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RF-11-1169Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 163326 Permit Number: RF -6 -11 -1169 Scheduled Inspection Date: December 14, 2011 Inspector: Bruhn, Norman Owner: PLATON, MELETIOS Job Address: 1450 NE 103 Street Miami Shores, FL Project: <NONE> Contractor: CG CHASE CONSTRUCTION MANAGMENT INC Permit Type: Roof Inspection Type: Final Work Classification: Hurricane Mitigation Phone Number (305)513 -6347 Parcel Number 1132050310040 Phone: (305)644 -4461 Building Department Comments ADD STRAPS TO TRUSSES TO WALL CONNECTION TO BRING ROOF IN COMPLIANCE WITH ROOF MITIGATION Passed Failed lot /6 -f( Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP - 161449. NO ONE HOME. NO PERMIT. JR Cc-- December 13, 2011 For Inspections please call: (305)762 -4949 Page 9 of 53 A 1'CONSULTING ENGINEERS, INC. ROOF STRUCTURES CONSULTING UPLIFT TEST EXPERTS LAB CERTIFICATION No. 01- 1224 -5 4383 SW 70 C. Miami, Florida 33155 TEL. 305 -740 -9550 FAX 305- 740 -9550 Miami, December 09/2011 To: City of Miami Shores Building Department Ref: A.C.N. Roofing, LLC. 128 SW 84 Ave. Rd. 2nd fl. Miami, Fl. 33156 Job Site: 1450 NE 103 Street Miami Shores, Fl AFFIDAVIT: INSPECTION ROOF TRUSSES Dear Building Inspector: 1, Jose A. Martinez, P.E., performed de following Inspection on the roof framing and roof framing anchors at above referenced location, and hereby certify that the roof framing was conventional wood joist spaced approximately at 24" on center. The Inspection revealed that the straps were installed with a minimum of 6 -8 nails per straps, in accordance with the Florida Building Commission by rule 9B- 34.047 F.A.C. This report is b o r 'limited visual review of existing structural components. (Attached P i ent Jo A. Martinez, P.E. Pit Name License Number. P.E. # 21522 STATE OF FLORIDA — COUNTY OF MIAMI DADE Sworn to and subscribed before me this December, 09/2011 / Personal known or Produce Identification • DA , RIS RUIZ MY C • MISSION # EE048214 .a;,; '•' EXPIRES App 05,2015 (407 39aoi53 Merida . = rv+ca.com i 1 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795 -2204 Parcel Number Applicant 1450 NE 103 Street Miami Shores, FL 1132050310040 Block: Lot: MELETIOS PLATON Owner Information Address Phone Cell MELETIOS PLATON 1450 NE 103 Street MIAMI SHORES FL 33138- (305)513 -6347 Contractor(s) Phone CG CHASE CONSTRUCTION MANAGII (305)6444461 CeII Phone Type of Work: Hurricane Mitigation Additional Info: Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Repairs Scanning Fee Technology Fee Total: Amount $2.40 $2.00 $2.00 $0.80 $111.00 $3.00 $3.20 $124.40 Pay Date Pay Type Amt Paid Amt Due Invoice # RF -6 -11 -41317 07/07/2011 Check #: 2446 $ 124.40 $ 0.00 Available Inspections: Inspection Type: Final PE Certification Letter 1 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. Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy July 07, 2011 Date July 07, 2011 1 Miami Shores Village Building Department 90050 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 Permit Typr BUILDINGG ROOFING k OWNER: Name (Fee Simple Titleholder): b j74411.4.)/0 Address: K-/ SD A) A- /d 3 57' ,44N,' re. City: RA /4 YLt / State: /�. Zip: Tenant/Lessee Name: Phone #: Email: Permit No. Master Permit No. JUN 2 8 2011 BY Phone #: JOB ADDRESS: /G/ S U /() /-v /03 ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes NO %X Flood Zone: CONTRACTOR: Company Name: C- 4- C I'st CONS jlev(i'11o,.d 114 4M T. r ) l✓C Phone #: 3 DC. !o `f f.- Y Address: 1 Z X10 S SW W/ Ave r City: M (A )*1 ( State: 'f=L Zip:. %/ S' 6 Qualifier Name: 3-43°A) C-14-AS e Phone #: 3 05 1, Si'F - '116_ State Certification or Registration #: QC- / CO 7 Z 3 2 Certificate of Competency #: Contact Phone #: 3 6 � ``f`F - ''/Y6 / Email Address: JG Ff AS c e GH-A-s E C iy . co/14 DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ s) 70O Square/Linear Footage of Work: tL 4 Deficriptib�gb'#�Wdi�1E / ion ONew pair/Replace ODemOtion 12A`J,S 7d %/L-45S % GO.4 LL (v cjd 1ic,4) ***** * * * * ******** ******>K*********>k>x **** Fees*********> k****** * *** * ** ****** ** *>K> *** * **x *** Submittal Fee $ Permit Fee $ / / / CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 12 -1 • LII! 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. 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 approved and a reinspection fee will be charged. Signa — Signature Contractor The forego _• instrume . edged before me this The foregoing instrument was acknowledged before me this day of , 20 _, by , day of , 20 11_, by �QSQn Ng/ who is personally known 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: Sign: Print: Print: My Commission Expires: APPROVED BY My Commission! DEROS vi My COMIIISS1011 Expires Feb 5, 2012 %Wq°.� Commission # DD 755679 6,ft'"zr Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) STATE OF FLORIDA • DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 CHASE, JASON JOHN C G CHASE CONSTRUCTION MANAGEMENT INC 8860 SW 176 STREET MIAMI FL 33157 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE (850) 487 -1395 DATE - ..�. „_ BATCH NUMBER i ;BUSINESSTAX RECEIPT COUNTY STiATE OF FI:ORIDA .40/ `EP'ti „30, AYEAT PLACE OF'BUSINES ITY COAEIGHAFTER $A 501192 -9 USINESS NAME /LOCATION CG CHASE CONSTRUCTION MANAGEMENT INC 12805 SW 84 AV 33156 UNIN DAD, THIS IS NOT A BILL — DO NOT PAY WNER °CG. CHASE =:CONST eo TYppe o} Business 207 A�MN NOf i1S IS: ONLY A " "L CAL BUSWESS TAX RECEIPT IT DOES ;NOT. PERMIT THE HOL"DEHTOI,VJOLATE ANY EXISTING REOULATORY OR ZONING LAWS 3.OF: THE COUNTY+ ORc-CITIES. NOR DOES' n EXEMPT' THE HOLDERPROM ANY OTHER PERMIT-; OR ' LICENSE REQUIREDABY LAW. 'THIS 1S NOT A? CERTIFICATION - OF THE' HOLDER'S QUALIFICA- TIONS'. 7. ?I?AYMENT' RECEIVED MIAMIeDADE COUNTYTAX COLLECTOR: 07/16720.1.0 0228 0010001 000075.00 SEE OTHER SIDE FIRST-CLASS U.S. POSTAGE 1 PAID MIAMI, FL PERMIT NO. 231 RENEW RECEIPT NO.' DO NOT FORWARD CG CHASE CONSTRUCTION MANAGEMENT INC CLARENCE 6 CHASE PRES 12805 SW 84 AVE RD MIAMI FL 33156 11111111111111 11111 1111111111111111111 111111111111111113g71i1 'i`'"RU'"" CERTIFICATE OF LIABILITY INSURANCE DATE(M 06/22/DDIYYYY) 2/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 15 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certlflcate holder in lieu of such endorsement(s). PRODUCER Insurance Office of America, Inc. 100 NE Third Avenue Suite 850 Ft. Lauderdale, FL 33301 CONTACT Catharine Soedarto NAME: ac°,No,Ea): (954) 334 -2401 I ac,No): (954) 318 -1383 E -MAIL ADDRESS: PRODUCER CUSTOMER ID B: INSURER(S) AFFORDING COVERAGE NAIC$ INSURED C.G. Chase Construction Management, Inc. 12805 SW 84 Avenue Road Miami, FL 33156 -6514 IINSURER INSURERA: Illinois Union Ins Co 27960 INSURERB: Ins Co of State of PA 19429 INSURERC: 09/01 /2011 INSURERD: $ 1,000,000 $ 100, 000 INSURER E : PREMISES (EaEoccurrence) PREM F : CLAIMS -MADE 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 CONTRACTOR 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 WVD POLICY NUMBER POUCY EFF (MMIDD/YYYY) POUCY EXP (MM/DDIYYYY) LIMITS /4 GENERAL LIABIUTY COMMERCIAL GENERAL LIABIUTY OCCUR G22034212006 09/01/2010 09/01 /2011 EACH OCCURRENCE $ 1,000,000 $ 100, 000 X PREMISES (EaEoccurrence) PREM CLAIMS -MADE X MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENII_ AGGREGATE LIMIT APPLIES PER: poucY n 7E , 7 LOC PRODUCTS - COMP/OP AGG $ 2,000,000 7 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea acddent) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA UAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY OFFICER/MEMBER EXCLUDED ECUTIVEEl (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC005- 86- 596505/01/2010 05/01/2011 X I TORY LIMIT ORYLIMT S ER ISL- E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule K more apace is required) Proof of insurance only. *30 Days /10 Days notice of cancellation for non - payment of premium in accordance with policy provisions Miami Shores Village Building Department 10050 NE 2nd Avenue Mimi Shore, 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. AUTHORQEDREPRESENTATIVE �S John Harrold /SOEDAC A TI"1■I All A..6M •.s'1 ACORD 25 (2009/09) et'i 108 - . III.....- .v..v..v... The ACORD name and logo are registered marks of ACORD Al - CGNSU'LTING ENGINEERS, INC. Miami, June, 16/2011 To: City Of Miami ShoreS Building Department CITY COPY Roofer: A.C.N. Roofer REF: 1450 NE 103 Street Miami Shores, FI INSPECTION ROOF TRUSSES Dear Building Official: 1, Jose A. Martinez, P.E.. performed an Inspection on the roof framing and roof framing anchors at the above referenced location, and hereby certifies that the roof framing was conventional wood joists spaced approximately at 24» on center. The inspection revealed that additional straps & nailing are required with 6 - 8 nails per straps, as adopted by the Florida Building Commission by Rule 98 -1047 F.A.C. This report is based on limited visual review of existing structural components. (Attached Photos). Please do not hesitate to contact my office if you have any questions regarding this matter. Sincerely yours, Jose A. Ma nez, P.E. P.E. # 0 509 4383 SW 70 CT MIAMI FLORIDA 33155 • TELEFAX: 305 740 9550 * 4 e * - FIRST -CLASS U S. POSTAGE PA1D' MIAMI, FL ;; PERMIT NO. 231 SUS 2110_ 501192 -9. QUSINESS NAME /'LOCATION`'. CG CHASE CONSTRUCTION MA x;NC "12805 SW 84 AVE ,RD 33156 UNIN DADS COUNTY, QWNER CG CHASE CONST RUCTION °MGMT " INC " $ec.T of Business - - " 20'ADMTN� OFF:IGE:/OPERATION r}S 'ONLY .A LOCAL gS TAA RECEIPT. IT wti THIS IS; NOT A. BILL -DO-NOT PAY RENEWI "RECEIPT NO. .,yOT y.PERMR' THE 1REGULy RYYOR miC,F THE NOR IT? ■EXEMP7" THE nOM 7IY:'OTHER LICENSE 4iJ:GIJMED OY LAW. THIS IS ;tNO11'eAk OERTIFICATION OF TIiEIiQLDER.,S .OUALIFICA- ENT RECEIVED 'PARADE COUNTY TAX COLLECTOR:_ 07/16/2010 02280010001 000'075.00 SEE OTHER SIDE DO NOT FORWARD CG CHASE CONSTRUCTION MANAGEMENT INC CLARENCE G CHASE PRES 12805 SW 84 AVE RD MIAMI FL 33156 1,it1„ II III 11 III 1i1,111„ 1111111111 11111111 111111111 MAWti STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487 -1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 CHASE, JASON JOHN C G CHASE CONSTRUCTION MANAGEMENT INC 8860 SW 176 STREET MIAMI FL 33157 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE • �.titlrsSRn �i. �o,'v �.t:�,,ff'.'�•C.•r- �� ;,,�48 „f¢> �` rt Paz t}'�',,�j�W�dr,� �4�gd'`�, G i1 n^�a f�, .�a., „ (.. j�''�..�., uot, s '�4+.fit. 4�15 ' CHASE -1 OP ID: JY '4`.. -- CERTIFICATE OF LIABILITY INSURANCE DATE,MMlDD1YYYY) 06/22/11 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 poiicy(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 305 - 262 -0086 BUTLER, BUCKLEY, DEETS INC. 6161 BLUE LAGOON DR., STE 420 MIAMI, FL 33126 Garrett T Butler CONTACT GARRETT BUTLER IA/C.NNo. Extl :786- 216 -1769 FAX No): 305- 262 -0187 E -MAIL ADDRESS: GBUT@BBDINS.COM INSURERS) AFFORDING COVERAGE NAIC # INSURER A : Ins Co of the St of PA LIABILITY COMMERCIAL GENERAL LIABILITY INSURED CG CHASE CONSTRUCTION MANAGEMENT, INC. 12805 SW 84 AVE RD MIAMI, FL 33156 INSURER B : INSURER C : INSURER 0 : $ INSURER E : $ INSURER F : COVERAGES CERTIFICATE NUMBER: 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. NOTVNTHSTANDING 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 IMVD POLICY NUMBER POLICY EFF IMMIDD/YYYY) POLICY EXP (MMIDDIYYYY) O GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ PREMGETO RENTED PREMISES (Ea mew ) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES —1 POLICY n JET PER: LOC PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS H RED AUTOS _ SCHEDULED AUTOS AUTOS WNED (Ea SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (P r a cidT DAMAGE $ $ UMBRELLA LIAB EXCESS UAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED 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 WC5865965 05/01/11 05/01/12 WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, If more space Is required) MIAMI SHORES VILLAGE 10050 N E 2 AVE. MIAMI SHORES VILLAGE, FL 33138 MIASHVI 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 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD