Loading...
PL-08-1328Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP -90204 Permit Number: PL -7 -08 -1328 Scheduled Inspection Date: July 11, 2011 Inspector: Hernandez, Rafael Owner: COOK, MARIANNE Job Address: 360 NE 105 Street Miami Shores, FL 33138- Project: <NONE> Contractor: DESMAR PLUMBING INC Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1121360130020 Phone: (305)594 -4930 Building Department Comments NEW PLUMBING FOR ADDITION Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Y� July 08, 2011 For Inspections please call: (305)762 -4949 Page 32 of 32 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 6EIIM3�j APR 262010 gl BY: BUILDING Permit No.0 OS -132g PERMIT APPLICATION Master Permit No.12C0 10 2,4 FBC 20 7)-01t.- ��.� 80 ` ^��� Permit z PLUMBING 6 OE1- (CF `� Type: 3ms3 °S l�(`(I Owner's Name (Fee Simple Titleholder) (1A 4,r 1 ii-vJ sJ,2. Coo L Phone # /G? 5- I Si- " S (O g Owner's AAnpAddress (e D N_ )D5 5-r Q City kVt\t A.; i�,),O/t.Q -5 State `t' ( Zip ') I O Tenant/Lessee Name Email Phone # Job Address (where the work is being done) 3 0 Ne_ 1o5 51- City Miami Shores Village County Miami -Dade Zip FOLIO /PARCEL# -© ("2j A ®2 /S,2c. 5 i ' ( -L( -{�' tC 1(1- (.. h 34`1 Is Building Historically Designated YES NO 'V Flood Zone Contractor's Company Name /2e---' 1(/.4 y e t ;, itr Contractor's Address )'7y' (4 /(( ey` Phone # .26 S r J ~/ *° 2?- City te-i /- •- .t State P Zip 7 S' / 4 4 Qualifier Name /:;_74..", 4 I.,- (r) o (- GA C,6' 1 V. Phone # S .5 "Ct s-76?"' State Certificate or Registration No. '" ,2' (V% 2. ''l e f ` (/ X ertificate of Competency No. 5 - 2 2 u g) . `:7 Contact Phone 28 -,...c-;2-e7;--,(74,42 ' c: j` E -mail Architect /Engineer's Name (if applicable) "TA-C.0 1j Qj 1-4( [ 1 b Phone # 30S 2$ (" 33 ?1 (� 'cOfl ® o Value of Work For this Permit $ Square / Linear Footage Of Work: Type of Work: ❑Addition ❑Alteration ❑New Describe Work: t; k Pj 1- 0 Fi ✓Ne` ❑ Repair/Replace 3oa562\0- ❑ Demolition * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * ** Fees************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submi allva V '''' " OQ(09-a CCF $4`�0 CO /CC $ Notar Tr ii4ng /E ation Fee $ Technology Fee $ (0 AO _ Scanning $ lite Radon $ ' J 1 DPBR $ i •) Bond $ Double Fee $ Structural Review. $ Violation date: Total Fee Now Due $ a61-z0 See Reverse side - 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 i l not be approved and a reinspection fee will be charged. Signatur The for day o who Owner or Agent Si Signature Q Contractor oing instrument was acknowledged before me this —�lThe foregoing instrument was acknowledged before me this • 20 (� , by j/A .. � • , . of A.Fe 1L , 2010 , by E7t)Q'tRvvn AiL)4,:'rZ, NOTARY P Sign: Pri me or who has produced As identification and who did take an oath. LIC: who is personally known to me or who has produced entification and who did take an oath. i NOTARY ` U LIC: My Commission Expires: Sign: Print: ?o`';`::Z AN DEE Sf2NNIM * my" McomisSION #OOr 9A5 My Commission Expires: EXPIRES: September 17, 2010 %oFFVe Bonded Thru Budget Notary SWANS *** * * * * * * * * * * * * * * * * * * * *9Fk:F*** *:F 9;****:P is is 9:: F: F:F 9***** *k* * ******k k *k**** APPROVED BY -(2Sf -Cc Plans Examiner (Revised 07 /10 /07)(Revised 06/10/2009) Engineer Clerk checked Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING PERMIT APPLICATION FBC 2004 Permit No. 17 ()?5- ) n2t Master Permit No. Lc); — /d Z Y Permit Type: Plumbing Owner's Name (Fee Simple Titlehdlder) (,tVt Pi q (wl lE ( . k Phone # C S 7 5 % - 5-1c? 5 S State F L Zip 73 i' C Owner's Address City 11, ?(`A( Tenant /Lessee Name Phone # '3- E -MAIL: Job Address (where the work is being done) 3 (,_,C A ; IQ 5 :'51- City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL #11 -ao4. -a Af 4,20 cs. P &v 'B /t t 7 Z..0 3'4 Is Building Historically Designated YES NO Contractor's Company Name eh u/ 142,.f Cv1R-Ep,2J'I' City %-f i in r State 1LOri CL°I Qualifier Name aiflae E ( ' / 12L Contractor's Address we State Certificate or Registration No. CFTC 0577 tog E- MAIL:Cilei(te,JCL/)p ✓L horn'il CO/Y) Architect /Engineer's Name (if applicable) Phone # Phone # OS - ! S /89 Zip 1 I Phone # 25S - 37a -s/ 8 9 - Certificate of Competency No. Value of Work For this Permit $ r SQO D-- Square / Linear Footage Of Work: Type of Work: Addition [Alteration ❑New ❑ Repair /Replace ❑ Demolition Describe Work: `` � y ?i'. 17 P { a6 f rt N N Q,vi in/A`%I L►11,41 DCP,n L i weS ******** * * ** * ********* * **************** Fees**** ******* *ic*>Yx******xxxxxx w*xx*r.xxz xxxx* w* Submittal Fee $ Permit Fee $ :4(e: : C CCF $ 4' CO /CC Notary $ Training /Education Fee $ I - (OA() Technology Fee $ (Q • 3 Scanning $3.00 Radon $ • &LJ DPBR $ i -v(3 Zoning $ Bond $ Code Enforcement $ Double Fee $ Structural Review. $ Total Fee Now Due $ a, See Reverse side —� Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City Zip 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 pen-nit 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 nqt be approved and a reinspection fee will be charged. Signature � 1` ''? C-7 -<' <4. ,,_ L- Owner or Agent The fore oing instrument was acknowledged before me this C day of r; ,200°1,by WIIfci1/tv..lZ C9a� who is personally known to me or who has produced % Nurs C.:\ C eAsk._. As identification and who did take an oath. NOT , PUBLIC: / 4/ , /. MY D, {MISSION # D Sig Print: Signature ontrac The foregoing instrument was acknowledged before me this /3 day of h p Y 7 , 20 oq, by Ch t f4,3 t who is personally known to me or who has produced ft DL CLOH S•3,5 17200.P as identification and who did take an oath. NOTARY PUBLIC: NS D509375 S: Jan. 22, 2010 My Commission Expires: L \Z-L\ U7 *x %X %x %xx * %X * * * * * * * * * * * * * *: * ** APPLICATION APPROVE (Revised 02/08/06) Sign: Print: NA L EVANS N # D1)s0927s `.r,,.22,2010 My Commission Expires: l • %Xr. XY. % X r. *xr. * *Y. % *XY. Y. % % % %Y %Y *X % % %Xr. at. % % * * * ** * * * * * * *Y. Plans Examiner Engineer Zoning TO:1 800 685 7530 3055944939 StAteeri.F.kefirix . • -,342-11.01-0: DEtAR:ra- NT Oltriiii311410§ ..:Vg:-P4tONAlem R.14 qt14.T11514. ,l08f19/0.,1 01381)-31163 ' : ••••• • tsp. .t■itrhutiNg CONTRACTOR ANasu, EDVARDO DASMII Pc . . -. • CERTIFIED reader the proleislozwen h.4ft9 Vet ssrtiinthat att. AUG- 31,. 214.0 ' :11084118190210 APR-23-2010 09:04 FROM:DESMAR PC AC# 444886.p. - • • • Ramon. ilE=1.4..x.xort 13staworAoNsimugzitwzxcENA1P-*:vc413D-: - sOto L0.9. 0.64i:o ., • DATE', BATCH NUMBER L .EN.SE 31A1V--- • 3055944939 TO:1 800 685 7530 P.4/6 4:1418/2009' 613asots7.4. 790. BUS II400 ZATIOR , Named below 'pmf 'IFZED -..7d, Under the provigiOns 61 7Chapter 489 FS, • . - Expiration dat0-. AUG 31,- 2Z11 (TILT s IS NO :RPR7,9:M.• K TH.I:S COMPANY TO atrupiEWs calty—TF- it ' HAS A -V.T*LX.FIER: ) wsmAR ;c: • 7933 Nic Mimi . CILARL 1E; CRIi4tr, GOVERNOR.:;.: • FL 166 r • • • • DISPLAY AS REq y 1.0:13* LAW' CHARLES W. DRA00 SECRETARY ONA:L REGULATION ING BOARD. SEQ# L080 819,021.0 9 CRARLEt MIST . WV33419-#. CHARLES W. DRAGO SE CRETARY TO:1 800 685 7530 3055944939 APR -23 -2010 09:04 FROM:DESMAR ' 607648-3 BUSINESS NAME/ LOCATION DOMAN PC INC • 7933 NW 64 ST 54166 UN1N DADE COUNTY This IS NOT ABILL- DO NOT PAY .OWNER DESMAR PC INC •Sof. Ty* et Buelnets was a 12,6AfDINB CONTRACTOR BOSIRESS TAX MEWL IT GOES NOT NEW THIS HOLDER TO MATE ANY MOM MOWERY OR MAIM LM9S O THE wow OR ORIEL RCS DOES IT exam THE ROWER FROWEIT OTHER PERMIT OR- LICENSE REWIRED BY LAIC Mlle NOT, 14. CtAI1O1LY THE HOMER OWRINEOR.. TR" PxnaiirrIneffiEV. RIME•OME MIRY TO-. VOU.EOTORL Duzi1.209 • --7.:6003poo0321 40000.75.40.11:" SEE OTHER SIDE RENEWAL' RECEIPT.NO. • 633874-8 *STATE* CFC1.427442 'FIFtST,CLASS Ur& POSTAGE PAID MIAMI,. FL PERMIT.N0431 WORKER/S. - • 2 • DO NOT FORWARD DESMAR PC INC MARIA L CEBALLOS PRES 231 NW 63 AVE MIAMI FL 33126 hhuhllAmdlunilAMI ACORD CERTIFICATE wtonut'L:R (305) 270 -1424 pan AR Assurance Agency, Inc 9100 Sunset Drive �.L CLIIIl FL 33173 -3433 451116E0 3ESMAR PC, INC. 1933 NW 64 ST MIAMI COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWI I H3TANLIIN(3 ANY i REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS CERTIFICAI E MAY B1: I'..UF't) OR MAY PER I AIN THE INSURANCE AFFORDED BY THE POLICIES DESCkIBED HEREIN 18 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS t)1 :sUi.1, r'L)LIC FE AGGRCCAIE LIMIT SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADD 'L I-IC..7'701P NE ',TN t NERD TYPE gF,NSURANCE{ POLICY NUMEIS. DATE............ �...�.._ °___. -- A UENeRALttAB%UTY / / / / CA. HU4 Ct/PIthNr,f__ 1; _ 1 'O0 000 I X �LMINER..1At. GCNERA1 LIADIUtY D 1 o RENTED 100.0001 PREM, tee -�ft ,• . ■ g I ' CLAIM MADE 3OCCUH 3004120082 01/07/2010 01/07/2011 MPSEXP thy urnFL ±±e , 4 __ y -uUO :,,0°°,000) PE °ORAL 4 All//NAlly_ i_, _ / / G NERAL AGIuRe:3ATe Po _ _Z 000 Li CIU PRQUUL r3 - (t,MI 4t• .- d 2,0000.000 FL 33166— OF LIABILITY INSij'RNCE DATe I1d1nLUD1YVrT) 04/20/2010 1 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMAnap ONLY AND CONFERS NO RIGHTS UPON THC CEKiri ICE TE1 HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND ON I ALTER THE COVERAGE AFFORDED Br THE POLICIES 8CWW INSURERS AFFORDING COVERAGE _ J N_AIC, d INSURER A NORTH POINTE CASUALTY INS 1 INSUReRB BUSINESS ST INS CO INSURER C - FIR - --- _— —_ ' I 1 INSURER D 1NSUR PR • NI AGGI4t' ACE LMII APPLIES NCR X 1 Pa 7,-.9„: LOC AUTOmCtlU-e LIABILITY AN'T AUTO ALL OWNED AUTOS CIiEDULLD AU1 OR HIRED AUTOS NUN OWNED AUTOS f GARAGE UABIUTY ANY AUTU L U1ceSS,UMermLLA LIAt31L1TY _I ne curt CLA,M:. MAnF COM81NtO SINr9LE LIMOS 11 (EP acwtler.4 - -4 — .- — ODDILY INJURY P1u pe'a':°+!_ BOl ILY INSIIP.Y 1P81wnb,n li / D'.UVC1 t13Lr 141,T NT S Tj WORKERS COMPT-NSATIDN ANU EMPLOYERS' UABIUTY ANY PROPRIF.TOWPARTNER1EXECUTIVE 1 OFFN•C'R+MGMEER EXLLUDFO° I! fCT avLCPae uPaa, SPBC IAA PR • V SKINS beitw PROPERTY UAMAL�L• LPe ars,atPt! AUTO ONLY - A'..' ' lT. OtMbP7IAN ,TAN't,t AU10 ONL Y A,,,: d 11 i EALIJ• -- ADC11 - ..1nTp • — — T 92103296 11 ?IO�� OOu EL Fo.CN A! -C iD NT 5 LL 00 DO fiL InSEASS EA ERIPL,LYtt• 1. LU1 EASE- Pt)LI, LPPMI Z O0,000 OTHER DESCRIPTION OF OPERAT10Nu1LOGA11ONS1VENICL65 l87CGLUBIONB ADDED BY ENDORg6/u1EN1FSPECIAL PROVISIONS / 1 / CERTIFICATE HOLDER 141aJn- Shores Village Btsiid, t.g DaDartsient 10050 N.E. 2 Ave. Miami Shores ACORD 25 (2001/05) fle 114S026 ;G +ie; uc (305) 756 -5972 FL 33138- 9.2'd 0£SL S89 008 1:01 CANCELLATION SHOULD ANY OF WI. ABOVE OFS.CRIHBO POI ICIF$ tlE CARL -( -'.' H:.IUitt- =1-.1 THEREOF THE VssumO INSURER /TALI PNUtiavtm. tU V'A' Wi11F1CA1'E HOLDER NAMED TO TNL I.tFT LIJ t EXPIRATION DATE FAILURE TO DO SCPHAtP POSE NO OBLIGATION OR LIABILITY OF ANY KIN' 5 I INSURER, ITS AGE 15 • R ENTATI . S AUTHORIZED REP - ELECTRONIC LASER FORMS. INC .800)327.0545 6£6M76SS02 ;' ACORD CORPORA i ION 13 Od I4S3a : WO21d 170:60 0T02- 22 -21dU ACORD,. CERTIFICATE OF LIABILI TY INSURANCE PRODUCER (305) 270 -1424 Pan Am Assurance Agency, Inc 9100 Sunset Drive Miami INSURED DESMAR PC, INC. 7933 NW 64 ST MIAMI FL 33173 -3433 FL 33166- DATE (MM /DD/YYYY) 04/20/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AMEND, EXTEND ALTER THE COVERAGE IAFFORDED BY THE POLICIES BELOW.OR INSURERS AFFORDING COVERAGE NAIC # INSURER A. NORTH POINTE CASUALTY INS INSURER 9: BUSINESS FIRST INS CO INSURER C: INSURER D INSURER E: CERTIFICATE HOLDER ( ) Miami Shores Village Building Department 10050 N.E. 2 Ave. Miami Shores ACORD 25 (2001/08) fn,; INS025(0108).05 (305) 756 -8972 FL 33138- SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN N FAILURE TO DO SC)^SHA INSURER, ITS AGE TS 0 AUTHORIZED REP GE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ENTATI S. ELECTRONIC LASER FORMS, INC. - (B00)327 -0545 © ACORD CORPORATION 1988 Page 1 of 2 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 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AGGREGATE INSR TYPE OF INSURANCE POLICY NUMBER 3094120082 POUCY EFFECTIVE DATE (MMtDD/YY) / / 01/07/2010 / / / / POUCY EXPIRATION DATE (MM/DD/YY) / 01/07/2011 / / / LIMITS EACH OCCURRENCE 1,000,000 $ 1, pQ 0 , 0 00 LTR A NSRD NSRD GENERAL LIABIUTY COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 X MED EXP (Any one person) $ 5,000 1 CLAIMS MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 / GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: T I I LOC POLICY 17 JEC ( / 1 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) $ GARAGE LIABILITY ANY AUTO / / / / AUTO ONLY - EA ACCIDENT $ EA ACC $ OTHER THAN AUTO ONLY. AGG $ EXCESS/UMBRELLA LIABILITY / / / / / / / / EACH OCCURRENCE $ AGGREGATE $ lOCCUR CLAIMS MADE $ DEDUCTIBLE S $ RETENTION $ B WORKERS EMPLOYERS' ANY OFFICER/MEMBER If yos, SPECIAL PROPRIETOR/PARTNER/EXECUTIVE describe COMPENSATION AND LIABILITY EXCLUDED? under PROVISIONS below 52103296 08/16/2009 / / 08/16/2010 / / X � MO N% NS F R EL EACH ACCIDENT $ 500,000 E.L DISEASE - EA EMPLOYEE $ 500, 000 E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER / / / / / / / / / / / / DESCRIPTION OF OPERATIONS /LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ( ) Miami Shores Village Building Department 10050 N.E. 2 Ave. Miami Shores ACORD 25 (2001/08) fn,; INS025(0108).05 (305) 756 -8972 FL 33138- SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN N FAILURE TO DO SC)^SHA INSURER, ITS AGE TS 0 AUTHORIZED REP GE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT POSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ENTATI S. ELECTRONIC LASER FORMS, INC. - (B00)327 -0545 © ACORD CORPORATION 1988 Page 1 of 2