DS-13-259413 Miami Shores Village
t�
Building
Department
p l 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
NOV 2013
FBC 20 tC:)
Permit No.
Master Permit No.
Permit Type: BUILDIN ROOFING
JOB ADDRESS: _ "I _� 1 _� IN - 1tRM If'
City: Miami Shores County: Miami Dade
Folio/Parcel#: ]`?)� (0 ® l �' ` 09 P 0
Is the Building Historically Designated: Yes NO Flood Zone:
1.
OWNER: N-ame (Fee Simple Titleholder): nae e E',' Off io ' Phone#:
Address: /-p
nou City: I Y%1 I � 1 state: _- � I zip:
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: Io 6 \w/tl S n Phone#:
Address: —2110 Ni ;1)1�.p. -C )q .
City: State: t" Zip-,_, 2-0
Qualifier Name: ,��1��,,I L� Ii�I Y�� I Phone#:L r qZ V i
State Certification or Registration #: 99 Certificate of Competency #: /I
Contact Phone#: Email Address: �l®i II�IItI��rJO
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $50249 () - Square/Linear Footage of Work:
Type of Work: ❑Addition ❑Alteration ❑New dRepair/Replace
Description of Work: % R-- b6 a JP/'�n o pl�'CiVIC1.
❑Demolition
wova
Color thru tile:
xx�xxxxx�xxxxx�mxxxxxx�xxx�xxxxxxx�xxxxFees*����x����x����x���x:mxn���x��x�xx����������x
Submittal Fee $�50'Permit Fee $ CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not b approved and a reinspection fee will be charged.
Signature Signature
O r or Agent Contractor
The foregoing instrument was acknowledged before me this 15 The foregoing instrument was ackno ledged before me t this
day of '0 Cr. .20 13, by nif- mh ) day of 20 13, by
who is personally known to me or who has produced who is person ly knmv*+ + or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign:
Print:
My Commission
APPROVED BY
MY COMMISSION # EE 629857
EXPIRES: September 27, 2014
Bonded Thru Notary Public Underwiters
Sign—
Print: «J_
My Commission KI MY COMMISSION#EE08W
fllZ EXPIRES: September 27, 2014
a Bonded Th. Notary Public Urrderwriters
��� �k�%k�I:�kXaBark�kdc�knk�k$a�kok8s8sx�rk=k�k�k�ksk�kskek�k�kak�k�k8+�k�k�k�k��kak�k�k�k�k�k�kak�k��ok�k�k�k=k�k�ksksk�Nak�k�ksk
`C
Plans Examiner �� 5 Zoning
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT `OF,� CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) Dz)n 114 E'-�1 on. Q hereinafter referred to as the owner of
the following described property (address):
Legal Description Lot _ Block —7 Subdivision o Ib 6 hore � S ec
Folio # I� �.���� o ✓ 1��
Requests permission to install (describe work): - IiC i � o b —) tc_ i,/.— i'if"��1 {
Within the public right of way of (address)
IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows:
1. To maintain and repair, when necessary, the above-mentioned items) installed within the dedicated right of
way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said
items within public right of way including restoration of street by reason of the Owner's failure to do so,
such expense shall be paid by the Owner or shall constitute a lien against the above described property
until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from any
and all liability, which may rise by virtue of permitting the installation of these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days
notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s)
to be removed and a lien being placed on the property and/or assessed against the Owner for all costs
incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land
and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until
such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County,
Florida by the Village Manager of Miami Shores Village (or his fully authorized representative).
SIGNED, SEALED, EXECUTED AND ACKNOWLEDGE on this day of Q I l )b -C i, 201
(Owner's Signature)
SIGNED, SEALED, AND DELIVERED in the presence of:
LESLIE DEARMAS
MY COMMISSION # EE 029857
�= EXPIRES: September 27, 2014 f
11F, •'•• Bonded Thru Notary PubAc UM WMfft ers
2
HOLST01 OP ID: ACE
11%. ' CERTIFICATE OF LIABILITY INSURANCE DATE 1 3 }
10/02/2013
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
-PRESENTATIVE 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 Phone: 561-966-8883 NAME: T Evergreen Insurance Agency
Evergreen Insurance Agency
583105th Avenue N, Ste 2 Fax: 561-964-8885 WC. N E :561.-966-8883IFAX
Royal Palm Beach, FL 33411 E-MAIL Arc No):56I-964-8885
ADDRESS: angela(AevergreeninS.net
VV V GR/+VG17 %-rK t lrl%,A I r- IYUIYItatK: 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
INSUREMS) AFFORDING COVERAGE
NAIC i
INSURER A: First National Insurance Co.
24724
INSURED Hollywood Stone, Inc.
2110 N. Dixie Hwy.
Holl
Hollywood, FL 33020
INSURER B: American States Insurance Co.
002287
INSURER c: Fla. Citrus, Bus. & Industries
POLICY EFF
MMlDD
INSURER D: Travelers
10647
INSURER E:
GENERAL LIABILITY
INSURER F
VV V GR/+VG17 %-rK t lrl%,A I r- IYUIYItatK: 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
POLICY NUMBER
POLICY EFF
MMlDD
PO CY EXP
MMIDDfYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,
A
X COMMERCIAL GENERAL LIABILITY
01013706764
09/30/2013
09/30/2014
PREMISENcurrence $ 200,000
CLAIMS -MADE ® OCCUR
MED EXP (Any one person) $ 10,
X
X Contr Liab & XCU
PERSONAL &ADV INJURY $ 1,000,000
X Broad Form
GENERAL AGGREGATE $ 2,000,WO
X
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMP/OP AGG $ 2,000,OM
POUCY X PRO- LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Es accident) $ 1,000,000
AUTO
01010687046
09/30/2013
09/30/2014
BODILY INJURY (Per person) $
ALL OWNED SCHEDULEDBODILY
INJURY Per acdden[ $
( )HIRED
IxANY
AUTOS AUTOS
AUTOS X NON -OWNED
AUTOS
PROPERTY DAMAGE
Per accident $
X
UMBRELLA UAB
X
OCCUR
EACH OCCURRENCE $ 1,000,000
B
EXCESS LIAB
CLAIMS -MADE
01 SU4217294
09/30/2013
09/30/2014
AGGREGATE $ 1,000,000
DED I X I RETENTION $ 10,000
$
WORKERS COMPENSATION
X WCSTATU 0TH-
AND EMPLOYERS' LIABILITY YIN
N
E.L. EACH ACCIDENT $ 1,000 000
r
C
ANY PROPRIETORIPARTNERIFJrECU11VE
OFFICERIMEMBER EXCLUDED?
N t A
0642589
04/01/2013
04/01/2014
E.L. DISEASE - EA EMPLOYEE $ 1,000,000
(Mandatory in NH)
It yes, describe under
E.L. DISEASE- POLICY LIMIT $ 500,00
DESCRIPTION OF OPERATIONS below
D
Equipment Floater
Q7660102813237711-13
09/30/2013
09/3012014
Newly own 250,000
DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, Ir more space is required)
Brick & Paver Installation
Miami Shores Village
10050 NE 2nd Avenue
Miami, FL 33138
MIASH01
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISION&
AUTHORIZED REPRESENTATIVE
V IUUU-ZU1U ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
4DEL A DA4A
WV1
CTQB
'anstruction Trades Qualifying Board
NESS CERTIFICATE OF COMPETENCY
E0900186
LLYWOOD STONE INC
Is certified u nder the provisions of Chapter 10 of Miami -Dade County
e
QUALIFYING TRADE(S)
0008 CONCRETE ENGINEER
r- a
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1
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4 CHAIN -
A. I tE;Tr LINK FENCE A
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LOT 13
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1150 E. ATLANTIC BLVD, A ACCURATE LAND SURVEYORS, INC.
POMPMO BEACH
FLORDA 33060 or #3635S�W 2 OF 2
FOUW -
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TEL(954) 782-1441
FAX, (954) 782-1442
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SOUTH 1/2 LOT 14
LOT 13 BLOCK 7
BLOCK 7
5' PROPERTY
SETBACK
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FIELD AREA
38'x 19'
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I SEPTIC TANK I
RITA 610
75.00' Porw NAM
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TEL(954) 782-1441
FAX, (954) 782-1442
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SOUTH 1/2 LOT 14
LOT 13 BLOCK 7
BLOCK 7
5' PROPERTY
SETBACK
"h -
FIELD AREA
38'x 19'
I 20"seperation I
I SEPTIC TANK I
RITA 610
LV.QL CEETIFICATIQN,
UrAL*s ottwrwtw notwd fwlJ m-mbumments are fn ugr"ownt %4 ah ftw"J. meAswernwl Thu, is to majify Om I have teminty surveyed the prupWy dvaibW
lkatiop show" havon arc torsed on a twwiy% of hwA in the tiles doing fittv caption and have m or found mors as as
Ilio Candi shown herwrt at¢re not W-6tracted forowner*h1p rledkt> or%tul, %;aurrwubt indicated on this sketch and that said above gsawd sww*y and sketch
ur odwr manm of records by Accurow Land �mxvcyiys, Inc Am- acvuratv and oaff'w to the b" ofmy knaw6dge and belief, I
Ovataft of l4na" and NVW6, if urry su a cart 4ptiamumd, fv(14'r certify than thin survey nu mitumm T"hmrw Stwwards
This suiwy isft pmpetly ol`Aocutaw Ui4dSuvt)ors, lix. and slwli 1401 tae urxJ ul amki, RuW 3J-17 AaVwJ bg the FilmWitDoW oft-lod SurW'yar5
mprodu"d in whok or m purl akidumjt wrimn —1-7t�wion (k.101wr lit, 2WO
75.00' Porw NAM
AND attj
20'- 19132"
6X W�kt PAVEMENT
00' Rl!;HT-OF7W,AY
.20
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MIAMI AVENUE
GRAPHIC SCALE
LV.QL CEETIFICATIQN,
UrAL*s ottwrwtw notwd fwlJ m-mbumments are fn ugr"ownt %4 ah ftw"J. meAswernwl Thu, is to majify Om I have teminty surveyed the prupWy dvaibW
lkatiop show" havon arc torsed on a twwiy% of hwA in the tiles doing fittv caption and have m or found mors as as
Ilio Candi shown herwrt at¢re not W-6tracted forowner*h1p rledkt> or%tul, %;aurrwubt indicated on this sketch and that said above gsawd sww*y and sketch
ur odwr manm of records by Accurow Land �mxvcyiys, Inc Am- acvuratv and oaff'w to the b" ofmy knaw6dge and belief, I
Ovataft of l4na" and NVW6, if urry su a cart 4ptiamumd, fv(14'r certify than thin survey nu mitumm T"hmrw Stwwards
This suiwy isft pmpetly ol`Aocutaw Ui4dSuvt)ors, lix. and slwli 1401 tae urxJ ul amki, RuW 3J-17 AaVwJ bg the FilmWitDoW oft-lod SurW'yar5
mprodu"d in whok or m purl akidumjt wrimn —1-7t�wion (k.101wr lit, 2WO
Is
2
3
TLANTIC BLVD.
YPANO BEACH
,CRIDA 33060
?E OF SURVEY:
AC.CURrATE LAND SURME.YORYS, IN;C
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#3535
SFAX. (954) ;782-1
I
HEET
BOUNDARY
JOB NUMBER SU 12=340;1
'LEGAL DESCRIPTION:
LOT 12 AND THE NORTH TY OF LOT 13, BLOCK 7 OF AN AMENDED PLAT OF MIAMI SHORES, SECTION NO. OC
ACCORDING TO THE PLAT THEREOF, AS RECORDED IN PLAT BOOK 10, PAGE 70 OF THE PUBLIC RECORDS
DADE COUNTY, FLORIDA.
ADDRESS: 9717 N MIAMI! AVENUE MIAMI SHORES, FL 33150
FLOOD ZONE: X
BASE FLOOD ELEVATION: 'N/A
CONTROL PANEL NUMBER: 120652-0302-L
EFFECTIVE: :REVISED: 9/11/2009
LOWEST FLOOR ELEVATION: N/A
GARAGE FLOOR ELEVATION: N/A
LOWEST ADJACENT GRADE: ;N/A
HIGHEST ADJACENT GRADE : ;N/A
REFERENCE BENCH MARK: N/A
CERTIFY TO:
1. RONNIE L. MARTIN AND MARIA MARTIN
2.
a.
5.
6.
TES:
.0
E A
TbllS CI,7RVFY CONSISTS OF A MAP AND A 'EXT REPORT. ONE IS
NOT VA._ID VI THE OTaER,
S
MWERSHIP OF FENCE AND WALLS IF ANY, NOT DETHRMINLD.
LA TnTH A i
THIS SURVEY IS MADE FOR, THE EXCLUSIVE USE OF; THE CERTIFIED HEREON, TO
BE VAUD ONE YEAR
ATURE AND
FROM THE DATE OF SURVEY AS SHOWN HEREON.
NAL RAISED
• CENTRAL ANGLE
LEGEND
OF ABBREV1AT10NS:
A FLORIDA
ARC LENGTH
LTSIEAL
SURVEYOR
n CHOROBEARINO / 1�
WAPPER.
RADIUS /// OR '+•
ELEVATK?NS BASEDON NOVD igN
D.S.
• DEED BOOK
RIOHT OF WAY S0. FT •
SOUARE FEET
MAIN? •
MAINTENANCE
CLF
• CHAIN LINK FE
C' POINT OF CURVATURE P.CP,
PERMANENT CONTROL POINT
B.C.R.
BROWARD COUNT`/ RECORDS
WF
• WOOO FENCE
T, POINT OF TANGENCY P.8.C,R,
PALM BEACH COUNTY RECORDS
O.0 R.
DADE COUNTY RECORDS
BLVD.
• BOULEVARD
,I • WATER METER P •
PLAT
P.B.
PLAT 800K
AD
• ASSUMED DATUM
H OVERHANG Nd0 •
NAB• A DISC
OR a
RB
O"ICML RECORDS BOOK
1. M.
• IRON PIPE
NORTH P.O.C. •
POII+T OF COMMENCEMENT
F.F. •
FINISHED FLOOR
1. R.
• IRON ROO
' - SOUTH P.O.B. •
POINT OF BEGINNING
QNCN.
QNCROAGF/
P.R.M. •
PERMANENT REFERENCE MONUMENT
' EAST A/C •
W
• EST
AIR :CNOITIONER
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• CHAIN LINK FENCE
N.O•V•0. •
NATIONAL GEODETIC VERTICAL DATUM
FNO •
M BENCHMARK CHA TT. •
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CHATTAHOOCHEE
WOOD FENCE
U.E. •
D.E.
UTILITY EASEMENT
ORA WAGE EASEMENT
I . FIRE HYDRANT F.P L. •
FLORIDA POWER A LIGHT
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ANCHOR EASEMENT
s • OFFSET ELEV. •
ELEVATION
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GARAGE
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CA
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• CONCRETE WALL
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• MEASURED
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LP
LIOHTPOLE
M=
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To act, promote 8 improve the health
ple in Florida through integrated
te, county & community shorts.
Vision: To be the Healthiest State in the Nation
March 24, 2014
Hollywood Stone inc
2110 N Dixie Highway
Hollywood, FL 33020
Rick Scott
Governor
John H. Armstrong, MD, FACS
We Surgeon General & Secretary
RE: Modificaion to a Single Family Residence - No Bedroom Addition
Application Do ument Number: AP1133637
Centrax Permit ber: 13 -SC -1517520
9717 N miami Avenue
Miami, FL 33175
Lot: 12 Block: 13 Subdivision:
Dear Applicant,
This will acknowledge receipt of a floor plan and site plan on 01/27/2014 for the use of the existing
onsite sewage treatment and disposal system located on the above referenced property. No
Objection. Paver Patio. Reviewed by N. Gumbs.
This office has reviewed and verified the floor plan and site plan. you submitted, for the proposed
remodeling addition or modification to your single-family home. Based on the information you
provided, the Health Department concludes that the proposed remodeling addition or modification is
not adding a bedroom and that it does not appear to cover any part of the existing system or
encroach on the required setback or unobstructed area. No existing system inspection or evaluation
and assessment, or modification, replacement, or upgrade authorization is required.
Because an inspection or evaluation of the existing septic system was not conducted, the Department
cannot attest to the existing system's current condition, size, or adequacy to serve the proposed use.
You may request a voluntary inspection and assessment of your system from a licensed septic tank
contractor or plumber, or a person certified under section 381.0101, Florida Statutes.
If you have any questions, please call our office at (305) 623-3500.
Sincer
Nicole Ls
Engineering Specialist II
Department of Health in Dade County
Florida Department of Health www.FloridasHealth.com
in Dade County - • , Florida TWITTER:HealthyFLA
PHONE: (305) 623-3500 FACEBOOK:FLDepartmentofHealth
YOUTUBE: fldoh
HOLST01 OP Ib: AOIE
s
A� t CERTIFICATE OF LIABILITY INSURANCE'M(M ao 14
THIS. CERTIFICATE IS ISSUND AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, &MND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
MOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONWnTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND TNI; CERTIFICATE HOLDER.
IMPORTANT: If the aerl]flcato holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed, It SUBROGATION 18 WANED, subject to
the terms and cc mditlons of the policy, certain policies may require an endorsament. A statement on this cartificalte does not confer r1ght3 to the
certificate holder In lieu of such endorserrignft.
PkODU ER Insurance Agency
683106th Avenue N Ste 2
Royal Palm Beach, FL 33211
5ver reen Insurance Agency
061-986411183 1-m-631Ri .0844MS
A
Anno an eta Ve rs0nin>3.net
MURWq8I AMROMOOVERAGE 014
INGURIIR A : PlMt National Insurance Co. 24724
09130/E014
INBUMD Hollywood Mons, Inc,
2140 N. Dixie Hwy.
Hollywood, FL 33020
muncR o: Travelers 10647
INUUR6R a, American States Insurance Co. 18704
INsufa;BR D : FUBA
nusuReR H
GENEfM AGOREOATE $ 2,000,00
IN8taR6IiP =
awls lU:4:! TC -I pid.4�I�f I ' ]'.TAUS -m Ti17TA111
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTO 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,
EXC-IJSIONSAND OONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS,
7YPROPINOURANCl3
NUIIu ag
AMP
Lmn's
A
X COMM062 I. GIRWAAL LIAMTY
DoE 191 OCCUR
X Contr Llab A XCU
013706X34
09/3012013
09130/E014
EACH OCCURIENCt $ 1,000,000
e S 200,0
MED W°"e m' • 10,0
X PLI & Broad Form
PERBDNAL a ADV INJURY 3 1,000,00
DENT. AGGFAOAM UMM APPLIES PER:
poLNCY a ❑
GENEfM AGOREOATE $ 2,000,00
$ 2,00010
C
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