DS-13-100-/
CONTRACTOR: i ` 1 r # rr J'
SUBMITTAL DATE: _ .i... 21
ADDRESS: L 71 • AI.
RESUBMITAL DATES: 111 ill 1
PROJECT • ra 1i A.ri1,1" ■ /r
r /t
ZONING\ ti °
FIRE
IMPACT FEES
ELECTRICAL
HRSIDERM
PLUMBING
NOC ,�; ,-,
MECHANICAL
II
BLDG
Miami Shores Village
a1943 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
r\'.43 - IA\
Bi ING Permit No.
PERMIT APPLICATION Master Permit No.
Permit Type: BUILDING
JOB ADDRESS: /' /401eae M.? e/ crr
City: Miami Shores County: Miami Dade Zip: 33
Folio/Parcel #:
JAN . 7 NU
ROOFING
Is the Building Historically Designated: Yes NO
Flood Zone:
OWNER: Name (Fee Simple Titleholder): Alyiriti Phone #: 2/2-- Zee g Z2°
222 g,. e 517"wi --
/Y �
Id,! State: /o/ /607
d+�
Address:
City:
Zip:
Tenant/Lessee Name: Phone #:
Email:
CONTRACTOR: Company Name: gei[t 0 3 as ac Phone #: 786' Z-r-3 'f Y. 1 /
Address: /5,5'8 /V 2J 8 - r
City: le-ow-se �. s State: ��
Qualifier Name: y6'� �.z...�
State Certification or Registration #: C c4 I S 511 Certificate of Competency #:
Contact Phone #: 786 ° 0.7e_ z.0 DZ.. - Email Address: ,IA l'!` ®,�i/&,..- s0•i'//, G9 4-t
DESIGNER: Architect/Engineer: Phone #:
Zip:
Phone #:
336
Value of Work for this Permit: $ e3) Square/Linear Footage of Work:
eration a ONew
Type of Work: ❑Additi
Description of Work:
ORepair/Replace
ODemolition
Color thru tile:
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ees************* * * * * * * * * * * * * * * * * * * * * ** * * * *** * **
Submittal Fee $ Permit Fee $ C J CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
Technology Fee $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address r ,
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 comme cement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In e absence o such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature // _ % / Signature
Owner or Agent 7
The foregoing instrument was acknowledged before me this 7 The foregoing instrument was acknow Jed bef /ode me�this
day of , 20/ , by �� 7 , day of � , 20 (3 , by tY' �F` bec ,
who is personally known to me or who has produced who is personally known to me or who has produced
Contractor
?As identification and who did take an oath.
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
duo °e
e
•
e
My Commission Expires: y ;DOl53828 °: Q ` My Commissio s `�� e
‘N•lpv.°S0811... y y #01 39538281: ° 4�� 3Altw; eS lipi.. )"olon rut` s0�,(NS.
*�r �r �r�r�r�r �r �r�r �r �r x�r.ti�r�r °r * Hft$$ 1i4,1�r °r �r�r�r�r�r�t�r,��r�r�r �r�r�r,x�r�r�r�r�t ,x x,x �r * *i - .4CSr I***************
APPROVED BY
Plans Examiner
Structural Review Clerk
t
(Revised 41/. 6ises1,3 /12/2012) )(Revised 06 /10 /2009)(Revised 3 /15 /09XRevised 7/10/2007)
Folio
11- 3206 - 013 -1750
Property Address
142 NE 103 ST
Owner Name(s)
DADE CTY 142 TRS
1480 LAKEVIEW DR
DELAND FL
33720
Primary Zone
1000 SGL FAMILY - 2101 -2300 SQ
Use Code
0001 RESIDENTIAL - SINGLE FAMILY
Beds /Baths /Half
2/1/0
Floors
1
Living Units
1
1,524
Lot Size
8,475 SQ FT
Year. wilt
1938
Legal Description
MIAMI SHORES SEC 1 AMD PB 10 -70
LOT 9 & E1/2 LOT 10 BLK 13
LOT SIZE 75.000 X 113
OR 12673 -2579 1085 1
COC 25040 -3828 09 2006 5
OR 25040 -3828 0906 01
Current
Previous
Year
2012
2011
Land Value
$94,403
$72,618
Building Value
$118,932
$118,993
Market Value
$213,335
$191,611
Assessed Value
$210,772
$191,611
Current
Previous
Year
2012
2011
Homestead
$0
$0
2nd Homestead
$0
$0
nior"
$0
$0
Veteran Disability
$0
Civilian Disability
$0
$0
r)
$0
$0
Disclaimer.
MIAMI -DADE COUNTY
OFFICE OF THE PROPERTY APPRAISER
PROPERTY SEARCH SUMMARY REPORT
Honorable Pedro J. Garcia
Property Appraiser
Aerial Photography 2012
Current
Previous
Year
2012
2011
Exemption/Taxable
Exemption/Taxable
County
$0 / $210,772
$0 /$191,611
hoof`
$0 / $213,335
$0 /$191,611
City
$0 / $210,772
$0 /$191,611
Regional
$0 / $210,772
$0 /$191,611
Date
Amount Recording
Book -Page
Qualification Code
9/2006
$0
25040 -3828
Sales which are disqualified as
a result of examination of the
deed
6/2006
$0
24609 -0643
Sales which are disqualified as
a result of examination of the
deed
6/2006
$377,500
24603 -0001
Sales which are qualified
10/1985
$59,000
12673 -2579
Sales which are qualified
The Office of the Property Appraiser and Miami -Dade County are continually editing and updating the tax roll and GIS data to reflect the latest property information
and GIS positional accuracy. No warranties, expressed or implied, are provided for data and the positional or thematic accuracy of the data herein, its use, or its
interpretation. Although this website is periodically updated, this information may not reflect the data currently on file at Miami -Dade County's systems of record.
The Property Appraiser and Miami -Dade County assumes no liability either for any errors, omissions, or inaccuracies in the information provided regardless of the
cause of such or for any decision made, action taken, or action not taken by the user in reliance upon any information provided herein. See Miami -Dade County full
disclaimer and User Agreement at http: //www.miamidade.govfinfo /disclaimer.asp.
Property information inquiries, comments, and suggestions email: pawebmail @miamidade.gov
GIS inquiries, comments, and suggestions email: gis @miamidade.gov Generated on: Wednesday, January 09, 2013
Return to
Name: Pat Kiehl
1480 Lakeview Dr.
Deland, P1. 32720
Address..
This instrument prepared by:
Address:
FoUoa 11- 3206 -013 -1750
11111111111111 11111111111111111 11111 11111111
C ;h N 20O6R1 9120
OK Bk 25040 Fos 3828 - 34.25° (2a9)
RECORDED 10/25/2006 11;14:52
DEED LDC TAX 0.607
HARVEY RUVIN, CLERK, OF COUR1
MIAMI -LADE COUNTY? FLORIDA
DEED TO TRUSTEE
STATE OF Florida
COUNTY OF Dade
titZS YNDENTORE, made this
S
4?20 Surp t }lr.. *219,. M ami, P1. 33143
the first part ..(her.teutter referred to
Pat Kiehl
Dade County 142 Trust "•
1480 Lakeview Jr.: peiapd, P1. 32720
second part (hereinafter referred to as "Grantee ")
12 day of Septembe
atiols
r • 2006 between
of
party of
As "Grantor " }, and
Trustee of
(an executory Trust), of
, party of the
WZTNESSSTf, that the said party of the first part for and in consideration of the
sum of Ten dollars ($10.0o) and other valuable consideration, sash in hand paid, the
receipt of which is hereby aaknovledged, has bargained, sold, and does by these presents
grant, bargain, sell, remise, release, transfer, convey and forever quitclaim the right,
title, interest, claim or demand which the said pasty of the first part has or may have in
the property; .
Lot 9 and the East 1/2 Lot 10,in Block 13, of MIAMI SHORES
SECTION ONE, Amended Plat, according to the Plat thereof,
as Recorded in Plat Book 10, at Page 70, of the Public
Records of Miami- Dade,County, Plorida.
The Property herein conveyed shall stand as sole aeesarity for obligations or
Grantees hereunder. .
TO kin AND TO HOLD the said described premises with all the members, rights and
appurtenances upon the Trust and for the uses and purposes herein described and in the
existing Declaration of Trust and Land Trust Agreement of said Trust and the Trust set er and Pull
aubdivids, powmanage, and protect o.saideal estate os hereby to said Trustee to purchase, improve,
streets, highways er alleys and to vacate and subdivision or part he dedicate parrs,.
subdivide said real estate as often as desired: to contract/ part renovate; and to re
sell: to grant options to purchase, to sell on any ? to renoback, to repair; to
release mortgages: farms, to take back, foreclose and
Hill to convey said eal estate orwany or without consideration, successor to tarty s in
linanci y
Trust, all of the title estate part thereof to a s id Tr ore; toadone e,
dedi.oate, , plater and authorities vested in said real estate. te,
part thereof, Mortgage, time pledge t collateral as otherwise encumber said real astate. der aa^Y
for to time to eontraot. to lease, or. if required, hire
said real estate, or any past - thereof, in ever managemetC
loss anoe, in present se°din9 in the tutus., a � upon any terms and for any period or perioods of
time, not sr
extend lae°ss upon terms end for any single demise the -tern of 49 years, and to renew er
modify leases and the forma and and period or periods of time and to amend, change or
grant options to.. lease, .options tororeaaw leases ! options any time hate t e wholefor and tt
of. the reversion end to cOntraot ra ctin ner o to fixing the mountcof or sen rant
future rentals, to exchange said g the manner thereof, fixing the amount al present and
Property, to grant easements or charges of any part to for other real or assign any
right, tittle use or interest in Or to said real estate p my par convey ; assign eal
with said property and every any Part thereof; to deal as
it would be lawful for past thereof in all other ways and for other whether sconsideration as
to or different from see any person above spec the sans any time with the ether, wheth similar
tiling lawsuits and hiring counsel.
specified, at sty time or ;loses hereafter, intruding
In no aaee shall any party dealing with said Trustee in relation to said real
tenet* es go whom said Seal estate or any part thereof shall be conveyed, contracted to be
sold, leased or mortgages by said Trustee, be obliged to see to the application of any
purchase money, rent or money borrowed or advanced on said premises, or be obliged to see
that the terms of this trust have been complied with, or be obliged to inquire into the
in necessity or expediency of any ecC.of said Trc1tee,_or be obliged or privileged to inquire
may or the tarns of said .Treat Agreement; and every deed, trust deed, murtgege,
OR ev, 25040 PG 3329
LAST PAGE
lease, management agreement or other instrument executed by said Trustee in relation to
said zeal estate shall be conclusive evidence in favor of every parson relying upon or
claiaing,under any ouch conveyance, lease or other instrument (a) that at the time of the
delivery thereof the Trust created by the indenture and by said Trust Agreement was`in
full force and effect, (b) that such conveyance or. other instrument was executed in
accordance with the trusts conditions and limitations contained in this Indenture and in
said Declaration of Trust and. Land Trust Agreement and binding upon all beneficiaries
thereunder, (o) that said Trustee was duly authorised and empowered to execute and deliver
every such :dead, trust deed, hest, mortgage, manngeaant agreement er other inatrument,
(d) if the conveyance is made to a summates or successors in trust, that such successor
or successor. in trust have been properly appointed and are fully vested with all the
title, estate, rights, power., duties, and obligations of the said predecessor in trust.
and (e) Trustee is prohibited under the tares of the aforesaid Trust Agreement to reveal
the terms and conditions of said Trust Agraamant or the records 'of the Trust without
express written authorisation from the holder(e) of the power of direction of the Truat.
Any contract, obligation or indebtedness incurred or entered into by the T_:uatse
in **mention with said real estate my be entered into by the Trustee in the name of the
then beneficiaries under said Trust Agreement, as their attorney in fact, hereby
irrevocably appointed for such purpose, or, at'the election of said Trustee, in its own
• name as Trustee of an express trust and not individually and the .Trustee shall have no
obligation whataeever with roapeat to any such contract, obligation or indebtedness except
only so fax as the trust property and.fundc in the actual poosesaioa of the Trustee shall
be applieabls for the payment end'disehargs'there'f, Ood ell paraons and - corporations
whomsoever shall be charged with notice ot this condition .from the date of the filing for
recordo! this deed..
Any litigation arising in connection with this document will be adjudicated under
the laws of the State of Florida. In the .event any portion of this
armament shall be found to be not supportable under Florida Statutes, the
remaining provisions shall continuo to be valid and subject to enforcement in the courts
without exception. In like manner, any obligations of either party which may become law
shall be binding on both parties as if included herein.
The following individual shall be the Successor Trustee with the same powers as
stated herein)
Cynthia Sellers
The interest of each and every benetioiaxy hereunder and under the Declaration of
Treat and Land Trust Agreement hereinbsfore referred to and of all persons claiming under
them or any of them shall be only in the earnings, avails and proceeds arising from the
sale or other disposition of said real estate end such interest is hereby declared to be
personal property, and no beneficiary hereunder shall have any title or interest, legal or
equitable, in or to said real estate as such but only an interest in the oarninge, avails.
and proceeds thereof as aforesaid.
Yt is the intent of Granter(e) to create- this Trust and the Grantor's) rally
warrant(s) the title to said real estate and will defend the same against the lawful
claims of all persons whomsoever.
IN MUMS Wartele. the Granter aforesaid has hereunto set
12 day of September , za 06 ,
itnees:
tress)
STATE or Florida
COUNTY or Dade
Grantor:
Grantor:
eel this
(Seal)
sva i do Vila - Pres.
(Seal)
S hereby certify that on this day, before me, an officer duly authorized
to administer oaths and take acknowledgments, personally appeared
Osvaldo Vila known to me to be the person
described in and who executed the foregoing instrument, who acknowledged before
me that he executed the same, and en oath was pot taken. (Check one)
Said person(s) is /are personally known to me; Said person(v) provideddtthe
following type of identification
Witness my hand and Officia Seal in the Cohn
this ) 2 day of Septem eT,
my C m s) eras
?,ak- `r Coommissronn # DD4e2454
qo Expires September28, 2009
wil p satin hop Pam unmet., 'r SCOMac p
to lastreforesaid
Notary Signature
Notary Printed Name
ASSIGNMENT OF BENEFICIAL INTEREST IN TRUST
ASSIGhfkt T is this %fI/ day of %`U Sf 0.40g by
"hose addrass i ;/.¢02) 044S- /Ge:.vssww
(hereinafter pp1arred to as
'ASStgnoYy, 0 - ... �. ri ddre
<e i0 ss Es
arc) % I v i N /tr.y
(hereinafter reNtrord- to -as''
VETNES
EREAS, tits Assignor is a beneficiary of it trust created
, by instrument dated ' !y es Se
narhIng r AL as Trustee, and
WHEREAS, the Assignor desks to assign to the Assignee all of Assignor's banal interest in the
trust; and
y
WHEREAS, the bust instrument does not profit such assignment;;
NOW, THEREFORE, for valuable conaderation,,the ocelot of which is hereby acknowledged. the Assignor-
hereby assigns to the Assignee all Assignor's interest as a beneficiary of the Tress. including: aft monies•aue cr
to become due to the Assignor thereunder: and
The Assignor etnhortbee the Trustee of the Trust to pay directly to the Aasfgnee all morale
benefits representing, of arising from, the interest eselgned hereby.
IN WITNESS WHEREOF. the Assignor has exeaaed this assignment the day and year Wu above swine,
Signed, scaled and delivered in the promos eft e4 ,- °, an,e 444
,tt,Grc.K -sijee ,(� rr1aaoye.Z
or other
rheas ssi4, r..+/reL.
SATE OIL t %�,ad.�
COUNTY 'OY jrIIs,#
The fore : oing; inatrtt; en t was executed an
,?oo by
What
/NCINISSED1111M7S932
nue
ya
l ,F'µL i,►
( EAL5
147 A w 8ifl2t expixea:
1�i1
THIS DOOMONT` SHALL NOT BE RECORDS:
OF ANY COUNTY.
Eow t dged before we
State of d a.
zN TEL PPBLIO RECOO DS
IVI iami Shores VHIage
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RECEIPT
PERMIT #: *-100 DATE: Daa °(10
I, $i dl� C5CQYbVO,k
Contractor
Owner
❑ Architect
Pick up 2 sets of plans and (o, er) 1.0 ) 1"0 YS
Address: 142 NE, 100
From the building department on this date in order to have corrections done to plans
And /or get County stamps. I understand that the plans need to be brought back to Miami
Shores Village Building De4rtmentto continue ,e itting process.
Acknowledged by: X
PERMIT CLERK INITIAL: ,r
do.
RESUBMITTED DATE:
PERMIT CLERK INITIAL:
Rick Scott
Governor
John H. Armstrong, MD, FACS
State Surgeon General
(Prestige Builders)
100 NE 89 Street
Miami, FL 33175
RE: Contingency Letter
Application Document No: API097113
Centrax Permit Number 13-SC- 1455090
OSTDS Number
142 NE 103 St
Miami, FL 33175
Lot:9
February 15, 2013
Block:13 Subdivision:
Dear Applicant:
This will acknowledge receipt of an application dated 02/11/2013 for a permit to use an
existing onsite sewage treatment and disposal system located on the above referenced
property.
From a review of your completed application, it has been determined your existing system is
adequate for the proposed use.
This permit is granted for the construction of a new driveway. There will be no increase in
sewage flow or characteristics and no impact on the unobstructed area.
APPROVED
If you have any questions on this matter, please call our office at (786) 315 - 4444.
Enclosures
cc:
Sincerely,
910 gi 1
iZeLeA vCal
Astrid Edwards, Engineer Supervisor III
Miami -Dade County Health Department
1725 NW 167 St, Opa Locka, FL 33056
Phone: (305) 623 -3500. Fax: (305) 623 -3645 . http: / /www.MyFloridaEH.com
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Cfy' .742o
1111111111111111111111 111111111111111 11111111
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION
PERMIT NO.13 —1 (a.Th TAX FOUO NO.
STATE OF FLORIDA:
COUNTY OF MIAMI-DADE:
THE UNDERSIGNED hereby gives notice that improvements will be made to certain real
property, and in accordance With Chapter 713, Florida Statutes, the following information
is provided in this Notice of Commencement.
CFN 2O13RO17616
OR Bk 28518 F's 0481; (1p9)
RECORDED 03/06/2013 12:39:14
HARVEY RUVINp CLERK OF COURT
MIAMI-DADE COMM FLORIDA
LAST PAGE
Space above reserved for use of recording office
1. Legal description of property and street/address: 47-"9 pl ■
e.44-pci-. 4
e
2. Description of Improvement:
iriej 020,
3. Owner(s) name and address: AP."2-04) Arke;tomi
Interest in property: Ze„.7.-14,0 ;.-.7 ,01:4_,,Efeedgreattleav
Name and address of fee simple titleholder
4. Contractor's name, address and phone number: sel
,_ I,f
5. Surety: (Payment bond required by owner frpm contractor, if any)
Name, address and phone number: /4
Amount of bond $
6. Lender's name and address:
7. Persons within the State of Florida deslgnateq by Owner upon whom notices or other documents may be served as providsd by
Section 713.13(1)(a)7, Florida Statutes, e/ a-ATE OF FLORA COWRY OF D'AUE
cor-444.
Name, address and phone number fir /9 0 HERM' CERTIFY thn't this is ,o tai? oppv of the
713.13(1)(b), Florida- Statutes.
8. In addition to himself, Owners designates th . following person(s) tmcake=a4op,(61:4ffiglellin5ayiaLthe-Lleaaori6"'"' ritiiitioe-as-Provid
Name, address and phone number. VAlaiL7141AM
Mita ay Wydri_ r ; p fff.
Ctirt
qr
ri,murewolgovzioriiireosi;
NT-sf
9. Expiration date of this Notice of Commencement
(the expiration date Is 1 year from the date of recording unless a different date is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK
OR RECORDING YOUR NOTICE OF COMMENCEMENT.
SIgnature(s) a
Prepared By
Print Name
uthorized Officer/Director/Partner/Manager
Prepared By
4o7 rgevt- 4...g.erdsum....- Print Name
Title/Office
°Wedged before me this '4
Individually, or C3 as for
Personally known, or
produced the following type of identffi
Signature of Notary Public:
Print Name:
(SEAL)
day of
c h.
ft
ZeI7
VERIFICATION PURSUANT TO SECTION 92.525. FLORIDA STATUTES
Under penalties of perjury, 1 declare that 1 have read the foregoing and
that the facts stated In it are true, to the best of my knowledge and belief.
Sigyr(s) ol n
By
123.01-52 PAGE 9/10
- or • er(s)'s Authorized Officer/Director/Partner/Manager who signed above:
By
03/07/2013 14 :22 9549560555
COVER ALL INSURANCE PAGE 01/01
ACORD CERTIFICATE OF LIABILITY INSURANCE
RODUCER
OVER ALL INSURANCE
800 W. ATLANTIC BLVD.. '3 -"\O
1ARGATE, FL 33063
'H (954) 952 -0006 FX (954) 856.0555
MIRED PRESTIGE BUILDERS CORP.
15958 NW 82ND PLACE
MIAMI LAKES, FL.33016
DATE (MM1DDlYYYY)
0310712013 -
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ALTER THE COVERAGE AFFORDED BY NOT POLCCI S BELO N.
INSURERS AFFORDING COVERAGE
INSVRERA: BENCHMARK INSURANCE COMPANY
INSURER e:
INSURER C:
INSURER 0:
INS, RER E:
NAIC #
:OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
(SR
DD'
POLICY NUMBER
POL 4Y_ - OLYYI�A70 M IO RATION LIMITS
GENERAL UABILITY
X COMMERCIAL GENEJ(ABILITY
CLAIMS MADE I X OCCUR
GE 1. AGGR GATE LIMIT APPLIES PER:
POLIcYI PF o- I 1 LCO
AU- OMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
0S110776
1010112012
10101/2013
EACH OCCURRENCE S 300,000
PREMISF�tF� a DANIANTE 100,000
MED E)SP (Any one ',arson) $ 5,000
PEa$ONAL & ADY INJURY $ 300,000
GENERAL AGGREGATE 6 600,000
PRODUCTS - COMP!OUGG $ 5001000
COMBINED SINGLE LIMIT
(Ea aoald nt)
a
BODILY INJURY
(Per person)
$
BODILY INJURY
(Peraoddert)
S
RoFE �tDAMAGE
$
GARAGE LIABILITY
ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRI €TQRIPARTNER /EXECUTNE
OFFICER/MEM R EXCLUDED?
It es, duaCribe under
II e , AL PRD $J0N$ ba(aw
OTHER
AUTO ONLY. E4 ACCIDENT 5
OTHERTHIAN EA ACC 3
AUTO ONLY: AGO $
EACH OCCURRENCE a
AGGREGATE 5
$
3
�Y3TAN• I0 a
E.L. EACH ACCIDENT S
E. L. DISEASE - EA EMPLOYEE 5
EL DISEASE - POLICY LIMIT 5
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES ! SXCLUSIO
GENERAL CONTRACTOR
CERTIFICATE HOLDER
$ ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
VILLAGE OF MIAMI SHORES BUILDING DEPT
10050 NE 2ND AVE
MIAMI SHORES FL 33138
CANCELLATION
St OULO ANY OF THE ABOVE DEB0111BED POUCISS BE CANCELLED BEFORE THE EXPIRATION
TE TNPIIEOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
N CE TO ,' ERTIFICATE HOLDER NA TO THE LEFT, BUT FAILURE TO DO 30 SHALL
1M OSE NO TION OR 1JABILITY KIND UPON THE INSURER. ITS AGENTS OR
R RESENT -. n
AUTHOR
ACORD 25 (2001108)
® ACORD CORPORATION 1988