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MC-10-644Inspection Number: INSP- 140770 Scheduled Inspection Date: April 29, 2010 Inspector: Perez, JanPierre Owner: GREENWELL, JUDE Job Address: 36 NE 111 Street Project: <NONE> Miami Shores, FL Contractor: AFFORDABLE AIR & HEAT & ELECTRIC CONTRACTOR Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Permit Number: MC -4 -10 -644 Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1121360040040 Phone: 305 - 770 -4167 o4 Passed t Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments April 28, 2010 For Inspections please call: (305)762 - 4949 Page 12 of 22 Project Address 36 NE 111 Street Miami Shores, FL 1121360040040 Block: Lot: JUDE GREENWELL Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Address Parcel Number JUDE GREENWELL 36 NE 111 ST MIAMI SHORES FL 33161 -7047 Valuation: Total Sq Feet: $ 5,200.00 Contractor(s) Phone AFFORDABLE AIR & HEAT & ELECTR 305 - 770 -4167 Cell Phone Phone Tons: 3.5 Additional Info: AC REPLACEMENT Classification: Residential Approved: In Review Comments: Date Denied: Date Approved: : In Review Type of Work: MECHANICAL Fees Due CCF Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Submittal Fee Submittal Reversal Fee Technology Fee Total: Amount $3.60 $1.20 $205.97 $3.00 $50.00 ($50.00) $4.80 $218.57 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Pay Date Pay Type Invoice # MC -4-10 -37604 04/16/2010 Check #: 33287 04/21/2010 Check #: 8810 Amt Paid Amt Due $ 50.00 $ 168.57 $ 168.57 $ 0.00 Expiration: 10 /18/2010 Applicant 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 contractor to do the work stated. April 21, 2010 Date Cell Available Inspections: Inspection Type: Final April 21, 2010 1 BUILDING PERMIT APPLICATION FBC 2004 Permit Type: Mechanical ) Owner's Name (Fee Simple Titleholder) Jude t P rnAje/ r Phone # e Vele r 2/q4 Owner's Address 3 ' ��� /1 I Cit f ,0 o/' /OH. &J State -***" Zip /( / Phone # Tenant/Lessee Name E -MAIL: Miami Shores Village Building Department Job Address (where the work is being done) /I/ City Miami Shores Village County Miami -Dade l 2 * / 360 004000' FOLIO / PARCEL # Is Building Historically Designated YES NO V Contractor's Company Name k L rei-dt Air deaf Phone # Contractor's Address �J /V 6 I a,© 61 State City 17144114 Qualifier Name J oni P ( n Q /7 State Certificate o Registration N E -MAIL: TAnO Notary $ Scanning $ •0O Radon $ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795.2204 Fax: (305) 756.8972 Bond $ Code Enforcement $ Double Fee $ Permit No. in C 10 Master Permit No. �j 1 0777 94007 111 Certificate of Competency No. C ®v2") DPBR $ Zip Phone # Zip /0 pniEEVNIIT Att era..Wk L 2,',M Architect /Engineer's Name (if applicable) . s Phone # Value of Work For this Permit $ Square / Linear Footage Of Work: r' Type of Work: ['Addition ['Alteration ['New # ,Ef Repair/Replace ❑ Demolition Describe Work: io kid /ill acxxaYxxxxxxaYxxxxxxxx xxxxxxxxxxxxxx nYxxxxxF` S x xxxxxxxxxxxxxxxxxxxxxxxx**** *,,**xxxxxx xxxx Submittal Fee $ O,O Permit Fee $ / X ■ 0 t \ CCF $ 3,(p CO /CC Training /Education Fee $ . SO Technology Fee $ 9. Zoning $ Structural Review. $ Total Fee Now Due $ 1 (oS . S1 ----- See Reverse side --> 4w Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. l 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: 1 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 subj to attachm nt. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspectir hich occ ' seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not b . ;roved an rei pection fee will be charged. Signature The foregoing in day of Sign: Print: My Commission Expire x *x,Y,4 APPLICATION APPROVED BY: (Revised 02 /08/06) Owner or Agent ument was acknowledged before me this , 20 j ?by JLS6Z'€1/ , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: 4.01,t, B 00 # uolss1WWo3 ��°3`. C1OZ unp sarldx3 •ww03,Iyy i• �= E PlJald to a)elS - m°aru.�sjp„_._ '' ,e Signature Contractor The foregoing instrument was acknowledged before me this day of , 20 e by JO!) r/eres &' , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: IWWO3 ap`� V i�. � mg.; tuAt i;t#tlx3'Wwo3 EPlJ°Id to Gins 3p9n,ct F _ ***tiCI iwbw 15 3H1 °( "44 d',,,,: Sign: Print: My Corn x,kxxxxxxxxx Plans Examiner Engineer Zoning ITEM UNIT FEE ITEM UNIT FEE ITEM UNIT FEE BATH TUB SWITCH OUTLETS SPACE HEATERS DISHWASHER LIGHT OUTLETS CENTRAL HEATING //)k, DISPOSAL RECEPTACLES ' NC (WIND) FLOOR DRAIN SERVICE TEMPORARY NC (CENTRAL) . , Lj /2 / GREASE TRAP SERVICE SIZE IN AMPS DUCT WORK INTERCEPTOR SERVICE REPAIR/METER CHANGE REFRIGERATION LAVATORY APPLIANCE OUTLETS PROCESS AND PRESS PIPING LAUNDRY TRAY RANGE TOP UNDERGROUND TANKS CLOTHES WASHER OVEN ABOVE GROUND TANKS SHOWER WATER HEATER U.F. PRESSURE VESSELS SINK. POT /3 COMP. MOTORS 0 -1 HP STEAM BOILERS SINK, RESIDENCE. MOTORS OVER 1 -3 HP HOT WATER BOILERS SINK, SLOP. MOTORS OVER 3 -5 HP MECHANICAL VENTILATION TEMPORARY WATER CLOSET MOTORS OVER 5 -8 HP TRANSPORTING ASSEMBLIES URINAL MOTORS OVER 8 -10 HP ELEVATORS /ESCALATORS WATER CLOSET MOTORS OVER 10 -25 HP FIRE SPRINKLER SYSTEMS INDIRECT WASTES MOTORS OVER 25 -100 HP COOLING TOWERS WATER SUPPLY TO: MOTORS OVER 100 HP VIOLATION NC UNIT NC WINDOW REINSPECTION FIRE SPRINKLER AIR CONDITIONERS HEATER -NEW INST. STRIP HEATER HEATER - REPLACE GENERATORS TRANSFORMERS LAWN SPRINKLER -WELL GENERATORS TRANSFORMERS SWIMMING POOL GENERATORS TRANSFORMERS WATER SERVICE SPECIAL PURPOSE SEWER CONNECTIONS OUTLETS COMMERCIAL UTILITY -SEWER SIGN TUBES UTILITY - WATER SIGN TRANSFORMERS SEPTIC TANK SIGN TIME CLOCK RELAY FIXTURES FAINFIELD, 4" TILE/RES. ANTENNA PUMP & ABANDON SEPTIC TANK TELEVISION OUTLETS SOAKAGE PR CU. FT. VIOLATION CATCH BASIN REINSPECTION DISCHARGE WELL DOMESTIC WELL AREA DRAIN ROOF INLET ' SOLAR WATER HEATER FIRE STANDPIPE POOL PIPING LAWN SPRINKLER SYSTEM GAS RANGE METER SET (GAS) GAS PIPING AN APPLICATION FOR BUILDING PERMIT MUST ACCOMPANY THIS ADDENDUM. IF A MASTER PERMIT HAS BEEN OBTAINED, THE OWNER'S NOTARIZED SIGNATURE NEED NOT BE PRESENT ON SUBSEQUENT APPLICATIONS. PLEASE CIRCLE 0 DISCIPLINE APPLIED FOR: PLUMBING ADDENDUM TO BUILDING PERMIT APPLICATION ELECTRICAL PERMIT # WWW.ahridireclory.org This combination qualifies for a Federal Energy Efficiency Tax Credit when placed in service between Feb 17, 2009 and Dec 31, 2010. Certificate of Product Ratings AHRI Certified Reference Number: 3445037 Date: 4/15/2010 Product: Split System: Air - Cooled Condensing Unit, Coll with Blower Outdoor Unit Model Number: 4TTB4042E1 Indoor Unit Model Number: 4TEE3C04A1 Manufacturer: TRANE Trade /Brand name: XB14 Manufacturer responsible for the rating of this system combination is TRANE Rated as follows in accordance with AHRI Standard 210/240 -2006 for Unitary Air - Conditioning and Air - Source Heat Pump Equipment and subject to verification of rating accuracy by AHRI- sponsored, independent, third party testing: Cooling Capacity (Btuh): 40000 EER Rating (Cooling): 13.00 SEER Rating (Cooling): 16.00 A * following a rating indicates a voluntary rerate of previously published data unless_ accompanied with a WAS which indicates an involuntary rerate. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRI. This Certificate shall only be used for individual, personal and confidential reference purposes. The contents of this Certificate may not, in whole or in part, be reproduced; copied; disseminated; entered into a computer database; or otherwise utilized, in any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The information for the model cited on this certificate can be verified at www.ahridirectory.org, click on "Verify Certificate" link and enter the AHRI Certified Reference Number and the date on which the certificate was issued, which is listed above, and the Certificate No., which is listed below. $ up' Alr- Condltioning, H eati g, and A� fA `1 RefrIge Institute 2009 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 129158239039531014 Manufacturer: Permit Required? Yes ❑ No Permit Number City /County Issuing Permit , ,/ L "Mk li �7 (�,s Scheduled Inspection Datelr'vne . For further information in the event of problems call: The Home Depot Comfort Center, 888 - 523 -4822 or (Installation Professional's Phone #) 6 T 1'...a ndenser/Heat Pump #1 Model # .per l T 4 64-2- i coo [] ,„p Model # Serial # _om ermostat Model # ICC ) 14 . ar 20 ❑ Condenser/Heat Pump #2 Model # ❑ Air Cleaner Model # Serial # ❑ Humidifier Model # ,� Fu rnace /Air Handler #1 Model # �j, � "°A � �6® � 9 " Atpther �� Serial # Model # � TR `'t • 0 P i:.® ❑ Furnace/Air Handler #2 Model # ❑ Other Serial # Model # Permit/inspection Information: Permit Required? Yes ❑ No Permit Number City /County Issuing Permit , ,/ L "Mk li �7 (�,s Scheduled Inspection Datelr'vne . For further information in the event of problems call: The Home Depot Comfort Center, 888 - 523 -4822 or (Installation Professional's Phone #) Name J V F / e , C 1 2 . _ C . e l , V W Address , 9 t . 4 . . 1 \ 6 6 T 1'...a Phone Ws: Day , ,y Even em O 9 City, State, Zip tt,i, I _om Home Improvement Agreement: HVAC Installation The Installaticin Professional named below will furnish, install and service the equipment listed below at the price, terms and conditions as outlined on this form. Home Depot Information: 'Lead 0 1 � � 1�`� 4 4(x23 Store # THD Installer ft Customer Information: Equipment Information: (attach additional list of equipment if necessary) Provider ❑ Extended Service ❑ Home Depot ❑ Manufacturer Agreement Length 0 Year 010 Year ❑ 12 Year ❑ Other Type ❑ Complete System/Pkg Unit ❑ Accessory ❑ Condensing Unit ❑ Boiler LeVihz, NV-13 k c 47 (4 ❑ Furnace/Air Handler ,they Check all that apply: ❑ New Amp electric service /disconnect ❑ Clean work area to customers satisfaction 0 Complete system startup Notice of Cancellation form received: ❑ Remove existing equipment from premises ❑ 33 point installation audit Initial Termination clause reviewed: ❑ Other Prices quoted will be VALID for a period of 10 days from the proposal date of this contract. NOTICE TO OWNER: DO NOT SIGN THIS CONTRACT IF BLANK. YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME YOU SIGN. Total Investment $ - qg 5- ; 6,s5- *Total Amount $ Down Payment $ (Partial pay states only) Balance Due (upon finish date of installation) $ Payment Schedule; You agree that payments will be due as indicated below. If You are paying by credit, debit, or The Home Depot card, the account may be charged or debited (as applicable) on the same day that it is accepted by the THD Representative or Installation Professional. Initial Definhlons: "You "/'Your" means the customer identified above: "Installation" means the installation services specified in this Agreement. "Installation Professional" or "Professional' means an independent contractor authorized by Home Depot (licensed and insured as required by Home Depot and applicable law) and the contractor's employees, agents and subcontractors. "Agreement' means this Special Services/Home Improvement Agreement betweenYou and Home Depot U.S.A., Inc. (interchangeably referred to as "Home Depot "), which includes this page, the General Terms and Conditions following this page, the State Supplement, the Invoice or Specifications and any other documents expressly made a part of this Agreement Please see this Agreement's General Terms and Conditions for additional definitions. Acceptance and Authorization: By signing below,You authorize Home Depot to (a) arrange for Installation Professional to perform Installation and/or (b) order and arrange for the delivery of special order merchandise, including special order merchandise that may be custom made, as specified in this AgreementYou understand this Agreement constitutes the entire understanding between You and Home Depot and may only be amended by a Change Order signed by Home Depot (or by Installation Professional or its authorized representative on Home Depot's behalf) andYou.This Agreement expressly supersedes all prior written or verbal agreements or representations made by Home Depot, Installation Professional,You, or anyone else. Except as set forth in this Agreement, You agree there are no oral or written representations or inducements, express or implied, in any way conditioning this Agreement, and You expressly disclaim their existence. Do not sign if blank or incomplete. (Installation Professional's/permitting information may need to be provided toYou later.) By signing,You acknowledge that You have read, understand, and accept this Agreement in its entirety.You further acknowledge receiving a complete copy. Keep it to protect Your legal rights. DISTRIBUTION: White—Home Depot Copy Yellow— Customer Acceptance & Invoice Copy Pink— Installation Professional Copy Gold— Customer Proposal Copy HD-243 (8/6/09) . 04/21/2010 08:33 !.• - :4'1 • 6 /1 - _ ..• • SEE OTHER SIDE 3056548152 *kE •• • wvarzw-,-••—•;*• 4•;0$1■tga`:. ...p-...74--4•i%r...A14,.._•9 = ApFoRDA 4 - osofigpr - st$ .rt; mIAMX DO NOT FORWARD AFFORDABLE AIR & HEAT INC 515 NE 190 ST MIAMI FL 33179 kih Pa it 1 I 1 if I 1 1 y I h I RAW NsT• AsS .•7 54 - AFFORDABLE • ' ••••• •■•■ • • ••■, •••• • • • • ••• • • • • ••••••• ••••••• •••••• ■••. •••••• •••. •ii•PAii,■•:, t4. • . . I' Ez0f.:FLORIDA • , . Itc■N, • , . !- PRO.n.$8.10iSiAL REGtitaktiOiTi.. • ‘.•••• ,•*" . RVITalgEN.PING:•.. BOARD •••• 4: •.` • ''''‘. • ; • " • '• • • • . S L0808130421 . . • •;;;;;;1.7. • • : .• • \••••••• • • • • • . . • • '..•• • : f • PAGE 01 • Cif:ARLES ;i•W . ...DRAGO •.: ••••• ;-: ° • . • THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 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. AGGREGATE UMFTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR A INSRL TYPE OP INSURANCE POLICY NUMBER CPS1174416 DA TIVE 03/17/10 POLICYTION DATE 03/17/11 $ GENERALLIABIUTY X coMMERCULG,RNERALLIABILflYY EACH OCCURRENCE PISES ma EXP (Any one person) PERSONAL SADV INJURY GENERAL AGGREGATE PRODUCTS- COMP/OP AGO $ 1000000 $ 100000 S 5000 $ 1000000 $ 2000000 $ 2000000 CLAIMS MADE X OCCUR X BLANKET NOS GEMLAGGREOATE 7 LIMIT APPLIES PER: POLICY I J n LOC AUTOMOBILE ""�"`' _ - _ _ LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED COMBINED SINGLE LIMIT (ES =Went) S RY Pet person) EODILYINJURY (Per acc dent) , $ PROPERTY DAMAGE (Per ecclden° $ GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: A130 $ EXCESSNMBRELIA LIABILITY 7 OCCUR ❑ CLAMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS COMPENSATION AND EMPLOYER$' LIABILITY ANY PROPRETORMARTNER/EXECUTIVE OFFICERIMEMItSR ECCLUDED7 If Yee. desalt* under SPECIAL PROVISIONS below OTHER �y I TAY l MITE I I D ER E.L. EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES 1 ( EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS - CERTIFICATE HOLDER CANCELLATION - 04 City of Miami Shores Village 10050 M.E. 2nd Avenue Miami Shores FL 33138 ACORO 2N mnnvnet SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE HEREOF, THE I$SUINO INSURER WILL ENDEAVOR TO MAR 30 DAYS WRITTEN None TO THE CERTIFICATE BOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE ND OBUOATION Ok LIABILITY OF ANY FOND UPON THE INSURER. Ire AGENTS OR REPRESENTATIVES, AUTHORIZED ESENTA _ 04/21/2010 08:33 3056548152 AFFORDABLE PAGE 02 ACORD CERTIFICATE OF LIABILITY INSURANCE PRODUCER " ahn- Carlin 11 Company, Xnc. 350 S. Dixie Highway -- Miami FL 33133 - 9984 Phone :305 -4416 -2271 Fax :305 - 448 -3127 INSURED COVERAGES Affordable Air a Heati Inc. 515 NE pp 0 a Streeet i0 f�o Miami. FL 33179 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER k INSURER B: INSLIKeR G: INSURER D: INSURER E eeottednie ineuranas Camp DATE (MMIDD/T YY) 4 ATFO R 3 04/01/10 MC E ® ACORD CORPORATION 11188 ACORDTM CERTIFICATE OF LIABILITY INSURANCE PRODUCER Risk Transfer Programs, LLC 366- 481 -9363 219 East Livingston Street Orlando, FL 32801 A, 04/21/2010 08 :33 3056548152 AFFORDABLE PAGE 03 First Financial, Employee T.eaaing. Inc. Ph 94x -32s- 7143,0 B 00- 824- 7.805/3 X 941 -883 -5852 3745 Tamiami Trail Port Charlotte, FL 33952 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDI1JON 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 CONArONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R W 1 TYPE OF INSURANCE POUCY NUMBER mum* EFFECTIVE POLICY EZFIRATION _ RATE oswp4/yn DATE 041/1/001YY1 LIMITS OTHER GENERAL 1 ma0„ ry COMMERCIAL GENERAL LIABILITY CLAIMS MADE ® OCCUR OEM. AGGR ATh LIMIT APPLIES PER: POLICY J n LOC ADTOet0Sn.E UASO:JTY, ANY AUTO ALL OWNED AUTOS SCHEDULED Amos HIRED AUTOS NON - OWNED AUTOS GARAGE IJABIUTY H ANY AUTO EXCESSYUMSRFl I e•LJABILITY 0000R ® CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY pROPREETaWAIRUNERIEXECUTI OFFICER/MEMBER EXCLUDED? Er • o���� a y SF ECWL °Qm1KTNS below CERTIFICATE HOLDER City of Miami Shores Village 10050 PE 2 Ave Miami$Roree, FL 33$38 ACORD 25 (2001/08) W$LTHPE 000066 0a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL' DER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTERTHE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: STJA XII>avranco Company INSURER a INSURER C: INSURER D: INSURER E: 12/31/2009 CANCELLATION 0 I AUTHORIZED REPRESENTATIVE Page 1 of 1 40134 3&0H OCCURRENCE PREM ISES IE MED EXP (Any One pa eon) PERSONAL a ADY INJURY GENERAL AGGREGATE PRODUCTS - COMPIOP AGG COMBINED SINGLE LIMIT BODILY INJURY (P.Paeon) BODILY (Per =Went) PROPERTY DAMAGE (Persaddent) AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: AQP2OVXM EACH OCOURRENCE AGGREGATE EA ACC AGG 3 5 S 3 3 s ��7T1� p 5 • X ITORY IMIT3I I PR E.L EACH ACCIDENT 3 E L DISEASE - EA EMPLOYEE $ E.L. DISEASE • POLICY UMET 3 DATE(MMIDD'YYYY1 12/18/2009 NAIC # DESCRIPTION OF O?ERAnoNE / LocomoNS /muftis / E tc lUS10Na ADDED BY ENnQRSgVtRNT/ SPECIAL PPOVt8+oN5 Coverage is extended to the leased employees of alternate employer (Florida, Georgia and Texas Operations Only), Affordable Air B Heat Lac. {j 5205 (Effective 12.07.2006) PLEASE CALL FIRST FIN TCr,AL FOR AN UPDATED LIST of COVERED EMPLOYEES. 1 ,0 00 , 00 0 1,000,000 1,000,000 eNWLD ANY OPTIC ANOVE DEac R(ass POUSILO SE cANOELLED BEFORE THE EXPIRATION DATETHEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 35 DAYS WRITTEN NOTICETO THE CERTIFICATE HOLDER NAMED LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ® ACORD CORPORATION 1988