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BP-05-487Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 7! BUILDING PERMIT APPLICATION FBC 2001 Permit Type (circle): I�Building lectrio Owner's Name (Fee Simple Titleholder) , %& Owner's Address 6 99 Tenant/Lessee Name O Noc�Fcs-4,� No. Plumbing . Mechanical Roofing �f Zip Phone # �`--- Job Address (where the work is being done) to y 7 & Z�/VV City Miami Shores Villa a County Miami -Dade Zip Is Building Historically Designated YES NO_I.-' Contractor's Company Name owv Phone #_ Contractor's Address City State Zip_ Qualifier State Certificate or Registration No. Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # A� d� $ Value of Work For this Permit�r Square Footage Of Work: Type of Work: ❑AdditV* 'n ❑Alteration ❑New LIQ' Repair/Replace ❑ ;Demolition Describe Work: e-/ Y,�o�e,ef, � Submittal Fee, $ f Permit Fee $ 1,22 CCF $ N �j ` CO/CC Notary $ Tri ining/Education Fee $ o Technology Fee $ _ mQ Scanning $ Radon $ Zoning Bond $ Code Enforcement $ Structural Plan Review. $ Total Fee Now Due $ I (Continued on opposite side) 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 L 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 t be approved d a r inspection fee will be charged Signatur Signature caner or Agent Contractor The f oma ac owledged beforb me this The foregoing instrument was acknowledged before me this day of, 20 �y D(,I f7 i bAatQ NX4C4 day of 20 _, by , who is personally known to me or who has produced who is personally known to me or who has produced It CCI Ll I ( As i ntiicL&j� oatl NOTA LIC: $��Public, State of Florida . expires Jan. 25, 2008 Sign: o. DD 284571 Print: 1 f1 NOTARY PUBLIC: Sign: Print: as identification and who did take an oath. My Commission Expires: v� > t t Z���� My Commission Expires: APPLICATION APPROVED BY: chc 05/13/03 CQ 2 PlanZaminer Engineer Zoning VILLAGE OF MIAMI SHORES BUILDING DEPARTMENT OWNER BUILDER DISCLOSURE .STATEMENT , for the property Legally described as Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S. 489.103 (7), I have read and understand the following disclosure Statement, which entitles me to avork as my own contractor, I further understand that I as the owner must appear in person to complete all applications. DISCLOSURE STATEMENT State law requires construction to be done by licensed contractors. You have applied for a permit under an exemption to that law. 'The exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must supervise the construction yourself. You may build or improve a one -family or two-family residence or a farm out -building. ! You may also build or improve a commercial building at a cost of 525,000.00 or less. The building must be for your own use and occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the construction is completed, the law will presume that you built it for sale or lease, which is a violation of this exemption. You may not hire an unlicensed person as your contractor. It is your responsibility to make sure that people employed by you have licenses required by state law and by county or municipal licensing . ordinances. Any person working on your building Nvho is not licensed must work under your supervision and must be employed by you, which means that you must deduct F.I.C.A. and with -holding tax and provide workers, compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances, building codes and zoning regulations. Proof of ownership provided ( ) initial of reviewing clerk Tlie foregoing instrument Z Was acknowledged before me this qday o� 20 0-',S- By .� By DO, 4S, ,Cu;j� �6�UL__ who is personally known to me or who has Produced 9�1n[ Qy �kYi 1� f�a 1 I ( as identification w,�o di tog RNAKER Notary Public, State of Florida My comm. expires Jan. 25, 2008 No. DD 284571 Own i_Notary c�_-1 I z,WbV Owner uUuri i Y yr LP�Ur) SkVi iu�niore6_ AFFIDAVIT The undersigned Affiant, �f c�e� �' oes hereby attest that the (propertf owner) attached survey, performed by (name of survepor's company) A--,. performed on , is an accurate representation of the existing conditions and (date of survey) locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than six (6) months old. The Affiant, as property owner, firrther agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits.. Further, Affiant sayeth naught. V,itness(sign and print) B � . f ant/1'roperty owner Witness(sign and print) 1 � SWORN TO AND SUBSCRIBED before me this day of Affiant is personally known to me, produced '7 < 2 ti1�4 ���sidnf ration. 0 9 St , STEPHANIHONAKER Notary Public, State of Pbrida My comm. expires Jan. 25, 2008 No. DD 284571 0 9 ZONING CRITIQUE SHEET JOB ADDRESS: X/�j 9,::) - APPLICANT: 0 APPLICATION: PERMIT # D4TEI � coNmr� s INITIALS • CRITIQUE SHEET f - JOB ADDRESS (f APPLICANT - PHONE # APPLICATION SHEET OF MISCELLANEOUS DATE Z(INNIJVG : �= �vlr- 5- PERMIT NO. ADDRESS: MIAMI SNORES VILLAGE BUILDING / ZONING DEPARTMENT•- SECTION BY DATE ZONING' ELECTRICAL MECHANICAL. PLUMBING FIRE PUBLIC WORKS STRUCTURAL BUILDING OFFICIAL t. Subject to compliance vdth alt Fader4 State. Cou*.Vlttap lutes and tW&dons. Vftge a onsl6tlit for accvra oflor rasutts float P Y cY these pians. 2. This copy of plans mast be available ca tuRdinq site at no inspection will be conducted. INITIALS no 'res P Y cY these pians. 2. This copy of plans mast be available ca tuRdinq site at no inspection will be conducted. INITIALS Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 Permit Permit Status: APPROVED Issue Date: 12/19/2005 Expires: 12/19/2006 Permit Number: BP2005-478 Owner's Name: DANIEL DOWECK one: Permit Type: Fence/Wall Parcel #: 1132060141560 Work Classification: Wire Fence Block: Lot: Job Address: 699 92 Street NE Section: PB: Miami Shores Village, FL 33138- Contractor(s) Phone Primary Contractor HOME OWNER Yes Comments: METAL FENCE FOR SECURITY OF RESIDENCE Additional Information Final Foundation Type of Construction: Wire Fence Additional Info: In consideration of the issuance to me of this permit, I agree to perform the work coverea nereunaer in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above-named contractor to do the work stated. Fees Due Amount CCF $0.60 Education Surcharge $0.20 Permit Fee - Wire & Wood $122.00 Scanning Fee $6.00 Technology Fee $3.05 Total: $131.85 Building Department File Copy Applicant Signature FW -12-05-23160 Total: Total Square Feet: 122 Total Valuation: $ 250.00 Due Amt Paid NOTICE: In addition to the requirements of this permit, there may be additional restrictions applicable to this property that may be found in the public records of this county. AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT DISTRICTS, STATE AGENCIES, OR FEDERAL AGENCIES. RE C01 '1211 ::10'5 r0Q, 26i MC901 0327441 CASH II11.31. n9. iI Ile1 II Ll / / / / / LOCATION MAP Scale: Y= 120' 13 1 12 1 11 1 10 15' ALLEY J. m — ATS — 9219R— — ST. LEGAL DESCRIPTION All of Lot 21 and a portion of Lot 22 in Block 63 Section 3, MIAMI SHORES SECTION 1-7, according to the Plat thereof, of the Public Records of Miami -Dade County, are particularly described as follows: Begin at the SW corner Lot 22 then East 25 feet to a point, in a Northwesterly direction 131.23 feet to a Point on the North line of Lot 22; thence West 7.0 feet, along the North line of said Lot 22 to the Northwest corner of Lot 22; then South along the West line Lot 22, 129.99 feet to the Point of Beginning. Property Address: 699 NE 92 STREET MIAMI SHORES, FL 33153 Flood Zone: "X" Community Panel No. 120652-0093 Base. Flood Elevation: N/A Map Revised: March 2, 1994 FOR THE BENEFIT OF: DANIEL DOWECK AND DENNIS DOLAN �ulllllllllllllm m�lllllllllllm MAMO PP,.TS JR_ & .SSOCL,XES, E*,C. II}{{V�I}}IIIIII SURVEYORS - MAPPERS - PLANNERS 300 S.W. 107th Avenue - Suite No.214-Mlaml, Flodda 33174 Volce(3W 551-6000- Fta(3=221-1239 E -mall: mprats®bellsouth.net Certificate of Authorizahon No.:4249 The above 'BOUNDARY SURVEY'. represent the herein described property and it Was completed Leder my 94mvffilon and or direction. to the best of my knowledge and beAef and it dm also meets the Nlrlrxn rTednrtod Standard set forth by the Rodda Board AdrnhVshdive Code, SURVEYOR'S NOTES 1) The above copfloned Property was surveyed and described based an the above Leo ftdip9an harished by Client. 2) This Certification is only for the lands as described. B Is not as certification of Titre. Zoning. Easements. or Fieedon of Encumbrances. ABSTRACT NOT REVIWED. 3) There may be additional Restrictions not shown on this survey that nary be to" in the Pubflc Records of fids County. Exardnafion of ABSTRACT OF TITLE wfR have to be made to detertNne recorded kvinn 1s. H any affecting this property. 4) Ownership a ggeot to OPINION OF TITLE. 8)TypeofSUrvey BOUNDARY SURVEY. Er) Location and Identiticatfon of UtARies and or adlace nt to to property were not seaaed as such hfamation was ABBREVIATIONS L -Arc P.T.=Pdrd of Tanpanry BM.-BendeMadc P.OB=PoWdBepNp Cde,=CoIcAosed P.C.=Pdd dWhrol." gw 7 as ` E =East R/W-mo$d'Wuy MA=MarnunerdLk* SEC .=sedtm N =Nam awn-Sde ear P.CP.= PemwtrentconhdPdd S.=South PAM.=PGftnW1ed RVIOM eMaMmeN T=Taped 4 14 R 15 10 Wooenee WF.= dF L18 Elev.=Elevation 20 21 22 23 24 67.87 8QW 28 80' W m — ATS — 9219R— — ST. LEGAL DESCRIPTION All of Lot 21 and a portion of Lot 22 in Block 63 Section 3, MIAMI SHORES SECTION 1-7, according to the Plat thereof, of the Public Records of Miami -Dade County, are particularly described as follows: Begin at the SW corner Lot 22 then East 25 feet to a point, in a Northwesterly direction 131.23 feet to a Point on the North line of Lot 22; thence West 7.0 feet, along the North line of said Lot 22 to the Northwest corner of Lot 22; then South along the West line Lot 22, 129.99 feet to the Point of Beginning. Property Address: 699 NE 92 STREET MIAMI SHORES, FL 33153 Flood Zone: "X" Community Panel No. 120652-0093 Base. Flood Elevation: N/A Map Revised: March 2, 1994 FOR THE BENEFIT OF: DANIEL DOWECK AND DENNIS DOLAN �ulllllllllllllm m�lllllllllllm MAMO PP,.TS JR_ & .SSOCL,XES, E*,C. II}{{V�I}}IIIIII SURVEYORS - MAPPERS - PLANNERS 300 S.W. 107th Avenue - Suite No.214-Mlaml, Flodda 33174 Volce(3W 551-6000- Fta(3=221-1239 E -mall: mprats®bellsouth.net Certificate of Authorizahon No.:4249 The above 'BOUNDARY SURVEY'. represent the herein described property and it Was completed Leder my 94mvffilon and or direction. to the best of my knowledge and beAef and it dm also meets the Nlrlrxn rTednrtod Standard set forth by the Rodda Board AdrnhVshdive Code, SURVEYOR'S NOTES 1) The above copfloned Property was surveyed and described based an the above Leo ftdip9an harished by Client. 2) This Certification is only for the lands as described. B Is not as certification of Titre. Zoning. Easements. or Fieedon of Encumbrances. ABSTRACT NOT REVIWED. 3) There may be additional Restrictions not shown on this survey that nary be to" in the Pubflc Records of fids County. Exardnafion of ABSTRACT OF TITLE wfR have to be made to detertNne recorded kvinn 1s. H any affecting this property. 4) Ownership a ggeot to OPINION OF TITLE. 8)TypeofSUrvey BOUNDARY SURVEY. Er) Location and Identiticatfon of UtARies and or adlace nt to to property were not seaaed as such hfamation was ABBREVIATIONS L -Arc P.T.=Pdrd of Tanpanry BM.-BendeMadc P.OB=PoWdBepNp Cde,=CoIcAosed P.C.=Pdd dWhrol." CA=CenteBre PRC =POW GI RevateQrNok" C8.8.= Condd64lodn9nrdae ROE. =Rana. E =East R/W-mo$d'Wuy MA=MarnunerdLk* SEC .=sedtm N =Nam awn-Sde ear P.CP.= PemwtrentconhdPdd S.=South PAM.=PGftnW1ed RVIOM eMaMmeN T=Taped W.= West TWP-Tovrtdsp CS.F.Moln"force Ens. -Erre odened' Wooenee WF.= dF FF.=FWeh Fkror Elev.=Elevation A/C=At CaWtiana not requested 7) Unless otherwise noted. this Ram has not attempted to locate Foofts ad/or FoundaRas (LederQand). 8) This PLAN OF SURVEY. has been prepared for the exclusive use of the entities Homed hereon The Certificate does not extend to any uaunaned party. 9) If Bearings A%own they are based on: ELEVATIONS NOTES: (IF REQUESTED AND SHOWN) 1) ma Indicates eAd fro Sevatiors 2) Elevaflons are referred to the Nallaned Geodetic Vertlood Dahm. 3) BENCHMA[a( (Used) &M.No. Beve fore Feat Location: REv�rcaNs: J.N.: Date: "rt123 NOT A VALID CERTIFICATION J.N.: Date: VYITNOUT THE SURVEY00.'S ORI®NAL SIGNATURE AND RAISED B7E,OSSfA sEAI. PREsfevr. J.N.: Date: `J �W.0-PFatS Jct Professional Surveyor cnd,Mapper No.3332 Si31e of Florida CAD. File. T:19093 Original date:. 04-13-05 0aUP,dohx MeeREY60FQ Field date: 04-11.05 Original J.N.: 19093 PLAN o f s u R v e v ui�llllllllllllm„mllllllllllll�u� Scale 1 "= 20' - VAley Found Nab. , • • .. ' .�_ :. • } ,W.a. ter : •• AAeter �', •.. — �dh '.'.'....'..'..'.'..'..'.'.'..'.'.'.'.'.'..'.'.'.1.'0'.''.(..M.....} .'.'y'.....:...... .od+ !, ---— ------ eas.conc.curb .. Found1' ''''''''.''''' . .... Iron Pipe Area No Cap.'''''''''' AspR ........................................cal,m .:::::'':'' CS........4.7 TIi ---^- 9 ......... .. '•mer _ 22_58 . -.. . 27.0P I n• -• � ' • Inti .'..14.x' ' � `•6 MARIO PRATS 7R.. & ASSOCIATES, INC. II�III����IIIIII���I SURVEYORS - MAPPERS - PLANNERS 300 S.W. 107th Avenue - Suite No.214-Miami, Florida 33174 Voice(305) 551-6000- Fax(305)221-1239 Certificate of Authorization No.:4249 • ' • • �i �' • / / / / / f �F� Cap � Found 1' ,( No Iron Pipe / r No Cap 79.76—�—_~'tai 0- 5.00' (Plot) 15.74 (Meas.) Southeost Corner Block 63 C.A.D. Fte: T:19093 Odgind date: 04-13-05 1Far UP-dWm reeWASOPW Field date: 04-11-05 Original J.N.: 19093 aev ' cak.m =a' 37.07 10,0V IN _ Bddt Wall (a• NGh) F 1 I ' 3' �Cakm+ 3 N �1 N 0,1 O N �m Found 1/2 N A m , I ^ U 4 P ap O m .. CLQ N (� d cw= No Cap No CIron J La U i 13z C� •�•. I v O r � as.de 25.ar -, a� 7498' 75:10'. i f2ec,) 75.16' (Meas:).•: .. r- p c o lc� AMhcit 16.5' Parkway 34 ' 30 I O Qi N ........ '.'.'.'.'. �...... )� •'•"•"...........'.".".'.'..".".'.'..'...'.'.'.'.' r ..........................................:- t ......... . c+7 ..................................... ............................................................................... b 22.47 ___ .. ,...... x .......................18.9 Pavement"...........................�...... _ ...... ............................................................... F. .......... 1........ .. 9.92' J MARIO PRATS 7R.. & ASSOCIATES, INC. II�III����IIIIII���I SURVEYORS - MAPPERS - PLANNERS 300 S.W. 107th Avenue - Suite No.214-Miami, Florida 33174 Voice(305) 551-6000- Fax(305)221-1239 Certificate of Authorization No.:4249 • ' • • �i �' • / / / / / f �F� Cap � Found 1' ,( No Iron Pipe / r No Cap 79.76—�—_~'tai 0- 5.00' (Plot) 15.74 (Meas.) Southeost Corner Block 63 C.A.D. Fte: T:19093 Odgind date: 04-13-05 1Far UP-dWm reeWASOPW Field date: 04-11-05 Original J.N.: 19093 =a' 37.07 10,0V '• _ Bddt Wall (a• NGh) I 1 I ' 3' �Cakm+ 3 N �1 N 0,1 O N �m Found 1/2 Found 1 J2' �D. N m , I Iron Pipe P ap I cw= No Cap No CIron es� La i 13z ”' m °h^� :. as.de 25.ar -, a� 7498' 75:10'. i f2ec,) 75.16' (Meas:).•: °. `- AMhcit 16.5' Parkway Asphal ........ '.'.'.'.'. �...... •'•"•"...........'.".".'.'..".".'.'..'...'.'.'.'.' ..........................................:- t ......... . c+7 ..................................... ............................................................................... .. ,...... x .......................18.9 Pavement"...........................�...... _. .. ...... ............................................................... .......... 1........ .. ...............t................................................................)............ MARIO PRATS 7R.. & ASSOCIATES, INC. II�III����IIIIII���I SURVEYORS - MAPPERS - PLANNERS 300 S.W. 107th Avenue - Suite No.214-Miami, Florida 33174 Voice(305) 551-6000- Fax(305)221-1239 Certificate of Authorization No.:4249 • ' • • �i �' • / / / / / f �F� Cap � Found 1' ,( No Iron Pipe / r No Cap 79.76—�—_~'tai 0- 5.00' (Plot) 15.74 (Meas.) Southeost Corner Block 63 C.A.D. Fte: T:19093 Odgind date: 04-13-05 1Far UP-dWm reeWASOPW Field date: 04-11-05 Original J.N.: 19093 10/15/14 01:03PE Mesa Bros 3056302699 P.01 CERTIFICATE OF LIABILITY INSURANCE I DATE (MbbDD'YYYY) vi I THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLV AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS014 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. tM terms n ft ttts oertlftcate holder Is a'Jn ADDITIONAL INSURED, the policy(I©sj must be endorsed. N StJBR04ATION 1S WA1Vl=D, suolect to the terms and eanditions Of 11110 pollCy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In 11OU of such endorsement(s), PRODUCERCONTACI — - S10110heripe Insurance Saiulrop.,_ Inc. NAME: dii$'Q2S 293C1 F.xl. 208* RO 60 3442 P1,40Ng �i61•%4ti•5047 FAX TOquosta. FL 3$4$ IA FAX tool: E M I fwll: E•MASL A$DWESS; cats@Progressivaemplayer.com INSVNED - —............ .......................... ............ ..... . Progressive EMP10y0r Management CO, Ing, And all its affiliates ,1114 subsidiaries For Co•onlpioyeea Cf mesa Brothers Irt $407 Parklane Or -Sar-Isola, FL 34243 FN5URCH(b�AFFOROlNO COHEAAGE • r � , • ,,,,_, _ t�AtC 11 ................ tNsuRr R w :TdChrtptpgy k)Surancv Company, trsC•... _._ 42378 tnlsuRSR e 1NSVNER C INSURER 0: INSU94A F ; THIS IS TO CEl3T1FY THAT Th1E PUL.lC:l1- OF INSURANCE I..1ST 0 i SCOW HAVE BEEN I:S;iUirD TO THE INSUREt7 NAM�P ABREVISIO EIFOR THE POI liCY PS1410D INDICATED, NOTWITHSTANDING ANY REQUIRFMFINT, TERM OR CONDITION OF ANY QONTRACT OR OTHER DOCOMF,NT WITH RESPECT TO WHICH THIS CERTIFICATP- MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROED BY T148 POLICIES DC-SCRI69D HEREIN IS SUBJECT 7O ALL THE TERMS, EXCLV$IONS AND CONDITIONS OF SUCH POLICIES. 1,IMIT y SHOWN MAY HAVE 86E1d RECIUCED BY PAIL? CLAIM$, 11111: TYPE OF INSURANCE A17t?L'.8t1Bt1: ' I • • •' • Pi)L'EL°Y (�FPY PbU0 *bp OFNERAL UAHILrry POLICY NUMB R /Y MM/DDIYYYY LIMITS FACrrOCCUARCNCL• y CC)FAtraEri( iAl. GEN[R1u. CtAlIFW3'v DAMAC,,F TO�RFN1'Ei) CLAIMS -MADE 0 OCCUR Pr,,G ul5[ i 115.1 ocetwer+,cel s ME:O FXr•+:Any one palwni $ Pf,9S()NAL d AUN' INJURY $ ...... GENGRAL AOC*. GEN'LAGGREciarE LIMIT M+PLIES Pr`fl' .. • ........ PCUCY per' LQC PRODUCTS . COMP.'QP A04 S AUTOMOBILE LIABILITY ANY AUTO COMBINED SIN 41MIT {Ha aoci0g . S. SGNrnOULtiT7 BODILY INJURY (Por pornaa I '0 AUTO^a NON•OWNED Bc)KY INJURY {Per sa k*n1)S AUTOS LWORKERCOMPE RAOH 0P'%URREN.CF.C,:,ArMS.A,tAOteAG(iAFCvA'PF NrIONS S S COMPENSAVIOR t.• 4315td5 g AND LMtPLOYQRS' LIADILnY 09/15/2014 10/01/20t� y( WL u ATV Id• 11 ANY PROPRIETOR/PAATN$Rir;XtcGUTIVE T 1 N T,pRY LIMITS, (MarsdFRry Irl N A EXCLUDED? N A E.t. CAC4 ACCIOANT g 1,000.000 If Yun, rtvMelbp v+Nlkef DF .RIPTIp3J tjp Caf@NATIONS beltaw DISEASE • EA EMPI.C/YEE $ 1,000,000 E.:. D19EAsr . POLICY LIMIT S 11000.000 0MRIPtION OF OPFRATIONS I LOCATIONS r vaHjom (Atteeh ACORD 101. Addlti4nar FfeneerKe SCI)Qd le. 11 more spacv jr. mquuW) 00verago is extended to Co-c4mP1OY00s {,Ut net sUhcontl.ictors of Mesa Brothers Inc LIC01138 #E013001670 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BeroRE THE EXPIRATION DATE Ttttitteop, NOTICE WILL. BE OELIVEREt! IN ACCORDANCE WITH THE POLICY PROVISIONS, Miami Stsoros Village AUTHORIZED REPRssuvTATIVN 10050 Northeast 41nd Avenue Mi arnt, FL 331313 f"'_ ACORD 252010/05 Page I of I 114/ 4988-2040 ACORD CQRPORATION, All ( ) The ACORD name and 1000 Ore registered marks of AC©R't)