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PLC-20-544Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 A Issue Date: 03/12/2020 Permit NO.: PLC-03-20-544 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 09/08/2020 Location Address Parcel Number Project 9899 NE 2 AVE, Miami Shores, FL 1132060134360 NE 2 AVE SEWER CONNECTION Contacts SOUTHTRUST BANK NAT'L ASSOC Owner SOUTHTRUST BANK NAT'L ASSOC Applicant 9899 NE 2 AVE, MIAMI SHORES, FL 331382350 9899 NE 2 AVE, MIAMI SHORES, FL 331382350 JOHNSON - DAVIS INCORPORATED Contractor WILLIAM CLARK CLIFFORD CRYER 604 HILLBRATH DR, LANTANA, FL 33462 Business: 5615881170 Iditu@johnsondavis.com Mobile: 5617184531 Description: ABANDONMENT OF EXISTING OSTDS SEPTIC TANK Valuation: $ 800.00 on Requests: Inspection titi4949 PER HEALTH DEPARTMENT GUIDELINES Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $110.30 Credit Card 03/12/2020 $110.30 Amount Due: $0.00 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. Futhermore, I authorize the above named-co-Mr-a-etKto do the work stated. L /247-0 Authorized Signature: Owner / Applicant / Contractor i( / ( Agent e�f Date March 12, 2020 Page 2 of 2 Miami Shores Village RECEIVED Building Department MAR 12 2020 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY. INSPECTION LINE PHONE NUMBER: (305) 762-4949 . ' FBC20)�-�� BUILDING Master Permit No. PLC-7-18-1901 PERMIT APPLICATION Sub Permit NO.`P _C n3- -,?b -5" 9 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑■ PLUMBING ❑ MECHANICAL [:]PUBLICWORKS [:]CHANGE OF [:]CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9899 NE 2 AVE, Miami Shores, FL City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132060134360 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): SOuthtrust Bank Nat'l Assoc Phone#: Address:9899 NE 2 Ave City: Miami Shores State: FL Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Johnson -Davis, Inc. Address: 604 Hillbrath Drive City: Lantana State: FL Qualifier Name: William Clark Clifford Cryer State Certification or Registration #: CFC1430348 p: 33138 hone#: (561) 588-1170 Zip: 33462 hone#: (561) 588-1170 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ $800 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Demolition Description of Work: Abandonment of existing OSTDS septic tank per Health Department guidelines Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $_ DBPR $ CO/CC $ Notary Double Fee $ Bond $ TOTAL FEE NOW DUE $ _ (Revised02/24/2014) 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 $2500, the applicant must promise in good faith that a co of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject attach ent. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection hich occur seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be a proved and reinspection fee will be charged. Sign or AGENT The foregoing instrument was acknowledged before me this I � day of W(n1 20 DO by fl, U- U i (Tr'a 0 who is personally known to Ve or who has produced &. on- as identification and who did take an oath. Signature 9� CONTRACTOR The foregoing instrument was acknowledged before me this I day of YN&4/r-1 l 20 Q () by Wilhoo1 01 awr who is personally known to me or who has produced �-KOInCt i,. ,la r7 as identification and who did take an oath. NOTARY PUBLLC: NOTARY PUBLIC: Sign: g gaw" Sign: Print: 4— -}- i[9 Print: �(�JJ)n `,a-kA.C1 Seal: \\J Seal: Q 'Commission DAWN M. CELONA �,. (rosbeism Jambaptis>)a # GG 155920 State of Florida +;�o`.i Expires November 14, 2021 ***:**s***ids*s ��AY�ielrM�lheiol��lciipe�sss*��*asp*sss*r****r*** eond�s7�F$'>9il�i!':�9Q'rTlllA *s*s:**s*s �r Camoifoion No. fits 907288 APPROVED BY Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) Sindia Alvarez From: 1uan.G.Guerrero@wellsfargo.com Sent: Thursday, March 12, 2020 10:24 AM To: Sindia Alvarez Subject: RE: Business Ownership Please note that the information listed below is correct. I'm authorized on behalf of wells Fargo to sign and act as an agent. © OTHER AUTHORITY SIGN NON -WELLS FARGO DOCUMENTS AS AN AGENT OR DFFICER OF WELLS FARGO AUTHORIZED Sincerely, Juan G Guerrero RB Branch Manager II Miami Shores Branch Welts Fargo Bank, N.A. 19899 NE 2nd Ave I Miami Shores, FL 33138-2350 1 MAC: Z6228-010 1 Main Phone: 305-751-0700 1 Direct: 305-420-1951 1 Fax: 305-420-1949 1 NMLS ID: 647016 Juan.G.GuerreroCa WelisFar o.com This message may contain confidential and/or privileged information. If you are not the addressee or authorized to receive this for the addressee, you must not use, copy, disclose or take any action based on this message or any information herein. If you received this message in error, please advise the sender immediately by reply email and delete this message. Thank you for your cooperation. 1 From: Guerrero, Juan G Sent: Thursday, March 12, 2020 10:19 AM To: 'aIva rers@msvfl.gov' <aIva rers@msvfl.gov> Subject: Business Ownership Sincerely, Juan G Guerrero RB Branch Manager II Miami Shores Branch Wells Fargo Bank; N.A. 19899 NE 2nd Ave I Miami Shores, FL 33138-2350 1 MAC: Z6228-010 1 Main Phone: 305-751-0700 1 Direct: 305-420-1951 1 Fax: 305-420-1949 1 NMLS ID: 647016 Juan.G.Guerrero(a)WellsFaLgo.com This message may contain confidential and/or privileged information. If you are not the addressee or authorized to receive this for the addressee, you must not use, copy, disclose or take any action based on this message or any information herein. If you received this message in error, please advise the sender immediately by reply email and delete this message. Thank you for your cooperation. Sindia Alvarez From: Juan.G.Guerrero@wellsfargo.com Sent: Thursday, March 12, 2020 10:19 AM To: Sindia Alvarez Subject: Business Ownership Sincerely, Juan G Guerrero RB Branch Manager II Miami Shores Branch Wells Fargo Bank, N.A. 19899 NE 2nd Ave I Miami Shores, FL 33138-2350 1 MAC: Z6228-010 1 Main Phone: 305-751-0700 1 Direct: 305-420-1951 1 Fax: 305-420-1949 1 NMLS ID: 647016 Juan.G.Guerrero(cD-WelisFargo.com This message may contain confidential and/or privileged information.'lf you are not the addressee or authorized to receive this for the addressee, you must not use, copy, disclose or take any action based on this message or any information herein. If you received this message in error, please advise the sender immediately by reply email and delete this message. Thank you for your cooperation. e STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Well Fargo) PROPERTY ADDRESS: 9899 NE 2 Ave Miami, FL 33138 LOT: 10 &11 BLOCK: 32 SUBDIVISION: PROPERTY ID #: 11-3206-0134-360 PERMIT #: 13-SC-1972062 APPLICATION # : AP1422078 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1245619 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ ] GALLONS / GPD CAPACITY A [ ] GALLONS / GPD CAPACITY N ( ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ J GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] ABANDONMENT PERMIT D L j SQUARE FEET SYSTEM EXPIRES 90 DAYS FROM R [ ] SQUARE FEET SYSTEM DATE OF ISSUANCE A TYPE SYSTEM: [ ] STANDARD [ j FILLED [ ] MOUND [ ] I CONFICURATION: [ ] TRENCH [ ] BED [ ] N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE ( ][ ][ABOVE/BELOW] BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE ( ][ / )[ABOVE/BELOW] BENCHMARK/REFERENCE POINT L D 0 T H E R 'ILL REQUIRED: O.UU I INCHES EXCAVATION REQUIRED: j I INCHES Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The tank shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected by the health department after it has been pumped, ruptured and filled with sand and covered. PERMIT T() ABANDON SEPTIC TANK MUST BE PUMPED BY A ST TE REGISTERED SEPTIC TANK CONTRACTOR OR S NTE LICENSED PLUMBER, BOTTOM OF TANK OPENS OR RUPTURED, AND TANK FILLED WITH CLEAN EAN OR CERTIFY COMPLETION OF AtSUvt wvt[n mmu SPECIFICATIONS B TITLE SCHEDULE INSPECTION WITH THE T APPROVED BY: UDUR-- TLE: Engineering Specialist II Dade CHD Jasua D HarnaadarAoosta DATE ISSUED: 03/03/2020 EXPIRATION DATE: 06/01/2020 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 1._:.4 r1.1142207e s NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. '� COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. �� COPY OF LIABILITY INSURANCE* D. 'COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ........................................................................................... BUSINESS NAME: �OIAPJSaN 8Aff: ,_TNC, BUSINESS ADDRESS: 60q Mx Le- iy-m Qftye CITY LAovTAIvA STATE ZIP 3 Z-1656 BUSINESS PHONE: 5CY - << 10 FAX NUMBER (56 () CELL PHONE (5L-L) -711 - y 53 \ QUALIFIER'S NAME: "[ c r~ 6-AA k, CRYm- QUALIFIER'S LIC NUMBER: GFL 1 Lk S n 3 L? 0 i� i �c Ron DeSantis, Governor Halsey Beshears, Secretary Florida dpr, STATE OF FLORIDA � CpD WE DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION LNORILICENSING BOARD THE PLUMBING CON RAC�T,OR' F. EREtN��S�CER-T IED UNDER THE t PROVISIOC iAP ERt48WEFLORI;DA-S:TATUTES CR EXPIRATION DATE: AUGUST 31, 2020 Always verify licenses online at MyFloridaLicense.com RD 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. ANNE M. GANNON /i CONSTITUTIONAL TAX COLLECTOR Serving Pahn Reach County Serving you. P.O. Box 3353, West Palm Beach, FL 33402-3353 www.pbctax.com Tel: (561) 355-2264 "LOCATED AT"" 604 HILLBRATH DRIVE LANTANA, FL 33462-1656 TYPE OF BUSINESS OWNER CERTIFICATION # I RECEIPT #/DATE PAID AMT PAID BILL # 23-0069 PLUMBING CONTRACTOR I CRYER WILLIAM CLARK CLIFFORD CFC1430348 I U20.167954 - 12/$0/19 $27.50 840196238 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2019/2020 LOCAL BUSINESS TAX RECEIPT JOHNSON DAVIS INC JOHNSON DAVIS INC 604 HILLBRATH DRIVE LANTANA, FL 33462-1656 %4t# ANNE M. GANNON CONSTITUTIONAL TAX COLLECTOR Sensing Palm Beach County Serving you. P.O. Box 3353, West Palm Beach, FL 33402-3353 www.pbctax.com Tel: (561) 355-2264 LBTR Number: 2020125389 EXPIRES: SEPTEMBER 30, 2020 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. —LOCATED AT"" 604 HILLBRATH DRIVE LANTANA, FL 33462-1656 TYPE OF BUSINESS I OWNER CERTIFICATION # I RECEIPT #/GATE PAID AMT PAID BILL # 23-0105 CW PLUMBING CONTRACTOR ICRYER WILLIAM CLARK CLIFFORD CDC1430346 I U20.167954-12/20119 $264.60 B40196239 This document is valid only when receipted by the Tax Collector's Office. STATE OF FLORIDA PALM BEACH COUNTY 2019/2020 LOCAL BUSINESS TAX RECEIPT JOHNSON DAVIS INC JOHNSON DAVIS INC 604 HILLBRATH DRIVE LANTANA, FL 33462-1656 LBTR Number: 2020125390 EXPIRES: SEPTEMBER 30, 2020 This receipt grants the privilege of engaging in or managing any business profession or occupation within its jurisdiction and MUST be conspicuously displayed at the place of business and in such a manner as to be open to the view of the public. IOHNINC-n2 SMAJFSKI CERTIFICATE OF LIABILITY INSURANCE DATE A E(MMI I 020 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 Sharon Majeski, ARM POP CT Johnson Insurance Racine 1103 Hunter Dr Ste 100 Mount Pleasant, WI 53406 PHONEFA (A/C, No, Ext): (920) 433-7107 (A/c, No):(877) 264-8586 noMoRIE : smajeski@johnsonfinancialgroup.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Zurich American Insurance Company 16535 INSURED INSURER B: American Guarantee & Liability Insurance Co26247 INSURER C : Homeland Insurance Co of NY 3"52 Johnson -Davis Inc INSURER D: 604 Hillbrath Dr Lantana, FL 33462 INSURER E INSURER F : C_OVFRAGFS 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 LTRA TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF 7/1/2019 POLICY EXP 7/1/2020 LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FJX� OCCUR GLO 9813382-01 EACH OCCURRENCE $ 1,000,000 IS DAMAGE TO RENTED occurrence)$ 300,000 MED EXP (Any oneperson) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 1XI JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE LIABILITY X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS SSyyN D X AUTOS ONLY X AUTOS ONLY BAP 9813380-01 7/1/2019 7/1/2020 COMBINED SINGLE LIMIT (Ea$ 1,000,000 BODILY INJURY Per person)$ BODILY INJURY Per accident $ P arr accdent AMAGE Fe $ $ B X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE AUC 5676415-01 7/1/2019 7/1/2020 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED I X I RETENTION $ 0 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 C3066378-01 7/1/2019 7/1/2020 X PERSTATUTEERH E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ A C Equipment Floater Pollution CPP 4289118-01 7930030920004 7/1/2019 7/1/2019 7/1/2020 7/1/2020 Leased Rented Occ/Aggregate 300,000 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Removal of Existing Sceptic Tank. Plumbing Contractor License #: CFC 1430348 Miami Shores Village Building Dept 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. AUTHH,ORIZED RlEPPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD