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SGN-19-1359Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Imoffn-h k Issue Date: 08/13/2019 Parcel Number 9020 BISCAYNE BLVD, Miami Shores, FL 33138 1132060110120 Contacts Permit NO.: SGN-06-19-1359 Permit Type: Sign Work Classification: Repair Permit Status: Approved Expiration: 02/10/2020 WAL MIAMI LLC Owner BRUCE HERMELEE 275 MADISON AVE, NEW YORK, NY 10016 PARAMOUNT SERVICE & MAINTENANCE Contractor NATHAN SOCARRAS Business: 9544338001 DANNY@PARAMOUNTSM.NET Description: REPLACEING EXISTING SIGN FACES ONLY WITH Valuation: $ 1,300.00 Inspection Requests: NEW GRAPHICS 05-762-4949 Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $1.20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee $50.00 Planning and Zoning Review Fee $35.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $152.10 Payments Date Paid Amt Paid Total Fees $152.10 Credit Card 08/13/2019 $152.10 Amount Due: $0.00 Building Department Copy 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 ce tha�all e foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and ning. Fore, I_au# ove named contractor to do the work stated, Authorized Signature / Applicant ( Contractor 7 Agent Date August 13, 2019 Page 2 of 2 BUILDING PERMIT APPLICATION d�B JILDING ❑ ELECTRIC in ❑PLUMBING ❑ MECHANICAL JOB ADDRESS: 9020 Biscayne Blvd -_, i c n. Occupancy Type: Load Miami Shores Village '�C4F Building Department ✓101 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 1--) 6jrk Master Permit No. Sub Permit No. ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS _ ()I Z-0 Is the Building Historically Designated: Yes NO X - Construction Type: Flood Zone: BFE: FFE: _ OWNER: Name (Fee Simple Tifleholder):i WAL MIAMI LLC t ddress?. 801 SECOND AVENUE 21 FLOOR :City: NEW YORK NY Tenant/Lessee Na e: WALGREENS CO. =,Emaif: :9Pa0 crGM Cc/,l � ne#:j 212-490-0050 10017 CONTRACTOR: Company Name: Paramount Service & Maintenance Phone#: 954-433-8001 Address: 7789 N.W. 52 Street City: Doral Statue: FL Zip: 33166 / Qualifier Name: L J U C!q �/cTr Phone#: State Certification or Registration #: r/ S 1 Z06112 1 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: ✓.`" City: State: Zi . Value of Work for this Permit: $ V Square/Linear Footage of Work: l Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Replacing existing sign faces ONLY with new graphics L L.1 k16 Oi5 JV Specify color of color thru tile: 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) ( /— 2 �� Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Zip 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 fee will be charged. Signature - Sig at ,OWNER or AGENT+ CONTRACTOR kThe foregoing instrument was acknowledged'i'efore m-e this --23 day of MAY 20 19 6) (--JACK FORGASH - who is personally known to The foregoing instrument was acknowledged before me this _6 t- day of r 120 by A' IA�t t1a,i -Foe4 oc-i , w o is personally no n to fine or who has produced` ' _ T _ as' me or who has produced (identification and wlio did'Eake ;NOTARY PUBLIC; I'Sign:j (Print:; :Seal: ******************* APPROVED BY GREE ..V Ne •. •' STATE OF NEW YORK ' NOTARY PUBLIC: {QuatiWed n Nam County' tZ ��---p4�1GRt7U159 �et' . _ _ • c.� _• %z9v UP0 ua 4 identification an ho di take a NOTARY P LIC: �� • . .. * //i��� � Q Sign: L ' Seal: •�� �o�o ��� Plans Examiner Structural Review M �" (k,0 o(U Zoning Clerk (Revised02/24/2014) Property Search Application - Miami -Dade County Page 1 of 1 OFFI'01 OF THE PROPERTY APPRAISER .., Summary Report Property Information Folio: 11-3206-011-0120 Property Address: 9020 BISCAYNE BLVD Miami Shores, FL 33138-3222 Owner WAL MIAMI LLC Mailing Address 801 2ND AVE FL 21 NEW YORK, NY 10017-8632 PA Primary Zone 6200 COMMERCIAL - ARTERIAL Primary Land Use 1111 STORE: RETAIL OUTLET Beds / Baths / Half 0/0/0 Floors 1 Living Units 0 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 15,206 Sq.Ft Lot Size 46,494 Sq. Ft Year Built 1996 Assessment Information Year 2018 2017 2016 Land Value $2,429,312 $2,557,170 $2,185,218 Building Value $800,725 $534,008 $970,688 XF Value $0 $0 $0 11 Market Value $3,230,037 $3,091,178 $3,155,906 Assessed Value 1 $3,230,037 $3,091,178 $3,135,000 Benefits Information Benefit Type 2018 2017 2016 Non -Homestead Cap Assessment Reduction $20,906 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description 6 53 42 ASBURY PARK PB 4-110 LOTS 14 & 15 LYG W OF W RM//L BISC BLVD LESS N17.62FT OF LOT 14 & PORT OF TRACT A LYG S OF A LINE Generated On : 6/13/2019 Taxable Value Information 2018 2017 2016 County Exemption Value $0 $0 $0 Taxable Value $3,230,037 $3,091,178 $3,135,000 School Board Exemption Value $0 $0 $0 Taxable Value $3,230,037 $3,091,178 $3,155,906 city Exemption Value $0 $0 $0 Taxable Value $3,230,037 $3,091,178 $3,135,000 Regional Exemption Value $0 $0 $0 Taxable Value $3,230,037 $3,091,178 $3,135,000 Sales Information Previous Sale Price OR Book -Page Qualification Description 01/02/2012 $2,900,000 28005-3000 Qual by exam of deed 12/01/1997 $2,139,500 17931-1209 Sales which are qualified 12/01/1994 $625,000 16794-2329 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.gov/info/disclaimer. asp Version: https://www8.miamidade.gov/Apps/PA/propertysearch/ 6/13/2019 Walgreens 6013 Miami, FL 40 200 1 /2" 195 1 /2" Wa4M M l!"1 LI drive thru pharmacy 120 1/2" 116 112" I I (� 14 L -� 2" SCALE 1:50 Note: Cabinet, Retainers and Pole to be painted to match Matthews 313 Dark Bronze Color Schedule: 3M translucent vinyl films 3M #3730-53L - Cardinal Red 3M #3630-8057 — Blue 3M #3630-49 - Burgundy White face background Existing Proposed c z G:) IV AGI 1#01 2019 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT DOCUMENT# L11000107159 Entity Name: WAL MIAMI, LLC Current Principal Place of Business: 801 SECOND AVENUE 21ST FLOOR NEW YORK, NY 10017 Current Mailing Address: 801 SECOND AVENUE 21 ST FLOOR NEW YORK, NY 10017 US FEI Number: 45-3529500 Name and Address of Current Registered Agent: HERMELEE, BRUCE G 2100 CORAL WAY SUITE 702 MIAMI, FL 33145 US FILED Feb 19, 2019 Secretary of State 4826697902CC Certificate of Status Desired: No 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: Electronic Signature of Registered Agent Date Authorized Person(s) Detail : Title MGRM Name FORGSON WALCENTERS, LLC Address 801 SECOND AVENUE 21ST FLOOR City -State -Zip: NEW YORK NY 10017 Title MGRM Name SAKOGE SOUTH 1, LLP Address 1761 NOCATEE DRIVE City -State -Zip: COCONUT GROVE FL 33133 I hereby certify that the information indicated on this report or supplemental report is hue and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am a managing member or manager of the limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 605, Florida Statutes; and that my name appears above, or on an attachment with all other like empowered. SIGNATURE: ELLIOTT FORGASH MEMBER 02/19/2019 Electronic Signature of Signing Authorized Person(s) Detail Date 2019 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT DOCUMENT# L10000104218 Entity Name: FORGSON WALCENTERS LLC Current Principal Place of Business: 801 SECOND AVENUE 21ST FLOOR NEW YORK, NY 10017 Current Mailing Address: 801 SECOND AVENUE 21 ST FLOOR NEW YORK, NY 10017 US FEI Number: 27-3651785 Name and Address of Current Registered Agent: HERMELEE, BRUCE G 2100 CORAL WAY SUITE 702 MIAMI, FL 33145 US FILED Feb 19, 2019 Secretary of State 010246202OCC Certificate of Status Desired: No 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: Electronic Signature of Registered Agent Authorized Person(s) Detail : Title MGRM Name FORGASH, JACK Address 801 SECOND AVENUE 21ST FLOOR City -State -Zip: NEW YORK NY 10017 Title MGRM Name FORGASH, STUART Address 801 SECOND AVENUE 21ST FLOOR City -State -Zip: NEW YORK NY 10017 Title MGRM Name FORGASH, ELLIOTT Address 801 SECOND AVENUE 21 ST FLOOR City -State -Zip: NEW YORK NY 10017 Date I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am a managing member or manager of the limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 605, Florida Statutes, and that my name appears above, or on an attachment with all other like empowered. SIGNATURE: ELLIOTT FORGASH MEMBER 02/19/2019 Electronic Signature of Signing Authorized Person(s) Detail Date WAL MIAMI LLC 801 SECOND AVENUE 21 FLOOR NEW YORK , NY 10017 To The City/County of Miami- Dade County Re: Commercial sign permit procurement for 1 Walgreens # 3173 Dear Sirs or Madam, I, Jack Forgash of WAL MIAMI LLC, owner of property located at 9020 Biscayne Blvd Miami Shores, FL 33138, hereby authorize Paramount Service & Maintenance and their agents to sign applications, apply for, pay for, and pick up permits, building and electrical for the tenant, Walgreens CO, as authorized agents. Walgreens CO is responsible for any work performed by the agent currently contracted for commercial signage work. AUTHORIZED AGENT State of Ny County of N� SIGNATURE --- --------------------------------------------- -------------- PROPER OWNER SIGNATURE Before me personally appeared ; S A O-� FQr a S k , to me well known and known to me as the person described in and who executed the Yoregoing instrument, and acknowledged to and before me that he executed said instrument for the purpose herein expressed. Witness my hand and Official seal this 93 ro day of ( p / , 2014 Stamp = v: OF NEW YORK s NOTARY PUBLIC �! '•,OuaGfied in Nassau County: � otcR707597 ' .v,? J� '�JAJ'D Notary Public Ron DeSantis, Governor STATE OF FLORIDA Halsey Beshears, Secretary DEPARTMENT OF BUSINESS,AN,D=PROFESSIONAL REGULATION 6%-J er-rT,...k��•..ELECTRICAL,,�MRACTORLICE, SING 130ARD THE SPECIALTY ELEC�TRIGA'LQNTICTOIIEREI_NQ.,'CEk ` TIFIED UNDER THE �}.��_,.,.,�� PROVIS ON-§+O-F'Cr�AP,�TER,489== IORIDf AI'STA+ UTES SO'C 'R�RSAS, NA-THAwl��,� K PA�RAOUNT JERVICE ��G-O. P. �r; � V8-%NW,-52NSST tDO;RAL-FL.- 3166 "l\�;� ,��'•ti`,.`�,'} .r_ _�; iTi � � ('� � - GIs r� Y ' L��ENSL-t�l,�l`� ICI BER:tE51�2�0�12f29 EXPIRATIbN0ATE:_AUGUST 31, 2020 Always verify licenses online at MyFloridaLicense.com Do not alter this document in any form. This is your license. It.is{Onlawful for anyone other than the licensee to use this document. 11 A 0 2019]""'2018 2017 Paid PFzid Paid Account number. 7210802 Business start date: 10/01/2016 Physical business location: DORAL Business address: PARAMOUNT SERVICE & MAINTENANCE CORP 7789 NW 52 ST DORAL, FL 33166 Contracting 10/01 /2018-09/30/2019 SPEC ELECTRICAL CONTRACTOR Documentation Required by Occupation: State/County License or Certificate Document Received: ES12001729 -1 Arrnunt Retails Account history Mailing address: PARAMOUNT SERVICE & MAINTENANCE CORP C/O NATHAN T. SOCARRAS 7789 NW 52 ST DORAL, FL 33166 Owner(s) PARAMOUNT SERVICE & MAINTENANCE CORP C/O NATHAN T. SOCARRAS 7789 NW 52 ST DORAL, FL 33166 NAICS code: 23821 Units: 4 Restricted Municipal Contracting 0 1 /18/2019-09130/2019 Units: 1 SPEC ELECTRICAL CONTRACTOR RESTRICTED TO HOMESTEAD Documentation Required by Occupation: Certificate of competency number or state registration number. Document Received: ES12001729 0 Print this bill a Print this bill ACCOMT CERTIFICATE OF LIABILITY INSURANCE 11-.� DATE(MM/DD/YYYY) 1 05/02/2019 THIS CERTIFI 'ATE 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 Occidental Risks Services, Inc C M ACT VICKY FERNANDEZ PHONE . (305) 433-4068 IF,,Axc (888) 678-2045 11890 SW 8st Suite 516 AnnRE-MAIL NckyCoccidentafrisks.com INSURERS AFFORDING COVERAGE NAIC S Miami, FL 33184 INSURER A: SCOTTSDALE INSURANCE COMPANY 41297 Phone (305) 433-4068 Fax (888) 678-2045 INSURED INSURER B : VANTAPRO SPECAILTY INSURANCE COMPAN 44768 INSURER C : EVANSTON INSURANCE COMPANY 35378 PARAMOUNT SERVICE & MAINTENANCE CORP. INSURER D : 7789 N.W. 52ND STREET DORAL FL 33166 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 CLAIIMS. ILTR TYPE OF INSURANCE INAR ADD UVD POLICY NUMBER MM POLIDYL POLICY D/YYYYP LIMBS A COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE Q OCCUR ElMED N N CPS3144760 04/30/2019 04/30/2020 EACH OCCURRENCE 2,000,000.00 PREMISES occurrence) _f S 100,000.00 EXP (Any one person) S 5,000.00 ❑ GENT AGGREGATE LIMITAPPLES PER: POLICY © PRO- JECT ❑ LOC ❑ OTHER PERSONAL a Am INJURY s 2,000,000.00 GENERAL AGGREGATE S 3,000,000.00 PRODUCTS - coMP/OP AGG s 3,000,000.00 S B AUTOMOBILE LIABILITY Q ANY AUTO OWNED SCHEDULED ❑ AUTOGE HIRED ONLY Q ANON -OWNED ❑ AUTOS ONLY AUTOS ONLY N 5087-0128-00 08/26/2018 08/26/2019 C0:a D t SINGLE LIMITS a ma 1,000,000.00 BODILY INJURY (Per person) S BODILY RYWPE=Y((Per accident) S S C ❑ UMBRELLA LIAB OCCUR d EXCESS Las CLAIMS -MADE N N EZXS3007372 04/30/2019 04/30/2020 EACH OCCURRENCE s 4,000,000.00 AGGREGATE s 4,000,000.00 DED 0 gfEMNTION S s WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERIEXECUT❑ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) (ryes, describe under DESCRIPTION OF OPERATIONS below A NIA P R OER 11 E.L. EACH ACCIDENT S E.L DISEASE - EA EMPLOYE S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space is required) ELECTRICAL CONTRACTOR - COMMERCIAL & RESIDENTIAL INCLUDING ELECTRICAL SIGN WORK. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E. 2ND AVENUE MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) OF The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE Date 1/16/2019 Ftroduter: Plymouth, Insurance Agency TINS Certificate is issued as a matter of information only and confess no 2739 U.S. Highway 19 N. Holiday, FL 34691 rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. (727) 938-5562 Insurers Affording Coverage NAIC # Insured: South East Personnel Leasing, Inc. & Subsidiaries Insurer A. Lion Insurance Company 11075 InsurerB: 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer C: Insurer D: Insurer E: Coverages The policies of insurance n issued to the insured or the policy period indicated.Notwithstanding arty 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 at the terns, exclusions, and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. INSR LTR ADDL INSRD Type of Insurance Policy Number Policy Effective Date Policy Expiration Date Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence Commercial General Liability Claims Made Occur Damage to rented premises (EA occurrence) Mad Exp Personal Adv k*iry eneral aggregate limit applies per. Policy ❑ Project ❑ LOC General Aggregate Products - ConWOD Agg UTOMOBILE LIABILITY Combined Sim Limit (EA Accident) Any Auto Bodily k"y All Owned Autos Scheduled Autos (Per Person) Bodily Injury Hired Autos Non -Owned Autos (Per Accident) Property Damage IN (Per Accident) EXCESSIUMBRELLA LIABILITY Each Occurrence Aggregate Occur ❑ Claims Made Deductible A Workers Compensation and WC 71949 01/01/2019 01/01/2020 X I WC Statu- OTH- Employers' Liability tory Limits ER E.L. Each Accident $1,000,000 Any proprietor/partner/executive officer/member E.L. Disease - Ea Employee $1,000,000 excluded? No If Yes, describe under special provisions below. E.L. Disease -Policy Limits S1,000,000 Other Lion Insurance Company is A.M. Best Company rated A (Excellent). AMB # 12616 Descriptions of Operations/Locations/Vehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 92-68-268 Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are leased to the following "Client Company": Paramount Service ✓& Maintenance Corp Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s;, while wonting in: R. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or email certificates@lioninsurancecmipany.com Project Name: ISSUE 08.15-17 (BP) REISSUE 01-16.19 (AR) BeqIn Date: 31412014 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE, BUILDING DEPT. Should any or the above described policies be cancelled before the expiration date thereof, the issuing insurer will endeavor to mail 30 days written notice to the certificate holder named to the left, but failure to do so shall impose no obligation or liability of any kind upon ffw insurer. its agents or representatives. 10050 N.E. 2NDAVE MIAMI SHORES, FL 33138--- _--- —