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MC-12-649Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 172315 Permit Number: MC -4 -12 -649 Scheduled Inspection Date: April 25, 2012 Inspector: Perez, JanPierre Owner: ALVAREZ, KAREN Job Address: 1350 NE 102 Street Miami Shores, FL Project: <NONE> Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Contractor: AFFORDABLE AIR & HEAT & ELECTRIC CONTRACTOR Phone Number Parcel Number 1132050230060 Phone: 305 - 770 -4167 Building Department Comments REPLACE 5 TON g-e-9t/± eyt-A Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments I April 25, 2012 For Inspections please call: (305)762 -4949 Page 14 of 24 04/25/2012 16:02 3056548152 AFFORDABLE wrightsoft Project Summary Entire House AFFORDABLE AIR & HEAT,INC PAGE 01 Job: 30079 Date: 04.25.12 ®y: JON FREEMAN Project Information For: ALVAREZ RESIDENCE 1350 NE 102 STREET, MIAMI SHORES, FL 33138 Phone: 305-505-1286 Notes: REPLACEMENT h^6- A' l i -4111 Desi • n Information Weather: Miami, Intl AP, FL, US Winter Design Conditions Outside db Inside db Design TD 50 °F 70 °F 20 °F Summer Design Conditions Outside db Inside db Design TD pally range Relative humidity Moisture difference 99 °F 75 °F 14 °F L 0 558 gr /lb Heating Summary Sensible Cooling Equipment Load Sizing Structure 46020 Btuh Structure 39314 Btuh Ducts 5455 Btuh Ducts 4328 Bluh Central vent (154 cfm) 3389 Btuh Central vent (154 cfm) 2355 Btuh Humidification 0 Btuh Blower 0 Btuh Equipment Toad 55464 Btuh Use manufacturer's data n Rate/swing multiplier 0.94 Infiltration Equipment sensible load 43191 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 3747 Btuh Ducts 2065 Btuh Heating ooling Central vent (154 cfm) 5866 Btuh /k (f 2) 12151 121 1 Equipment latent Toad 11680 Btuh Air changes/hour 0.32 0.16 Equipment total load 54871 Btuh Equiv. AVF (cfm) 92 46 Req. total capacity at 0.70 SHR 5.1 ton Heating Equipment Summary Cooling Equipment Summary Tide TRANS Model 10 KW Efficiency Heating input HTeeating rise Actual air flow Air flow factor Static pressure Space thermostat Make TRANE CO. Trade TRANE CO. Cand 4TTR6061E1 Coil RAM7AOC80H51 100AFUE Efficiency 16 EER 57500 Btuh Sensible cooling 40250 Btuh 57500 Btuh Latent ding 17250 Btuh 26 °F Total cooling 57500 Btuh 2000 cfm Actual air flow 2000 cfm 0.038 cfmBtuh Air flow factor 0.046 cfmBtuh 0.00 in H2O Static pressure 0.00 in H2O Load sensible heat ratio 0.80 Printout certified by ACCA to meet all requirements of Manual J 8th Ed. - wrl9hteapt- Rlghl -& fte Residential 6.0.119 R$R30383 C:\My DecurnentetW,tghtecft HVACW,BENOrnp Cele = MJe onentetiori e N 2012 - Apr - 2518:08:33 Po$e ° 0,.. -:S6T) BVIDING PERMIT FBC Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 xEcEINTia�., APR 1 a Nit BY.: Permit No. r� q PPLICATION Master Permit No.h Permit ype: MECHANICAL %� OWNER: Name (Fee Simple Titleholder): '1QlC <Th / �`vQce 2 Phone #: , d 50 Address: kS 50 NiT7 `o . _ city: t'Ai3C\\1 State: V" L zip: O3 \‘'S Tenant/Lessee Name: Email. 1(�t /1' Phone #: JOB ADDRESS: 50 NI, (fl . City: Miami Shores County: Miami Dade Folio/Parcel #: t .390 5-- O3 3 - OO (cD Is the Building Historically Designated: Yes NO Flood Zone: Zip: 33 \ J CONTRACTOR: Company Name: A c-cc Cd (SOP T 1 r A \--\e alt Phone#: Address: �5n� N E \ ctO City: 1 " \ OM 1 State:t.. - Qualifier Name: JOC \ VCeeC' C n Zip: \�Q Phone #: 5- qi--10-0T44) State Certification or Registration #: CAC ©Li 11 1 Certificate of Competency #: Contact Phone#: a35" Q 4D- Email Address: DESIGNER: Architect/Engineer: N / �� Phone#: Value of Work for this Permit: $ Type of Work: ❑Address ❑Alteration Description of Work: quare/Linear Footage of Work: ❑New ❑Repair/Replace Rep 1 5 —ION With IDuw Demolition * **************** **** ** x******** ** * **** Fees*%** v** �x�x�x�x�x�r�xx��xx� *�r****+xa��x�xa��x�x **** * *** � ***** Submittal Fee $ iCJQ� Permit Fee $ '7 k k V CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) N /I\ Mortgage Lender's Address City State Zip MiN 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: promise in :.: od whose pro for the fi inspectio s a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must t a copy of the notice of commencement and construction lien law brochure will be delivered to the person nt. Also, a certified copy of the recorded notice of commencement must be posted at the job site s seven (7) days after the building permit is iss In the ' sence of such posted notice, the a reinspection fee will be charged Owner or Agent The foregoing instrument was acknowledged before me this CO The foregoing instrument was acknowledged before me this (C) , day of !! 20 , , y k3retic 1 v zz 7 , day of 0 Y , by iOrk MG: n , e or who has produced me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: A.61110 , ►� 1 NVA .: 4 My Commission %AWL MY COMMISSION #DD916106 • EXPIRES: AUG 12, 2013 Bonded through 1st State Insurance APPROVED BY ans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NOTARY PUBLIC: MY COMMISSION #DD9 6106 es: EXPIRES: AUG 12, 2013 Bonded through 1st State losurance Zoning Clerk s Miami Shores Village Building Department 10050 N. E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): 135n NE id City: Miami Shores Village County: Miami Dade Zip Code: 1��u ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES NO ❑ Contract Attached: YES t✓ UNIT BEING REPLACED DATA NEW UNIT ��.4 Aft" MANUFACTURER �,� 7Z v e 0 /-/ AHU or PKG. UNIT MODEL # 777177712 etbl/s 97-7 - 52,4/61/46rn /0 .A COND. UNIT MODEL # y 6 0 /il KW HEAT S"'- NOM TONS AHU‘C CU3cl PKG 1) M.C.A AHU CU` g PKG AHU�� CU(� PKG 2) M.O.P AHU CU PKG AHUUy® CUOO PKG 3) VOLTS AH6 CUd%® PKG PKG UNIT / / PKG UNIT / / ,® ©d EER/SEER ./e...____„. YES REPLACING DUCTS YES 40 . NO REPLACING THERMOSTAT OM NO YES �01." NEW 4 °CONCRETE SLAB YES YES ati7 NEW ROOF STAND YES '4 NO NEW RETURN PLENUM BOX NO 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse /Breaker Size): 3. Voltage of Circuit (208/240/480): 0 (-) 0 4. Size Disconnecting Means: l`o Contractor's Company Name: P Phone 5 ?b ° 077? State Certificate or Regi ion N. ' C.O 1 / Certificate of Competency N. Signature (Qualifier's signature only) Date: .//7/2_,..„ ....I CERTIFIED TM www.ahridirectory.org This combination qualifies for a Federal Energy Efficiency Tax Credit when placed in service between Feb 17, 2009 and Dec 31, 2011. Certificate of Product Ratings AHRI Certified Reference Number: 4385368 Date: 1/27/2012 Product: Split System: Air - Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: 4TTR5061 E1 Indoor Unit Model Number: *AM7A0C60H51 Manufacturer: TRANE Trade /Brand name: XR15 Manufacturer responsible for the rating of this system combination is TRANE Rated as follows in accordance with AHRI Standard 210/240 -2008 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): EER Rating (Cooling): SEER Rating (Cooling): 57500 13.00 16.00 * Ratings followed by an asterisk (*) indicate 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 disclainhs 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.ahrldlrectory.o TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRL This Certificate shag 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. ©2012 Air - Conditioning, Heating, and Refrigeration Institute rg. LocA Air - Conditioning, Heating, 1 A and Refrigeration Institute CERTIFICATE NO.: 129721557510093999 Air Conditioning & Electrical Contractors Affordable Air Hea, WHERE QUALITY IS AFFORDABLE 515 N.E. 190th Street • Miami, FL 33179 Dade (305) 940 -0777 Broward (954) 987 -9943 CAC048111 HOME if a5-72% WORK # OTHER #: ok-ez„. JOB NAME: STREET: EC0001140 CITY: STATE: ZIP: MANUFACTURER CONDENSER I PACKAGE MODEL AIR HANDLER MODEL S.E.E.R. EST NUAL OPE NG COST JOB DESCRIPTION: Al 1 < Lid �1i i `i1► A /.AI' , AL ! / 11 e. J'arri Ate elef Ve lW Lion,' a DESCRIPTION OF SERVICES PERFORMED AIR DISTRIBUTION: Ductwork will be designed, fabricated and installed in accordance with accepted engineering practices and in compliance with all building codes In force on above dtte.� 70 DUCTWORK: - ' A 1. r 45 �c System of flex/flber an or ductwork with outlets and returns. Subject to modification according to structural or other requirements. LABOR WARRANTY: a Service will be provided free by us for a period of A E C year(s) from date of installation during regular working days & hours. MANUFACTURER WARRANTY: Parts Warranty (Yrs.) A Compressor Warranty (Yrs.) EXTENDED WARRANTY: Provided through for year(s). AFFORDABLE AIR & HEAT, INC. WILL PROVIDE: YES INSTALLATION OF EQUIPMENT REFRIGERATION LINES ( ) OR FLUSH rAt, ❑ GRILLES ( ) RETURNS ( ) ❑ PERMIT FEE(S) & PLANS, IF REQUIRED ❑ DRAIN PIPING ( ) OR FLUSH AIR HANDLER SUPPORTS CONDENSATION PUMP EMERGENCY FLOAT SWITCH HURRICANE TIE -DOWNS CONCRETE SLAB fl Title to the above merchandise remains with Affordable Air and Heat, Inc. (seller) until paid for in full. In case of default in any terms of this contract, the seller shalt have the right to take immediate possession of said merchandise and full amount of the purchase price then unpaid shall become immediately due and payable atthe seller's option without notice or demand. All monies paid shall remain with the seller as liquidated damages. In the event the services of an attorney are required to enforce the interest of the seller, the purchaser shall be required to pay all reasonable attorney's fees together with interest and all costs thereto. No warranty service shall be performed on accounts with an outstanding balance. Lahr warranty excludes, existing ductwork, existing electrical systems, and maintenance related repairs. In the event the purchaser refuses to allow seller to commence work after the contract has been executed, purchaser shall be responsible to the seller for 25% of the total price as liquidated and agreed damages. Seller shall not be responsible for any existing building or electrical code violations. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from the contract speclfications involving extra costs will be executed upon written orders and will be subject to charges over and apgve his estimate. Initial Here NO EXISTING YES El THERMOSTAT CARPENTRY ❑ °r BALANCE AIR FLOW .1'' 0 REMOVAL OF JOB SITE DEBRIS ELECTRICAL-WIRING (POWER CONTROL) ❑ CONNECT TO EXISTING SERVICE /PANELS .� INC ELEC j AL VIE AMPS OTHE ay' OTHER , �� ❑ OTHERs\is, �'► <:°� �'`� " y ❑ NO ❑ EXISTING 0 0 0 6�E]'' COST REBATES/CREDITS TOTAL COST A —1 00 Less 7? / a) ,'o, . as B 4 v J Payment to be made FINANCING as follows: J ';1 AVAILABLE " deposit, balance upon start -up. This TAE Option Authorized Company pang proposal subject to ABOVE Pte, SPECMICATIOie MID Chosen Signature Q.Y .Signature ` accept - . = within l Date ff option of the seller. WUl. BE MADE AS 1 i Date / • ays and is void there after at the CONDITIONS .:1 ! ;' 1 T M :. AUTHORIZE TO BO THE WORK AS SPECIFIED. PAYMENT ACORO' CERTIFICATE OF LIABILITY INSURANCE OP ID: AP DATE (MMIDD/YYYY) 04/10/12 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 Sow. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 Hallandale Branch Riemer Insurance Group PO Box 250 Hallandale, FL 33008 -0250 Vita japan an man INSURED Affordable Air & Heat, Inc. 515 NE 190 Street Miami, FL 33179 800 - 742 -1691 954 - 454 -9552 CONTACT NAME: PHONE (AIC. No. Ext): FAX (A/C, No): E -MAIL ADDRESS: PRODUCER AFFOAI1 CUSTOMER ID of INSURER(S) AFFORDING COVERAGE INSURER A :Wesco Insurance Co. NAIC S INSURER B : INSURER C : INSURER D : 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. 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 JNSR SUER WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DD/YYYY) OMITS A OK GENERAL LABILITY COMMERCIAL GENERAL LABILITY OCCUR WPP1055018 -00 03/17/12 03/17/13 EACH OCCURRENCE $ 1,000,000 X AMAGE TO RENTED PREMD ISES (Ea occurrence) $ 100 000 CLAIMS-MADE X MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 Mt AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,000 PRO- LOC POLICY $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA LAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes describe under DESCRIPTION OF OPERATIONS Y / N N / A WC STATU- OTH- TORY LIMITS ER E.L EACH ACCIDENT $ E.L DISEASE - EA EMPLOYEE $ below E.L DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES `Attach ACORD 101, Additional Remarks Schedule H more apace Is required) Air Conditioning Contractor; Service, Installation & Repair CERTIFICATE HOLDER CANCELLATION ill City of Miami Shores Village CITYMIA tY g 10050 NE 2nd Ave Miami Shores, FL 33138 I 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 c),44/0.,%.. Cgefekst.t.",,,,jt----%..._ ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '4 °° CERTIFICATE OF LIABILITY INSURANCE OP ID: GW DATE (MM/DD/YYYY) 04/10/12 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 pollcypes) must be endorsed. If SUBROGATION IS WAIVED, subJeGt to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certlflcate does not confer rights to the certificate holder in lieu of such endoraement(s). PRODUCER Hickman, Johnson & Simmonds 11400 Parkside Drive. Sto.401 Knoxville, TN 37934 Aaron M Hammon CON7E7 f0T 865 - 288-63 6 865671.2943 PHONE uuc. Emu EMAIL Ao DUSSRR 1(11 . Nelt INSURERISI AFFORDING COVERAGE NAIL INSURED Affordable Air & Heat, Inc. 515 NE 190th St Miami, FL 33179 -3911 COVERAGES CERTIFICA DiSYRERA INSURER B : INSURER C INSURER D INSURER E: INSURER F • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED, NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY LIMBS SHOWN MAY HAVE BEEN POIJGY MAIM ISSUED TO CONTRACT THE POLICIES REDUCED SY HAM �F THE INSURED OR OTHER DESCRIBED PAID CLLAIMS, iMMfD NAMED ABOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS HERON IS SUBJECT TO ALL THE TERMS, TYPE OF INSURANCE ti p__ GONRRALLAWN COIAMERCIAL GENERAL UABILnY 0 OCCUR EACH OCCURRENCE t p PABIE.etx,nano.l $ CLAIMSMAcE MED DIP (Any ampintail $ PERSONAL S. ADV INJURY $ _., GENERALAGOREaA7e S GEN1. —1 AGGRE^GATE LIMIT APPLIES PER:. POUCYI I n Loa PRODUCTS • COMP/OPROI $ $ AUTOMOBILE WIBILGY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -0WNMDAUTOS COMBINED (SINGLE MIT DM $ BODILY INJURY (Per person) $ — BODILY INJURY (Par= Nerd) 5 PROPERTY DAMAGE (Per issiderd) s _ — 1 $ — UMBRELLA UAD CXCEGS LIAR —OCCUR EACH OCCURRENCE $ CIAIMS.MADE AT , 3 — DEDUCTIBLE RETENTION $ s s A WORKERS AN ANY OFFICERIIAEMBER t1 no, DESCRIPTION COMPEMATION PLO ARILITTY Y IN N N f A WC840 -0025701 02/25112 02/25/13 X 1 T J oJ�e E.L. EAC I4 ACCI>ENT $ 1.000.000 PROPRIETOR/PARTNER/EXEC EXCLUDIM In MB describe tn*r OF OPERATIONS sw 5.L DISEASE -EAEMPtOYEE $ 1,000,000 EL, DISEASE - POLICY u S 1,000,000 DEBCRIFIWN OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Atgch ACORD 101. AddBbeel ReeaetYS &Annut..If Iwo epees Is leWlled) CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES VILLAGE 10050 NE 2nd AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE FxPIRATIDN DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WRH THE Ras, PROVISIONS. AUTHORIZED REPRESENTATIVE Aaron M Hammon m 1988 -2009 ACORD CORPORATION. AU rights reserved. ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD