done):_
City: Miami Shores
State:—Florida Zip Code:/ -
Contractor's Company Name: H S.4 Y-atk nts T: n ,,• Phone # 3o 5- 3 Y5- /974
Address: 5215 Scy 103 Av e -
City: K4ami State: FC. Zip Code:_33/69s-
Qualifier's
3/(Gs-
Qualifier's Name : Rt4u L M •05-A Lic. Number. L G 13 oo 1 Vo
Architect/ Engineer of Record Name:
Address:
City:
State:
Describe Work: /?.iAl
Phone #:
Zip Code:
1 hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwilling to complete the contract. I hold the Building Official and the
Miami Shores harmless of all legal involvement.
Signatur Signature
�or Contractor or Architect
The foregoing instrument was aknowledged before me
this day of ,2011�,by/�'-its
Who is personally known to me or who has produced
�( �C as indentification.
Nota lic:
Sign:
Seal: c M
�xwr�,.,a,wwr�i.xoaz
�� pW*CUndMwirs
•�YFiWU
The foregoing instrument was aknowledged before me
this _X %ay of , 204by
who is personally own to me or who has produced
as indentification.
Notary
Seal: ct+ ►+E"#QGj 051
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
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ROOFING
CT 9 4 418
FBBC 20 �
Master Permit No. _eP VS -1-7- IZ-7
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleholder): %�>O/J�GDi% !J/� Phone#: __W'!�__ 210' %fes
Address: �lTZ��XIAV
z9u .SI
City: %���M�'-�I�CJi� �-s State: C�i�/Gf Zip:
Tenant/Lessee Name: Phone#:
Email:
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ , . ....._ ..,.x.CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ Ho
m.
CONTRACTOR: Company Name:
Phone#:
/01
Address: 2
City:
tate:
Zip;
3 34 L jr
Qualifier Name:
Phone#:
State Certification or Registration #: C�C ��S��Zd
Certificate of Competency #:
DESIGNER: Architect/Engineer:
Phone#:
Address:
City: State:
Zip:
(� /l
0 Value of Work for this Permit: $ V 0
Square/Linear
Footage of Work:
Type of Work: ❑ Addition ❑ Alteration
❑ New
❑ Repair/Replace
❑ Demolition
Description of Work:C�I�SeGZP 6:;,-e6:;,-e�4h<
<'l��
�a A -R w o, anA
cab&
1E), s uo +o z s�-mc,
Poo
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ , . ....._ ..,.x.CO/CC $
DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ Ho
m.
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City, .
State
Zip
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 approv nd a reinspection fee will be charged.
Signatur Signature
L,CVNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
day ota?±,2 a 20 by
CGA Si'31Qj � , who is personally known to
me or who has produced �X _ as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: �---
APPROVED BY
(Revised02/24/2014)
The foregoing instrument was acknowledged before me this
3k -d day of Oc-�Ohr r 20 19 by
ol�—Y CIO S inct who is personally known to
me or who has produced as
NOTARY
'Print': 0 .0
a
---
NEMIGUEz Seal: YANADYPRIETO
'� = MY COMMISSION # FF 21
W COMNLSSION / GG 176551 ?.: *_ A
EMRES. joy M /7, 2022 a•. a= EXPIRES: March 25, 2019
onoed Pudicurdemi�s od F:�: ' Bonded rh ro Nowt' Pubic UndervjriW3
Plans Examiner
Structural Review
Zoning
Clerk
'Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if.
1. The officer owns at least 10 percent of the stock of the corporation, or in the case of
an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
er
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of 0o,✓ 20.
By Mon 1 I✓Q S, -,4V,4 -s who is personally known to me or has produced
as identification.
Notary.
SEAL:
II .o ;Vu;1.,. LIZETTE LLORET II
.•'�(JMLo` Commission # GG 118087
My Commission Expires
'�� „` June 22, 2021
A
} Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CHANGE OF CONTRACTOR / ARCHITECT
Permit N.A1'0e- s17/z7l
Owner's Name (Fee Simple Title Holder):,e � %:��Q -,OIJ IJ Phone #: 710- ! A&T-
Owner's Address: /90 /03151T
City:
State :
Zip Code: 3.3/381
Job Address (Of where work is being done): / 41O�)N E A/,?z
City: Miami Shores State:—Florida Zip Code: 33-3
Contractor's Company Name: ��� �. Phone #: .3 S S' 33
Address:�L-
City:
Qualifier's Name:
State: XL Zip Code: �v S
Z, Lic. Number:
Architect/ Engineer of Record Name: Phone #:
Address:
City: /� State: Zip Code:
Describe Work:
1 hereby certify that the work has been abandoned and/or the contractor/architect
is unable or unwto complete the contract. 1 hold the Building Official and the
Mi i Shores harmless of all legal involvem
Signature Signature
The foregoing instrument wasknowledged before
�me,, I
thi�gay of L-4,2 ,byonL—n 1 Q} �fhJ>-fs
Who is personally known to me or who has produced
as indentification.
Notary ubli
Sign:
Seal: ASINE MIGU¢
�r .
MY COMMISSION # GG 176551
EXPIRES: January 17, 2022'
o cto Architect
The foregoing instr ent as aknowleed�dged before me
this day of - 20(&
who is personally known to me or who has produced
as indentification.
Notary P is
Sign:
Seal:
OVAAINE MIs" # GG 76551
W COU
roc EXPIRES: JWWY 17, 2022
U
BMW 71ru Nolan PuDNc
RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY
- F Lida
r
STATE OF FLORIDA
DEPARTMENT OF BUSINESS P- OFESSIONAL REGULATION
CONSTRU O�Nt N t 4 R C ING BOARD
:.-
THE RESIDENTIAL P C A'C-ON. k4 EI `1,
rTOI HE IFIED UNDER THE
PROVIS CO SCOT Gam_ TE8 J?A STA UTES
Off ISS?Jmak,.._..
M.
UT..ERRISES. II�7�Cj
�►
L-L• OO FI�33024
L CsENSM- E P 14 4 0
EXPIRATI6Nt .� TE:T . CJGU 31, 2020
Always verify licenses online at MyFloridaLicense.com
r Do not alter this document in any form.
This is your license. It is unlawful for anyone other than the licensee to use this document.
y
BROWARD COUNTY_ LOCAL BUSINESS TAX RECEIPT -�'
,
t#5S Ahdrews Ave., Rm- A-100: Ft_ Lauderdale, FL 33301-1895 —954-831-4000`-
VALID OCTOBER 1, 2018 THROUGH SEPTEMBER 30,29.19-%.
DBA:"
Business Name: �'r ;<usEs INC Receipt #-. 180-269060
• Business Type:sENFJZAL CONTRACTOR
Owner Name: PATRICIO F-STOPINAN Business Opened:l0/01/2014
Business Location: 6728 ATLANTA
ST State!County/Cert/Reg:ccci511963
{'
xoLLYwooD Exemption Code:
;#
Business Phone: 954-709-9519
';f!
Rooms Seats Employees Machines Professionals
1'
For Vending Business only
Number of Machines:
.,
s
Vending Type:
Tax Amount Transfer Fee NSF Fee �O�ty
Prior Years Collection Cost Total Paid
27.00 0.00
2.70 0.00 0.00 29.70
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY
IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business
within Broward County and is
non -regulatory in nature. You must meet all County and/or Municipality planning
{
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
's
the business is sold, business name has changed or you have oved the
business
i
location. This receipt does not indicate that the business is lemgal or that
it is in compliance with State or local laws and regulations.
;
ss ,
Mailing Address:
.;
,.
� ;
PATRICIO ESTOPINAN
6728 ATLANTA ST... -Receipt #05A-17-00000253
K
HOLLYWOOD, FL 33024 Paid 09/12/2018 27.00
t,
- -
-
2018 -2019
«
JIM161Y PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 6/30/2017
PERSON: ESTUPINAN
FEIN: 260003378
BUSINESS NAME AND ADDRESS:
ODISSEY ENTERPRISES INC.
6728 ATLANTA
HOLLYWOOD FL
SCOPE OF BUSINESS OR TRADE:
33024
Licensed General Contractor Licensed Pod Contractor
EXPIRATION DATE: 6/30/2019
PATRICIO
R'PORTANT_ Pwsuard to Chapter 410.05(14y F.S.. an officer of a corporation who elects exemption from this chapter by Ming a certilicate of election under
+ •s section may not rem benefits or compensation under this chapter. Pursuant to Chapter 440.05(12). FS.. Cerftates of election to be exempL.. apply
: •:,r within the scope of the business or trade listed on the notice of election to be exempL PUM=d to Chapter 440.05(13), F.S., Notices of election to be
__ • smpt and certificates of election to be exempt shall be subject to revocation if at any time after the Nang of the notice or the issuance of the certificate, the
son named on the notice or certificate no longer meets the reqs of Oft section for issuance of a certificate. The department shall revoke a
_ rOiicate at any time for failure of the person named on the certificate to meet the requirements of this section.
DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13
QUESTIONS? (850)413.1609
Scanned by CamScanner
DATE (MMIDDM"'n
Aco CERTIFICATE OF LIABILITY INSUMNICE 08/30/2018
ERS NO IS
THIS CERTIFICATE IS ISSUED AS A MATTER ONE rn�YON ONLYE AND
CONF
OR ALTER RTHE COVIGHTS PERAGE AFFORDED BY THE ON THE CERTIFICATE DPOLICHES
CERTIFICATE DOES NOT AFFIRMATIVELY OR
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ,as,must be endorsedll . If SUQROGATion IS WAIVED, subject to
IMPORTAN11 11 1 T11 : H the certificate holder is an ADDITIONAL INSURED, the policy(
, By require an endorsement. A statement on this certificate does not confer rights tot e
the terms and conditions of the policycertain policies m
certificate holder in Lieu of such endorsement(s). CN SCMaT lin Perez �F
PRODUCER (305) 418-8411 (305) 41$-8413 PHONE 305 418-8411"c No : 305 418-841:
Westward Insurance Services, Inc EADD�RESS: Westwardins@belisouth.net NAIL 17
4905 NW 72nd Avenue INSURERS AFFORDING COVERAGE
Suite 5 INSURER A* Atlatic Casual ce InsuranCom an
INSURED
Odissey Enterprise Inc
6728 Atlantic Street
Hollywood, FL 33024
OVERAGES CERTIFICATE NUMBER: THE INSURE NAMED
THIS IS TO CERTIFY E POI ANYI REQUIREMENT TERM OR CONDITION OFBANY CONTRALTEEN ISSUEO OR OTHER DOCUMENT WaTH RESPECT ALL
THEWHI
THIS
INDICATED.
CERTIFICATE MAY
BE ISSUED OR MAY PERTAIN,
ONS OF SUCH POLICIES.TLIMiTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HEREIN IS SUBJECT TO ALL THE TER
EXCLUSIONS AN IpDD SL SL UBR J POLICY EFF ' POLICY EXP L�(MITS
R POLICY NUMBER 1 MDD M
TYPE OF INSURANCE EACH OCCURRENCE S 1 000.000
GENERAL LIABILITY DAMAGE TO RENTED S 1 OO 000
PREMISES Eaoccuvence
✓ COMMERCIAL GENERAL LIABILITY ( L230000255-4 2/02/2017 (� 2/2/2018 MED EXP (AnY One Perron) ES1
000
CLAIMS -MADE t - : OCCUR 1j j PERSONAL & ADV INJURY 000-900
t1 1 wr _DPr:ATE I S 2.000.000
LIMIT APPLIES PER:
AUTOMOBILE LIABILITY
ANY
LLWN � SCHEDULED
AU
AU TOSS OOAUTOS
f } NON -OWNED
HIRED AUTOS %I AUTOS
UMBRELLA UAB I_ I OCCUR
EXCESS UAB CLAIMS -MADE]
DED 1 RETENTIONS i
WORKERS COMPENSATION ;
AND EMPLOYERS LIABILITY Y I N
ANY PROPRIETORIPARTNERIEXECUTIVE ❑ !i N I A
OF ndatoryEn NH) EXCLUDED?
General Contractor CGC�1511963chACORD101.AddltlonalRemarks5chadule.lEmomapacaisroqulrad)
Certificate Holder is listed as Additional Insured.
S
S
BODILY INJURY (Per person) i S
BODILY INJURY (Per accident) ( S
PROPERTYDAMAGE IS
(Per accident)
�S
EEL.
E.L.
S
S
SHOUt1D MY OF THE 4 DESCRIBED POLICIES BE CANCELLED BEFORE
THE IRATION ,FfATE EREOF, NOTICE WILL BE DELIVERED IN
ACCOR16AN E WITH THE P ICY PROVISIONS.
Miami Shores Village Builldin.,g� Deparment
10050 NE. 2nd Avenue, Miami. Shores AM,ORTLED P NT VE
Florida 33138. If/ Maylin Perez
1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
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