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PL-11-1834Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 165179 Permit Number: PL -10 -11 -1834 Inspection Date: January 30, 2014 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: DEVELOPMENT GROUP, REALTY Work Classification: Septic Job Address: 68 NW 100 Street Miami Shores, FL 33150- Phone Number Project: <NONE> Parcel Number 1131010180460 Contractor: JASON'S SEPTIC INC Phone: 305- 252 -1080 Buildina Deoartment Comments NEW 1050 GAL TANK Passed Ea" Inspector Comments Failed El ;a Correction Needed _ f 0' Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re4nspection fee is paid. For Inspections please call: (305)762 -4949 January 30, 2014 Page 1 of 1 Miami Shores Village SCE -VF- Building Department JAN: 2 9 2014 0050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BY SPECTION'S PHONE NUMBER: (305) 762.4949 FBC 20 BUILDING Permit No. FL 11 I ? `f PERMIT APPLICATION 1 IN Permit Type: PLUMBING Master Permit No. JOB ADDRESS: C� n W 1 004 h :54 City: Miami Shores County: Miami Dade Zip: ISO Folio/Parcel #: i/ 3 / 01' 4)/,F DY('0 Is the Building Historically Designated: Yes OWNER: Name (Fee Simple Address- (A J\) �") City: NO Flood Zone: As 4,?s ;Tb State: F) Zip: 35 150 Tenant/Lessee Name: Phone #: Email: CONTRACTOR: Company Name: is Vie. � � � Phone #: _305 '10` r 77r? Address: I -3-sq/ 5W y ye-. City: State: F Zip: 3' 3 Qualifier Name:; , 9^ 'fix V� Phone #: -3 0:5 96d ' l WO State Certification or Registration #: S t: Oco i %4 qq Certificate of Competency #: Contact Phone #: S 'S a 5;� / 0'F) Email Address; \DSO `^ S 1C DESIGNER: Architect/Engineer: 1 Value of Work for this Permit: & /• � ®[� Sanare/Linear Footage of Work: 3 �© -f' Type of Work: ❑Address ❑Alteration ++ ❑New ❑Repair/Re place ❑IDemolition Description of Work: e,W K O �� T� � � W L]300 + F �9 Submittal Fee $ Permit Fee $ ->>J 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 Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State zip 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 b delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencemen m be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. ,,jn the ab of such posted notice, the inspection will not be approved and a reinspection fee will be charged. �� Si .-Qjt v' " ," Owner or Agent The foregoing instrument was acknowledged before me this .24 4) day of 20 _N, by A-0 r H0 Qe- y + , who is personall known tome or who has produced_N.9� -7 b ZW -(� As identification and who did take an oath. NOTARY PUBLIC: Pu6Hc'stm of My Commissio s Joanna M Feliciano° e or wp My Comnmsalon FF 082753 j Expires 01/12/2018 �/ Contractor The omg instrument was acknowledged before me C1 day of .�osY�Voory , 20 / b hls�nv6 Mr� v� , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: eReY3t�YaY4e4ede Yak k:YsYoY�Y9e & &:Y &�9aoF�Y4e x Y� YsY,k3: Y�F: �r: FFnY4c4nYsY4r��Y�: Y3nY�Y3: 3r4e1k4z: k3e3eiY�3: 3e3esk4e�9e�Y��Y: Y: Y�Y9e3e4e4e4c9e�r9e9e4e4e4rie�Y4: �Yde kdeFe4e9e�Y9e9e9e3e4c4e4e3e�Y3e�Y� APPROVED BY K�:IXT–/V Plans Examiner Structural Review (Revised3 /12/2012 )(Revised 07 /10 /07XRevised 06 /10 /2009)(Revised 3/15/09) Zoning Clerk Miami Shores Village '751 , wilding Department OCT 0 5'20'11 00 0 N.E.2nd Avenue, Mi ami S h o r es, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BY: " " "° BUILDING Permit No.PL-- (1 '-� 1 PERMIT APPLICATION FBC 20 Permit Tvne: PLUMBING Master Permit No. Tenant/Lessee Name: ^44 Phone#: /t' /A- Email: r. JOB ADDRESS: && /y w On .J*° City: Miami Shores County: Miami Dade Zip: 33 1 —1 S Folio/Parcel #: % 3/0) OR o tl f vo Is the Building Historically Designated: Yes CONTRACTOR: Company Name: Address: ��Q I Alm NO Flood Zone: City: State: Zip: 330(a Qualifier Name. State Certificatio Contact Phone#: DESIGNER: Architect/Engineer: r Phone#: Ili) (IC1 Value of Work for this Permit: $ I tZ� ")Square/Linear Footage of Work: 300 �p Type of Work: ❑Address ❑Alteration ❑New ;Iftepair/Replace ❑Demolition Submittal Fee $ -'L Permit Fee $ 300 CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such ed notice, the inspection will not be approved and a reinspection fee will be charged. 111111111111VR��E 01 m Owner or Agent The foregoing instrument was acknowledged before me this . day of �: , (1 20 , by � i' btR Ue 2R) Contractor The fo 301g instrument was acknowledged before me this day of Q , 201, tai = , kiln '1 le; m-j 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 PUBLI Sign: /1 " Sign: Print: 0� /� �, c�C/o, Print: My Commis ion My Commis `o NESTOR VAZQUEZ MY COMMISSION # OD923828 ' 407 39M FlDridwf �m APPROVED BY ®� Plans Examiner Structural Review (Revised 07 /10 107)(Revised 06 /10/2009)(Revised 3/15/09) NESTOR VAZQUF °e MY COMMISSION # 009238 ,78 `-- iFP°�daW�.com Zoning 09/30/2011 18:48 FAX STATE OF FLORIDA, DEPARMONT Or xzaLTB MITE GMMGM TASAT1iMNT AND 0I9POSM SYSTM CONSTRUCTXCH PSMT CONSMUCTION PMWT BoA: OSTDS Repair APPLICANT: (Real ate Capital) PROPERTY ADDMNS; 88 NW 100 St Mtomt, FL 33175 LOT: 13 ELOCRs 5 sOS MSION: PROPERTY M 0: 11- 3101 -013 -0460 im 003/003 PEacT #-.13-SC-1371328 APPLICATION s:AP1048480 DATE PAID: MM PAxa: RECEIPT 0• Der #: PRMG18 [BECTZON', %=MSHIP, RANGE, PAR= NtDOM] [OR TAx M NMMR] ereTEM MUST BE CONSTRUCTED IN ACCCWM= WITH gp=117CA',t'IONS AND STAbMARDS Op SEICTS0M 3e1-0065, B.S., AM Cmu=R 64E -6, B.A.C. DEPARMUNT APFFMAL 01T $Y8Tm4 Dog$ NOT GARANTEE $ATISBACOM PSWOMMME FOR MY SPECIFIC ft=QD or TUC. AW CWW IN M►TERIAL FACTS, WHICH SERVED AS A BUIS FOR 7:8SUhM OF THIS PELT, REOMXE THE APPLICANT TO MDDjyr TgE PEMUT APPLICATION. BUCK t4MIFlCA XWB MAY RESULT TN THIS PEMUT ZZINC MADE N17LL AND vom. ISSUANCE OF THIS PEECT 0095 NOT MOMPT THS APPLIMM FROM CCEWJAW= W2TH onn MWERAL, STATE, OR LOCAL PEM CTTWG REQUEMM FOR DEVraLORONT OF THIS PROPERTY, 6Y8TZH DESI= a= sPECxprCATION$ T t 1.060 ] GALZM3 / GPD SBadC CAPACITY A t 0 l CALLMS / WD CAPACITY P [ 0 ] GALLONS 12R&ME XMIERCHPTOR CAPACITY 12MMON CAPACITY $THOLE TANK :1250 GALLONS] is [ ] essr LOWS D053NG TANK CAPACITX t I GALLONS it t I D05138 PER 24 AIRS $Pumps [ D t 300 ] SQQARa BEET In trench configuration eye= A [ 0 ] SQUARE MT SYSTEM A TM SYS=; [xJ O Mt07ARD t ] FILM t J MMM [ ] I CoN7i'IGt7RATI0N: [x) Tam= I I BED [ ] N B LOMMON of 73MCE bUM: FFE: 13.16' NOVD I ELEVATION or PROPOSED MTH4 SITE E DOTTOM OF DRAINF2ELD TO BE [ 27.90 ] 11 nwims i'1' ] [ ABOVE &a .LWJwMMMWMMF1M2MM VQMW t 57.96 ] EtES FT J [ ABOVE' u 13ENCEAI'MM /Rg8E1W= POINT L D >PIJ+L �: t ] INC�B E7CCAdA'PION REQU7 hull 1060 g septic tank. o - Install 310 Sq ft drainfield in trench c onfiguragon. T - Install 12" of alightly limited soil under bottom of drainffeld, AA - Elevation of bofm of drainfield to be no lass than 8.3' NOVD. - Not for additions a The licensed contractor Installing the oyatem Is responsible for Installing R the minimum dory of tank in w=rdence with s. 84E- 6.013(3)(1), FAC SPECI77:CA 1=8 BY: AEON "80N I DATE I$9M. TITLE: The contractor (or designs) is required to perform a soil boring adjacent to the drainfield excavation at the time Of final Inspection. Prior to final Approval. qta DOH inspector shall witness fire $oil boring and compare the results to the original site evaivatlon submIM. A reinspection fee wie be asesssed If the Contractor is not at the jobslte at the arranged time. EnQimmv Specilaist II Dade CHD DH 4016, 08/09 (Obacl(ftee all previous editions which may not be us") Incanmcatodi 64E- 8.008, FAC S"XRR=CN DATE s 12129!2011 e i.1.4 AP1040400 M53169 Page 1 of 3 `• MIAMI-QA DE COUNTY TA CTOR 14 iaLER ST;, let FLOOR MIAMI, FL 33130' JASONS SEPTIC INC JASON NESENMAN FIRES 13341 SW 88 AVE MIAMI FL 33176 i „li, 111111, 1ili1„ 1,! 1, 11i111i1i1111l1 ,1,li „! „i,,,li�i�f,i 2010 LOCAL BUSINESS TAX RECEIPT 2011 F FIRST -CLASS MIAMI- Ab>= NTY 2011 LOCAL BUSINESS TAX RECEIPT 2012 U.S.IPOSTAGE FIRST -C U-S. SS AGE TAX COLLECTOR MIAMI -DADE COUNTY - STATE OF FLORIDA MIAMI, FL PIK PERMIT NO. 231 140 W. FLAGLER ST. EXPIRES SEPT. 30, 2012 1 St FLOOR MUST BE DISPLAYED AT PLACE OF BUSINESS MIAMI, FL MIAMI, FL 33130 PURSUANT T COUNTY CODE CHAPTER 8A - ART. 9 & 10 PIERMtrmo.231, 1 htis Is I�tQ A SILL - DO NOT PAY ^ NE�lE4lAL ' 517536 -7 ' �. euANSMNC GC. #"1444 1540:967-7 13f44, SW 88 AUK 33Z7 UNIN VAUE COUNTY ' � oWNeR'^� -� 4 JA30N5 SEPTIC INC WORKER /S 1T ' IPE$CI TY - PLUMBING CONTRACTOR 3 11ft -I$ ONLY - A_�._OCAL SUM M TAX R IT ,OEB NO PERMIT TH$ TO VIOLATE ANY _ 1 eU rae „ DO NOT FORWARD `• MIAMI-QA DE COUNTY TA CTOR 14 iaLER ST;, let FLOOR MIAMI, FL 33130' JASONS SEPTIC INC JASON NESENMAN FIRES 13341 SW 88 AVE MIAMI FL 33176 i „li, 111111, 1ili1„ 1,! 1, 11i111i1i1111l1 ,1,li „! „i,,,li�i�f,i 2010 LOCAL BUSINESS TAX RECEIPT 2011 F FIRST -CLASS MIAMWADE COUNTY - STATE OF FLORIDA U U.S.IPOSTAGE EXPIRES SEPT. 30, 2011 �y v RAID MUST BE DISPLAYED AT PLACE OF BUSINESS MIAMI, FL PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 P PERMIT NO. 231 r TH - 517556 -7 RENEWAL BUSINESS NAME I LOCATION RECEIPT NO. 540967 -7 JASONS SEPTIC INC CC 0 SEP031444� 13152 SW 93 PL JJ 33176 UNLN DADE COUNTY OWNER JASONS SEPTIC INC Sec. Type of Bushum TY PLUMBING CONTRACTOR PAYMM RECOM ' ISAIN "AN COUNTY TAX ;COLLECtOM 09/30/2010 60080000263 000075.00 SEE OTHER SIDE WORKER /S 1 DO NOT FORWARD JASONS SEPTIC INC JASON NESENMAN PRES 13152 SW 93 PL MIAMI FL 33176 11111„ 1111,,,114,,,{ 111111i11111111111111111111111111 Sam 4 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFEREA'.CE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIV 02/28/2010 EXPIRATION DATE: 02/28/2012 PERSON: JASON A NESENMAN FEIN: 851105881 BUSINESS NAME AND ADDRESS: JASON'S SEPTIC INC 13152 SW 93'-PL MIAMI, FL 33176 SCOPE OF BUSINESS OR TRADE: 1- SEPTIC TANKS IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the notice of election to be exempt R E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. CUT HERE - QUESTIONS? (850) 413 -1609 * Carry bottom portion on the job, keep upper portion for your records. J OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 Registered Septic Tank Contractor JASON A NESENMAN 13341 SW 88TH AVE MIAMI FL 33176- ' JASON'S SEPTIC INC. Business Authorization: SA0031157 SR0031444 Registration Expires on September 30, 2012 10/05/2011 12:01 7862067066 --- CERTIFICATE PRODUCER Galloway Insurance 17354 South Dixie Highway Miami, FL 33157 Phone (305)255 -1681 Fax (786)2W7O86 GALLOWAY INSURANCE PAGE 01 O.F.-LIABILITYINSU RANCE r BATE (NRWDDIYYI_. THIS CERTIFICATE IS ISSUED AS A MATTER & INFORW616N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLOSR. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER TMAP-M-M-29-E-AEFORDIF111 R)LEH9.F.P. LICIES BELOW.... INSURERS AFFORDING COVERAGE NAIC # Insurance CnMnanv INSURED Jason's Septic, Inc. INSURER A BUrlinatnn In 8763 SW 129th Street INSURER 13; INSURER C' Miami, Florida 33176 TKSURr M I Vendor# 264564 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED To THE INSURED NW90 ABOVE FOR N POLICY PKW605 —INDICATED. NOTWrd4*rANDRG- ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTMFR 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. AOGR LNAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AWLi POLICY eFFECM XIR INSRD: TYPE OF INSURANCE POLICY NUM13ER . 7,!ALr,.(Yl LIMIT$ GENERAL LIABILITY EACH OCCURRENCE $1,00000() COMMERCIAL GENERAL LIABILITY 1838009067 12107=10 12107=11 PR EWSjkt(tsa s9wn—Ir.") CLANS MADE [I OCCUR MED EXP (Any one pm m)- A PD; Ded: $260/01alm PERSONAL & IIV $1,000,0 0. GENERALAGGREGATE $2,WO,000i 17 i��. j. )00.. ...1 Or-N4- AconECATE: LIMIT APPLIES PER: PRODUCTS - COMP /OP 000 POLICY []PROJECT ❑ Loc AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANT AU10 (Fo awfido ❑ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (per person) ❑ HIRED AUTOS ❑ NON OWNED AUTOS BODILY INJURY reociderd) PROPERTY DAMAG.F. GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ❑ I ❑ ANY AUTO OTHER THAN AUTO ONLY: EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE �❑ OCCUR Ej CLAIMS MADE AGGREGATE DEDUCTIBLE RETENTION 5 6 RT r"A- T-10 - 14 —.Mt F EMPLOYER• LIABILITY ❑ WC STATU- ❑ 0TH• ANY PROPRIETOR I PARTNER! EXECUTIVE YIN _TORYLIMMS. ER-. OFFICER /MEMBER EXCLUDED? EACH ACCIDENT f�d E . L. nLRFASF - P()I KY I IMIT OTHER . . .... DESCRIPTION OF OPERATtQWj1-%,-Q--CA* TI-0- N, E*M'** CLEO I EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS ln$Wllation, Service, Repair, Excavation, Maintenance and Cleaning of Septic Tanks... `Please note that any changes to this policy must be submitted to the Insurance Company for approval""... City of Miami Shores 10050 NE 2nd Avenue MISMI Shores, Florida 33138 Attn: SuilldIng Dept Fax 111305-7-543-8972 ACORD 26 (2009/01) QF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE MWIRATION DATE THEREOF, THE ISSUING INSURER *LTL!t)=M TO MAIL 30 DAYS WRITTEN NOTICE TO THE CER ED TO TiKLOT, BUT FAILURE TO 00 80 SMALL IMPOSE N LIG N OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR R AUTHORI[ZED REPPMESIENTATIVI! I Jose H Romero, Licensed Agent-A225234 P NIIII-XI09 ACORD CO P ON. "All "rights "risimW. The ACORD name and logo are registered marks of ACORD 06/26/2012 12:01 7862067866 GALLOWAY INSURANCE PAGE 01 CERTIFICATE OF LIABILITY INSURANCE -- A s z —WMWV"' PRODUCER Galkmy Insurance THIS CERTIFICATE IB ISGU60 AS A MATTER OF INFORMATION ONLY 17364 South DiX19 Highway HOLDER.THHCERTIFlCATE DOES NOT AMEND, EXTEND OR Mlaml, PI 33157 GE AFFORDED BY•THE_ I,Awl _ Phwm (305)295.1681 Fax (786)206.7088 INSURERS AFFORDING COVERAGE NAIL A FBA; Atlantic Ca8WlaRy_insurance COnpany- mOURSD Jason's Septic, Inc. INSURER B GlU NlauS Insurance Gvm pany 133413W 88th Avenue INSURER C: Miami, Florida 33176 J Vendor # 264664 INS..W" [INSURER E. M COVERAGES _ THE FbLtts 0 IN8URAMCd USTED HAVE BEEN ISSUED TO THE INSURED NAMED AHVVk: MK me POLICY PERIOD MICATED. NOTWITHSTANDING ANY RECUIREMENT, 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 OSSOMBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGCREGAT6 LIMITS SHOV01 MAY HAVE BEEN RROUCED NY PAID CLANS. M ADD'L __... _ . P TYPE OF INSURANCE POLICY NUMBER °MXY LFFECM@ pgLIf.Y67IPRATM�Ai LIMITS DATE (InttMWYYY'r) SrAiE 1MpUbr�YlIMf1J - - - Q ALL OWNED AUTOS BODILY INJURY [, C� SCHEOULEDAUTOS (P� ❑ HIREDAUTC0 8001LYINAMY ❑ NON OWNED AUTOS �(ParecddenO i r,�vrrr%1 r bor- -vc ❑ — _..... . __�_ _.._ 1Vaeci "- GARAGE LUOLIYY AUTO ONLY - EAACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC _. ❑ AUTO ONLY: AOG EXCESS 1 UMBRELLA LIABILITY -- � EACH OCCURRENCE ® OCCUR ❑ CLAIMS MADE �6 12/27/2011 12/27/2012 AGGREGATE ' ❑ DEDUCTIBLE ® RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I I E.L. EACH ACCIDENT R ANY MHtWKIt t UK I YAK I NtK I tRt(:U 1 NL OFFICER I MEMBER EXCLUDED? f(f t iin WQ EA, DISEASE - EA EMPLOYEE .. _ A r' u LM _..— -•- - - - -•• - - -- , E.L. DISE"S - POLICY LI-rr —.._. . ._..---- - -_.... . DBSCRB►i}ON OF OPERATIONS / LOCATIONS t YGFaCLBS / E]CCLUSION9 AQDBD BY ENDORSEMENT I SPBCUWL PROVLRtON3 Installation, Service, Repair, Excavation, Maintenance and Cleaning of Septic Tanks... "Please note that any changes to this policy must be submitted to the Insurance Company for approval"... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POL(C� Be 'LED BEFORE THE EXPIRATION DAYS THEREOF, THE! ISSU W INSURER VOR TO MAIL Village of Miami Shores 30 DAYS VItRIMN NOnCE TO � CERTIFICATE of NAMED TO 100$0 NE 2nd AWtBnUEr TRLT&T, BUT FAILURE TO DO 60 SHALL OWWOSE No OR LIABILITY t Miami Shores 33138 OF ANY KIND UPON THE INSURER 1YS AcRENTS OR REP Miami i Shore Dept AUTHORED REPRESENTATIVE I J Fax # 305- 7W8Q72 Jose H Romero, Ucensed AgBM A22523A AGORI? 28 (,2�9►rotl oi� _ .. _ .. _......... ® isse- zogeACOrio CORPORA N. A11 'riahb . The ACORD name and h*o are 1"I red matt of ACORD GENERAL LIASILRY E EACH OCCURRENCE _ $1110 C $1 COMMERCIAL GENERAL LIABILITY L L- 027002718 1 12/08/2011 1 _ $ ❑ E n CLAM MADE OCCUR M MED EXP (Any one pwaw) _ _ $2,C $1,C i r,�vrrr%1 r bor- -vc ❑ — _..... . __�_ _.._ 1Vaeci "- GARAGE LUOLIYY AUTO ONLY - EAACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC _. ❑ AUTO ONLY: AOG EXCESS 1 UMBRELLA LIABILITY -- � EACH OCCURRENCE ® OCCUR ❑ CLAIMS MADE �6 12/27/2011 12/27/2012 AGGREGATE ' ❑ DEDUCTIBLE ® RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I I E.L. EACH ACCIDENT R ANY MHtWKIt t UK I YAK I NtK I tRt(:U 1 NL OFFICER I MEMBER EXCLUDED? f(f t iin WQ EA, DISEASE - EA EMPLOYEE .. _ A r' u LM _..— -•- - - - -•• - - -- , E.L. DISE"S - POLICY LI-rr —.._. . ._..---- - -_.... . DBSCRB►i}ON OF OPERATIONS / LOCATIONS t YGFaCLBS / E]CCLUSION9 AQDBD BY ENDORSEMENT I SPBCUWL PROVLRtON3 Installation, Service, Repair, Excavation, Maintenance and Cleaning of Septic Tanks... "Please note that any changes to this policy must be submitted to the Insurance Company for approval"... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POL(C� Be 'LED BEFORE THE EXPIRATION DAYS THEREOF, THE! ISSU W INSURER VOR TO MAIL Village of Miami Shores 30 DAYS VItRIMN NOnCE TO � CERTIFICATE of NAMED TO 100$0 NE 2nd AWtBnUEr TRLT&T, BUT FAILURE TO DO 60 SHALL OWWOSE No OR LIABILITY t Miami Shores 33138 OF ANY KIND UPON THE INSURER 1YS AcRENTS OR REP Miami i Shore Dept AUTHORED REPRESENTATIVE I J Fax # 305- 7W8Q72 Jose H Romero, Ucensed AgBM A22523A AGORI? 28 (,2�9►rotl oi� _ .. _ .. _......... ® isse- zogeACOrio CORPORA N. A11 'riahb . The ACORD name and h*o are 1"I red matt of ACORD �• DIVISION OF • Environmental Health tb ,Q Florida Department of Health Miami -Dade County Health Department 10� �Q OSTDS/Well Division 0lj� 11805 SW 26 St. • Miami, FL 33175 O n y Inspector �� Dated — J SLIM Address �7Q .1,57 DS Comments: