Loading...
ELC-19-2515Miami Shores Village EN-rERED Building Department OCT 232019 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 FBC 20 Master Permit No. Sub Permit NoELC-) D — 1 —0515 ❑ REVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS t�^ JOB ADDRESS:69�416.h) a 2-h of V M'v, INICAN cr-s_-� r�tc r- � City: Miami Shores County: Miami Dade Zip: 3$ Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): w4?y ulu<7 wlt Y Phone#: 3b • gS "l9. ��(1 Address: i1300 iNid, ? I�V1l . City: NAPAI f R GE State: ���� Zip: 3 � 16 I Tenant/Lessee Name: Email Phone#: CONTRACTOR: Company Name: Lr `rn efts/,*�/�� /�� �'�k hone#: 5Q _ u�g y !b 6_ Address: '� C2. 65Z)C J� 11 Q4? y City: AN34 . A"% I M4a State: , Zip: 7 if Qualifier Name: C34 T 6T 7►-� 3F Co. Phone#: State Certification or Registration #: �� Od/�Sq'� Certificate of Competency #: DESIGNER: Architect/Engineer: / Phone#: Address: City: State: Zip: Value'of Work for this Permit: $ 2-1!5 ay. _, Square/Linear Footage of Work: 4,11 Type'of Work: ❑. Addition ElAlterationiNew Repair/Replace ❑ De olitAion Description of Works / �/ALLY •� " ..xJ wML: HwnNNl.M`r+Jlze.':a'..`SM:wA.;:.rP.n.Hwe.>1rs.exs•".N'w:»Y ' _ j +SAY °•,1'�•ii1. •=� � .. � SOecifycolor.of color thru tile: x�. r��t o\\'• �:: �,.,i r;; h�t.rtieS: K.x'.i !.•.... ,. r�i, S'� Submittal Fee $ Permit Fee $ CCF Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) z 1. i Bonding Company's Name (if applicable) // /I / , 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:' , • �� < ` L •• w7 i lSi+r � ,'e .t 1 ti `3 `E '.�R P "WARNING TO "&WNER: 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 ent mu osted at the job site for the first inspection which occurs seven (7) days after the building permit is issu I the abse c of suc posted notice, the inspection will not be approved and a reinspection fee will charged. Signature ' Signature t " OWNER or AGENT The foregoing instruument was acknowledged before me this h{ , r day of VC/ fi�/���i 20� by SAL , �1 Null A who is personally known to or who has produced identification and who did take an oath. NOTARY Sign:_ Print: Seal: rc'"��EfFRYJ.YAO �.; ..CCaatt�ilyon..�O�Q�t9916 •,`1 • �w NY�O�101 ���..�..•� as CONTRACTOR ' The foregoing instrument was��acknowleMged befoireomeIhis V "day of."O (>i-"3 20• I / by N1 007•1 _ �qV C ✓ , who is personally known to me or who has produced l— as N T1 Sign:_ Print: Seal: and o 'd take an oath. LIB IC: "\�f1An. l.n fi •��G WAS 2 / .iN• :Z 1'GG2a�xi ' • a�.e°�aed thN°`y -'••. *46 . he Lmds ' �Q A STATE O�•`\��� ############################################################################################################ APPROVED BY Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) Physical Add. 2040 NE 161 Street N. Miami 33161 Suite 302C Mailing Add P.O. Box 611004 N. Miami Fl, 33261 Date: 1011012019 Project: Barry University Dominican Hall Village of Miami Shore Building Dept. &�L r- --08-Gq-lSoZ Would appreciated to cancel Existing permit and issue new permit For Dominican Hall. Best Regards Bagher Nimroozi Authorized Agent of Lincoln Electrical Contractor Inc. Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 09/20/2019 Permit NO.: LC-08-19-1802 Permit Type: Electrical - Commercial Work Classification: Low Voltage Permit Status: Approved Expiration: 02/17/2020 Location Address Parcel Number Project 11300 NE 2ND AVE, Miami Shores, FL 33161 1121360000050 BARRY UNIVERSITY Contacts BARRY UNIVERSITY INC Owner BARRY UNIVERSITY 11300 NE 2 AVE, MIAMI SHORES, FL 331616628 LINCOLN ELECTRICAL CONTRACTOR INC Contractor BAGHER NIMROOZI Business: 3056941616 Description: INSTALL 4 ANONCIATION SPEAKERS Valuation: $ 2,500.00 Inspection Requests: LIBRARY 3OS-762-4949 Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $1.80 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.60 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $111.90 Payments Date Paid Amt Paid Total Fees $111.90 Credit Card 08/20/2019 $61.90 Check # 3148 08/05/2019 $50.00 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 A 51T: rtify t at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating con toning Futh ore, I authorize the a ove nam cro actor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date August 20, 2019 Page 2 of 2 BUILDING PERMIT APPLICATION 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 CIED AUrO5019 FBC 201 "1'°* Master Permit No. '� L a— 08 - 1 q_ 1802 Sub Permit No. ❑BUILDING V` ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP ,,//������pp ''^' �]�. ►-�/ -�^ CONTRACTOR �) n/� DRAWINGS JOB ADDRESS: ��'1 zy VWvIVI�'� �l T 11 �Oo mb � Ak `�19 "^1qy 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): {`y-1my Phone#:- ZYT� .7flY Address: i I3oo N( -it Qyr7 City: 91 AA 1 S: W ff .e.I' State: Zip: 3 31 6 l Tenant/Lessee Name:: Phone#: Email: 1ycw�--'- CONTRACTOR: Company Name: n C 0/ ih E;�l tom[ �(c CGS Phone#: 3 c,5 - 64 q - l Q b Address: P 0- a 0,C (,(too(/ City: MT 3n , State: 9= 1 i Zip:-3 Qualifier Name:'n aLa, �n va- C �" rm 0(2 Z( Phone#: State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: 0.r°,> Value�of Work for this Permit: $ % 6in,20 - �-O Square/Linear Footage of Work: Type of Work: ❑ Addition p ❑ Alteration �NeVu Y ❑ 'Repair/Reeplace ❑ Demolition y Description of Work: �i1 S- a l f A I1 C h CV? S Kea r ecify color` of color thru tile: Submittal Fee $ 1 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) , A - 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 Imus sted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In nce of such posted notice, the inspection will not be approved and a reinspection fee will be charged. A ) OWNER or AGENT 1# The fore&ingihstrument was acknowledged before me this day of l� 1 20 by who is personally known to me or who has produced as ion and who did take an oath. Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of,1 � 120 by J (1� MIN gl00��, who ispersonallyknown to me or who has produced t'��y as identification and who did take an oath. NOT PUBLIC: N ``�♦♦���PSMINE r�/,� `111111111/// .•NMISSI�•/� iNOTARY PUBLIC: ♦%AN e�%,� "Oy 1 Sign: _ •.• v, . *_Sign: `, . �, ,n n , Print: J a `! r t w� #FF9547gg ; �Z 20, 2� . • O� Print: F 70 .gam :�O`� Seal: •• ����ial/0 �SiASEflF��` Seal: ���i` • .pG: APPROVED BY04�✓/ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 2019 FLORIDA NOT FOR PROFIT CORPORATION ANNUAL REPORT FILED DOCUMENT# 711458 Apr 30, 2019 Entity Name: BARRY UNIVERSITY, INC. Secretary of State 6920455029CC Current Principal Place of Business: 11300 N.E. SECOND AVENUE MIAMI, FL 33161 Current Mailing Address: 11300 N.E. SECOND AVENUE MIAMI, FL 33161 US FEI Number: 59-0624364 Certificate of Status Desired: No Name and Address of Current Registered Agent: DUDGEON, DAVID 11300 NE SECOND AVE LAVOIE HALL #209 MIAMI, FL 33161 US 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 Officer/Director Detail Title S Title T Name DUDGEON, DAVID Name ROSENTHAL,SUSAN Address 11300 NE SECOND AVE Address 11300 N.E. SECOND AVENUE City -State -Zip: MIAMI FL 33161 City -State -Zip: MIAMI FL 33161 Title D Title PD Name BUSSEL, JOHN Name BEVILACQUA, SISTER LINDA Address 11300 NE SECOND AVE Address 11300 NE SECOND AVE City -State -Zip: MIAMI FL 33161 City -State -Zip: MIAMI FL 33161 Title VP Name MURRAY, JOHN Address 11300 N.E. SECOND AVENUE City -State -Zip: MIAMI FL 33161 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 an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617, Florida Statutes; and that my name appears above, or on an attachment with all other like empowered. SIGNATURE: DAVID DUDGEON SECRETARY 04/30/2019 Electronic Signature of Signing Officer/Director Detail Date Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ........................................................................ 0 M M M M M ............ 1 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: BUSINESS ADDRESS: P- O_ 6\9K L t f CITY Av - gla STATES ZIP CODE 3 3 2 6 BUSINESS PHONE: (305L- ) C3A_ ()�, ` FAX NUMBER (Ll5tf) sq �( q,.q G 3 CELL PHONE (3a!5; ) 8-gq-"72 QUALIFIER'S NAME: q g h 41,'611-00 al QUALIFIER'S LIC NUMBER: ' r(5 0 0 (Sq f E-MAIL ADDRESS (IF APPLICABLE): n Created on 3/19/09 BY MLDV 1 RV 3/26/09 MLDV RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS!-.fA-4D-PROFESSIONAL REGULATION ELECTRICAL,CQI�1. Tt 1tS�LI'Cig NG BOARD THE ELECTRICA F(O'I T CTORiHEREIN 15 ER� ,y �'Fy�Q UNDER THE PROVISIO S, OF3'CH=APTER -Q9 FLORJTV— TA. UTES NT -,OZ -4( LNCO+LN ELEC�GRICAL CONTRACTO: -C -' ,0-2-220-,NAV=rF, E HOI-NOOD ; EXPIRATIOMDA� TE ►U„Gi1ST 31, 2020 Always verify licenses online at MyFloridaLicense.com Ell' a Do notalter this document in any form. This is your license. It is unlawful for anyone other than the licensee to use, this document. ®' City of North Miami Beach Community Development Division Business Tax Receipt 17050 NE 19 Avenue North Miami Beach, FL 33162 MAIL TO: LINCOLN ELECTRICAL CONTRACTORINC P.O. BOX 611004 NORTH MIAMI,FL 33261 Thank you for choosing the City of North Miami Beach! You can now visit us on-line at www.citymnb.com or you can e-mail us at NMBBTR@citynmb.com The CiN of Noah Miami Beach NowM(>`reBealAd THIS IS YOUR 2018-2019 BUSINESS TAX RECEIPT. Important Reminders: Business Tax Receipts expire September 3(P of each year. You must submit all fees and documents (if applicable) prior to that date or you may be subject to delinquency fees, an additional Cost Collection Fee of $250.00, placement of a lien on the property, andlor involuntary shutdown of this business by the Police Department. You are required to notify the City, in writing, if there have been any changes in ownership, location, nature of business, any contact information, and/or when this business ceases operations. This is in order to ensure that you are not billed in error. Failure to notify this office of such changes may result in the assessment of penalty fees and collection activities. Have any more Questions? Our friendly staff is here to assist you by phone, (305) 948-2917, Monday -Friday from 8:30 am.- 5:00 p.m., or at our office Monday -Friday from 9:00 a.m.- 4:00 p.m. We would love to hear from you! *** THIS IS NOT A BILL — DO NOT PAY *** Please detach the below receipt and display in a conspicuous place. 2 018 - 2 019 City Of North Miami Beach Valid 0 9 / 3 0 / 2 019 BUSINESS TAX RECEIPT No.: 182627 - NEW Acct No: 796404 Taxes: 127.05 DBA: LINCOLN ELECTRICAL CONTRACTORINC Penalty Fee: 0.00 Location:2040 NE 163 ST 304B Credit: 0.00 NORTH MIAMI BEACH, FLORIDA TOTAL PAID:$ 127.05 ACtivity: OFFICE ONLY: CONTRACTOR This receipt is non -transferable without City approval and is only valid at the location(s) listed herein Remarks: -fW*'MWA Rk' li D� NowMorelieautidul! ACORD® 3'IFIATE OF LIABILITY INSURANCE DATE (MM)DDIYYYY) 07/26/2019 THIS CERTIPICATE?d ISWED AS.A MAtTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFffMAq�hrELY 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 endorsements . PRODUCER CON7 CT Robert Sistrunk Heart Of Florida Insurance Group/ Ocala FAX PHONE 352 394-4884 WC 352 394-1275 6027 SW 54th Street AIL Rob heartflorida.com INSURER 3 AFFORDING COVERAGE NAIC Suite 200 INSURERA: UNITED STATES LIABILITY INS Ocala FL 34471 INSURED INSURER S : Florida Citrus Business & Industries Fund 31259 INSURER C Lincoln Electrical Contractors INSURER 0 PO Box 611004 INSURER E : INSURER F: North Miami FL 33261 COVFRAnFR CFRTIFICATF Nt1MRFRR REVISION NIIMRFR: 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 TYPE OF INSURANCE ADDL SUSR POLICY NUMBER POLICY EFF POLICY EXP LIMBS A X COMMERCIAL GENERAL LIABILITY CLAIM&MADE I OCCUR 71 CL1724390A 10/12/2018 10/12/2019 EACH OCCURRENCE $ 1,000,000 _ DAMAGE TOR NTED PREMISES (Ea occurrence I $ 100,000 MED EXP (Any oneperson) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑- PE LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG s 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED r SCHEDULED AUTOS ONLY AUTOS __ HIRED t NON -OWNED AUTOS ONLY �_ AUTOS ONLY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ $ UMBRELLA LIAR EXCESS LLIAB HOCCUR - CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I X I RETENTION B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY �ICERIMEM ER EXCLUDED? ECUTIVE Y ] (Mandatory In NH) If yea, describe under DESCRIPTION OF OPERATIONS below NIA 10636041 04/01/2019 04/01/2020 I PER T ORTH- 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 I LOCATIONS I VEHICLES (ACORD 101, Additional Remafla Schedule, may be attached If more space Is required) Electrical Contractor Miami Shores Village Bldg Dept. 10050 NE 2nd Ave 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 Robert Sistrunk ©1988-2015 �CORD1CORPiRgATION. All rights reserved. AGOKD 25 (206/03) The ACOKD name and logo are registered marks ofJkCORV ;. Y .