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PL-14-400 •� 4 Miami Bores Village Building Department 7BY: R .0 4 2014 18050 N.E.2nd Avenue,Miami Shores,Florida 33135 Tel: (305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(3011)762,4949 FC 20 BUILDING P®r m It No.PPL PERMIT APPLICATION lister Permit No. Permit Type: PLUMBING JOB ADD 00 City; MWW Shares County: Miami Dada dip: Folio/Pareel#:_1 I Ianca�1 Is the Building Historleally Designated:Yes NO bloodZone: 111aa ftoL!U± -3W •Naue(Fee Simp1® 3- 1C ,Address: City: State: Tenant/Ussee Name: Phone#: Email: CONTRACTOR:Company Nam:_ �S-��•d�5 �l.)Yh Y`�Q� Phone#: 9,5 Address: 5101 Q0 11 1 ��.r• City: LA/►C P •� State: zip:33r3c',� Qualifier Nance: inn �,��Ui�; Phone#: 0 State Certification or Registration#: C 1� o 2 —cardficate of Competency#: Contact Phone#: Q2_g (&2i3 Email Address: DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ `'1,IA,A/�� Square/Linear Footage of Work: Type of Work: ®Addre s 6Alteration brew URepair/Replace DDemolit aT: Description of Work: 'F Submlttal Pee$ Permit Fee$ e `—CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DRPR$ Bond$ Notary$ Training/Education Fee$ Technoloa Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$_ ,,� Bonding Company's Name(if applicable) Bonding Company's Address City State zip 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 AFTMAVPI': 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 ENAPROVEMENTS TO YOUR PROPERTY. IF YOU INTEL 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 ar tilcaal must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered.o MA perst,," whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at:he 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 Slgtlature W Owner or Agent Contractor '73109re going instrument was ac owledged before me this The foregoing instrument was acknowledged before J ,20 1H by day of ly7arril ,20 LYby1 K '1 rs®Wally known to me or wh has produced who i rsanaily knr� to me or who lias produced q�'Os As identification and who did take an oath. as identification and who did take oath x TC: NOTARY PUBLIC: % 00 (nNz z $ �P Print: n' Q mission*9 62n E ' s: My Co, ssion Expires: a' N 1 pN ` APPROVED BY p � ��-®*,/ Plans Examiner Zoning Stitllt°al Zvi®w <�ixi' (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Y Y STATE OF FLORIDA¢�p��j ®� g9 • gpq��gy� 8/Z� OF BUSINESS PROFESSIONAL i IO CONSTRUCTION LS Gr (13S®) 487-1395 T S STRM32399-0783 �� e7 a' lG. leg V& 33328 t s '�r.i8ny. Aqf .g • wee With thlt3 Ort®ol`the neaely Cuto Million � ' j•r �° b `�°•: F • . n,�taed b�►the �ofB and Regulad " •� � TaIB andbusinesses range from Oct to yacht brokem tom► '. .P wque and they keep � '0'IOrldB+a economy� .. � 684 CYCO57.602 c� 128®3. ! Evay tsywe,�k to the way we do business ons In order to tete you !:� about out .. n .c�h. ' Them you can unim about our the that :t�: Y ;;, . i you, t0 and lMM More about the r ,. �!a `° t .I-. ' t•1� o s�o..�.,. Departnent C.,. C .tip W r. ;,• �4ACAN rr' 1 �'~• , mission at the License sbWe t0 so that Can your atistomers. � +f�i: doing bushess In Floritim, congratuistichs on your now ficansel WE IN ;,^ ...,� �:' ;�'?cs, r I� ig` '.�,�: �- � f .f�" s.,' ;�, � :t•aT��"r= r .la i r :� ,. '� � a�}. ';s ". ` t4.'$"�.it. .r + .�r'`G• t $ - 3207250117 i 480 s g{tea ;a ..:., ••jia _ itS:•.:.,j a.:C C: y `.,<f d� °g 4;�` { � �: �, '� _ 5•>: :3 ., is j �.ral: qu cotes AVQ,•. 1 .i20 4 :• t,, , r,:.R°•' S' .•7.. 4F j\ �+. eel .. ;t t. a •t4 t i lit k; L1 '�'� •a �>' `':e� &�'.j ¢M 'd. !s tG .it: .�"y' � 3�,•F`, t y �,'+r.: fZ ir�:L. 9 � 3 VJI ' :Jl: '`t YP.�1 � rl-:� 4' „ (d0'i®•i',� R'p: t9 rc"+i 4i'f .4n 3? .. ` t-.k� y.v:+e:,�. """�'{ aye. :•�?:,e :,i^"L.•i' .: ;h•;,t• INP. #� r{, :; •"iF Via. ;w 6'7 r'� ;•�u.,..'y' ,� f jjk : •a."` f P., �s+ t •'i Jt�r• a t i¢;' f''-� 'At t ` ra q ik . �s4 !ri., ,� r >� `�`F+t pt t: dr `,5'r• za- weem SECRETARY + i •t.;a �w bk' t,1gt ale. t'm.0 !, 4 Y•� ,.•v' ts., w� t° �'' �jw2�Y; k�; ' ~- ... a'•l• .;. r,�.. lr,:.....�.R':,ai ... wr..�►o.�.�+.�fr�1�. a•r+ ..P..7 LL ' a-- c `sem r� .r '*• _ � F� 33 4.' y k' 7 su_ JAI x 1- s9[t �: _ iy i� S*f At.'�S l _ 5� _ sA✓f —."-i f ee{Es`�.. av i� ,v I CERTIFICATE ®®T'FICATE F LIABILITY IAI .' INSURANCE ppURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATO 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 pollcy(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 endorseme s. PRODUCER Collinsworth,Alter,Fowler&French,LLC 8000 Governors Square Blvd 308 822-7800 a N 306 3n24A3 Suite 301 Miami Lakes,FL 33018 INSURISM61 APF@R!)INA O@VBRAAIE tf 0 INSURffRA;dt3W6Ui0U6 Lines Insurance Comp9py 13604 INSURED INSURSR e:Philadel hia Inderrift In Co 16006 J&J Davis Plumbing Service,Inc. IN R 9:Scottsdale lndemn 00 16680 8101 SW 111th Terrace INS RERD:Brld etleld Casual Ins Co90395 Davie,FL 33328 Z§yffil c P COVERAGES CERTIFICATE NUMBER: INSURER PREVISION 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. ILTR NSR ACUL OR POU EF TYPE OF INSURANCE ICY NU ER L1M1T8 GENERAL LIABILITY EACH OCCURRENCE 10000,00 A X COMMERCIAL GENERAL LIABILITY SLPGOL0203300 9/14/2013 9/14/2014 P EMISES(Ee a Waal eg 100,0001 CLAIMS-MADE L.X OCCUR MED EXP LAy orm areas) B %4001 PIZRSONAL&ADV INJURY 83 o OrOO GENERAL A0GREGATE 9 r 0,00 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO � _a0 POLICYX PRO LOC AUTOMOEILEILIABILITY B I II pO aN s3r t ,� B X ANY 41JTO PHPK1074230 9/14/2013 9114/2014 BODILY INJURY(Per Person) IY�NED AUTOSU�D BODILY INJURY(Per awdent) ,m * NON-OWNED X HIRE{ AUTOS X AUTOS (PPS MOMr X LAB X OCCUR EACH OCOLIRRE 09 6 1,0 0 C ex"Ss LIAR CLAIMS-MADE XM0033247 911412013 9114/2014 AGGREGATE1,Q00,0 I Rig tt NTI S RetAntio► duc WORKERS COMPENSATION AND 8MPLOYERS•LlIABIL1TY D ANY PROPRIE`TORIPARTNE CUTWEYIN 83039/210 4/012013 41512014 E.(,.EACH AOCIDENT S 11006,00 OFFICERIMEMBEREXCLUDED? N/A (MandeWry to NH) B,L.DNE3MSE-EA EMPLOYE >a � 11000106 If 91"P0"N®urger RAT N ma s.L.DISMS-MLItAYY WNIT 11000,00_ LiMMP"",OF OPERATIONS!LOCATIONS I VEN181"(Misch ACORD 101.AddrdoW ReMAM BaWule,U=M Brae to mgwmd) Plumbing and Gas RTIPIC ` HO ER N TI GNOULI1 ANY OF THIN ADM DESCRIBED POL.ICI88139 CANl9RLLOP SOFORE Miami Shores Village THE EXPIRATION DATE THERSOP, NOTICE WILL, BE DELIVERED IN 10060 NE 2nd Avenue ACCORDANCE WITH THE POLICY PRQVI81ONS. Miami Shores,FL 33138 AUIMORIZED IREPROHNFAWN 5 100842 10 ACORD C610,ORA Y1 Il 1s r;emd. ACORD 25(2010108) The ACORD game and logo are registered marks of ACORD COUNTY' -1 AX RECEIP 1 71 i 115 S.A►t Avs., .A-IW,FL Lit dale,FL 333014M-954-MI-40M VAUD OCT013ER 1,2013 THROUGH SEPTEMBER 30,3014 RgCW#- .189-239311 DEW J & J DAMS PLUMBING SERVICE INC � � ALL OTHER TYPES CENTRA I� 13"b"m tum. IGEN CONTRACTOR) OwnerNam:jamm N DAvis °02/17/2011 5101 SN IIITERR .11-CLPG-17197-4 DAVIE 8� DookHM •954-680-6543 .>�• Room PnAmdonab V � w TQC T F� a $ 4 }A n s C T9d R� 27.004.O - . - ®.flS 27.00 Y IN YOM RACE OF BUSPIESS TM BECOMM A TAX RECEIPT •$t om Is WuW for de p~of Is y In nghm YOU awd rime al b Ttf Mmm Tax Rem*t mid be emnbffW when or -ym have awded M budom .ThIs or OW aieIn axrvmmw Wo Stab Gr iow lows OW romfielm's. EMM Addmm J & J• DAVIS PLWMDM SERVICE INC Receipt ftSIL-12-06011932 51{81 SN 111 TE2R Paid 07/30/203.3 27.00 DA®'S8, FL 33328 2013 Floilde=of Agriculture and mournerSeMoss 8 L*AW PeWsum Gas In ion P.O.Box 6700 Tallahassee, F 323994700 Ucem Number. 23687 Bohm Malling Addmw LiewaW Location Addrm J DAVIS PLUMBING SERV=INC. J&J DAVIS PLUMBING SIRVM INC. 101 Sw 111TH TOR 6101 ew 111TH Ten DAME,FL 332204M ®AVID,111.$33284737 at ft bo"of tl>is ft"Is wHd ONLY for 0WnPnY WCOW 8t 11cam aftmW to expire 9W become kwP911100 b9c8m Of%Um to mmw- T14 fte for reeftwe*m of a lkww Is equal to the oe4nW 1100MIS fGG and Owd bs paid before tlt®licensee may imam oparaftli. IN TW MM 0 AN 0M§NW 21MOE AT THIS S—US—IN-M 629&W L- TNS ftw"may be V9180no firm or corpqraWnibr the remainder of the cent Room yew upon wrftwrequag to the deparMient by ft od*W lWww holder, Lkenw ftnefere must be approved by the chgaijiTmi: AD Haereft requirenwO must be met by the reneftree and a VwWw fee of$50 will apply. To apply for a twebr,conted the Bureau of LP Gas impeoWne at(860)921-1600. Pumuant to ChWar 527,Flodda StWutw.LP Gas Iwannes must prmffl proof oft to any owwumsr. owner,or aid user upon requeW when ergaged In the budngss of mvichig,teeft,ropaIrIM,nw*dalrft or hftmv LP G"Systems and/or equo"ent ForfLdurecon poiridance,Wm made any needed owraeffm ordmvw to yaw bAhm mdbV addrew wW*r ywr ftersed b000n addrew and return to UPPERPORTION wkh coffeefts tw. FW da DepwUM'It of AWWWJM IWConsumer Services Bureau of UqueW POWGum On Inspedion P.O.am 67M FlodO 323994= sftte of Fwda Deparbnent of Agriculture and C Services Dkftlon of Consumer Servk= ussn"1111mber. 23W BVII'96m Bureau of Liquefied petwieum Gas jnspecdon Deb of bow: Saptat!W lyDats. AugM31.-2014 2013 (8W)921-1600 LIMM ftw $MOD Tal"assee, Fiord Tm wd 009: OW *MY • Allb Limefied 'retroleunn was License LP GAS INSTALLER OWWCATWI W&Y atseafto UTA2,FWW sbumetw J &J ®AVIS PLUMBING SERVICE INC. $101 8W1111TH TER DAVI% FL 33W8-4737 COMMISSIONER OF AGRI"TURE 1 i ,� M .y :oma ^^ k d :sv �;'.,�,•`,: p iJi'r k � 4� ti t�t a A�'y,r,r�x °.. ``f Fmt �_ '�qa. ; e� e r ^r1}' 'gy. q •i A rf" LY i t v s>p.,M `T2 �r� f. m LV Y�5 r.'_ a '(, a •i .nS �� ,f G '.a'��5^r 4 ° SYee a 4°xt.. -.l � i.��",�y... �a'a�, ,`t.aa '��''n•^ Y $'�#' '��Zt � -^sem' a�'yst .t�i� -¢w fl'��u -r. Ryy d�6 f: d n b s+ 4.- mer. e� •^ i t d r t- dry `i. r �9 qc, `� dr �#3. ,�.'i'a� i �a,�f.`�,A'^v� Lh ,`�,� `�'°�r t"�r rd r a,,�`i;�-'3-r v,�••3:R� r:�f � 'Sr, .�2 �r".{.'s. - d,�S.g Y +,v,8''r . 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' VICE INC. mom !i .W)T"' a. _'5 •v, ''p 44 y .y,. � x4 dF e+r+► �rvw� vy.�.�.w't f ', z1 r(tay'�]101trr''�.� .•5 . .. �•d'� a `�`r,- rrt � r,sr��i F f� ��.Y+Y'i d.T iya d ..y-...- � � ! y� ;� �p��j ♦ !° ,Y of.T /tkt a" ¢'° �q'. t L � t. 3c�'�ga' :,1F,IaII �'i t t4q T i �}f°Yt'wt t YTl;,N,y4. `4P�+ .{ L �t J y L 4 4 t 4� 5 3�• i,.z^�} j.) ,u" . f3.'r ,Rt 7 F�,a^s' 1 •?°'a.d,E'rv' am* T•�'�`PJI,"�•°7n a. � c >a i 'r, a`} k 1' �' - 1 � t- 4��',Ar! a�°.." :�'•` r d+.� '�' .��a ��;. x r '`�.+svK !t_y -t��"'VF,��fsA Y � ��� Pir v iri^�J:9„�,JJ' �,• r� � - p+ 4'=�r5•a'�, r �:✓'a,.'7F '�y:.Ir4j•. '�'.`T.ci� :' �v r t� F� d' d A "ct 34 �. Z - -r3,` x• �P ' lY�Ls r wt� i w 5 r�•;.fri'M �.+9�,r si K p i. f �:_ "" r �'' t' 1 9 _ at L !sr7° . A d- 'l :tt 1'} r^ �4 41 � ay A L / yl .S•) f . ...p asL:r..+rV,,tr rw..W.is. q....gef."'r e+.i.fip t�+�^fr+"�!?!`is.�7:.t e..tir.�;G..3.s sr.^..nr,,.Te fs+s...w':r+aar '•.r r. - ..r� f- Yt'4 qW _ t, �,rk` � � :a a, s<✓'��� .Y'•+.y^ _SM�hy .yi r�r v 9 rF ,,;r; - ] b •1 ' % ,Kr �n�k} rtr�. �d• X -.ro �,., � r t .i a �!s}, jv i'. � '� aR ai y �cr b � � b�,'r'• 1- 4 x ,Le - r �. ..:> � r. ` � .. r t' t 1 f Val J J DAMS PLUMBING 5 1i SW 2I lea Terrace ® ftMPJDA 33325 (354) 68543 www.jjda�lrnb�cag.�rrr� r CUSTOMER'S ORDER NO PHONE DATE / NAME �q 'f - "ADDRESS O m c fV JC' 90 _fir✓ � --— –_� _ _— ---- -- � SOLE)BY CASH , � , ., DSE.R rD -PAID QTY. DESCRIPTION PRICE AMOUNT rw 1 1 1 -x 1 i 1 ti 1 _ TAX 1 . =Y: RECEIVED BY TOTAL All claims and returned goods MUST be accompanied by this bill. Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax:(305)756-8972 Inspection Number: INSP-208244 Permit Number: PL-3-14-000 Scheduled Inspection Date:April 02,2015 Permit Type: Plumbing- Residential Inspector. Diaz,Osvaldo Inspection Type: Final Owner: MATEO,RAYMOND AND DAMARIS Work Classification: Addition/Alteration Job Address:900 NE 100 Street Miami Shores,FL 33138- Phone Number Parcel Number 1132060340220 Project <NONE> Contractor: J&J DAVIS PLUMBING SERVICE INC Phone: (954)680-6543 Building Department Comments PLUMBING AS PER PLANS Infractio Passed Comments INSPECTOR COMMENTS False 00, Inspector Comments Passed J�� Failed - L� Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid April 01,2015 For Inspections please call: (305)762-4949 Page 1 of 34 III •"""`� JWDAVI-01 SSIMEON CERTIFICATE OF LIABILITY INSURANCE 1 DAT4/4/2 D/YYY1) 4/4/2014 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 policypes)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 CONTACT NAME: Collinsworth,Alter,Fowler&French,LLC PHON o Ext:(305)822-7800 a No): (305)362-2443 8000 Governors Square Blvd Suite 301 E-MAIL ADDRESS: Miami Lakes,FL 33016 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Starr Surplus Lines Insurance Company 13604 INSURED INSURER B:Philadelphia Indemnity Ins Co 18058 J&J Davis Plumbing Service,Inc. INSURER c:Scottsdale Indemnity Co 15580 5101 SW 111th Terrace INSURER D:Bridgeffeld Casualty Ins Co 10335 Davie,FL 33328 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE DL R POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER M D D GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY SLPGGL0203300 9/14/2013 9/14/2014 pAMAGE TO RENTE REMISEs tp.occurrence $ 100,000 CLAIMS-MADE FX-I OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X pRa LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident B X ANY AUTO PHPK1074230 9/14/2013 9/14/2014 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOSX NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 4,000,000 C EXCESS LIAB CLAIMS-MADE XBS0033247 9/14/2013 9/14/2014 AGGREGATE $ 4,000,00 DED I I RETENTION $ WORKERS COMPENSATION X WC STATU- I OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER D ANY PROPRIETOR/PARTNER/EXECUTNE YIN I 830391210 4/5/2013 4/5/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space Is required) Plumbing Contractor/License#CFC057W2 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE e lt_� ©198&2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �I