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PL-13-1169Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 192188 Permit Number: PL -5 -13 -1169 Scheduled Inspection Date: June 05, 2013 Inspector: Hernandez, Rafael Owner: BRUCE, JON & KIMBERLY Job Address: 1113 NE 98 Street Miami Shores, FL 33138 -2507 Project: <NONE> Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Drainfield Phone Number Parcel Number 1132050180260 Contractor: NU BLACK SEPTIC & DRAINFIELD COMPANY Phone: (954)410 -2589 Building Department Comments REPAIR DRAINFILED Infractio INSPECTOR COMMENTS Passed Comments False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments June 05, 2013 For Inspections please call: (305)762 -4949 Page 21 of 47 9\ V5i)\,\‘0 Miami Shores Village uilding 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 BUILDING PERMIT APPLICATION =MIMI 14#24203 (h) 5.4 FBC 20S Permit No. Master Permit No. Permit Type: PLUMBING JOB ADDRESS: 1113 NE 98th Street City: Miami Shores.. County Miami Dade : FoliolParcel#: 11-3205-018-0260 Is the Building 'Historically Designated: Yes NO X Zip: 33138 Flood Zone: OWNER: Name (Fee Simple Titleholder): (.175pi--) efri-oCk- Phone#: 3e).5 -'76-8-(22-1 Address: 9J■A4. 44 ABOIJ e•-• City: State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Nu-Black Septic & Drainfeld Company Phone#: 954-9274090 Address: 27 NW 4th Ave City: Dania Beach State: Florida Qualifier Name: David Nuby Sr. State Certification or Registration #: SR 0931118 Certificate of Competency #: Contact Phone#: 984-9274090 Email Address: nublack@comcast.net DESIGNER: Architect/Engineer: Phone#: zip: 33004 Phone#: 954-410-2589 Gen Value of Work for this Permit: $ 6,000 Type of Work: LlAddress CIAlteration Description of Work: Replace Drainfield Square/Linear. Footage of Work: ...51/55t1 A-17 LiNew tiRepair/Replace CIDemolition ****************************************Fees******************************************** Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ co/cc$ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DU--$1?.1M,11 Nat 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, BOIL FRS, 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 w 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. The foregoing instrument was acknowledged before me this'25 day of P IH , 20 6 , by Jovi 114I 'E yt who is personally known to me or who has produced R-- f2�1�, As' identification and who did take an oath, NOTARY PUBLIC: Sign: Print: 11Vx�� My Commission Expires:€/ /161701 C— ♦Y p.., otary Public State of Florida • Silvio Ortega . �Av My Commission EE115658 Contractor The foregoing instrument was acknowledged before me this day of a) all , 20 L3, by ,r w` ?14 , who is personally known to me or who has produced PQr5DI! (l identification and who did take an oath. NOTARY P Sign. Prin es . , 7` " AUY GAINES •'- CO s Ee' ►c uL." klmenci I / r My Commission Expires: ,Aix (q, 061 k APPROVED BY -2.84 3 Plans Examiner Zoning Structural Review (Revised3t12i2012)(Revised lilti 0107)(Re ised 06110 2009)(Revised 3/15/09) Clerk STATE OF FLORIDA DEPARTMENT OF NA Ll$$3 PERMIT #:13 -SC- 1473288 oNSrTE SEWAGE v APPLICATION #: AP1108374 EWAGE TREA NT AND DIS CONSTRUCTION PERMIT P8 �® DATE p PMIT SYSTEM AID: FEE PAID: CONSTRUCTION PERMIT FOR: APPLICANT: Tyler Bruce OSTDS Repair PROPERTY ADDRESS: LOT: 17 PROPERTY ID #: RECEIPT #: DOCUMENT #: PR907301 BLOCK: 179 11-3205-018-0260 SYSTEM MUST ORCTAX ID NUMBER] TOWNSHIP, RANGE. PARCEL NUMBER] 361.0065, F � CONSTRUCTED D I- ACCORDANCE SATISFACTORY AND CHAPTER WHICH SERVED PERFORMANCE FOR 64E -6, F.A.C. F,A DEPARTMENT WITH SPECIFICATIONS AS A SPECIFIC OVAL AND STANDARDS PE APPLI APPROVAL ISSUANCE CATION. SUCH FOR ISSUANCE OF PERIOD Tom. OF SYSTEM DOES OF SECTION ANCE OF THIS MODIFICATIONS THIS PERMIT ` CHANGE NOT GUARANTEE iTATE, OR LOCAL PERMITTING PERMIT DOES NOT ,EXEMPT M`�'Y RESULT IN THIS QUIRE THE APPLICANT IN MATERIAL FACTS, PERMIT CANT Ta MODIFY THE REQUIRED FOR DEVELOPMENT APPLICANT OP FROM BEING MADE NULL OF THIS PROPERTY, COM�'LIANCE WITH `�D VOID, [ 900 1 OTHER FEDERAL, YSTEM DESIGN AND SPECIFICATIONS GALLONS / GPD 0 1 GALLONS / GPD 0 ]LONE GREASE INTERCEPTOR ]LONS DOSING TANK `�K CAPACITY Existing septic tank to remain. CAPACITY CAPACITY [MAXIMUM CAPACITY GALLONS @[ 375 ] SQUARE FEET ] bed configuration drainfiel SYSTEM YPE 0 1 SQUARE FEET SYSTEM: [XI STANDARD ARD [ I FILLED SYSTEM [ 1 TRENCH [xl BED BENCHMARK: [ 1 EVATION Top of bottom floor, 8.50' OF PROPOSED SYSTEM SITE NGVD TTOM OF DRAINFIELD TO BE I REQUIRED: rvert elevation of drainfield )CATION OF [ 0.001 INCHES ottom of drainfield elevation to be no less than 5 -US p to be no less than 6.46' PERMIT IS NOT F [] [ 0.20 I [ INCHES [ 2.20 1 [ INCHES system is sized for 3 '00 gpd. quired drainfield area III a new drainfield to CATIONS BY: 0 BY: MED : OR 'ADDITION MOUND [ [ ABOVE [ ABOVE SINGLE TANK:1250 GALLONS] 1DOSES PER 24 HRS #Pumps BENCHMARK/REFERENCE POINT BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 28.002 INCHES NGVD. .96' NGVD. bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow achieve Drainfield $ ze re quire quire tilirilIPPIPP- ilifhPP- 05/ X13 /(Qir Obsolete $iRit d'emg3$;'a ,l p Zvi g ®itions time b tin ; t.i F' cav do of the al rirspuctiz. ,r. Pr! l v�treld excavation at the 'nspeator shall witness i ur t,, Ft��i �Pproval, the DOH e sslt° to the It wine ,i irk! boring �vut +orr tee ihil r.;1. . . o .valuation sub d compare the t the jcbsite at tic ar: #ued }time. lt the contractor is not TITLE: TITLE: which may not be used) AP1108374 EXPIRATION DATE: SE899432 Dads CND 08/22/2013 Page 1 of 3 MO OF ABEFEVIAllONS; —44r.cat'oadst L.41.0014.1'...*AlZb!vet _akar...4,1:44w . Tagtitt:. . feta .prr -fax': at itist;aainik . fatet. 1' cis TO 114. ;an' :=4OPERTY• a 1 ••• STATE OF FLORIDA DEPARTMENT OF HEALTH APPLIC'ATION FOR CONSTRUCTION PERMIT Permit A..pplicatic:n Number PART 11- SITEPLAN le: Each block repr.esents. 10 feet and 1 inch = 40 feet. 5%40. W.J. I FO. \ I sfAA \ ; RaACE r—* 10.0. AS p AV. 95. CO'(RP,.!) \ 1 ...:•,, , L..... 0'4 sq 1 1 • ■ exi: 5 . cA i.N1 .:-. 2:iLL.,s'aii:g i i i sl *- • c---ed _ .. ,• b ! :- 4:. ../•-•• 7.- i / ' '. • .. " C - "0 . ' .CO:4C. szde • • • a• i ttL:-.. st..A 92". - ..- . . .1 • _i •-• •:/1 -r..7,1fr, I.: :'' .1 ... . ,.. •i — ; ,1 ._,Lml.5.>1£6 .c'i '• '.. A 91. ;*. . ":'-'1 '''■ '., ■ 4.•'• . u 'go P F. r••• WL FO.t /2- ONE 11:6'Y - - 34.62' • • F.1_ „sLt,a • '...•-• • ..t 4.72_ 3";" I.- • • • I. • • • • • ; A.57-•*;,A..T Of4...E WAY ' t/ •••.,. FC. %01 7(5 III K. 7. C3 S. WALL 2 7.0' pAagWAY ASPII. 1 rez /CT.% ••• 7 PAVE).1,..:N 4- plan .submitted Approved Not Approved nate Cd'..1rty Heat': Departme7.:t ALL CHANGES MUST EE APPROVED BY THE COUNTY I-iEALTH DEPARTMENT c: re .s : sr..s :se F 5 Pa;.• 2 .7t 4 05/30/2013 15:39 9545839802 JI, INSURANCE PAGE 01/01 — CERTIFICATE OF LIABILITY INSURANCE 1 DATETIiiill/DD*) j 05/30/13 PRODUCER JW Insurance Services 100 North Stets Road 7, # 105 Margate, FL 33063 Phone (954) 583-7213 Fax (954) 583-2045 INSURED Nu- Black Septic & Drainfield Company, Inc 401 SW 12th Avenue ! I Dania Beach, FL 33004 .1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR „ 4:-.VE1;14.GE AFFORDED THE., INSURERS AFFORDING COVERAGE NAIC INSURER Canal ........ NSURER B: NSURER C: VSyRER D: — -- • -.— I, .• . . ••••• ___. • _ --• .___ _ ____ •......._ ..___ ..._..... ..._.__... T INSURER E: COVERAGES INSURER F: THE POEICIEST5P INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED RAI CA ft:, ABOVE FOR THE POUGY PERIOD IRBICATED. NOTWITHSTANDING --- ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VVITH 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. 11-TRLINSKi,.. __ TYPE 0...F INSURANCE . _. POLICY NUNIBER.......icsATEmwdcort...; INDR I ADO'L • POUCy EFFECTIVS POLICY EXPIRATION1 1 ; GENERAL LIABILITY 1 OATe, (MWD DNY) EACH OCCURRENCE LIMIT3 :V. COMMERCIAL GENERAL LIABILITY GLi 04639 100,665 ! 05/28/13 : 05/28/14 E TO RENTED PR,EMISES (Ea ocourenoe)_. , ,. : . .11.. CLAIMS MADE Fe OCCUR i A MED EXP (Any one person) _ !...1 17,BRiONAL8,Ti5714jUiti100,000 .• ..... : J . . . ...... ...._ _. .._ GENERAL AGGREGATE 200,000 GERI AGGREGATE LIMIT APpLIES PER' - COMP/OP AGG 100,000 , Se] POLICY L.] PROJECT LOC .. . Fire Damage Liability ..... _ AUTOMOBILE LIABILITY • ---- • • • . 1.‘..) ANY AUTO COMBINED SINGLE umrr , iEsecaldent) ... .. .... ........ • ",! ALL OWNED AUTOS 1 I SCHEDULED AUTOS (Per person) r:1 HIRED AUTOS • NON OWNED AUTOS BODILY INJURY (Per sodden i PROPERTY DAMAGE (Per acclaera) ! GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ; • .1 ANY AUTO I " OTHER THAN . EA !4P AUTO ONLY; AGG ........ EACH OCCURRENCE BODILY INJURY EXCESSIUMBRELLA LIABILITY .1 OCCUR E CLAIMS MADE .1 i DEDUCTIBLE RETENTION $ • WOkKEWS COMPENSATION ANEI EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE I OFFICER / MEMBER EXCLUDED? If Yes, deSCrIbe under SPECIAL PROVISIONS bAgw .. _ ; OTHER 1 DESCRIPTION OF OPERATIONS/LoCATIOWS Wiliam& TE XcLUA ttai- ADDED iiiiiNDOFtsEMENT / SPECIAL PROVISIONS SEPTIC TANK - INSTALL / SERVICE / REPAIR **" AGGREGATE TATU- OTH- EL. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE EL. DISEASE - POLICY LIMIT . . •••••••■••••■••• •• •■•••• ••••••••-• . CERTIFICATE HOLDER Miami Shores Villages 10050 NE 2nd Avenue Miami Shores, FL 33138 1FM- 305-755-8972 • " ACORD .4tiF - • CANCELLATION . ----- • - ----- SHOULD ANY OF THE ABOVE: DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THETOT, BUT FAILURE TO 00 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ....... ACORD CORPORATION 1988 Ilutil in IHI 11111 11111 11111 11111 011 NOTICE OF COMMENCEMENT CFN 2013R0419292 A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION1R -CE41 28649 PS 0008; (1p9) RECORDED 05/28/2013 14:32:36 HARVEY RUVINp CLERK OF COURT MIAMI-DADE COUNTY? FLORIDA LAST PAGE PERMIT NO. STATE OF FLORIDA: COUNTY OF MIAMI-DADE: TAX FOLIO NO. 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, 1. Legal description of property and street! address: -11.320508.0260 1113 N.E. 98th Street /Aram' Shores FL 33138 2. Description of improvement Draintield Repair 3. Owner(s) name and address: --- A Mt T. Brute II id° e interest in property:owner Name and address of fee simple titleholder: 4. Contractor's name and address: Np-Eilack Septic 84trahlfietd Company 2714.41/.4thAve. DanraBeach. F/331304 Ulla OF. FLOI'lleik coumwo . Surety: (Payment bond required Name and Address: Amount of bond $ 6, Lender's name and address: by owner from contrel64,z YchsOTIPYtittill odginal Mad 1,1 t1.4 Au> &to t.. WITATIlnylioad& UVIN, Mad QM* 201,1.4 Araffar.■ 7. Persons within the state of Florida designated by Owner u • • whom notice provided by Section 713.13(i )(a)7., Florida Statutes. Name and Address: Get, 4 other documents may- be served as 8. In addition to himself, Owners designates the following person(s) to receive a copy of the Uenor's Notice as provided in Section 713.13(1)(b), Florida Statutes. Name and Address: 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) Aug. 31, 2013 Signature of Owner Print Owner's Name JO c) Prepared by 0.-1.0101 Sworn to and sUbscribed before me this 2 day of /11 ith , 20 1,3 . Address: Notary Public: Print Notary's Name: My commission expires: NMmyPublIeStMedFlericW Silvio Ortega • my Commission EE115658 1,0, pp* Expires 07/26/2015 U TORE 1 6538 Collins Avenue Miami Beach, FL 33141 MIAMI -DADE COUNTY CLERK OF COURT RECORDS DEPARTMENT 22 N.W. 1ST STREET MIAMI, FL 33128 DATE:05/28/2013 TIME:02:32:36 PM RECEIPT:3390950 NU BLACK SEPTIC CO. REF: 954 -927 -4090 ITEM -01 NCO 02:32:36 PM FILE:20130419292 BK/PG:028649/0008 RECORDING FEE 10.00 COPIES 1.00 CERTIFICATION 2.00 POSTAGE FEE 0.46 Sub. Total 13.46 AMOUNT DUE: PAID CASH: CASH RETURNED: TOTAL PAID: REC BY:LORETTA DEPUTY CLERK $13.46 $13.50 $.04 $13.46 --7;;;q6,_75-7 z l IIIL Vlay, 22. 2013 12:42PM No, 2501 —P. 2/2 SATE (.- ,,,.., -.... Y) t CERTIFICATE OF LIABILITY INSURANCE 05/2212013 ,�,,r C>:RT THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTFICATE 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 certiilcate 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 does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT NAME: PRODUCER South Florida Casualty 416 North 4th St Lantana, FL 33462 Phone: (561) 533 -6144 Fax: (561) 533 -6170 INSURED NU -BLACK SEPTIC & DRAINFIELD COMPANY 27NW 4TH AVE DANIA BEACH, FL 33004 COVERAGES PHONE t.1e. EAR E•MAIL ADDRESS: IPAX IA/G Nol: INSURERS) APFORDING COVERAGE INSURER A; FOB! (Primary) INSURER BI Safety National Caeuaity Corporation (Excess- AM beak A Excellent -X) INSURER C: INSURER 0: INSURER 5; INSURER F: CERTIFICATE NUMBER: REVIS THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N/ INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCU CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED MB EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LtR TYPE OF INSURANCE IAODL SWVD POLICY NUMBER POLICY EFP (MMIOD/YYYY) POLICY EXP (MMIDDIYYYY) GENERAL LIABuTY COMMERCIAL GENERAL LIABLITY 1CLAIMS-MADE i OCCUR r3>:N L AGGREGATE WAIT APPLIES PERI PO- -] POLICY JECT n LOC AUTOMOBILE LIABLrfY ANY AUTO ALL OWNED OS HIRED AUTOS .--_ SCHEDULED AUTOS AUTOS -OWNED A B UMBRELLA LIAR EXCESS LAB OED I 1 RETENTION 5 OCCUR CLAIMS -MADE WORKERS COMPENSATION AND EMPLOYERS' LIABLILITY ANY PROPIETOR 'PARTNER/EXECUTIVE YI I OFFICER/MEMBER EXCLUDED? (Mandatory In NN) It yea, describe urxiar DESCRIPTION OF OPERATIONS below NIA A 10650868 B- SP4048186 10/31/2012 04/01/2013 10/31/2013 04/01/2014 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attaeb ACORD 101, Additional Remarks Sciwdule, if more apace is required) CERTIFICATE HOLDER Fax (305)7564912 MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI SHORES, FL.33138 ACORD 25 (2010/05) CANCELLATION NAIL IMED ABOVE FOR THE POLICY PERIOD ,-- MENT WITH RESPECT TO WHICH THIS REIN IS SUBJECT TO ALL THE TERMS, LIMITS _ EACH OCCURENCE $ PRFEM 3ES (E, oocurence) S 5 MED EXP (Any One Person) PERSONAL & ADV INJURY $ GENERAL AGGREGATE s PRODUCTS - COMP /OP AGO g S COMBINED MOLE LIMIT (;Ea accldennl1 BODILY INJURY (Per person) 5 BODILY INJURY (Per secitlent) 5 PROPERTY DAMAGE (Per ac�'denq $ $ EACH OCCURENCE $ AGGREGATE S S _ WC STATU• I QTH- TORY LIMITS 1 I ER E.L. EACH ACCIDENT s 100,000 E.L. DISEASE •EA EMPLOYEE S 100,000 E.L DISEASE - POLICY LIMIT $ 500,000 r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL OE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE p 1988 -2010 ACORD CORPORATION, All rights reserved. 05/16/2013 12:07 9545839802 JW INSURANCE PAGE 01/01 '�'�� DATE (MM/DpIYY) -. —' '°�..:.,. — CERTIFICATE OF LIABILITY INSURANCE r 05/76/13 f •PRODUCER JW Insurance Services THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 100 North State Road 7. # 106 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Margate, FL 33063 9I-TER THE COVERAGE AFFORDED BY THE FOLIC ES BELOW. -- __Phone (954) 583 -7213 Fax (954) 583 -2045 INSURERS AFFORDING COVERAGE NAIC /k INSURED Nu- Slack Septic & Drainfield Company, In INSURER A_Canal Indemnity 401 SW 12th Avenue INSURER s: Dania Beach, FL 33004 INSURER C: INSURER D: INSURER E: COVERAGES INSURER F: 7 THE POLICIES OF INSURANCE LISTED HAVE BEENIISSUED 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. INSR ADD X:Y EFFECTIVE POLICY EXPIRATION L[R _IN§RD • TYPE OF INSURANCE POLICY NUMBER DATE (1Wb DATE (MANGO/! GENERAL UABILITY Q COMMERCIAL GENERAL LIABILITY 00 CLAIMS MADE OCCUR A ❑ GEN'L AGGREGATE LIMIT APPLIES PER ❑ POLICY ❑ PROJECT ❑ LOC AUTOMOBILE UABILITY -- ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS 0 HIRED AUTOS ❑ NON OWNED AUTOS '❑ GARAGE LIABILITY ❑ ANY AUTO 0 EXCESS/UMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under SPECIAL PRQVISIONS below OTHER 0L103168 05/28/12 1 05/28/13 LIMITS EACH OCCURRENCE DAMAGE TO REFrrt PREMISES (Ea oCOurertce) MED EXP (Any One person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGO Fire Damage Liability COMBINED SINGLE LIMIT (Ea accident) - BODILY INJURY Per -rem.) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per aaiden AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: 100;000 5,000 100,000 200,000 100,000 50,000 EACH OCCURRENCE AGGREGATE AGO LT W STATU- ❑ OTH- TO /LIMITS E' E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS **** SEPTIC TANK - INSTALL / SERVICE / REPAIR * * ** CERTIFICATE HOLDER Miami Shores Villages 10050 NE 2nd Avenue Miami Shores, FL 33138 1 FAX- 306 2766 -D072 ACORD 25 (2W1 /OS) QF CANCELLATION SHOULD ANY OF THE AEQVE DESCRIBED POLICIES EE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 PAYS WRITTEN NOTCE TO THE CERTIFICATE HOLDER NAMED TO TIE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. • AUTHORIZED 'REPRESENTATIVE ACORD CORPORATION 1968 PLCASE GUT OUT THE CARD StfamA3F memo* D OmDEPARTMENT SERVit 3 CONSTRUCTION TNOUSTINt CIRTIPICATtOFILIECitpai To BE cm:1a m PROM PIRRiDA WORtififOr.COIRMiumel L•AW BELQW AND RETAIN FOR FUTURE REFERENcfi E F>^CT$V&• a+Ft1f2oy2 1DoPtounTuN ORM: 04f11f2014 .taliRSl3ete .• DAVID -DRAW' 3R••• • FEW 56 T [MAIMS A ADORESU• 40t SW Ind noutrya Dome snot ft 39004 SCOPE OP l ss ,OA .TRADE 1- Atuno eo 0n DRAINING SNITS' t11�mARTANT DP Puna= to Chapter 44O041,41 F&, an officer -of Leomocaniay.adia effects encomia from this •oblpter br filing ■ catificato or decline tinder MIT section >ty not recover benefits-or composiSation Calder this D chapter. PurSomit s0 Gtepw 440 .05(12). F.S., corttiaates of-olomforta.bc .R Yi a w'Pt• RR* air *HMO the scope of the Nelms. Dr..to o..tiNO.a,R Cho notice of &eeties to be enamor. E mirovont to Chapter 440.11543l. • F-5, fps -of slec+ioo •or- he•ottempt and verfNpetes of election to be exempt shaft be subjoin to remotion '+Ole after Me Mao of the nodes or the +sswnee of she cerdfietle.. see. perste, oo ed . on -tic• ttatitts • of certificate rte 'roofer moms the requirement" of Ibis section for issusgto of a. eerttfirara, The) ttepvrtment NIA ratlike a certificate at imp time for failure of ttte 'person. armed on the sertitieeco to reset the requirements of this socuon, • A St1ONS?'NNW '44341589-. BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954- 831 -4000 VALID OCTOBER 1, 2012 THROUGH SEPTEMBER 30, 2013 DOA: DAVID =BY NU BLACK SEPTIC TANK & ReceiptALI9, o TYPES CONTRACTS) Business Name: DRAIN Business Type: (SEPTIC TANK CONTRACTOR) Owner Name: DAVID 0013Y Business Location: 27 NW 4 A'c1E DANIA BEACH Business Phone: 954-927-4090 Rooms Employees 2 Business Oponod:oe /01/1989 State/County /CertlReg:sR93U.118 Exemption Code: Machin Professionals For Vending Business Only Number of Maahinos: Vendirm Tvpe: Tax Amount Transfer Fee NSF Fee Penalty Prior Years . Calla- aladion Cost Total Paid 27.00 0.00 * 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non - regulatory in nature. You must meat all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transfetred Wren the business is sold, business names has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. mailing Address: DAVID RUBY 401 SW 12 AVE DANIA, FL 33004 2012 - 2013 Receipt #038 -11- 00008655 Paid 07/25/202.2 27.00 Registered Septic Tank Contractor SR0931118 DAVID MAP( 401 SW 12 AVENUE DANIA FL 33004 NU -SLACK SEPTIC & GRAINFIELD - COMPANY Business Authbrizatien: SA0111760 Registration Expires on September 30, 2013