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PL-10-534 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL C L Phone: (305)795 -2204 Fax: (305)756 -8972 I nspection Number: INSP- 139363 Permit Number: PL -3 -10 -534 Inspection Date: May 26 2010 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: PIPER, SHERYL & MARK Work Classification: Septic Job Address: 1311 NE 103 Street Miami Shores, FL 33138 - Phone Number Parcel Number 1132050300110 Project: <NONE> Contractor: CHAPMAN SEPTIC SERVICE, INC. Phone: (305)815 -9901 Building Department Comments Inspector Comments Passed a � Failed l Correction ❑ l Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. For Inspections please call: (305)762 -4949 May 26, 2010 Page 1 of 1 S I V f Miami Shores Village ' 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 „ Phone: (305)795 -2204 o A`PMVED oai a U61*41 W W I Expiration: 10/03/201 Project Address Parcel Number Applicant 1311 103 Street 1132050300110 Miami Shores, FL 33138- Block: Lot: SHERYL MARK PIPER Owner Informatio Address Phone Cell SHERYL & MARK PIPER 1311 103 Street MIAMI SHORES FL 33138 -2623 Contractor(s) Phone Cell Phone Valuation: $ 2,450.00 CHAPMAN SEPTIC SERVICE, INC. (305)815 -9901 Total Sq Feet: 0 Type of Work: NEW SEPTIC AND DRAINFIELD Available Inspections: Type of Piping: SEPTIC Inspection Type: Additional Info: PLUMBING HRS Approval Bond Return : Abandonment Classification: Residential Final Rough Landscaping Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 Invoice # PL -3 -10 -37441 Education Surcharge $0.60 04/06/2010 Check #: 13866 $ 257.80 $ 50.00 Permit Fee - Additions /Alterations $300.00 Scanning Fee $3.00 03/30/2010 Credit Card $ 50.00 $ 0.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Technology Fee $2.40 Total: $307.80 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 06, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy April 06, 2010 1 Mia i Shores Village Bui ding Department R a A 2010 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: I(305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 By-. ' `... " "•`•• «"' BUILDING Permit No. �c� --• PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: PLUMBIN k 1 ?Iilp Owner's Name (Fee Simple Titleholder) c {,(L Owner's Address City M4 AAA State Ti Zip S 3S Tenant/Lessee Name _ /u, Phone # Email Job Address (where the work is being done) F 1 q Q 3 $ City Miami Shores Village County iami -Dade Zip FOLIO/ PARCEL # 2 dZ D " DILD Is Building Historically Designated YES NO Flood Zone Contractor's Company ame G �� `�. -'Lcr Phone # Contractor's Address City r yb-b..t State T Zip 5 3 o— V �ii?j Qualifier Name Phone # i' W State Certificate or Registration No. 5 s l ` 110 Certificate of Competency No. Contact Phone E -mail Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ _ eI F Square / Linear Footage f Work: 3 Type of Work: ❑Addition ❑Alterati6n ew Repair/Replace ❑ Demolition Describe Work: wow L c4 3V�1 " a VU . �f"dFic�FellE ics�F 9�x�•k 9e�e *a &y �F *:t 9e 9e9e *F ees * nt *9: 9e *Y 9F 9eFrd: z0dc $R 9i; �t#:gep +` ° ",�� " ••> 3 Submitta t ee 4 xr -- et „4 =_, q ` WWI V* Notary $ Training /Edu4ation Fee $ Technology Fee $ c Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ QQ 1 See Reverse side —� Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Alla Mortgage Lender's Address City 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HERS, TANKS and 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. e Signature Signature caner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 90 day of K 20 , by .5)"+t" l �� day of t , 20!p by a,4k , who is p ersonally know to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: �U�P�4.�Gktril�E� Sign: yX).?.JQ a_. Print: Print: N Q n-x. 50, 0 A4n&l I MESA t4 My Commi _ • Nobxy Pubitc . My�1"Cg►�"'�"'�' • My Comm + V 1ja6t, CttNTREIL Eq►ires Jun 15.201$ NAVY PubWc - 8 of Waidat Commis :ion # 00 rMtT7�t �. Comm. Emm Jun 15, 2018 B TtuoubA APPROVED BY 7 37 7 � flans Examiner Zoning Engineer Clerk checked i . (Revised 07 /10 /07)(Revised 06/10/2009) ` PERMIT #: 13 -SC- 1127186 STATE OF FLORIDA APPLICATION C AP957802 •� ` DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: DOCUMENT #: PR803655 CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: Marck Piper PROPERTY ADDRESS: 1311 NE 103 St Miami, FL 33138 LOT: 2 BLOCK: 6 SUBDIVISION: PROPERTY ID #: 11- 3205- 030 -0110 [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 REQ FO DEVELO OF TH PROPE SYSTEM DESIGN AND SPECIFICATIONS T [ J GALLONS / GPD CAPACITY A [ ] GALLONS / GPD CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ ] SQUARE FEET SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: j ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] 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 FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ ] INCHES 0 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 T tank shall be filled with clean sand or other suitable material, and completely covered with soil. Have the system inspected H by the health department after it has been pumped and ruptured but before it is filled with sand and covered. E R SPECIFICATIONS PEDRO N TITLE: APPROVED : °` TITLE: " l'j Dade CHD dro N Ospina • --- DATE ISSUED: 03/24/2010 EXPIRATION DATE: 06/22/2010 DH 4016, 10/97 (Previous Editions May Be Used) Page 1 of 3 v 1.2,d AP957802 SE-1 FEMaKIx #: 93-5_ C 1427'181 AarM�LrcATIaN #- AP967798 STATE O71' 8'LORIDA DEPARTbZW OF HEALTH DATE PAID: ONSITE SEWAGE TREATI41017 AND DISPOS" FES PAID: 40 SYSTEM RECEIPT 4: n emmT #; PR003965 CONSTRUCT2ON PWWGT FOR: OSTDS Repair AM'LICAW: Marck Piper PROPERTY ADDRE93. 1311 NE 103 St Miami, FL 33138 LOT: 2 BLACK; 6 3=1VIS =ON: PROPERTY ID #: 11- 3205 - 030.0110 [SECTION, TOWNSHIP, RANGE, PARCBL NOMBER] [OR TAX ID NNUMAER] SYSTBMC MUST $E CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARD$ OF SECTION 361.0065, F.S., AMID C HAPTER 645 -6, F -A.C. DSPARTl4ENT A"WVAL OF SYSTEM DOES NOT GITARANTEE SATISFACTORY V%Kr0=1ANCE FOR ANY SPECIFIC PERIOD OF TTW. ANY CRAM IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR I99UANM OF THIS PZ MCIT, nQVnw THE APPLICANT TO NWIFY THE PX MCZT APPLICATION. SUCH MODIFICATIW9 MAY RESULT IN THIS PERMIT BESN6 MADE M= AND VOID. TOSIM NCE OF THIS PEOU DOES NOT EXEMPT THE APPLICANT FROM CCaMIANCE WITH OTIMIt FEDERAL, STATE, 01 LOCAL PERMITTMG REQUIRED FOR DL' LO"NT OF TRIS PROPERTY, SYSTEM! DEST011 AND SPECIFICATIONS T [ 900 ] GALLOMIS / GPD _ t PGInSr CAPACITY A [ 750 ] GALLON$ / 6Pn CAPACITY N t 0 ] CALLOUS GREASE INTERCEPTOR CAPACITY [MAXIMUMS CAPACITY SINGLE TANK -1230 CALLOUS] K [ ] GALLON DOOMNO TANK CAPACITY [ ]GALLONS 9 ]DOSES PER 24 HRS #PLWPA t ] D [ 200 ] SQUABS FEET SYBTEM R [ 200 ] SQUARE FEET SYSTEMS A TYPE SYSTEM; [x] STANDARD t ] FILLED t ] MOM t ] I COUBiGURATxO1V: [ ] TXWC1H tx] SED [ ] a F LOCATION OF BENCHMARK: F.F_I -.: 9.50' NGVD I ELEVATION OF PROPOSED SYSTEM SITE t 93.60 ] [ INCta7C9 FT ] [ KBO'S AAUMJ w=M16alAlc nnREUCffi POINT E BOTTOM OF DRAINFIELD TO HE [ 61.$0 ] E INCHES FT I ( ABOVE / � BENCHM WAIRZFERINC8 POINT L D FILL REQUIRED: [ 0.00 ] INCHES EXCAVATION' REQUIRED [ 40.00 ] INCHES O THIS PERMIT IS FOR SYSTEM # 1 ONLY. 1-- Install 900 gal. category-3 septic tank equipped with an approved filter. 2 -The licensed contractor Installing the system Is responsible for Installing the m)nlrnum category of tank In accordance with Sec. T 64E.8.01 3(3)(f . 3- Install 200 of of drainfleld in bad Configuration. 4 Install 12" of slightly limited soil under the bottom of 4 dralnfleld_ 5- Parameter of emvatlon area shall be at least 2 ft wider and longer the e p sorption bed. 6 -Invert ss $ elevation of drainfield to be no le than 4.86' NGVD. 7. Bottom of drain� n e le hen 4.36�lMRGVC6& System # 2 to remain. � tom" • �.'M R SPECIFICATIONS Mr: N OSPINA TLE: APPROVED B TSTL$: Dade CHD orptn. DATE IS 3/25/2010 EXPIRATION DATE: 06/23/2010 DH 4016, 7.0/97 (Pxwious Editi,ona May Be Used) nave I of 3 V 1.1,4 ARW70 szU1972 b00 /L000 xvi 80 :91 010VU/60 0912912010 04:27 3054539304 PAGE 01 • CHAPMA 5FPnC `7MVi(M, INC DATL- J c� C) W" Lao s m 'Ac2 3 64--' -' ("Y)6 Be cl m r y � WK } • t t - -777W 7 � . . . . . . . . . . . X FLOR11DA DEPARTIAM OF CERTIFICATE OF AUTHORIZATION J F, t t SEPTIC TANK CONTRACTING _T Yhe Florida Department of Health hereby certifies the business or entit� dP !" named below has satisfied the requirements of Part 111, Chapter 489, Florida Statutes, for septic tank contracting and has been duty authorized by the department to provide septic tank contracting services under the name of: R� CHAPMAN SEPTIC -SERVICE INC. ,�� 111R, SA0910574 March 11, 2W9 Mwch 31,2011 Auffiorizagon Number Date Issued Expiradon Date M Cherfie A= M Ylamonte Ros, MD., M, PH, N, Crist, Governor WHOM 1. W state surgeon Clenral l it- N � a A ; Z From:Nickie Freeman FaxID: Page 2 of 3 Date:3/29/2010 05:03 PM Page:2 of 3 Rp® CERTIFICATE OF LIABILITY INSURANCE OP ID NF DATE (MM /DD/YYYY) THIS CERTIFICATE IS ISSUED AS A CHAPM -1 03/29/10 PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Augustyniak Ins & Financial Sv HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 8652 State Road 70 E ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Bradenton FL 34202 Phone: 941 - 755 -9500 Fax: 941 - 753 -9472 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: NW Mutual Insurance Coapany 23787 INSURER B'. Cha man Septic Service, Inc. INSURER C: P . BOX 431911 INSURER D: Miami FL 33243 INSURER E: COVERAGES 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 SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLIY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE C (MM /DD/YYYY) DATE (MM /DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 77PR6926403003 08/04/09 08/04/10 PREMISES(Eaoccurence) $ 100,000 CLAIMS MADE F57'I OCCUR MEO EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER, PRODUCTS - COMP /OPAGG $2,000,000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) M AGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F1 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION _ AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER ANY PRO PR IETOR/PARTNER/EXECUT IVE[::] OFFICER /MEMBER EXCLUDED? E.L. EACH ACCIDENT $ (Mandatory In NH) If yes, describe under E.L. DISEASE - EA EMPLOYE $ SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Miami Shores Village IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Building Dept. REPRESENTATIVES. 10050 HE 2 Ave AUTHQ IZEDREPRES ATI M iami Shores FL 33138 ACORD 25 (2009101) d 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From:Nickie Freeman FaAD: Page 3 of 3 Date:3/29/2010 05:03 PM Page:3 of 3 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009101) 10/06/2010 22:24 3054539304 PAGE 02 MAR /30 /2010 /TUR 10:24 AM Contractors Payroll FAX Ne.2397686387 P.004 /005 A DIM CERTIFICATE OF LIABILITY INSURANCE AC10 i nt Risk C LLC 13008E13O81432E7 P RODUCE R THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION 14160 flalloc Da #5 kwa op ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE D as T8 7525d HOLDER, THIS CERTIFICATE DOES HOT AMEND, EXTEND OR Dl (200) 632 -5096 (972) 715 -0959 INSURERS AFFORDING COVERAGE INSURED; AMS 1 /C /f: INSURER A: p or, Property and Casualty i gsurance C=PHU tIPTIC suvics INC. 1N`�LIRER B: e080 NW 51ST T.A1Fr1WRRTT.T..'TT. 13391 INSURER C: 13051 661 - 0628 Fax: (305) 053 - 5537 INSURER D: INSURtR E; THE POLICIES OF INSURANCE METED BELOW NAYS BEEN IROUED TO THE M(BURED NAMED ASDYE FOR 71 POLICY PERIOD N06CATER NOTWRNSTAND)NO My REQUIREMENT, TERM OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT)FICATS MAY 6E ISSUED OR MAY PERTAW, THE 44AW -AME AFFORDED BY THE POLICIES DESCRIBED HERM IS SUBJECT TO ALL 7HE 7ERM6, EXCLUSIONS AND CONOTT10N9 OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAYS MN REOUreD BY PAID CLAIM& -W TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY E IRATE LINKS GGdGRAL LIARLITY EACH 2OCURA6,NCE S --• COMMERCIAL GENERAL LABILITY FFM aAMAOE (" Dne Fed) S CLAMS MAM [:] OCCUR MW E7(P (Anyone Amon) S PERSONAL &ADV WARTY 3 GENERALADOREOATE S GEN'L A.00REGATE LM I AMID Felt PPODUCT2 - COMR/OP AGO i POLICY LOC ALTTOMOBA,E L(A KJIY ANY ALMO COMBIVEO SINGLE LAATr Z ALL OWNED AUTOS . BODLY NINETY SCHEDULC-0AUTOS (Perpereon} _ HTReD AUT(Y BODILY P1URY I O JJAUTOS (PerM=Idera S PROPERTYDAMAGE S 9ARAGIELIAQILfn AUTO ONLY - EAACCOENr S ANY AUTO OTHER7HAN EAACC $ AUTO ONLY: EXCESS LIABILITY GWCH OCCURRENCE E OOOWi DCUUM3 MADE AC40REGATE $ S BLE z S WORKERS CDMPENSATIDNAND STATLL aftOYOWLIARAM wc?7779990901 0E /01 /2009 04/01/2010 �. .. A E.L. EACH ACCDEJT S 1000000 6.L DISEASE - EAEWLDYEE 3 1000000 [TIMER EL.0ISEa9E POuCYuwr S 1000000 LIMITS S LIMITS : DCEDRIPTION 01 0 "- PAtMOLOCAYgN6NENICLF ,61E7ttYD38]NS ADDED BY ENDORjWMENTISpr;a , PR,OWWNS 1. This certificate remains in effect, provided Che C??ien s acCOUx1t is 1xlt�ooci 3Candia� with ANS. Coverage is not pr0vi0.e6 for eaa�� for which the cient is not reporting wages o ATIa 2 p Insured 100% Of Wo F, to CHAR Ay S�P�IC SERVICE INC. Cffcctive 09/01/2009 for employees leased from AMs. p Employers is �.IT:y a4 A n;p PIrPlo under the policy C ADDITIONAL INSURED, INSURER LETTER: le-AN ELLAIM SHOULD ANY OF YHS NIOVe D9SOAMED POLICES SE CANCELLED SEFORE THE EXPIRATION DATE THEREOF. TIS ISSU N61NSURER MILL ENDEavOq TO LAB. 30 DAYS MWSTTM DIOCAMI ssoxr,5 YILDAGL NOTICE To THE CeRTNIGLTeH OWL%% MALED TO THE LEFT, OW FAILMETO DO $0 SHALL 2UT10lbG Din. IMPOSE NO QM.16ATIONOR LIASLITY OR ANY KWD UPON THE SV , ITS AM NTSOR 10050 V.S. 2nd Avis. REPRESENTATIVES, RTAHI SRO]=, FL 33138 AUTNORtaD Rl!PRtlSLINTATIY! AGORD 25-S (7/97j 0 ACORD CORPORATION 1888 Masser x FLI- 4 � ''- _� . MIN AN " R7 lru VMA gg t �e � <� r a pgq �.�.� '�a q 3 -� a� •✓ t