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Name of Company or Corporation ,v C.
Nature of Business (flv,ih' eAl
Sworn to and Subscribed Before me
NOTARY PUI3LIC - State of Florida
My Commission Expires
Notary Public State of Florida at Largd
My Commission Expires Jan. 5, 1973.
APPLICATION FOR C0NTILACTOR' S LICENSE
MIAMI SHORES 'VILLAGE
FLORIDA
Address a // W ? 155T ,a,,,c7i,i i .5 e, Ac; Y Street No, or P. 0. I3ox City
Name of Owner 0, d R- / -e
( If a firm, the names of all members of the firm; if a co rporati on, the
names of all officers of the corporation,)
Names and Numbers Employees (fasters and Journeymen):
License Number other ilunicipalities: X0
References: C.,., c /f/-/ gm/.A e, / / ty,t4
( Signed)
Date � � , 3 //7/
Phone
Phone
7 /7,
Name and Amounts Insurance Carried: C e l c-.
; 4 �
__ Jilt 4.A at,rb::�;R:.ba4.t.ay yat: at..@ a4 a n a�:a@ at.at.. 4.�aat.a 2at.g" ' 4: • • , 6 . , : a 4, : • . -5 4. - ! . a : d : a : �: 4 .:a:. � �. - a., 1 � �:� t�s .
(` - .liT n n n n n C n r n n a n n n n n n n n n a? .:1 q n n ' n n n n ' n n a n n n1 n n • ' n n In H I q1 /n 1.
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4e THIS IS TO CERTIFY that the described policies, covering in accordance with the terms thereof, are in force as of the date hereof:
#
40•
�a•
v;G•
;
4G•
40
COVERAGE
# Workmen's
4,G•
4,G* Compensation
.x Employer's
?,c' Liability
• Comprehensive
4,a
4c. General.
.? Liability
c eluding
c Products
43t eluding
• Completed
$,G Operations
3G
'3 Comprehensive
410 •
Automobile
. ,a• Liability
+ells•
410 Excess/Umbrella
'4 Liability
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*
v :G
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Vie•
4j;G*
' gd G.
.K
7 -70
Salmi
SIM/I/
1.111
Insured:
COMPANY AND !EXPIRATION
POLICY NO. DATE
Statutory
Each Accident $ 100,000'
Each Person $
Each Occurrence $
Aggregate $
Aggregate $
EMPLOYERS
COMMERCIAL
UNION
#G 05 71 11
5/15/72
LIMITS OF L
Bodily Injury
Each Person $
Each Occurrence $
Combined Single Limit $
This Certificate is issued
Address
Dated 9/29/71 skc
Certificate of nsuranc e
BAILEY BROS., INC.
c/o W.D. Bailey
9818 N.W. 1st Avenue
Miami Shores, Florida
BUILDING DEPT. OF MIAMI SHORES
ATTN: MR, BRADFORD
MIAMI SHORES CITY HALL
MIAMI SHORES, FLORIDA
By
IABILITY
Aggregate
�Lr V 0 V V V V V V v 1 o V' 0 V V 1 V V V V V 1:1 ) 'V V V V V V V V V V V V V V V V V v
L N� '�' Y NC Y vi` 'r V .,' 4 'JFN� pf' N` V Ne 9c .� ¥ N•'r 4 'IVY 'IVY i�c IVY ye i .� ��� i so 1.
Property Damage
Nil
Nil
Each Occurrence $
Aggregate $
Each Occurrence $
4,a•
`3c
mac•
.
41c• This document is furnished for information only. It does not provide or convey any insurance. Unless specified hereon its
46• issuance does not make the person or organization to whom it is issued an additional insured under any policy of insur-
ance. It neither affirmatively nor negatively amends, extends or alters the coverage afforded by the contract of insurance
between the insured and any Company. Amendment, extension or change of such contract can only be effected by endorse-
ment issued by the Company and attached thereto.
Should any above described policy be cancelled, the Company issuing said policy will make all reasonable effort to give
notice to the holder of this document, at the address shown herein, but failure to give such notice shall impose no obli-
gation of any kind upon the Company or the undersigned.
.ego
.p;a•
#0.
PARK CO. OF FLORIDA, INC Agents
aib t� 41.A dss$sab_ �: : .? I' I` :'? 1 ' ' ? ? '? a - l' at 1, 4 "A '? '? .t. -..'7!z'.'-'?...?. t..tt I a . t . at. a ? ' ? . a, • :PIA 1 ,..1, -4, .A. .o.... A . _ ; �: •. 4....0,:, •s AAA 4. '''' .. vr
�• 7,-:".',1`: /p n T n s n n n n? m n n n n n n n n n n a? n n n n n n a n n n n n .0 n n � a n 'n n �� e n n T m n , 7.
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Alf,\ '4
lll1%• •ate
SININI Certificate of insurance . °'
4,e. •,r
4
'fie .*
ae. THIS IS TO CERTIFY that the described policies, covering in accordance with the terms thereof, are in force as of the date hereof: .
4 .4
40. .
40- BAILEY BROS., INC. •4
e Insured:
� � : c W.D. Bailey •
40. 9818 N.W. 1st Avenue
•,r
4e. Miami Shores, Florida •
4,e .?r
40 f LIMITS OF LIABILITY .
Property Damage .011.
.age.
Nil .a..
•4
•a1,f.
.4
NII •a '
•o
Each Occurrence $ 50,000 .a .
.4
Aggregate $ 50,000 .a
•ag.
Aggregate $ 50,000 . a.
.4
Each Occurrence $
a
.4
.4
.4
1c.. .4
4
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4e a
fie. • . a,(.
e
.3e COVERAGE
3e
• Workmen's
die
4e. Compensation
4 Employers
4,0. Liability
.3e. Comprehensive
3e
;e General-
.fie. Liability
4e• IN eluding
.,e Products
.4( IN eluding
'e Completed
4,0 Operations
e•
4 1 e ' Comprehensive
4a . Automobile
.30. Liability
.fie.
A,. Excess/Umbrella
*4 Liability
COMPANY AND
POLICY NO.
CENTENNIAL
INSURANCE
COMPANY
464 01 18 89
EXPIRATION,
DATE
2/23/72
Bodily Injury
Each Accident $
Statutory
Each Person
Each Occurrence $
Aggregate $
Aggregate
100,000
300,000
300,000
$ 300,000
Each Person
$
Each Occurrence $
Combined Single Limit $
This Certificate is issued
Address
BUILDING DEPT. OF MIAMI SHORES
ATTN: MR. BRADFORD
MIAMI SHORES CITY HALL
MIAMI SHORES, FLORIDA
.y
`„c. This document is furnished for information only. It does not provide or convey any insurance. Unless specified hereon its
4:e• issuance does not make the person or organization to whom it is issued an additional insured under any policy of insur-
e. ance. It neither affirmatively nor negatively amends, extends or alters the coverage afforded by the contract of insurance
4°' between the insured and any Company. Amendment, extension or change of such contract can only be effected by endorse-
e' ment issued by the Company and attached thereto.
.e.
4
4!e•
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40'
4e ,�D.��
410. By • , .C���
40• Dated 10/1/71 skc
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7 -70
Should any above described policy be cancelled, the Company issuing said policy will make all reasonable effort to give
notice to the holder of this document, at the address shown herein, but failure to give such notice shall impose no obli-
gation of any kind upon the Company or the undersigned.
PARKE
FLORIDA, INC.,
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