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PLC-15-2009 /5 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-245134 PermitNumber: PLC-8-15-2009 Scheduled Inspection Date: November 18,2015 Permit Type: Plumbing - Commercial Inspector: Diaz, Osvaldo Inspection Type: Final Owner: VILLAGE, MIAMI SHORES Work Classification: Addition/Alteration Job Address:10000 BISCAYNE Boulevard Miami Shores, FL Phone Number Parcel Number 1132050200010 Project: <NONE> Contractor: WM PLUMBING SEPTIC TANK&GREASE TRAP Phone: (305)495-0629 Building Department Comments REMOVAL OF EXISTING CAST IRON PIPE AND Infractio Passed Comments INSTALLATION OF NEW LINE AND NEW FIXTURES INSPECTOR COMMENTS False nspector Comments Passed CREATED AS REINSPECTION FOR INSP-241043. PARTIAL PENDING ED� BACK FLOW PREVENTER OK FOR TCO Failed ev Correction Needed Z l Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. November 17,2015 For Inspections please call: (305)762-4949 Page 13 of 33 MIAMI-DADE WATER&SEWER DEPARTMENT METER OPERTATIONS&MAINTENANCE MIAMI- CROSS-CONNECTION CONTROL UNIT 1001 N.W.11"STREET,MIAMI,FL 33136-2209 Phonef305)547-3046 Fax1706 25) 8-5485 BACKFLOW PREVENTION ASSEMBLY TEST DEPORT FORM ADDRffiSOFDEVICE:10000 Biscayne Blvd,Miami Fl. O6VI�RDFDEeRCE: Mia Shores Country Club-NEW 1 owNERCONTACT:Gabriel Fraga-(Contractor) PHONE. 305 49c(629 FA.ti 786 472 7111 ADDRESS OF OWNER: ZIPCODE: 33166 NAME OF TESTER CERTIFICATION#: EX UW1ON DATE:: PHONE:: 2 Roberto Conazo H02387 11-042017 305 273 6100 BUSINESS NAME: BUSINESS ADDRESS: ZIP CODE: MRC Plumbing&Backflow Inc. P.O.Bog 833323,Miami,Fl. 33283 3 TEST HIT MAKE:: MODEL# SERIAL#: DATE LAST CAL. SITE TUBE: Mid-West 835 09091454 02-04-2015 YES /NO TEST PLEASE MARK: R.P. XX D.C. P.V.B. MAKE OF ASSEMBLY:W ILKINS MODEL NO: SERIAL#: SIZE: 975XL 4145835 2" 4 LOCATION OFASSEMHLY:Center of the parking lot HAZARD/SERVICE: MEIERNO. 34770985 X ANNUAL TEST DATE OF TEST: 10/27/2015 METER READING: INITIAL TEST: SHUT OFF VALVE#1: SHUT OFF VALVE#2: CLOSED TIGHT: CLOSED TIGHT.- LEAKED: IGHT:LEAKED: LEAKED: LINE PRESSURE:60 PRESSURE STABLE:YES-NO D.C.V.A. R.P.LA. P.V.B. T CHECK VALVE NO.1 CHECK VALVE NO.2 DIFFERENTIAL RELIEF VALVE AIR INLET CHECK VALVE ES T Closed Tight: X Closed Tight: X FAILED 11D OPEN: FAILMTOOPOC LEAKED. Leaked: Leaked: OPENED AT: HELD AT: OPENED AT:2.6 PSI. PSI PSI PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DEFERENTIAL ACROSS CHECK 8.2 PSl 1.8 PSl IF THE ASSEMBLY FAILS FOR ANY REASON,COMPLETE THIS SECTION AND NOTE REPAIRS REMARKS t REASON FOR FAILURE(IF APPARENT): CHECK VAVLE NO.I CHECK VAVLE NO.2 DIFFERENTIALREIdEF VALVE P.V.B. R E CLEANED: CLEANED: CLEANED: CLEANED: P Al R S REPLACED: REPLACED: REPLACED: REPLACED: D.C.V.A. R.P.Z.A. P.V.B. R CHECK VALVE NO.I CHECK VALVE NO.2 DIFFERENTIALRE.IEF VALVE AM MET CHECK VALVE E T ES T Closed Tight: Closed Tight: FAILED TO OPEN: FAILED TO OPEN:- LEAKED:— OPENED AT: HELD AT: Leaked: Leaked: PSI OPENED AT: PSI IPSI PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK PSI PSI CERTIFY THAT I HAVE TESTED THE ABOVE ASSEMBLY IN ACCORDANCE WITH THE A.W.W.A.CROSS CONNECTION CONTROL MANUAL AND THAT ALL THE INFORMATION IS ACCURATE TO THE BEST OF MY ABILITIES. SIGNATURE OF CERTIFIED TESTER: Roberto Colklazo DATE:10/27/2015 NOTE: TEST FORM MUST BE COMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL BE RETURNED. RFs 0 Miami Shores Village P ti�7yp � tt Dorff l ilal �w� 10050 N.E.2nd Avenue Wo* Ouiiftcsffi dditl Alteration Miami Shores,FL 33138 0000 P'e� rl Itf etmat taitus-APPROVED `1'ffN ` Phone: (305)795-2204 fiLORIDA issue'Date:9/912015 Expiration: 03/07/2016 Project Address Parcel Number Applicant 10000 BISCAYNE Boulevard 1132050200010 MIAMI SHORES VILLAGE Miami Shores, FL Block: Lot: Owner Information Address Phone Cell MIAMI SHORES VILLAGE Contractor(s) Phone Cell Phone Valuation: $ 6,200.00 WM PLUMBING SEPTIC TANK&GREj (305)407-1970 (305)495-0629 Total Sq Feet: 00 Type of Work:REMOVAL OF EXISTING CAST IRON PIPE Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Classification:Commercial Re Pipe Scanning:3 Main Drain Heater Water Service Final Water Main Lavatory Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $4.20 Invoice# PLC-8-15-56663 DBPR Fee $4.50 09/09/2015 Check#:70209 $329.20 $0.00 DCA Fee $4.50 Education Surcharge $1.40 Permit Fee $300.00 Scanning Fee $9.00 Technology Fee $5.60 Total: $329.20 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 accur d that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above named ontra t t do the w rk stated. September 09, 2015 Authorized Signature:Owner / Apleoa Contractor ! gent ate Building Department Copy September 09,2015 1 Miami Shores Village AUG 10 M5 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 FBC 201 `�� r#7- BUILDING #7- BUILDING Master Permit No._6-0 /S — 22C97 PERMIT APPLICATION Sub Permit No. el-E./. - ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ME PLUMBING ❑ MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP 1 o oat' CONTRACTOR DRAWINGS JOB ADDRESS: 1000OBiscayne Blvd. Citv: Miami Shores County: Miami Dade Zip: 3313'2° Folio/Parcel#:01-0102-000-1060 Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Nameff ee Simple Titleholder):Miami Shores r. ltfb o Phone#: 5— _7-'S--2 LF— / Address l fid• I 7 City. Miami ,L state: Florida Zip. 331 ' ' Tenant/Lessee Name: �"�� ��� PhoneE#r�J�-- i Email: X22, CONTRACTOR:Company Name: WM Plumbing, Inc. Phone#: 305-495-0629 Address: 1825 Ponce De Leon Blvd., 232 City. Coral Gables state: Florida Zip: 33134 Qualifier Name: Gabriel Fraga Phone#: 305-495-0629 State Certification or Registration#: CFC 1427704 Certificate of Competency#: N/A DESIGNER:Architect/Engineer: Mr. Architect, LLC Phone#: 305-600-4399 Address:16300 NE 19 Avenue, Suite 211 city. North Miami Beach State: FL Zip: 33162 Value of Work for this Permit:$6,200.00 Square/Linear Footage of Work: Type of Work: ❑ Addition 0 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Removal of existing cast iron pipe, and installation of new sanitary line and new fixtures Specify co Submittal Fee Permit Fee CCF$ CO/CC'$, Scanning Fee$ DBPR Notary g,� Radon Fee$ $ ,d. Notary$ Technology Fee$ Training/Education Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 329 (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 qqthe job site for the first inspection which occurs seven (7) days after the building permit is issued the absence of such poste n Lice, the inspection will not be app ved and a reinspection fee will be charged. Signature ^' Signatu�--— OWNER or AGENT CONTRACTOR Thefol egoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this �G' day of I�U `�`r 20 I' by 67 day of U' 20 by who is per�l_y knamm to who is personally known to me or who has produced as me or who has produced a���S To as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: -- '( Sign: Sign: ti Print: U 11t"7 Print: umt-2 l f' 44 Seal: Seal: "'�'o"'••., ;`ate'°+%e%, TERESA NUNEZ•APONTE .w �e TERESA NUNEZ-APONTE c , axea� E ��*1ble/ylio►aI;Oaleokii8a �x.aaMw�xwx My Comm.Expires Jan 26,2018 's, .a. My Comm.Expires Jan 26,2018 Commissio 55 "•:'f�,.°'.' Commission rt FF 086355 AP `' Plans Examiner T; Zoning Structural Review Clerk (Revised02/24/2014) Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. X COPY OF QUALIFIER'S STATE LICENCES B. X COPY OF LOCAL BUSINESS TAX RECEIPT C.--X—COPY OF LIABILITY INSURANCE* D. X 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 must specify the description of opemtlons or contractor license number. ........................................................................................... BUSINESS NAME: WM Plumbing, Inc. BUSINESS ADDRESS: 1825 Ponce De Leon Blvd., 232 CITY Coral Gables STATE FL Zip 33134 BUSINESS PHONE: (305 407-1970 FAX NUMBER( 86 ) 472-7111 CELL PHONE(305 495-0629 QUALIFIER'S NAME: Gabriel Fraga QUALIFIER'S LIC NUMBER: CFC 1427704 KIL:K bVU 1 1,uuvtKNUh KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION s r CONSTRUCTION INDUSTRY LICENSING BOARD CFC1427704 The PLUMBING CONTRACTOR Named below IS CERTIFIED _ s Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 FRAGA,GABRIEL VVM PLUMBING SEPTIC TANK&GREASE TRAP 1825 PONCE DE LEON BLVD 232 CORAL GABLES FL 33134 MINN. ISSUED: 06/18/2014 DISPLAY AS REQUIRED BY LAW SEC1# L1406180001092 Ji► 07976 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - (30 NOT PAY 6247670 B T-./ BUSINESS NAMEMOCATIONI RECEIPT NO. EXPIRES WM PLUMBING SEPTIC TANK&GREASE TRAP RENEWAL SEPTEMBER 30, 2015 9858 COSTA DEL SOL BLVD 6512322 Must be displayed at place of business DORAL FL 33178 Pursuant to County Code Chapter 8A-Art 9&10 OWNER SEC.TYPE OF BUSINESS WM PUJMBING INC 196 PLUMBING CONTRACTOR PAYMENT RECEIVED CFC1427704 BY TAX COLLECTOR Worker(s) 1 $45.00 07/23/2014 CREDITCARD-14-029525 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the holWa qualifications,to do business.Holder must comply with any governmental or nongovernmental regulstory laws and requirememls which apply to the husion:s. The RECEIPT N0.above auk he displayed on all commercial vehicles-Miami-Dada Code Sec Ba-M. Far mare iMorncatian,visit www°cap aov/Nxcallecror AC®n� CERTIFICATE OF LIABILITY INSURANCE DAT08/051DI201155 � 08105! 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 pollcy(1es)must be endorsed. H SUBROGATION IS WANED,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 Rau of such endorsement(s). PRODUCER CONTAME:CT Agustin EstiNas NA General Insurance Group Corp. PHONE 786)280-4113 777771M No): (305)351-8461 10350 SW 64th St. E L agustin@genins.net Miami,FL 33173 INsu 8 AFFORDING COVERAGE NAIL A Phone (786)280-4113 Fax (305)351-8461 INSURER A: United Specialty lnSUrance Company 12537 INSURED INSURER 6: Granada Insurance Company 16870 W M Plumbing,lnc./DBA W M Plumbing Septic Tank&Grease Trap INSURER C: 1825 Ponce De Leon Blvd,232 # INSURER D: Coral Gables,FL 33134. FL 33175- 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 REQUIREIVENT,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 ADDLSUSR POLICY—MMLYIMNUMB LIMITS EFF POLICY EXP LTS © COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 ❑ CLAIMS-MADE © OCCUR PPREM SES ETO a erre $ 100,000.00 MED EXP(Any one person $ 5,000.00 A F1 N USA4089808 05/2912015 05/29/2016 PERSONAL&ADV NJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000.00 ElPOLICY ❑ PR ❑ LOC PRODUCTS-COMP/OP AGG $ 1,000,000.00 ❑OTHER $ AUTOMOBILE LIABILITY V111 de., ANGLE LIMIT 300,000.00 ❑ ANY AUTO BODILY INJURY(Per person) $ B ❑ ALL © AUTOS 0110FL00007468 08/26/2014 08/26/2015 BODILY INJURY(Per acdderd) $ ❑ HIRED AUTOS ❑ AUTOS NON-OWNED Per mcid DAMAGE $ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS UAB ❑CLAIMS-MADE I AGGREGATE $ ❑ DED RETENTION $ WORKERS COMPENSATION ❑PERE EMPLOYERS'LIABILITY Y/N STATUTE — ANY PROPRIETOR/PARTNER/EJ�CUTNy--� E.L.EACH ACCIDENT $ 0FFICEWMEMBEREXCLUDED? u N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yea,describe under DESCRIPTION OF OPERATIONS Wow E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Sehedute.If mare space Is required) Plumbing Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL r Fn BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue AUTHOR2ED REPRESENTATIVE Miarni Shopres,FL 33138 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101)QF The ACORD name and logo are registered marks of ACORD AC RA. CERTIFICATE OF LIABILITY INSURANCEDATE(MMtODJYYYY) 08/05/2015 PRODUCER Phone# (305)275-1777 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Empire Employer Solutions Group Corp. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 9415 Sunset Drrive,Suite 151 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami,FL 33173 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAiC# INSURED INSURERA:Associated Industries Ins Comp_ WM Plumbing,Inc - 1825 Ponce De Leon Blvd INSURER B: Coral Gables,FL 33134 INSURER C: INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE Of INSURANCE!NSR D' POLICYNUMBER PO TCY EFFECTIVE POLICY EXPFRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 4 l COMMERCULLGENERALLIABILITY - 15 PREM! S Eaocarence S i_ CLAIMS MADE El OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ — GENERALAGGREGATE S GEWLAGGREGATE LIMIT APPLIES PER' PRODUCTS-COMPIOPAGG Is POLICY l PRo, LOC AUTOMOBILE LUIBILITY COMBINED SINGLE LIMIT I $ANYAUTO ! (Eaaccldenl) _ -- ALLOWNEDAUTOS ! BODILY INJURY SCHEDULEDAUTOS {!(�Per� S HIRED AUTOS I BODILY INJURY $ NON-OWNED AUTOS (Per acddor t) -- -------- PROPERTY DAMAGE $ (Peracadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EAACC S I AUTOONLY: AGG $ EXCESSA)MBRELLALIA61LiTY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ 1 _ I DEDUCTIBLE y $ RETENTION $ I $ WORKERS COMPENSATION AND 1NCSTATU- OTH- EMPLOYERS'LIABILITY -- A ANYPROPRIETOR/PARTNERIEXECUTIVE AWC1046569 05/23/2015 05/23/2016 E.L.EACH ACCIDENT S 1,000,000 OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Nyea deacrtbeunder - SPECIALPROVISIONSbeIcw E.LDISEASE-POLICY LIMIT $ 1,000,000 OTHER I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS Plumbing Company for Residential and Commercial. CERTIFICATE HOLDER CANCELLATION Miami Shores Village BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 10050 NE 2nd Avenue DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Miami Shores, FL.33138 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIYE� C =� ):- —f ACORD 25(2001/08) OACORD ORPORATION 1988