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EL-15-3017 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-252488 Permit Number: EL-12-15-3017 Scheduled Inspection Date: February 10,2016 Permit Type: Electrical- Residential Inspector: Devaney, Michael Inspection Type: Final Owner: CARVALHO,ANNELI DE Work Classification: Service Change Job Address:356 NE 102 Street Miami Shores, FL 33138-2429 Phone Number Parcel Number 1132060135120 Project: <NONE> Contractor: MISTER SPARKY Phone: (954)785-1564 Building Department Comments REPLACE MAIN DISCONNECT ND INSTALL PANEL Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed f Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid February 09,2016 For Inspections please call: (305)762-4949 Page 24 of 44 From:Pat Chrapowicki FaxID:9419248799 Page 1 of 1 !/ Date:1/19/2016 10:05 AM Page:1 of 1 MISTS-1 OP ID: PT ,4�oizv CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYY) 01, 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 DUESS-NUI tiUNSIIIUIE-A'1;U'NI-RAC'I- BtIWtEN 1Ht ISSUING'INSUKtK'(Sf,,'AU'I-HUKIZtLT-- REPRESENTATIVE 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 CONTACT NAMAI Purmort Insurance,Inc. PHONE FAX 3340 Bee Ridge Rv-dd--- --- --- --- •c No.Ex :941-924-3803 _._ .-_..-- -- _-- • --- AIC Na: 941-924-8799..... ..... Sarasota, FL 34239 E-MAIL Kevin Foust ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Nationwide Mutual Insurance 23787 INSURED Mister Sparky INSURERB:Zenith Insurance Company 13269 6301 Porter Rd,Suite 10 INSURER C: Sarasota, FL 34240 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD __ ___— ......_.. —..._ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CAL LUJIVIVJHIVU VVIVUII IVIVJ Vr awl n rVLKACJ.LIMIIJ 0116MM NIH1 n/Avc DCCIV RCUUIiCU DI anti 1i Lmlmo. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDO E MMIDDLIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE occuR ACP3007294941 08/25/2015 08/25/2016 PREMISES Eaoccurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY7 PRO. ❑ )ECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 A X I11 Ml V D.'AOM0072Oioi1 00l0cl00ic 00!£c/2010 ooci�• e..+�nv(r'_.-_..,.,.., m ALL OWNED ISCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS HTOS NED APROPERTY DAMAGE 11TOS $ P 1 $ X UMBRELLA LIAB Xq OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAS CLAIMS-MADE XLSACP3007294941 08/25/2015 08/25/2016 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X STATUTE ER H B ANY PROPRIETORlPARTNER/EXECUTIVE YIN Z127348301 08/25/2015 08/25/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? � N I A If In NH) E.L.DISEASE-EA EMPLOYEE $ 1 000 000 f yes,describe under r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EC13004833 CERTIFICATE HOLDER CANCELLATION VILLM-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Village of Miami Shores 10050 NE 2nd Ave NE AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 U 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Miami Shores Villagel-ifffmff rVD6,t, entia! 10050 N.E.2nd Avenue NEy ( j�/Rg y� }'n Miami Shores,FL 33138-0000 ED, Phone: (305)795-2204 �toAtop+ I u a ;' 16t2 `1 Expiration: 06/05/2016 Project Address Parcel Number Applicant 356 NE 102 Street 1132060135120 ANNELI DE CARVALHO Miami Shores, FL 33138-2429 Block: Lot: Owner Information Address Phone Cell ANNELI DE CARVALHO 356 NE 102 Street MIAMI SHORES FL 33138-2429 Contractor(s) Phone Cell Phone MISTER SPARKY Valuation: $ 7,896.00 (954)785 1564 (954)275-6545 _...: N Total Sq Feet: 00 Type of Work:REPLACE MAIN DISCONNECT ND INSTALL Available Inspections: Additional Info: Inspection Type: Classification:Residential Review Electrical Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $4.80 DBPR Fee InVO1Ce# EL-12-15-57932 $4.15 DCA Fee $4.15 12/03/2015 Check#:0107 $50.00 $256.46 Education Surcharge $1.60 12/08/2015 Check#:0112 $256.46 $0.00 Permit Fee-Additions/Alterations $276.36 Scanning Fee $9.00 Technology Fee $6.40 Total: $306.46 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder 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. December 08, 2015 Auth zed Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 08,2015 1 \ \ Miami Shores Village ----- - � - A� Building Department SEC 0 3 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 F B C 20 /// BUILDING Master Permit No.,E/ /�_—,?2214- PERMIT APPLICATION Sub Permit No. ❑BUILDING 0 ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 356 NE 102nd st City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-013-5120 Is the Building Historically Designated:Yes NO X Occupancy Type: res Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Anneli De Carvalho Phone#:305-758-9048 Address:356 NE 102nd st City: Miami Shores State: fl Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Mister Sparky Phone#: 954-785-1564 Address: 1450 SW 3rd st suite A8 City: Pompano Beach State: FI Zip: 33069 Qualifier Name: Kevin R. Court Phone#: 954-275-6545 State Certification or Registration#: EC13004833 Certificate of Competency M DESIGNER:Architect/Engineer: Phone#: Address: (, City: State: Zip: Value of Work for this Permit:$ D Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace El Demolition aAM Description of Work: e.(, „�a ,1VLY SCALOA Ovi.1 1/I�1lAf. ®VILVIV.A Specify color of color thru tile.- Submittal ile:Submittal Fee$_ 4J Permit Fee CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ ' (Revised02/24/2014) 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,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 v� Signature i OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of e�-��2 ,20 1, ,by o�0 day of &1- ,20 /5— by AnIle (!%ryalAb ,who is personally known to LlIII1 R ed1.cr-�- who is personally known toCIL me or who has produced _� as me or who has produced as e identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: 0�Sign: Sign:62j � Print: �' _"TPrint: e ;``aAi irF M-BRYANT Notary Public-State of Florida Seal: Seal: J=.: ;•_ Notary Public State of Florida :N Qr My Comm.Expires Nov 3,2015 Deena J Court '%;lF o :� Commission#EE 143603 +� My Commission EE 192421 �lor�o Expires 07/29/2016 �g� s� � APPROVED BY .� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Oct 28 15 08:00a Mister Sparky Pompano 954-785-1566 p.1 OR •••• nm Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.$972 CONTRACTORS' REGISTRATION 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* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *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 most specify the description of operations or contractor license number. rrwr■■rer■carr■■■■esrrrr■■r■■wr■■w■rr■wwrwr*■w■raw■w■r■waw■r■■■wr■■rwr■rrr■rrr■■rrrr■rrrrw BUSINESS NAME: BUSINESS ADDRESS:_) CITY k) eflGA STATE–An, Zip 3 66 BUSINESS PHONE: R�5q—) f —S- 1 (4 FAX NUMBER LqZjj)�&5--/5'o(p CELL PHONE ) 175--ioZW {QUALIFIER'S NAME: _ KG,V 11'l { QUALIFIER'S LIC NUMBER:. LC )�60L(95 Oct 28 15 08:01 a Mister Sparky Pompano 954-785-1566 p.5 n' STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION EC13004833 ISSUED: 08119/2014 CERTIFIED ELECTRICAL CONTRACTOR COURT, KEVIN ROBERT MISTER SPAR" IS CERTIFIED under the provisions of Ch.489 FS_ Expkatkmdale:AUG 31.2al6 L140819-DO 03 1ERE Oct 28 15 08:01 a Mister Sparky Pompano 954-785-1566 p.4 -Mpana beach Florida's Warmest Welcome - -"CI'T Y OF P'OMPANU EACH BUSINESS TAX RECEIPT FISCAL YEAR: 2015-2016 THIS IS NOT A BILI Business Tax Receipt Valid from: October 4 2015 through September 30,2016 9/23/2015 4459683 MISTER SPARKY 1450 SW 3 ST 8 POMPANO BEACH FL 33069 THIS IS YOUR BUSINESS TAX RECEIPT. PLEASE POST IN A CONSPICUOUS PLACE AT THE BUSINESS LOCATION. BUSINESS.OWNER: COURT.ELECTRICAL BUSINESS LOCATION: 1450 SW 3 ST 8 POMPANO BEACH FL REGISTRATION NO: CLASSIFICATION 16-00086767 CONTRACTOR ELECTRICAL(CME) NOTICE: ANEW APPLICATON MUST BE FII:ED 1 TI•IE AUSIIJfSS NAM E,.OWNERSHIP OR ADDRESS-IS'CHANGED. TTtE TSSUANCE OF A BUSINESS TAX RECEIPT SHALL NOT 13E DEEMED A WAIVER OF ANY PROVISION OF THE CITY CODE NOR SHALL THE ISSUANCE OF A BUSINESS TAX RECEIPT BE CONSTRUED TO SE A JUDGEMENT OF TWE CITY AS TO THE COMPETENCE OF THE APPLICANT TO TRANSACT BUSINESS. BUSINESS TAX RECEIPTS EXPIRE SEPTEMBER 30TIlr OF EACH YEAR OD® DATE(MM/DDNYYY) ACR ` b CERTIFICATE OF LIABILITY INSURANCE 10/27/2015 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 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 endomement(s). PRODUCER CONTACT Yami le Corral NAME: Gil, Garden, Avetrani Insurance Group PHONE . (305)630-4757 NC No:(305)279-3022 10689 N. Rendall Drive E-MAIL ADDRESS: Suite 208 INSURERS AFFORDING COVERAGE NAIC# Miami FL 33176 INSURERA:Travelers Indem Cc of CT 25682 INSURED INSURER B Court Electrical Service, Inc. INSURER C: DBA Mister Sparky INSURER D: 1450 SW 3rd Street Suite A8 INSURER E: Pompano Beach FL 33069 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 L R POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMID MMIDD X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED A CLAIMS-MADE 1XI OCCUR PREM SESOEa occurrence) $ 100,000 660-8E676230 8/9/2015 8/9/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Electrical contractor license number: EC13004833 CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Bldg Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Derek Rodriguez/YC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 rgm4nat Dec 03 1511:42a Mister Sparky Pompano 954-785-1566 p.1 Cate CERTIFICATE OF LIABILITY INSURANCE 10/28/2015 Producers_Plymouth Insurance Agency This Certificate Is issuer]as a matter of information only and confers no 2739 U.S. Highway 19 N. rights upon the certificate Holder.This Certificate does not amend,extend r Holiday, FL 34691 or alter the coverage afforded by the policies below. (727)938-5562 insurers Afforcring Coverage NAIL# insured: South l=ast Personnel Leasing, Inc. &Subsidiaries Ensurer A: Lion Insurance company 11075 2739 U.S. Highway 19 N. insurer 13: Holiday, FL 34691 Insurer G. insurer D: Insurer E Coverages The policies of insurance listed belaa nava been issued to the insured named above for the policy period indicated. Notwithstanding any requiremem,term or condition of any contract or other ocumani with regpect to which this certificate may be issued or may pertain,the insurance afforded by the policies described herein is subject to all the terns,ex luslans,and condHans of such policies.Aggregate limits shown may have been reduced by paid daims_ INSR ADDL I Policy Effective Policy Expiration LTR INSRD Type of Insurance Policy Number Date Date Limits (MM/DD/YY) (MM1DDNY) GENERAL LIABILITY EachOsurTence Commercial General Liability Darnage to rented premises(>A Claims Made 0 Occur occurrence) Med Exp 3eneral aggregate limit applies per. Personal Adv Injury General Aggregate Paicy ❑project LOC Products.ComolOp Agg AUTOMOBILE LIABILITY Combined Single Limit Any Auto (EA Accld0nQ All Owned Autos Bodily Injury Scheduled Autos (Per Person) 1-fired Autos Bodily Injury Nan-Owned Autos (Per Accident) Property Damage (Per Accident) EXCESSIUMBRELLA LIABILITY Each Occurrence Occur ❑Clairns Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2015 01/01/2016d(/C Statu- OTH- Employers'Liability X bary Limits ER Any proprietor/partner/executive officerlmember E.L Each Accident s1,00o.000 excluded? NO E.L.Disease-Ea Employee sf,ow cco If Yes,describe under special provisions below. E.L Disease-Policy Limits sf.000,000 Other Lion Insurance Company is A.M.Best Company rated A-(Excellent). AMS#k 12616 Descriptions of Operations[LocationsNehicles/Exclusions added by EndorsementrSpecial Provisions: CUent ID: 0945-223 Coverage only applies to active employees)of South East Personnel teasing,Inc.&Subsidiaries that are leased to the following"Client Company': Court Eletdzical Semice-im dba Mister Sparlty Coverage only applies to Injuries incurred by South East Personnel Leasing,Inc.&Subsidiaries active ernployee(t,,while woridng in:R. Coverage does not apply to siatiAc ry employee(s)or independent contralxcr(s)of the Client Company or any other entity. A list of the active emp?oyee(s)teased to the Client Company can be obtained by faxing a request to(727)937-21313 or by calling[727)93&5562, Project Name: ISSUE 10-28-15(AF) CERTIFICATE HOLDER CANCELLATION l3ftin nate t6 23 tow MIAMI SHORES VILLAGE Should any Of the above described policies be cancelled before the expiration data thereof,fha fissuring BUILDING DEPARTMENT insurer will endeavor to mail 30 days written notice to the certificate holm named to the toll,bull failure to do so shall impose rm obligation or liability of any Idnd upon Lha 6isurer,Its agents or representatives_ 10050 HE 2ND AVE, MIAMI SHORES, FL 33138 DEC 0 3 2015 BY: t N tP�X C 3 0 W-1 C ry u 10 1-2-F 1 Nftry Public$toe Of Fbrida Ex :dr'r in M I�A 'A p y C ,=te 176009 k, Of fu Expires 11/13!2018 see • 000 0 ELECTRICAL REVIEW APPROVEDATE