Loading...
MC-14-1452Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-215445 Permit Number: MC -7-14-1452 Scheduled Inspection Date: July 30, 2014 Permit Type: Mechanical - Residential Inspector: Perez, JanPierre Inspection Type: Final Owner: SCHULTZ, MARK Work Classification: A/C Replacement Job Address: 101 NW 104 Street Miami Shores, FL 33150 - Project: <NONE> Contractor: AVEN AIR CONDITIONING Phone Number Parcel Number 1121360131420 uumung loepartment comments REPLACE 4 TON AC SYSTEM Infractio Passed Comments INSPECTOR COMMENTS False 713D July 29, 2014 For Inspections please call: (305)762-4949 Page 12 of 26 Inspector Comments Passed Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. July 29, 2014 For Inspections please call: (305)762-4949 Page 12 of 26 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ®8 2014 Tel: (305) 795-2204 Fax: (305) 756-8972 d �' INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 BUILDING Master Permit No. 52— PERMIT APPLICATION Sub Permit No. JOB ADDRESS: y()1 N.W. J O Li Z4 City: Miami Shores County: Miami Dade Zip: a a /lsz) Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): S®i 0A M A'i k- Sc6iLij Phone#: -5,33 SL 0 Address: S4 City: A 1"C% 5A\0'i a State: F Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: avem IAik'C'®�l�o-�ogio9o�PCs Phone#:(abS .3a;1`®ia 9 Address: -A& 2S S.W. 108 ZA City: t-rj � (A T---% State: �E S. Zip: a a `s i Qualifier Name: U e t +o Reor+A Phone#: AOS -)3-82- OI a State Certification or Registration #: C A C ®Id 2, GA 2 Certificate of Competency #: _ DESIGNER: Architect/Engineer: N/ A Phone#: Address: City: State: Zip: Value of Work for this Permit: $ $ Li i l Square/Linear footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New V! Repair/ eplace ❑ Demolition Description of Work: lRe p t A LeCY 4 "{n m S CG td rh L. Ole- rZ Submittal Fee $ Permit Fee $ Scanning Fee $ Notary Radon Fee $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO/CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ® MECHANICAL ❑PUBLICWORKS [:]CHANGE CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: y()1 N.W. J O Li Z4 City: Miami Shores County: Miami Dade Zip: a a /lsz) Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): S®i 0A M A'i k- Sc6iLij Phone#: -5,33 SL 0 Address: S4 City: A 1"C% 5A\0'i a State: F Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: avem IAik'C'®�l�o-�ogio9o�PCs Phone#:(abS .3a;1`®ia 9 Address: -A& 2S S.W. 108 ZA City: t-rj � (A T---% State: �E S. Zip: a a `s i Qualifier Name: U e t +o Reor+A Phone#: AOS -)3-82- OI a State Certification or Registration #: C A C ®Id 2, GA 2 Certificate of Competency #: _ DESIGNER: Architect/Engineer: N/ A Phone#: Address: City: State: Zip: Value of Work for this Permit: $ $ Li i l Square/Linear footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New V! Repair/ eplace ❑ Demolition Description of Work: lRe p t A LeCY 4 "{n m S CG td rh L. Ole- rZ Submittal Fee $ Permit Fee $ Scanning Fee $ Notary Radon Fee $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO/CC $ 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 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 )LA Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me thisAl day of l >, 0 _ . 201, by h !S*'C 44 y LT,',—'— who is personally known to me or who has produced As identification and who did take an oath. TI97Zl /011frig Sign:, Print: My Commission Expires: M[301 301 The foregoing instrument was acknowledged before me this day of '' , 20 I� by /a -C d UJ1� who is personally known to me or who has produced 1 1� NOTARY PUBLIC: Sign: Print; ' EfT ,22,58 : • * My C r Stye, �0�`�� STATE -•gall ****,;Tv -719/ APPROVED BY ON Plans Examiner Structural Review as identification and who did take an oath. Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) Zoning Clerk Miami Shores Village Building Department 10050 M E.2nd Avenue Miami Shores, Florida 33138 Tel. (305) 795.2204 Fax. (305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): 10 1 N, W . 10 4 ��- City: Miami Shores Village County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO :K ARHI Sheet Attached: YES Z NO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT C- MANUFACTURER hee t-1 C -1314 -SI) AHU or PKG. UNIT MODEL # COND. UNIT MODEL # KW HEAT fib ny.T' NOM TONS AHU CU PKG 1 M.C.A AHU CU PKG AHU CU PKG 2 M.O.P AHU CU PKG AHU CU PKG 3 VOLTS ® 3 AHU CU PKG PKG UNIT / / PKG UNIT EER/SEER 16 . YES N22 REPLACING DUCTS YES CNCP E NO REPLACING THERMOSTAT NO YES NO NEW 4°CONCRETE SLAB YES NO YES C NCD NEW ROOF STAND YES NO ES NO NEW RETURN PLENUM BOX ES NO 1. Minimum Circuit Ampacity ire Size): #t a 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 5 D A 3. Voltage of Circuit(g08/240/ 80): 4. Size Disconnecting Means: 6o Contractor's Company Name: JLb� F. �p o x±A Phone: so X-) 3a a-0 t 3 State Certificate or Registration N. CA 0.t3 Li 2 h 'P -'a Certificate of Competency N. Signature Date: % • 9 - 0 L (Qualifier's signature only) Miami shores V Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT B. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. C. COPY OF LIABILITY INSURACE* D. COPY OF WORKERS COMPENSATION INSURANCE* *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: A VLN R t Y C'0 ("jD a }' i Q N i N G (VLbeYk) Rfa-4A —tN e - BUSINESS ADDRESS: A 6 ZS- STATE ®- ZIP CODE �1 BUSINESS PHONE: ao r) R 2-0 S FAX NUMBER CMAL) 3 -2 - L4 97 A CELL PHONE L—) SA M L QUALIFIER'S NAME: i�4 U �, r4a R to -r � d QUALIFIER'S LIC NUMBER: C A C 0 4 2 6:Z 51 �# 6196-82& STATE OF FLORIDA DTFARTMEI�1'r Ob` .SUSII�TBSS AND PROF,S$SIONAL :R$G1ILATION CONSTRUCTZ . INDIIS'TRYLICENSING BOARD SECW L12071101093 000045 Focal Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY 1783704 BUSINESS NAME&OCATION RECEIPT NO. EXPIRES AVEN AIR CONDITIONING ALBERTO ACOSTA INC RENEWAL SEPTEMBER 30, 2014 8625 SW 108 ST 1783704 Must be displayed at place of business MIAMI FL 33156 Pursuant to County Code Chapter 8A — Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED AVEN A/C ALBERTO ACOSTA INC 196 SPEC MECHANICAL CONTRACTOR BY TAX COLLECTOR Worker(s) 1 CAC042622 $75.00 07/10/2013 TXHS1-13-020484 This Local Business Tax Receipt only confirms payment of the Local Business Tax The Receipt is not a license, permit or a certification of the holders qualifications, to do business. Holder mum Comply with any 90vOrnmsntOI or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles -,Nfiam-Oade Code Sec 80476. For more information, visit www miamidede.aoy[twoRector 09-13-2012 5� JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 11/17/2012 PERSON: ACOSTA FEIN: 650127646 BUSINESS NAME AND ADDRESS: AVEN AIR CONDITIONING ALBERTO ACOSTA INC 8625 SW 108 ST MIAMI FL 33156 SCOPES OF BUSINESS OR TRADE: 1- HEATING, VENTILATION, AYR-COND EXPIRATION DATE: 11/17/2014 ALBERTO IMPORTANT. Pursuant to Chapter 440 . 05041, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.051121, F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.051131, 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. QUESTIONS? 18501 413-161 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation iniuries of any uerson allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. / �q Owner Print Name: ` A L'T-z Signature: State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this I day of 9� 1�, , 20a�,1N111111////b, Um a EXNER0 Y (SEAL) •�r" Ty pe of Identification produced • 7� Contractor Print Name: eye % /96:)S+n� Signature: State of Florida ) County of Miami -Dade ) S• Sworn to and subscribed before me this day of 20 n►u,����� .'. •� .yam Ncn of Identification pradiit� PROPOSAL & SALES AGREEMENT PUMC—HASER: Name; §_Qj&_LA, �F�k�dn �1401& 00000EX.= I � 1111"WORM41 Sb T e L% tnT ekia OFFICE PHONE. j,401VIE PHONE: 'laaa- S ko ROUIPMENT SCHEDULE K!"01 SLOG. PERMIT' NO.: Data L-mx-.2MI4 PRICE: Li .9 00.00 L - - - I80.00 OUCTS Ain malmiriTION FLAW No. ceiling W&L I I Squimoment and material will be now- i firs! quality. Desig d. fabricated and installed according to acofipled angineering Dractics and in :with al' applicable building Codes in force of' ZbOvedate- S��Jp,mem vvil:,aontair, as supplied by the Manufacturer, high -low pmssure safety shut-off switches. auto rimfic VIP Over 10ad fo;";iii protection of the compressor and seal syst,Sln, ,Q* vo4-sge transformer control panei. T"rmostat shall be automatic wat' type and will provide itemiperature controi, for, 50'aolinq P- Hosting 89- WRANTY AND SWIM.-': Manutactu rer's Lim iteAD-M warranty on col-pressof SiVanufaCtLreeat-Yearwal-renty or. sit corn'Donients. seflis, Will. provide ?roe service and all neceNUY labor for 3 P6600 VP --rorn date of start -Lip. Others 0 -there c4glin imi-Q.,mi eos ree gue= ................. C; ....................... r� mp........ .. 10.Qok- -u-P ...... ar— *q TW* BILOW10M M4 COW 7wrMa0bat �lft@ cn;; 4niews . ........ I ..... ahon 80-1� ftm Street to ow"ll C, =;L1,11 Du= and C -64W ......................... 1W liquipybell, ............... ........... of "=L-rgw;r� ...- ................ F'0&-='nWV . . ....... .............. C41AMO- *f few'Of 00W, Ffill'-'51 t4C . ............ Alft tabula6z"I ........... ................. - Aces a eiparapce for gucts, 9011W 6 CQU, PM- or', Weft 0? Watw T 0WOM .......... ............... wa-w Ap4pt . ........... SC4150ULE 09 PAYMENTS. Dez"'S(; wi'V! or,_e7 Rc;;g?- .-n 3L=' "Ico-K SIGNIAT"URE All 00"CIMOPS m8d G*WPWd' rainsin In Seiler's "arre %V0 to sus'panded W Peel dus a=.­nl& Aven A& Condftning L Heating, Inc. Maintenance, Service, Installation Licensed & Insured (305) 332-0139 4;.ALas REDRAESEN, 1 ATNE Jul 08 2014 2:27AM HP Fax A6;81'* CERTIFICATE OF LI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONL' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUI REPRESENTATIVE OR PRODUCER, AND THE. CERTIFICATE HOLDEF IMPORTANT: If tha certlt(t8t® holder lawn ADDITIONAL INSURED, iiia poll0ypea the term and conditions of the policy, certain policies may require an endomem certificate holder In Heu of such endomemengs). PRODUCER Verges Insurance Agency 3185 W 76 St Suite 3 Hialeah, FL 33018 Phone— (195).698-9976 Fax (305) 698-9973 INSUNW Aven Air Conditioning 8625 SW 108 ST Miami, FL 33156 (305) 332-0139 COVERAGES CERTIFICATE NUMBER: THIS IS TO CERTIRY THAT THE POLICIES OF iNStIRANCE LISTED BELOWAV H INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDO EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAV tNSIi .....--- ... - . _ .. ..-..-. - ...._._..-.... �AODLISUHRI TYPE OF INSURANCE Ngo 4TH_ . _-- .- • -- _ .. _ . _i1 .yihl0� .. _: r+ol:ICr NyrAeEl GINERAL LIABILITY COMMERCIAL GENERAL LIABILITY ( A ; ❑ ❑ CLAIMS MADE ®OCCUR ; GL -41962-1 i I GEN'L AGGREGATE LIMIT APPLIES PER: �— 1 -I POLICY ❑ M ❑ LOC AUTOMOBILE LIABILITY ❑ ANYAUTO i ❑' ALL AT$ATOUUO j ❑ HIREDALITOS ❑ NON -OWNED Ir-�f n ❑ UMBRELLA LIM ❑ OCCUR ❑ EXCESS AB .CLAIMS -MADE L�„.DE,p _ ❑, RE?EN7'IS�N$. _ ... _.... � WORKQte COMPFNBATION r .. I AND EMPLOYERS' LIABILITY Y i N ANY PROPRIETOR(PARTNEIVEXECUTIVE OFFICERM.EMBER EXCLUDED? NIA • I (MandalwylnNH) I i 0 yN dercrlf,e under •DE3LRIPTIONOFOPERATIONSbelow,_ _. I _. _.. . i I � DESORPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANaoh ACORD 101, Addirlona) AIR CONDITIONING SERVICES AND REPAIR ADDITIONAL INSURED: Design Related 8101 Biscayne Blvd Miami, FL 33138 CERTIFICATE HOLDER CITY OF MIAMI SHORES VILLAGE 10050 NE 2 AVE MIAMI SHIRES, FL 33136 305-756-8972 ACORD 26 (2010)05) OF page 1 ABILITY INSURANCE °"T 07108;14 ' 07106/14 AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS :XTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES : A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED must be endorsed. If SUBROSATION IS WAIVED, subjectto nt. A statement on this certificate does not confer rights to the CONTACT DANAY VERGEL NAME: ----------- -- -- Sxq: (305) 698.9976 tom, Nch . _ (305) 59.879973.... 0' ADDRESS:.... m'gelinsOgmail.com MURERi$l AFFORDING COVERAGE NAIC 0 _-^ INSURERA: ASCENDANT COMMERCIAL INSURANCE INSURER B.:. . INSURERP: INSURER 0 INSURER B ..... . REVISION NUMBER: E BEEN ISSUED TO THE INSURED IdA ki ABOVE FOR THE POLICY PERIOD )F ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 1 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. E BEEN REDUCED 13Y PAID CLAIMS. PO ICY EFp POLICY� �pc�� LIMITS 1 . (MY1nk:ll(m/Rt7lYY1'1r1, .. - ._ _ ._ _ ... • , EACN.QC�u�gl?i€!�CE_ QanhwGE T� RENTED S 100,000.00 00 : p1i�116.F.,S�SaooGuLrtno_e).. ;... . _-•-. _-...... 04/7812014 0411912015: MSD EXP (Any one persm) S 5,000.00 PERSONAL a ADV INJURY $ 1.000.000.00 GENERAL AGGREGATE, $ , 2.000,000.00 . PRODUCTS • COMPIOPAGG . $ 1,000,000.00 • (�aMr�entl irvu�t �uvn I S T BODILY INJURY (Per perecn) $ BODILY INJURY (Per awkiont) $ tRgqAMAGE ' g P4d go Y. EACH OCCURRENCE $ AGGREGATE $ TWORAT YLIMlT3..❑ER _: E.L. EACH ACCIDENT S ._ E.L. DISEASE - EA EMPLOYEE $ EL,.DISEfISE -POLICY LIlA7', S Ike Sabedure, It more spars Is required) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ®1988.2010 AC D CORPORATION. All rights reserved. The ACORD nam and logo are registered marks of ACORO