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RC-14-853Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-231168 Scheduled Inspection Date: April 30, 2015 Inspector: Rodriguez, Jorge Owner: , Job Address: 578 NE 93 Street Miami Shores, FL 33138 - Project: <NONE> Permit Number: RC -4-14-853 Permit Type: Residential Construction Inspection Type: Final Work Classification: Alteration Phone Number Parcel Number 1132060141050 Contractor: WALTER L LISTA INC Phone: (305)469-2525 rtuuamg uepanment comments INTERIOR REMODELING KITCHEN AND 2 BATHROOMS Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments PassedR CREATED AS REINSPECTION FOR INSP-231049. Replace sod on front of house Gates leading to pool must be self closing and locking with locks min. 54" from floor Failed ❑ REPAIR BROKEN SIDEWALK Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 29, 2015 For Inspections please call: (305)762-4949 Page 10 of 29 Lo 5 "'iUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 cEKV APR 2 X014 9 1FBC 20 LC' Master Permit No. 1 Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION E] RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLICWORKS ❑ CHANGE CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: S �- S 3 .9A - City: Miami Shores County: Miami Dade zip: 3 3 3 Folio/Parcgi#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder) (Lc)S-F' C�� AA 4t!- � �� �� 6 T11: OS�) .5nn S/ f Address:_ 1252-(D v N U-> S 2 City: DO 2A`- State: 'P(.., zip: 331 (P(. Tenant/Lessee Name: Email: on 00101 12 - CONTRACTOR: Company Name: L l,S • L✓�� Phone#: Address: � a-9 6 k V r -s'. S. -` City: C-0 arm L- CP -a- \0'- State: zip: 33 i - Qualifier Name: W Phone#:E.-3 t2s-)44� 9 Z.cz,&— State Certification or Registration #: C6 C O 22 --1 +y Certificate of Competency M DESIGNER: Architect/Engineer: one#: Address: City: State: Value of Work for this Permit: $ SD • O o Square/Linear Footage of Work: _ Type of Work: ❑ Addition Alteration ❑ New Description of,. or -. I <<+^9 (X! m4ei'" SA AE M is Speci color of color thru tile: Submittal Fee $ ��'� Permit Fee $ Scanning Fee $ Radon Fee $ _ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ ❑ Repair/Replace 4b 47 -Hs u p ra# to bulk asia a� � rbwr4 CCF $ Zip: ❑ Demolition _ liv /Z) . PAtruT CO/CC $ DBPR $ Bond Technology Fee $ TOTAL FEE NOW DUE $ % L/ 7-' 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. r— Signature Signature Owner or Agent Contractor The fore in instrument as ack owledged efore a this54 The foregoing instrument was ackno dg d before me this day of r 20 by �ddy .42 day of 20 by whoZt, onally known to me or who has produced who is personally known to me or who has produced_ identification and who did take an oath. as identification and who did take an oath. NOTARY PWLIC:w h NOTARY PUBLIC: Sign: ► Sign: Print: Print: 2/2 �"Ti'l ml!- �„"'+� OANAY BAZAIN • J� YP •. My Commis on Expires: _ �-RS y Pow Fiji My Commission xp ��` •• WY Public - State of Florida My Gomm. Expires amt I. got? � My Cam Expires May. t, 20N e Commission # FF 013642 ;�, � Commit" * FF 013M BORM Tkfp11gt1�� NaWfy ?c I Bonded Through National AIWA APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) s Miami Shores Village 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. X 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* `*YOURINSURANM-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_arcontractor license number. BUSINESS NAME: W A'NC -Z- cS7-'V_ rrj G BUSINESS ADDRESS: 1 ',?9 (e I Pr, -V-4 4-: CITY Q)rev G &k6� STATE �(, ZIP CODE 3 i U BUSINESS PHONE:3( o E ) _ 4 � A 2 �2.0� FAX NUMBER (' ) CELL PHONE (1-) V6 E 4rZJ QUALIFIER'S NAME: W A -k A:E, LCC 4q QUALIFIER'S LIC NUMBER: CGC- STATE OF FLC-IDA DEPARTMENT -b? BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 ' 1940 NORTH MONROE STREET WS TALLAHASSEE FL 32399-0783 LISTA, WALTER L WALTER L LISTA INC 11002 NW SOUTH RIVER DRIVE MEDLEY FL 33178 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better For information about our services, please log onto www.myfloridalleanse.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We j constantly strive to serve you better so that you can serve your customers. i Thank you for doing business in Florida, and congratulations on your new licensel i DETACH HERE sTATE of Fromm AC 6-a.-SL&QE@ 7?k'P;ili,RTU=. * OF SUSINES$ An PROVESSIONA .. REGUTATION CGCO22774 `; lF% 127027392 CMTXFI» .0> 1 3£ RACTOR, LISTA, WALE' L WALTER L 'tl$ft X8 CBRTIFIIW under the prov4ions .of ch.489 ps Bapiratim dace, AUG 31,'.2014 !.1210.1002676 STATE OF FLORIDA DEPARTMENT OF BUJINESS AND PROFESSIONAL REGULATION CONSTRUCT ON INDUSTRY : LICENSING BOARD SEML12101002675 e IT I LICENSE 10 la .NBR X�97 rho GENERAL .CONTRACTOR: RIMSCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW REN LAWSON SECRETARY Local Business Tax Receipt Miami -Dade County, State of Florida =ili1S IS NOT ABILL - DONOT PAY I RTJ 5235650 BUS*Mgs NAMEa.00ATION RECEIPT NO- EXPIRES WALTER L LISTA INC RENAL SEPTEMBER 30, 2014 11002 NW S RNER DR 6471636 Must be displayed at Place of business MEDLEY R 33178 Pursuarit to County Code Chapter BA - Art. 9 & 10 OWNER BEC. TYPE OF SM11NESS PAyMENT RECEIVED WALTER L LISTA INC 196 GENERAL BUILDING CONTRACTOR By TAx COLLECTOR CGCO22774 $60.00 09/25/2013 Worker(s) 15 TXHS1-13-075072 This Local Business Tax Receipt only !N°toms�ym�It of the 1.�1 Bu iae= TmL Tde RMlpt is aot a license. se2oas. to do business. Holder mud comply with my goveremea� or permit. or a certification of the holders qualiff I to the bnshte nonllovemmerrtal regulatory lamand requirements which GPIV The RECEIPT N0. shove must be dlspleyed on an commercialvehicles - fj"aml-Qade Code See Ba -27L For more iuforuretion, visitiiuu: "'''II1�o°ire;cotlee[ s CERTIFICATE OF LIABILITY INSURANCE DA�M�D�) 04/25=14 'THIS CERTI C/yT E t31SSllEd AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICIhIdler DPES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TCtn 71FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESEOR PRODUCkR, AND THE CERTIFICATE HOLDER, IMPORTAf certificate ho der is an ADDITIONAL INSURED, the policy(ies) must be endorsed. N SUBROGATION IS WAIVED, subject to the terms citionsaft !icy, certain policies may require an endorsement. A statement on this certlfleate do" not Confer rights to the certificate in lieu of Suchdarsemen s . PRODUCER I CONTACT Paychex Insurance Agency Inc PAYCHEX NSt RANCE AGENCY INC. ISO SAWG S DRIVE (A1c, NU. E : 877-266-6850 (,arc, No): 5as-389-7426 ROCHEST R, I Y 14620 E-MAIL CBrts�paychex.corrl • INSURER(S) AFFORDING COVERAGE NAIL # INSURED INSURER A: ILLINOIS NATIONAL INSURANCE COMPANY 23817 Paychex Bu Ines s Solutions, Inc.i INSURER B. Walter L Lis R In t 911 PANOR MA rRAIL SOUTH INSURER C: ROCHESTE N 146264397 i INSURER D: INSURER E, t I INSURER FI COVERAGES I CI`Rlir- ATE Numartii: REVISION NUMBER: THIS IS TO C:RTIF Y THAT THE POLIdIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A13OVE FOR THE POLICY PERIOD INDICATED. f O ITHSTANDING ANY,• REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHEIR DOCUMENTWITH RESPECT TO WHICH THIS CERTIFICATE MAIL BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF MUCH POUCIRS. LIMITS SHOWN MAY HAVE SMN REDUCED BY PAID CLAIMS. TR TYPE OF 11 ISURANCE ADDLSUBR POLICY NUMBER POLICY BFR POLICYEXP GENERAL L TY NSR 6 (MMIDDIYYYYj (MWDDNYYY) LIMBS COMME ENOV& I (Halt TTY 3 EACH OCCURRENCE S I—N� M ��UK Si � DAMAGE TO RENT® s i MED EXP (Arty om pe -n) + PERSONAL & ADV INJURY $ EN'LAGGREG 7El1 rrAPPIrE9PSR I GENERAL AGGREGATE Is POLICY DJECT= LOC i PRODUCTS-COMPIOPAGG $ AUTOMOet LIA BILITY I ANY AUTO COMBINED SINGLE LIMIT (Ee accident I NLL AOME OLEO I BODILY INJURY W (Per peraon) S ninppAUT S ANF&WNED ! OD amd tR $ i PROPERryRAMAO� aECSd $ UMBRELU LIAR OCCUR S FACH OCCURRENCE S EXCESSDLAIWa MA02 AGGREGATE $ DID err102 WOMMRSCOM SAY NANI) $ 6"MOT VIM DUTY j 413255888 0610112013 06101/2014 X WQ7ACCID9-NTs ANY PROPRIEr E40(ECUYIve ; E.L. EACH 1,000,000,00OFFIGER%WME EXCL Dmz I � WA x EL, DI8E(MandatorylnNB $ 1,000,000.00It de>a U IrIN i 1 EL DISE8 1,000,000,00 I DESCRIPTION OF OP TIGNS I WCAMOws 1 V-VmGl.E9 (Attach ACORD 1M, Addidenal Romaft seh,m,to, ifgwre apace is V*Q,"d) Workers Cqm n� COverag0 Is provi(ied to only thane employees leased to, Waiver Gr Subr gatio granted in favor of the WrItleate holder. Mnot SUbCoAt aOtots of the named insured. GENERAL CO UTOR LICENSE NUOSE:R: CGCO.22774 , 1 CERTIFICATE HOIDER MIAMI SHOR S LLAGE CANCELLATION BUILDINp DEPT 10050 BHOULDANYOFTHEABOVEDESCRIMM POLICIES at CANCELLEDB NE 2N A 1 EFMTHECPIRATION FJ MIAMI SHOR S. I L 33138 DATE THEREOF, NOTICE WALL BE bNUVr;RED M ACCORDANCE WITH THE POLICY PROVMIONS, PUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NOOBLIGATtON OR WABILITY OF ANY KIND UPON THE COMPANY, ITs AGENTS OR REPREBENTAnVF% ' AUTHORIZED REPRESENTATIVE f ACORD 25 (201 105) ®1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks Of ACORI) i �. WAL M-1-01 RGOME,Z RTIFICATE OF LIABILITY INSURANCE` TEIMN/ bffr") 4/2612014 5 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. THIS t1ATIVEILY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOR13ED BY THE POLICIES iNSUJONCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED t; AND THE CERTIFICATE HOLDEk didar an ADDITIONAL INSURED, the policy(les) must be endorsed. It SUBROGATION IS WAIVED, Subject to 1Iloy, ce4tain policies may require an endorsement. A statement on this certificate does not confer rights to the dorsem�nt s . CONTACT Collinswo , AI r, Fowler S French, ILC NAME, 8000 Govan ars Square Blvd Alc No :(305) 822-7800 Na; (3 362 2443 Suite 301 I Miami Lakeg, FL 3016 ADDRESS: I INSURERS AFFORD IN0 COVFJiAGE NAICI! I INffilleD I INSUReRAtOhiO GAGUOIty COMPan i INSUPERa: Wafter L Lista, Inc. j j I2,16l1Nt to; 128 l Deva Street i INSURERD: Olt r 1 Gsaibles, FL 33'(56 . INSURER E t INSURERF: ;EXCLUSIO VERA13 S CERTIFICATE NUMBER: REVISION NUMBER: HIS IS 7 CEfITIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURER NAMED ABOVE FOR THE POLICY PERIOD INDICATE N TWlTHSTflNDIN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VutTH RESPECT TO WHICH THIS ERTIFlC E Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THE TERMS, 5 D CONDfrIONSO� SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REALICER BY PAID CLAIMS. TY E OP INSURANCE 1 POLICY NUMBER b IO CDIYYYY LIMITS ' GENERA UA LnY A X CO MER GENERALLIASILfIY EACH OCCURRENCE g 1,0001044 BKS(14)66897807 818/2013 8/612014 PREMi8E8 Ea vaaL:u— s 300,00 CLAI DE OCCUR MED P� (Arry one person) 8 15,00 PER6bNAL8ADV INJURY S 1,000,00 1 GENERALAGGREGATE S 2,000,00 FGERLRE TE LIMn APPLIES PERPRODUCTS• COMP/QP AGO S 2,000,00CY PRO- ! AUTOM ABIr.IYY L S CO ANY kUTCIALL MiNt C) E9 eCdderit S ALIT SA� ED D i BOQILY INJURY (Pcr psrsm) $ HIRE D 06 AUTOS 6D NON f3COI6.Y INJURY (Per dOG48iIn $ I Per wddent S �S x X OCCUR A EACH OCCURRENCE a 1,000,00 ° ss CLAD MADE USO(14)SS697607 81612013 SM2014 AGGREGATE g 1,000,00 DED X RETENTI N s 01000 AND E I C PENSATION S LIABp.TtY ffff CSTATUOTERFf ANr�RO IET P1PAR1NER/EXEcUnm -TO YUMITS OFFICE EM R EXCLUOW? N / A E.L aACH ACCIDENT S (Mand In N ) RIP N OPERf1TION5 bef� E.L DISEASE - EA EMPLOYEE S ROd E.L DISEASE • POLICY LIMIT S : 1 •i DESCRIP7IGN opE 'PONS/LOCATION /VENN:LES 1AttaonACGRD701,Aq�q(pda(ReYrtaNG6Schedul Ifrr:ors� General Conti actoLicense# CGC 022774. S Pow m mquirs4l Operations: onc eta Contractor I CERTiFICA H LDER j CANCELLATION I I, SHOULD ANY OF THE ABOVE nESCRIOED POLICIES BE CANCELLED BEFdRE i Shores Vilkage BuliBing DBpartmerrt THE EXPIRATION DATE THEREOF, NOMOE WILL BE OKLIVEREp IN 00 0 NE 2nd Avenu ACCORDANCE 1MTH THE POLICY PROVISIOMS. 1 1 Shorne, FL 3338 ` AUTMOPMo kEpPzEsENSAMvs ©1988-2010 ACORD CORPORATION. All rights ressrved. ACORD 25 01 105) The ACORD name and logo are raglstared marks of ACORD THIS CRF TIFI ATE IS ISS CERTIFIC kTE DOES NOT BELOW. THI - CERTIFiCA REPRESENT fVl: OR PRO IMPORTA 4T. If the ccrtltl the terms anc conditions o Certificate halt er in lieu of a F'RCbW9ft �. WAL M-1-01 RGOME,Z RTIFICATE OF LIABILITY INSURANCE` TEIMN/ bffr") 4/2612014 5 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER. THIS t1ATIVEILY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOR13ED BY THE POLICIES iNSUJONCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED t; AND THE CERTIFICATE HOLDEk didar an ADDITIONAL INSURED, the policy(les) must be endorsed. It SUBROGATION IS WAIVED, Subject to 1Iloy, ce4tain policies may require an endorsement. A statement on this certificate does not confer rights to the dorsem�nt s . CONTACT Collinswo , AI r, Fowler S French, ILC NAME, 8000 Govan ars Square Blvd Alc No :(305) 822-7800 Na; (3 362 2443 Suite 301 I Miami Lakeg, FL 3016 ADDRESS: I INSURERS AFFORD IN0 COVFJiAGE NAICI! I INffilleD I INSUReRAtOhiO GAGUOIty COMPan i INSUPERa: Wafter L Lista, Inc. j j I2,16l1Nt to; 128 l Deva Street i INSURERD: Olt r 1 Gsaibles, FL 33'(56 . INSURER E t INSURERF: ;EXCLUSIO VERA13 S CERTIFICATE NUMBER: REVISION NUMBER: HIS IS 7 CEfITIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURER NAMED ABOVE FOR THE POLICY PERIOD INDICATE N TWlTHSTflNDIN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VutTH RESPECT TO WHICH THIS ERTIFlC E Y BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THE TERMS, 5 D CONDfrIONSO� SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REALICER BY PAID CLAIMS. TY E OP INSURANCE 1 POLICY NUMBER b IO CDIYYYY LIMITS ' GENERA UA LnY A X CO MER GENERALLIASILfIY EACH OCCURRENCE g 1,0001044 BKS(14)66897807 818/2013 8/612014 PREMi8E8 Ea vaaL:u— s 300,00 CLAI DE OCCUR MED P� (Arry one person) 8 15,00 PER6bNAL8ADV INJURY S 1,000,00 1 GENERALAGGREGATE S 2,000,00 FGERLRE TE LIMn APPLIES PERPRODUCTS• COMP/QP AGO S 2,000,00CY PRO- ! AUTOM ABIr.IYY L S CO ANY kUTCIALL MiNt C) E9 eCdderit S ALIT SA� ED D i BOQILY INJURY (Pcr psrsm) $ HIRE D 06 AUTOS 6D NON f3COI6.Y INJURY (Per dOG48iIn $ I Per wddent S �S x X OCCUR A EACH OCCURRENCE a 1,000,00 ° ss CLAD MADE USO(14)SS697607 81612013 SM2014 AGGREGATE g 1,000,00 DED X RETENTI N s 01000 AND E I C PENSATION S LIABp.TtY ffff CSTATUOTERFf ANr�RO IET P1PAR1NER/EXEcUnm -TO YUMITS OFFICE EM R EXCLUOW? N / A E.L aACH ACCIDENT S (Mand In N ) RIP N OPERf1TION5 bef� E.L DISEASE - EA EMPLOYEE S ROd E.L DISEASE • POLICY LIMIT S : 1 •i DESCRIP7IGN opE 'PONS/LOCATION /VENN:LES 1AttaonACGRD701,Aq�q(pda(ReYrtaNG6Schedul Ifrr:ors� General Conti actoLicense# CGC 022774. S Pow m mquirs4l Operations: onc eta Contractor I CERTiFICA H LDER j CANCELLATION I I, SHOULD ANY OF THE ABOVE nESCRIOED POLICIES BE CANCELLED BEFdRE i Shores Vilkage BuliBing DBpartmerrt THE EXPIRATION DATE THEREOF, NOMOE WILL BE OKLIVEREp IN 00 0 NE 2nd Avenu ACCORDANCE 1MTH THE POLICY PROVISIOMS. 1 1 Shorne, FL 3338 ` AUTMOPMo kEpPzEsENSAMvs ©1988-2010 ACORD CORPORATION. All rights ressrved. ACORD 25 01 105) The ACORD name and logo are raglstared marks of ACORD Detail by Entity Name Florida Profit Corporation TRUST MORTGAGE LENDING CORP Flinq Information Document Number P04000096919 FEI/EIN Number 412142273 Date Filed 06/25/2004 State FL Status ACTIVE Last Event AMENDMENT Event Date Filed 09/27/2013 Event Effective Date NONE Principal Address 8600 NW 53RD TERRACE, STE 103 DORAL, FL 33166 Changed: 06/11/2008 Mailing Address 8600 NW 53RD TERRACE, STE 103 DORAL, FL 33166 Changed: 06/11/2008 Registered Agent Name & Address CALAS Group 2000 Ponce de Leon Blvd 6th FL Coral Gables, FL 33134 Name Changed: 01/25/2013 Address Changed: 01/25/2013 Officer/Director Detail Name & Address Title PD GONZALEZ, LEANDRO Page 1 of 2 http://search. sunbiz.org/Inquiry/CorporationSearch/SearchResultDetaiUEntityName/domp-... 4/28/2014 ---------- - - --------------- 0%1 M 0 9 AY �9 7201 r #: SHORES VILLAGE W1, 1 z 'Ffl DATE OA.P W1, 1 z 'Ffl I _ r r I -� 1 I '• i i i J i � I 1 13NG 6OUTER TO BE MARE THAN :ET FROM1G.E 1. PROTECT ED RECEPTACLE.,! PTACLE,; PUT D/WlPECOTAGLEIMER K. FIXED APPLIANCE$ !Otr lOEIJJ04TlTl��INp r : I Gooe 1 i go ' -- ••i•• .• '•••"s ' •�• ' , —_ ••.' I__.a••- �- 11 i I