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EL-13-1723Miami 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)162.4949 BUILDING PERMIT APPLICATION Permit Type: BUILDING JOB ADDRESS: Robin Avery JUN 0 6 2914 FBC 20 Permit No. EL -7-13-1723 Master Permit No. ROOFING City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-2232-028-0830 Is the Building Historically Designated: Yes NO X Flood Zone: 33138 OWNER: Name (Fee Simple Titleholder): Robin Avery Phone#: 305-891-4084 Address: 10618 NE 10 PI City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Phone#: Email: a_robin@comcast.net CONTRACTOR: Company Name: SafeStreets USA Address: 5660 W Cypress St Suite G 919-861-8521 City: Tampa State: FL Zip: 33607 Qualifier Name: William Alan Peacock Phone#: 919-861-8521 State Certification or Registration #: EG13000404 Certificate of Competency #: Contact Phone#: 919-861-8521 Email Address: jadams@safestreets.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 99.00 Square/Linear Footage of Work: Type of Work: OAddition OAlteration UNew URepair/Replace UDemolition Description of Work: "PERMIT RENEWAL" for Wireless Burglar Alarm - 1 Cell, 1 Panel, 2 Button Fob, 4 Door / Window, 1 Motion Color thru tile: Submittal Fee $ Permit Fee $ %,& ®° OP CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 10.2_<no 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 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 will not be approved and a reinspection fee will be charged. W Signature Si afore � Signature - Owner Owner or Ag Contractor The foregoing instrument was ac wledged before me this 2nd The foregoing instrument was acknowledged before me this 2nd day of June '20 14 by Robin Avery day of June , 2014 , by William Alan Peacock , who is personally known to me or who has produced DL 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: JARR®DAA, ADAMS NOTARY PUBLIC: JARROD M. ADAMS NOTARY PUBLIC a' ' NOTARY PUBLIC STATE•OF FLORIDA STATEOF FLORIDA Sign Sign: Print: rro Adams A' r Evoires 3/18/2016 print Ja d Adams a Fxoires 3/18/2016 My Commission Expires: 3/18/2016 APPROVED BY My Commission Expires: 3/18/2016 Z &IAC Plans Examiner Zoning Structural Review Clerk (Revised 3/1212012)(Revis (Y7/10/07)(Revised 06/10/2009)(Revised 3/15/09) STATE OF FLORIDA DBPARTJ>II W OF WOMBS AND PROPESSIONAL REt317LATION SLBCTRICAL COl+ MACTORS LICENSING BOARD (8501 4871395 • 1940 NORTH MONROR 8TR88T TALLANABBEB FL 32399-0783 PEACOCK"ETS t>1@A LLC M ALAN S3O 05SRR8 YNOR ROAD BUX TC1075Z9 Con dtlationei With this kense you become one of the near one million F1 clans Iicansed by the Department or Business and Profus anal RVAdon. Our professonals and budmesses range from architects to yacht brokers, from boxers to barbeque restaurants and 8rsy keep Florida's economy strong. Everyday we work to Improve the way we do bustrress in crderm serve you baits:. For IrdOrrnatlon about our services, please log onto www. i�nse cenr. There you can Md mors Mtomratton about over divisions an the regulations that IImpeddyyot ��es Axprriibet department newatetters and lean more about the odpOur mission at the Department Is: License EMclw*. Regulate Fairly. We constantly stove to serve you beater so that you oar serve your oustanrere. Thank you for doing business M Fiorift and congratulations on your now license{ AC# :1784.7•-8:•. •.: 4. 11110130004 6 Wagon"sig. of IAN „r�,:•.•BiA 118214227 _ • ?lQ� �!1'I�� di;;fslu p�n3�icros o�l.ts,4lJ9 !8 15��.dtas aw: 8rni:'31� :�1Qa�- L12S6' 9i�bs31 DETACH HERE CiF,FLORIpJ4 J . . R 5 Qxe UILU r W.'A W OWAMU $E(, r„ag06Z900631 04 • The A�Rtid 'BY®�Effi �rO'��1!� ��!1'AR ;°'IY>'t, 1~+Taioed belott• IB C1�1i'�'IF� •••�; }'� • a., • �• ��"' �' . .. Under the ' IP31 lciiin at -chap t NMpiration date$ =0 • 1. ,ZO�A .0 _ `��,. ►:.;+1 . /V1y�•�. � ;...• 4},4 ��:�. ,., Nva: .. ppm oiiK7 • ..V '•y •,,,+ `` �• 1• r ' . / ' ••' 0!- ` It 7 •,1.. 5660 V CYPBTRE>E'1' B TgG ;:t, `.r. �i''7 TA1MAMON :. FL•:33607 !�. „�►�''' RICK 000TT ' . .. ..... SEECCREETAARYY ..._.__.._.,.,_....__130VURNOli__...._..._._.__.._Q�..l�$�Ir►3REQt�•I.�t�D�1fv.SAW._._�_.___._...._.�........_._...».__.....__.__.._..... From ATC Processing OPS 8136126702 09105/2013 15:33 #991 P.0011001 HILL,QBORMN COUNTY RUSIK011,,,_I Tom( RN.EWAL_INIMCTIONSi Chapter 205.0535 (8) Florida Statutes requires one of the fa aWna. FEDERAL EMPLOYER IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER 1. SIGN and return entire tbrm In enclosed envelope. Your validated Business Tax receipt will be returned to you. 2. Business Tax receipts expire midnight, September 301h. Failure to display a valid Business Tax receipt atter September 30th Is a violation of Hillsborough County Ordinance 954. as amended by 02.5. MAKE CHECK PAYABLE TO: DOUG BELDEN. TAX COLLECTOR P.O. BOX 30012 TAMPA, FL 33830.3012 2013 0+4 HILLSBOROUGH COUNTY BUSINESS TAX RECEIPT FACLIMRS O MACHINS9 ROMT 8MP1.018 8 SAIEGMGME R0=TYPE Exph" 8.30.2014 FOLIO NO, 243108 H. WASTE SURCtIARt1E TAX 2.80.000 PUBLIC SERVICE ALARM SYSTEMS 112.00 L00ATION TAMPA 33907 BUSINESS 6880 W CYPRESS ST 0 PAFE STREETS USA LLP. LOCATION TAMPA 33807 MAILING NAME SAFE STREETS USA LLC D9UNQUENT OCT 31 201 MAILING 6305 RAYNOR ROAD STE 100 GARNER NO 27528 ADDRESS GARNER NO 27818 DODO BEL08N. TAX COLLECTOR DELINQUENT DEC 31209�� 34. Bus�NEss -roc HAS HIIRWPAIVA9USINEISTAXTOENGAGE 813$36.5400 SIGN IN 8LL9M & FROFENION.OR OMMATION8MCMED HEREON THIS BECOMES A TAX REORO TM01 VALIDATED OONTIA P1tifP x *1[: PAID - 21330 - 85 - 8/5/2013 *** 00011200 ra.w nv. 20+3.4014 HILLSBOROUGH COUNTY BUSINESS TAX NOTICE 2408 FACILITIES OR MACHINES ROOE18 SEATS 6MPLOYM 0 0 0 +0 H. WASTE CATEGORY CODE BUSINESS TYPE SURCHARGE TAX 290.000 PUBLIC SERVICE ALARM SYSTEMS 112,00 MAKE CHECK PAYABLE DOUG Bt:LDIJ+, TAX COLLECTOR P.O BOX 30012 TAMPA. FL 33UD4012 PAID - 21330 - 85 - 8/5/2013 *** 00011200 euelm"s 6060 W CYPRM Sr L00ATION TAMPA 33907 NAME: PAFE STREETS USA LLP. JULY 1-99PT 30 MAILING 5306 RAYNOR ROAD STI: 100 D9UNQUENT OCT 31 201 ADDRESS GARNER NO 27528 VELItMENT NOV 30 201 DELINQUENT DEC 31209�� 34. DELINQUkNT JAN 31 2014► `� . SIGN OONTIA P1tifP x ►6SvFIAI�OU8MYL10AA1t0l1FOpBV81lNBSTAIiiBF0AflR8U&F�49 on ocean M�ITED xenon u+e ie imm ruva �� PAID - 21330 - 85 - 8/5/2013 *** 00011200 `SIR i CERTIFICATE F LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/21/2014 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 policy(les) 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 John T. Costa Agency, Inc. P.O. BOX 2338 2025 Hamburg TPKE Suite J Wayne, NJ 07470 NAME: CONTACT Ralph A.Costa PHONE 973-835-8444 FVC No): 973-835-3056 EMAIL ADDRESS: ral h bur laralarminsurance.com INSURERS AFFORDING COVERAGE NAIC # 4/17/2014 WWW.burglaralarminsurance.com INSURER A: Scottsdale Insurance Comapny 41297 INSURED SAFE STREETS USA,LLC 5305 RAYNOR ROAD SUITE 100 INSURER 8: INSURER C: INSURER D: GARNER NC 27529 INSURER E: PRODUCTS - COMP/OP AGG $ 3,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: 199171327R 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 SUBR POLICY NUMBER POLICY EFF M DD POLICY EXP M/DD/YYY LIMITS A �/ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F✓ OCCUR CPS1962297 4/17/2014 4/17/2015 EACH OCCURRENCE $ 3,000,000 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 5,000 PERSONAL&ADV INJURY $ 3,000,000 GENT AGGREGATE LIMIT APPLIES PER: POLICYPRO-- LOC OTHER: GENERAL AGGREGATE $ 3,000,000 PRODUCTS - COMP/OP AGG $ 3,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A �/ UMBRELLA LIAB EXCESS LIAB ✓ OCCUR CLAIMS -MADE CUS0001193 4/17/2014 4/17/2015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED 1 ✓ I RETENTION $10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ A ERROR & OMISSIONS CPS1962297 4/17/2014 4/17/2015 $3,000,000 EACH CLAIM $3,000,000 AGGREGATE DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) License: EG13000404 Qualifier: William Alan Peacock Miami Shores Village 10050 NW 2 Ave Miami Shores Village, FL 33138 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 Ralph A. Costa ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD CgRT NO.: 19903?78 CLIENT CODE: EVERS-1 Angela Barbieri 4/21/201412:Q4:45 PM Page 1.gf.1 Arlenis Silvera From: a-robin@comcast.net Sent: Monday, March 17, 2014 3:06 PM To: Arlenis Silvera Cc: jpbanman@hotmail.com Subject: re: Request For Permit Extension Hello Arlenis, I am writing to request an extension of Permit Number: EL -7-13-1723. My residence location is: 10618 NE 10th Place, Miami Shores, FL. 33138. ADT alarm company is available 3/20/14 to make the service visit and correct the problem noted in the Inpection Worksheet. Thanks, Robin Avery 305-891-4084 1 Miami Shores Village Building Department a. 90050 N.E.2nd Avenue, Miami Shores, Florida 33138 r Tel: (305) 795.2204 Fag: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLI ATION ejF=WCT0R'01C0AW0 Permit Type: JOB ADDRESS: 10618 NE 10 PI W13 FBC 20 l c' Permit No. Master Permit No. s— ! n 23 City: Miami Shores County: Manu Dade Zip: Folio/Parcel#: 11-2232-028-0830 Is the Building Historically Designated: Yes NO X Flood Zone: 33138 OWNER: Name (Fee Simple Titleholder): Robin Avery Phone#: 305-891-4084 e,M—A 10618 NE 10 PI City: Miami Shores State: FL zip: 33138 Tenant/Lessee Name: Phone#: Email: 10 %-1 CONTRACTOR: Company Name: SafeStreets USA Phone#: 919-861-8521 Address: 5660 W Cypress St Suite G City: Tampa State: FL Zip: 33607 Qualifier Name: William Alan Peacock Phone#: 919-861-8521 State Certification or Registration k EG13000404 Certificate of Competency #: Contact Phonek 919-861-8521 Email Address: Jadams@safestreets.com DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 99.00 Square/Linear Footage of Work: Type of Work: ❑Addition ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: Wireless Burglar Alarm - 1 Cell, 1 Panel, 2 Button Fob, 4 Door / Window, 1 Motion Color thru tile: Submittal Fee $� Permit Fee $ ,©®' ®0 CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $M4 1 ) 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 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. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this 12th The foregoing instrument was acknowledged before me this 12th day of July 20 13 , by Robin Avery day of JUlY , 2013 , by William Alan Peacock who is personally known to me or who has produced DL who is personally known to me or who has produced As identification and who did take an oath. NOTARY P LIC: JARROD M. ADAMS NOTARY PUBLIC Sign: Print: JAdams a Comm# EE180336 My Commission Expires: Expires 3/16/2016 3/18/2016 identification and who did take an oath. NOTARY PUBLIC: JARROD M. ADAMS NOTARY PUBLIC Sign: FLORIDA Print: J od Adams Cornet EE180338 My Commission Expires: Expires 3/16/2016 3/18/2016 APPROVED BY.31 Plans Examiner Zoning Structural Review (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) C c: r: Rog CERTIFICATE OF LIABILITY INSURANCE °ATE 4 4126/21/28/209133 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 policy(les) must be endorsed. If SUBROGATION IS WANED, 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 JOHN T COSTA AGENCY INC P.O. BOX 2338 WAYNE NJ 07470 CONTACT NAME: RALPH A. COSTA PHONE No FIML ADDRESS: JTCAGY@OPTONLINE.NET INSURE AFFORDDLGCOVERAGE NAICd INSURER A: FWCJUA SAFE STREETS USA,LLC 5305 RAYNOR ROAD SUITE 100 GARNER NC 27529 FEIN: 274001370 Muffin B: °18URERe' INSURER D: INSURER E: INSURER F: ^0M r!Cif-ATG U"RM0=0- 1520d9Rnn9 REVISION raniI ER: 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. TYPE OF INSURANCE POLICY NUMBER t+oucY EFF POLICY EXP LIMITS GENERALL.IABILJTY COMMERCLAL GENERAL LIABILITY CLAIMS -MADE � OCCUR EACH OCCURRENCE $ PREMISES Ee oaarnerrcsl $ MED EXP one ) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- F-1LOC PRODUCTS - COMP/OP AGO $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED e SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS MBI eD SING LIMIT $ M BODILY INJURY (Per person) $ BODILY INJURY (Per-dderd) $ P ecgdderd GE $ UAABRELLA LIAR EXCESS LULB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OE0, RETENTION $10,000 $ $ A 11"ORtO3t4 COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? K (Mandatory In NH) H yes, deataibe under DESCRIPTION OF OPERATIONS below N I A 2857C315 4/24/2013 4/24/2014 WC STATU- p7� X TORY LIMITS -ER EL EACH ACCIDENT $ 1,000,000.00 EL DISEASE - EA EMPLOYEE $ 1,000,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddBonal Remarks Schedule, B move spew Is reqs) CERTIFICATE HOLDER CAC O Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AMORREDREPRESE"'TATIVE w woo -AU -Nu Pk%,WMV ACORD 26 (2010106) The ACORD name and logo are registered marks of ACORD 4 4 � 1 OF LIABILITY INSURANCEFr IDD/YYYY) DATE (MMvCERTIFICATE 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 policy(les) 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 John T. Costa Agency Inc. 2025 Hamburgg TPKE §uite J 2025 Wayne, NJ 07-470 www.burglaralarminsurance.com CONTACT NAME-- AME PHONE - ac No - E-MAIL ADDRESS: INSURE S) AFFORDING COVERAGE NAIC 0 INSURER A : Scottsdale Insurance 7 INSURED SAFE STREETS USA,LLC 5305 RAYNOR ROAD SUITE 100 GARNER NC 27529 INSURER 13: r n30104 INSURER C: INSURER D: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 1R2nnn19 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 AWL BR POLICY NUMBER POLICY EFF MWD(MMIDDIYYYYI POLICY EXP LIMITS A GENERAL LIABILITY CPS1720964 4/17/2013 4/17/2014 EACH OCCURRENCE $ 3,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑✓ OCCUR PREMISES (EaEence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 3,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 3,000,000 $ POLICY PRO LN B AUTOMOBILE LIABILITY 13UECUK0109 4/17/2013 4/17/2014 a B11- DtsING LIMIT $ 1,000,00 BODILY INJURY (Per person) $ ,/ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS R'( AUTOS BODILY INJURY (Per accident) $ PFte08ER DAMAGE $ P $ A ✓ UMBRELLA LIAB ✓ OCCUR UMS0027562 4/17/2013 4/17/2014 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 EXCESS UAB CLAIMS -MADE DED ✓ RETENTION $10,000 $ $ WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? NIA STATI - O7H TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ A ERROR & OMISSIONS CPS1720964 4/17/2013 4/17/2014 $3,000,000 EACH CLAIM I $3,000,000 AGGREGATE DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101, AddMonal Remarks Schedule, H more space Is required) Project Ref: CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ,,5"'""�� t*r— Ral h A. Costa ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD