MC-11-1019Inspection Number: I NSP- 160628
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Permit Number: MC -6 -11 -1019
Scheduled Inspection Date: September 07, 2011
Inspector: Perez, JanPierre
Owner: , BARRY UNIVERSITY
Job Address: 11300 NE 2 Avenue LaVoie Hall
Miami Shores, FL 33138 -0000
Project BARRY UNIVERSITY
Contractor: WAYNE GROUP & SERVICES INC
Permit Type: Mechanical - Commercial
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1121360010160 -12
Phone: (954)242 -9806
Building Department Comments
CHANGE 6 RETURN AIR GRILLS
cze / 7/
Inspector Comments
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
September 06, 2011
For Inspections please call: (305)762 -4949
Page 3 of 19
Miami Shores Village
Building Department JUN o 3 1071
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING
PERMIT APPLICATION
FBC 20
eaveeemoo
Permit No. II °t9
Master Permit NoQC.. 0 011—
Permit Type: MECHANICAL
OWNER: Name (Fee Simpl e Titleholder):
� � � 1\ � � \J + l Phone#: 3 9 C1 5
Address: `` 30 0 62 CAU
city: `N \\CtviA state: 1, zip: 33i (0 l
Tenant/Lessee Name: Phone#.
Email:: yG C \\(\c‘'\ - U" i - -e C, u
JOB ADDRESS: \ 3 co N -
VD 14a. 2-0q
City: Miami Shores County: Miami Dade Zip: 3 316
1
Folio/Parcel #: \ 1 - 21 2i`P ' l . Q -
�
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: \ i3O V \ e ` O up - S e (vt i O one#:
Address: 2.- 6 -LA O McISLf T(1 V2' 31l0
City: - ' - l.CAUa Q✓ agile J State: L
Qualifier Name: \ 5 )Cty Vl 2 \-- Q� �. r t ,
State Certification or Registration #: (`,A('_ 0 f D (0 0 , Certificate of Competency #:
Contact Phone#: Sa -133- t'7 Email ,Mdress: 1 V t- nOn ' G e 1�:I e (Q ∎ ■CP S
''
DESIGNER: Architect/Engineer: 1 1CA � J ¥mil. S 1k t
Value of Work for this Permit: $ ( Square/Linear Footage of Work:
Type of Work: DAddress DAlteration/ , 1' ❑New _ ❑Repair/Replace ❑Demolition
Description of Work: ( j am \ (,� i ' ' (d (i�'(U [ (IS Co ( ( r \ 5
OLL -733 (ogS7
Zii 33 3 tl
Phone: `mot ‘C(-4 '` -1 3 3- (D S 57
Phone#:
****** * * ** * * ***** ********** ****** ** ** * Fees**** * ** * ***** ******** * * * **** * ****** *ease ** **
Submittal Fee $ Permit Fee $ 1 0 CCF $ CO /CC $
Sunning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
M
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. 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, HEATERS, 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 appri and a reinspection fee will be charged. / l'
Owner or Agent
The foregoing instrument was acknowledged before me this
day of �, ��i , 20 L , by C15- �ri�, ((ir ,
who is rsonally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Exp.
* * *** * * * * * * * * * * * * * * * * * ** * **
APPROVED BY
—
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of y, `'i : r , 20 I i , by L A/ AL U•e �' {' ,
to me or who has produced
as identification and who did take an oath.
NOTARY PUB
Sign: - ( {:
Print: °(A4 ;aaP ,^ Jonathan Cuesta
rry Commission Expires: ?.', q- COMMISSION #EE041198
%,�o�'�F EXPIRES: NOV. 09, 2014
,irmP www.AARONNOTARY.com
* * * * * * * * * * * * * * * * * * * * * *** **+A+N****N d+* ********** *M************ ******
Structural Review
(Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk
06/0312011 14:15 9542412586
EMERALD
DATE:
COMPANY:
ATTENTION OF:
TO FAX NUMBER:
FROM:
6/3/2019
EMERALD CONSTRUCTION PAGE 01105
(954) - 241 -2583
Fax (954) -241 -2586
1086 N. W. let Court. Hallandale Beach, FL. 33009
FACSIMILE TRANSMITTAL. SHEET
ARLENE
NUMBER OF PAGES INCLUDING COVER SHEET
RE:
MESSAGE: WAYNE GROUP LICENSE AND INSURANCE
IF YOU DID NOT RECEIVE ALL THE PAGES INDICATED ABOVE
OR HAVE ANY QUESTIONS PLEASE CONTACT (954) 241 -2583
1086 N. W. 1st Court, Hallandale Beach, FL. 33009.
06/03/2011 14:15 9542412586 EMERALD CONSTRUCTION
MAY 17,2011 08:39A
PAGE 02/05
Page 3
BR WARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. tli'eews Ave., fort. A -100, Ft. L audetdale, l=L 33301 -18$5 w 954831 -4000
VALID OCT013�R 1 2Q10 THttOUGH s333841-1489504-
EPTEMBER 30, 2011
DB : R.Ipt# 183 -1810
Bueltt�eef ; WAYNE GROUP & t38RVIGF� INC ilIOATI 0 /AxRCoatn=TIQN CONTRA.
t3ualness Typb.(AIR CONDITIONING CONTRACfT
Busltteas Opened :10 /09/2001
State&Corlrtty!Csrt/Rdg :CAC 058665
Exemption Co s :NONEXEMPT '•
Owner 1N LEBERT w HARVEY/013 L
gusktsg I, :2821 SOMERSET DR 316
FT LAUDERDALE
amines* Phan : 954 - 733 -6557
Rooms
Sub
E0102‘++
2
Mseranes Professionals
rerVaxace babe=
b s of Mil inlet{:
Vergll,B Typo.
Tax Amount
Tntn&ar Foe
NSF Fee
Penalty
Prior Yews
CallecVon Cost
Total Petri
27.00
0.00
0.00
0.00
0.00
0.00
27.00
THIS REC IPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS MOWS A AS RECEIPT This fax is levied fort the privilege of doing business taco 8roword County and 18
non regulatory In nature. You must meet all County and/or Municipality planning
MEN VALIDATE and zoning:equlremerbs. This Business Tax Receipt must be transferred when
Me business is sold, busineaa nsrrre has changed or you have moved the
buslne=a sacatiori. Thta Toesipt does Rot iodic/de that the business Is legal or that
It la in compliance with State or local !emend regulations.
Mailing Address:
MERRY W EARN
a821 SOMERSET
FT LAUDERDALE
Y /QUAL
DR #316
FL 33311
2010 - 2011
Receipt ttoia -09- 00036831
nod on/xi/2010 21.00
tlrAf&IS Aw ^WW1 al a∎m• ■ ■••■ d ■ ■1 Paul ♦!l• ^A * • * %r b"kAr+aw.•
EMERALD CONSTRUCTION
nbfb312011
MAY 17,2011 08 :39A
t.•. w�.aan. r: biAi✓.a� -air .. .s.Va►:inwT +.oViMlkY" '- +Tr+ir -n•-.• 7Jai•.•..��Lt.n -. �.r:� """'""••••••."- 4"•`.. ...r rat•YWZ�_ .i...y'M�,...�.....i ... �..LI'
STATE OF ��a�taA AC# 5020839
DEPARTMENT OF HU3INSSS AND
PROFESSIONAL REGULATION
CAC058665 :07/02,/10 100007295
CERTIFIED
LEE RT
WAYNE GR
•
COND CONTR
HARVEY
:tot . SERVICES INC
• 1 `
it •
;.'•��i. w0.
IS CERTIFiND uncle zts-- el- --c• e- Fo
axpi etion date * AUG 31 2012 L10010200609
06/03/2011 14 :15 9542412586 EMERALD CONSTRUCTION
MAY 17,2011 08:39A
CERTIFICATE OF LIABILITY' INSURANCE
PAGE 04/05
page 2
OAT!DANDOMYYH
5/16/201].
THISCEMIRCATEIBIBBUEDABAKIKTIW0PINFORM4TIONONLYANOccMymtstortioNTSUP0NTHECEIERFICAIRROLDOLTNI9
CERTIFICATE DOES NOT AFFIRMATIVELY OR NE ►TivalY AMEND EXTEND OR ALTER THE COVFRACS APFORDBD BY 'ME POLICIES
MARL THIS ceRVICAT S Of M1B)NRAMCE DOES NOT CON$TIiUTE A CONTRACT BETWEEN THE WING NG INSURER(S). AUTHORIZED
REPRESENTMIVQ OR PRODUCER AND THE CIRT54CATE HOLDER.
unifthecellikats •n ADD'RIONAL INSURED, IM A141HI9s1 nnaat bn o idossad. 11 SUEROt1ATION 15 WAIVED, subject
am tenna and goodie** MINN poMcy, estINN mamma may vegw. an mutemoment A statement an Vi5 ewuaead does not confer eg hts to 1119
oats cats WSW in you of age •MaISOrtioot($).
woman
George B. Odiorne Inpursnts Agency Xnc
50 Boa 830
Brandon, FL 33309
Bust Marlon
wee
Wayne Group A Services, Inc.
2305 1191 20th Street
Oakland Park
COVERAt4U
3Z, 33311
01:3).6. a - Ibk IB:3)iNi YOxi • H••
MIlOIMMDAPPORDAM COWAN
S,;Bt18INESB FIRST VMS CO.
.Maggitgl. . -. .
RIIU ERss
1301
MSURIER DC
2011
THIS IS
INDICATED
CERTIFICATE
EXCLUSIONS
TO CERTIFY THAT THE MUMS OF 1Naui:ANCB USTEO BELOW HAVE BEEN
NOTWMTHSTANDtNO ANY REQUIREMENT, TERM OR CONDITION OF ANY
MAY SE IMMO OR MAY PERTAIN, THE INSURANCE AFFORDED BY
AND CONDITIONS OF &JOH POUGFB. LINTS SHOWN MAY HAVE BEEN
ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
CONTRACT OR OTHER RQGUMH3,IT YATH RESPECT TO NCH THIS
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU. THE TERMS,
REDUCED BY PAID CLAW&
MIR
�"'
TYP'EOF�IeAsce
T"+1
..
,+ i
EIC
L_ _.J2.1,!
Eii
- _,!_':11111
OALI:At1T.11V
CVIAE7iCIAL GC
�'i r' • ' • '
..wi...w�w.....�
...-
GLAIMIMMORPTIt=
Hlp,.EI(P prone Paten)
$
■
GEM
-
`P €REGNA1 _$ADVKURT
GOMM AQir1,M,�,aAtt
1
AGG LR9
REEOETAPPI SMIR.
IDIOCY `e • •
PRODUCTS- • ' - • AGG
$
5
APJTONIMIA
w
C
UA UTY
At1YAUlO
411. OAK° AUTOS
SCHEDULE AUTOS
MUD AUTOS
NONUWYNEDAUTOS
as MALE Miff
&
8OOILY ROW OtespwlIm)
t
MOLLY Y UUR V (ear
S
(Paraaidegal
.... __-
a
a
DMERr1LAIMS
E CUS LTA!
—
' COCUR
Mal T310E
$
AGGREGATE
$
„a,
N
A
MIDENNAMMIWWWwW ��® (OILoEO
dim
....13... 1-_-.1. .3.: =:
NIA
10.110515
iO /I$ /solo
10/13/2011
Y riClU -'WS.I a-
E.L 11 A D[M
,,.
9G O
EL .' = - - .•IAN :.
..049• GOO,
1 , . . i r
.L OI8EAU •POUCV UMtT
OESCRIPTION OPOPERATIONS400AT)Oltstlq MOM M OROlas,
/ygA.b
Ynonfaeelamaw/
PIIVUO a ynagrouptier'vi os$ .0
mind Scores, Village Boll
Acildin? Depetteent
10050 NZ 2nd Avenue
Mani Shores, 'FL 33139
v-vs , .,............ - -
MOULD ANY OF THE ABODE efc) POLICIES as CANCELUDI EI
rei IAPI1MTIDN DATC YNHt5OP, *DUCE WILL BE af$VERID IN
ACCORDANCE l$TII nfE POLICY PROVL�ONS.
AUpi0I1®)!lPR1ElB/TATN!
• a
.•-•=2 y: ':= -•'',' S
Ni ek D►Batltis (C) tag _ — —
ACORD 1'!i (2 YIDD;
QNB02600aeo/)
oa9 ORD CORPORATION. A
The ACORD name and tee em registered marks ISDI! iih11H r9D8tYgd
06/03/2011 14:15 9542412586
Liceosee Details
Licensee Information
Name:
Main Address:
County:
License Mailing:
LicenseLocation :
County:
License Information
License Type:
Rank:
License Number:
Status:
Licensure Date:
Expires:
Special Qualifications
Class A
Construction Business
EMERALD CONSTRUCTION
LEBERT, WAYNE HARVEY (Primary Name)
WAYNE GROUP & SERVICES INC (DIM Nam)
2821 SOMERSET DRIVE
FT. LAUDERDALE Florida 33311
BROWARD
2821 SOMERSET DRIVE
FT. LAUDERDALE FL 33311
BROWARD
Certified Air Conditioning Contractor
Cert Alr
CAC058665
Current,Active
09/22/2001
08/31/2012
Qualification Effective
02/20/2004
View Related License Information
View License Complaint
PAGE 05/05
1:89:27 PM 10/1512010
1 Terms of Use I 1 Privacy Statement 1
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. I/ COPY OF QUALIFIER'S STATE LIC CARD
B. t, COPY OF LOCAL BUSINESS TAX RECEIPT
C. ✓ OPY 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
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME: 1_ .e
BUSINESS ADDRESS: 2,8 £,ws97& CITY -frinta,0 erl-IJ,
STATE Fie" ZIP CODE 3 I /
BUSINESS PHONE: ( q.5z4 Z,Li iB6.6, FAX NUMBER (G ). 73? �` 7
CELL PHONE (_ QUALIFIER'S NAME: Li tO/ /`42Ji
QUALIFIER'S LIC NUMBER: C® In 6 "3
E -MAIL ADDRESS (IF APPLICABLE):
Created on 3119109 BY MLDV I RV 3126109 MLDV
AC # #()08
STATE OF FLORIDA
DEPARTMENT STRUcTIoNEINDuSTRY LICENSINGLBOA REGULATION
100007295 CAC058665
The CLASS A AIR CONDITIONING CQNTRACTOR
Named below 1S CERTIFIED
Under the provisions of Chapt n'489' FE.
Expiration date: AUG 31, 2012
LEBERT, WAYNE HARVEY
WAYNE GROUP & SERVICES INC
2 821 SOMERSET. DRIVE
FT. LAUDERDALE P .3.33 .1
CHARLIE RIST
GOVERNOR •
tiAY AS REQUIRED BY LAW
CHARLIE LIEN
INTERIM SECRETARY
JUL 21,2011 12:32A
- •
1
502E 8 9
!:3
STATE OF FLORIDA AC,/
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
CAC058665 07/02/10 100007295
CERTIFIED
LEBERT,
WAYNE GR
IS CERTI
COM CONTR
HARVEY
SERVICES INC
Ull r 489 FS
impiratio.n date; AUG 31 2012 L10070200609
JUL 21,2011 12:20A
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000
VALID OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011
DBA:
Business Name: WAYNE GROUP & SERVICES INC
er Name:LEBBRT W HARVEY /QUAL
Busts Location: 2821 SOMERSET DR 316
PT LAUDERDALE
BU !new Phone: 954-733-6557
ROM*
Saab
Employees
2
page 1
Receipt #:183-1810
Business Tyfpe'HEATht /RIRCONDITIDN CONTRACTR
(AIR CONDITIONING CONTRACTOR)
Business Opened:/ 0/09 /2 001
Stater-au nty/CertiRemmC 05B665
Exemption Code:NONExEMPT
Machines Professionals
For Vending Bioko** On*
Number of itachinaa:
Tee
Amount
27.00
Transfer Fee
0.00
NSF Fee
0.00
Penalty
Prior Years
Collection Coat
Total Paid
0.00
0.00
0.00
27.00
THI
Wit
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
BECOMES A TAX RECEIPT
VALIDATED
Math , Address:
LFI:RT W HARVEY /QUAL
282 SOMERSET DR #316
FT t UDERDALE, PL 33311
This tax Is levied for the privilege of doing business within Broward County and is
non - regulatory In nature You must meet all County and/or Municipality planning
and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business Iocatlon. This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations,
2010 - 2011
tteeeipt #019 -09. 00026634
Paid 08/17/2010 27.00
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave„ Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000
VAUD OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011
DBA:
8 Iness Name: WAYNE GROUP S. SERVICES
r Name: LEEER.T W IWtVEY /Qu ,L
Susie , Location: 2821 SOMERSET DR 316
rr LAUDERDALE
11099 Phone: 954 - 733 -6557
Rooms
SIgnatu
•
INC
Employees
2
Receipt #: 183 -1810
Business Type: HEATING /AYRC:ONVITION CONTRACTR
(AIR CONDITIONINd CONTRACTOR)
Business Opened:10 /09/2001
State/County/Cert/Reg:CAC 058665
Exemption Code:NONEXEmPT
For %Wine 9u$lneas Only
Machines
•
Professionals
Ta
Amount
Transfer Fee
NSF Fee
Penalty
Prior Years
-
Collection Coat
Total Paid
27.00
0.00
0.00
0.00
0.00
0.00
27.00
Receipt #018 -09- 00026634
Paid 08/17/2010 27.00
AR °® CERTIFICATE OF LIABILITY INSURANCE
I ;�22�2" INYT ')
THIS CERTIFICATE 15 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 ADDRIONAL INSURED, the policy() must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certaln 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
Stirling Insurance Services, Inc.
1700 North Dixie Highway
Suite 109
Boca Raton FL 33432
Ca RACT Nicole Rudman
INC No. emit (561) 338 -3030 1 T. Noh (561) 338 -3055
AEODRP„ ss ;ramdeenl @stirlingfinancial.com
INSURERS) AFFORDING COVERAGE
NAIC #
DIBuRERAtationwide Mutual Insurance
23787N
INSURED
Wayne Group 5 Services, Inc.
2821 Somerset Drive
11316
Fort Lauderdale FL 33311
INSURERB 4ationwide Mutual Fire
23779N
INSURER C :
10/11/2011
INSURER D :
$ 1,000,000
INSURER E :
$ 100,000
INSURER F :
172201309
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE USTED 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 POUCIES UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OP INSURANCE
ADD'
INSR
SUBR
MD
POLICY NUMBER
POLIC�ryY EFF
(MMIDDIYYYYI
PO CY EXP
GAIMINVYYY1
LIMITS
A
GENERAL
X
UA60.1TY
COMMERCIAL GENERAL LIABILITY
77103858833001
10/11/2010
10/11/2011
EACH OCCURRENCE
$ 1,000,000
PREMI8ES /EaENTocamence)
MED EXP (Any one )
$ 100,000
$ 10,000
1 CLAIMS -MADE X OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP AGG
$ 1,000,000
GEML AGGREGATE UMIT APPLIES PER:
�
T1 1 POUCY 1 GI I IE8- -I
I I LOC
$
AUTOMOBILE
_
_
_
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
SCHEDULED
AUTOS
NON-OWNED
INd D SINGLE OMIT
COMBBIE
BODILY INJURY (Per pineal)
$
BODILY INJURY (Pera:ddent)
$
PROPERTY DAMAGE
PROPERTY
accident)
$
$
B
X
UMBRELLA UAB
EXCESS UAB
X
OCCUR
CLAIMS -MADE
7701385883300
10/11/2010
10/11/2011
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
$
DED 1 1 RETENTION $
WORKERS COMPENSATION
AND EMPLOYERS' IIABRnY
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If ea describe under
DESCRIPTION OF OPERATIONS below
NIA
I TORY STATU- I I OT ER
E.L EACH ACCIDENT
$
EL DISEASE - EA EMPLOYEE
$
EL DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, 8 mare space Is required)
(305)
756 -9972
Miami Shores Village
Building Department
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.
Alrn(ORS:EDREPRESENTATIVE
Cheryl Fong /FONGC 'te' "'..--•
ACORD 25 (2010105)
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Date: 7/21/2011 Time: 4:58 PK To: 9542412586 Odiorne Insurance Page: 02
A`C,,o, R°f CERTIFICATE OF LIABILITY INSURANCE
7/21/201rc1
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(les) must 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
George H. Odiorne Insurance Agency Inc
PO Box 830
Brandon, FL 33509
SUSi Marlow
CONTACT
NAME:
RCN `E (813) 685 -7731 (AA/C, No): (813) 685 -1823
EMAIL
ADDRESS:
CUSR
CUSTOM
MERIDa:
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURED
Wayne Group & Services, Inc.
2305 NW 30th Street
Oakland Park FL 33311
INSURER A :BUSINESS FIRST INS CO.
OCCUR
INSURER B :
INSURER C:
INSURER D:
EACH OCCURRENCE
INSURER E :
DAMAGETO
PREMISES (Ea occurrence)
INSURER F :
COVERAGES
CERTIFICATE NUMBER 2010 -2011
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
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
MD
POLICY NUMBER
POLICY EFF
(MMIDDJYYYY)
POLICY EXP
(MMIDDMYYY)
LIMITS
GENERAL
LIABILITY
COMMERCIAL GENERAL
LIABILITY
OCCUR
EACH OCCURRENCE
$
DAMAGETO
PREMISES (Ea occurrence)
$
CLAIMS-MADE
MED EXP Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
GENt AGGREGATE LIMIT APPLIES PER
POLICY PRO-
JECT n LOC
PRODUCTS - COMP/OP AGG
$
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
COMBINED SINGLE LIMB
(Ea accident)
$
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
UMBRELLA LIAB
EXCESS LIAB
_
OCCUR
CLAIMS-MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION $
$
$
A
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
521.04595
10/13/2010
10/13 /2011
Y WC STATU- OTH-
ORY LIMITS ER
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
E.L. DISEASE - POLICY LIMIT
$ 500,000
DESCRIPTION OF OPERATIONS! LOCATIONS t VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
E
ON
Miami Shores Village
Building Dept
10050 NE 2nd Avenue
Miami ShoresVillage, 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
Nick DeSantis (C) /SHM -- --
-
- " — • - - - .— -
ACORD 25 (2009109)
INS025 (200909)
O 1988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
MIAMI -DADE
COUNTY
Building
Herbert S. Saffir Permitting and Inspection Center
11805 SW 26th Street
Miami, Florida 33175 -2474
786 -315 -2100
UESTED REVIEWS
❑ A L ❑ BLDG Li DERM ❑ ELEC ❑ ENRG ❑ FIRE
❑ HCAP ❑ LANDSCAPING ❑ MECH ❑ PLUM ❑ PWKS ❑ PWCC
❑ ROOF ❑ SIGN ❑ STRU LI ZNPR
❑ PERMIT BY AFFIDAVIT CHECK ❑ SHORT TERM EVENT AFFIDAVIT CHECK ❑ OPTIONAL PLAN REVIEW
U BLDG 0 ELEC UMECH 0 PLUM 0 STRU
miamidade.gov
Dear Applicant:
Please complete the following information for notification on the status of your plans.
Applicant's First Name: (PRINT CLEARLY) /2,„,_, 41 Last Name: (PRINT CLEARLY))
Cellular Number: 7 J ( (/ ?
Office/Home Number:
EMAIL Address:
Comments:
(i)cle7;U-r(
NOTE: IF AN EMAIL ADDRESS WAS PROVIDED YOU WILL BE NOTIFIED VIA EMAIL AND /OR AUTOMATIC
TELEPHONE CALL CONCERNING THE STATUS OF YOUR PLANS
-FOR OFFICE USE ONLY-
TO BE COMPLETED BY BUILDING AND OCCUPANCY REPRESENTATIVE OR PLANS PROCESSING TECHNICIAN:
Application Date: / / Clerk Name: Arrival Time:
Process No(s):
/ /
/ /
❑ Walk -Thru LI Drop -Off ❑ Rework ❑ Re -Issue
❑ Residential ❑ Commercial ❑ Plan Revision ❑ Shop Drawing
TO BE COMPLETED BY PLANS PROCESSING TECHNICIANS:
BLDG OA OD UN HCAP OA ODON ROOF OA CID UN
DERM OA OD UN
ELEC OA OD ON
ENRG OA OD ON
LAND OA OD ON
MECH OA OD ON
PLUM OA CID UN
SIGN OA OD QN
STRU OA OD ON
ZNPR OA CID QN
Customer Notified By: Date: / / Time:
123_01- 117 6/06