Loading...
PL-15-2150 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-252492 Permit Number: PL-8-15-2150 Scheduled Inspection Date: February 10,2016 Permit Type: Plumbing- Residential Inspector: Hernandez,Rafael Inspection Type: Final Owner: YORK,BRADLEY Work Classification: Addition/Alteration Job Address: 1291 NE 94 Street Miami Shores, FL Phone Number Parcel Number 1132050100101 Project: <NONE> Contractor. FERA PLUMBING INC Phone: (954)658-8086 Building Department Comments PLUMBING WORK TO INCLUDE TIEING INTO EXISTING Infractio Passed Comments GAS LINE FOR COOK TOP AND DRYER AT KITCHEN! INSPECTOR COMMENTS False BATH REMODEL TIE INTO EXISTING SEPTIC FOR KITCHENlBATH Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-242039. NO WATER. Failed 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 26 of 44 3 ,- rm t nto. P1,44&2I Miami Shores Village PermftType PIGErtilt]� Rasd�ntilr` ORES _ 10050 N.E.2nd Avenue NE VI1Cttt40' 8Sl#G&fi4�f1",�tlit �AltrratFon "•" Miami Shores,FL 33138-0000 E Permit M"PPRC3vtp °z Phone: (305)795-2204 �GORiDP' � .. 04W Expiration: 02/28/2016 Project Address Parcel Number Applicant Ll291 NE 94 Street 1132050100101BRADLEY YORK iami Shores, FL Block: Lot: Owner Information Address Phone Cell BRADLEY YORK 1291 NE 94 ST MIAMI FL 33138-2946 Contractor(s) Phone Cell Phone Valuation: $ 9,400.00 FERA PLUMBING INC (954)658-8086 Total Sq Feet: 0 Type of Work:PLUMBING WORK TO INCLUDE TIEING INT Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $6.00 Invoice# PL-8-15-56821 DBPR Fee $4.94 09/01/2015 Credit Card $313.88 $50.00 DCA Fee $4.94 Education Surcharge $2.00 08/24/2015 Credit Card $50.00 $0.00 Permit Fee $329.00 Scanning Fee $9.00 Technology Fee $8.00 Total: $363.88 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 z ng. Futhermore,I th ize the -named contractor to do the work stated. September 01, 2015 Aufhorized Signatu .Own / Ap ant / Contractor / Agent Date Building Department Copy September 01,2015 1 Miami Shores Village Building Department FAUG 24 2015 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 20iy s BUILDING Master Permit No.-'-2c - 1s— (q PERMIT APPLICATION Sub Permit No.(T L. - 15 — 0 Z ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL QPLUMBING ❑ MECHANICAL [—]PUBLICWORKS [:] CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1291 NE 94TH ST City: Miami Shores County: Miami Dade Zip: 5 Folio/Parcel#:1l"' 3 Z O O 1 Is the Building Historically Designated:Yes NO X Occupancy Type6F�S Load: N 14 Construction Type: C�Flood Zone:_ `r &!t,S BFE: FFE: OWNER:Name(Fee Simple Titleholder): /2Tt / (� � Phone#h o 0 Ql0�'- Address: Z C� N1— 15T/LC F7f— �^ City: W i 1F iJZ '- S �/V�G.� State: /1--e- Tenant/Lessee —C./ - Zip: 3 J Tenant/Lessee Name: // Phone#: c✓�Email: iqL 242l�S4 CONTRACTOR:Company Name: Phone#:R"V b cQ e-fa:�11426 Address: /.Y 45r A,, r �1Zfl City: �/ State: /' Zip:—Ty C'&L Qualifier Name: /N/[/l/-47f///�7/Lt/-/�% Phone#: / c]C State Certification or Registration#: r �LG Certificate of Competency Mee/r ��/e 14 7` DESIGNER:Architect/Engineer: -r)=A66fiAz &dzilt6e Phone#: �S! d V9 70el Address: 65-11 Noy A � -"V- 3 0� City: T_State:2112�--Zip:3331 Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition 5 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Z-4, � //L .-t/�C e u d T/ ` 1"V i zJ � 57/,4,? L7 2-/ e 2 C To /�/L 7r- , / /f /Q--P4 e Specify color of color thru tile: •� Submittal Fee$ Permit Fee$ `5 29, 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 whic ccurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be a Pro. d and a reinspection fee will be charged. Signaturiot Signatur ' O OWNE rAVA CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of ,fA44 20 ).5 by -�"� day of 20 by who is personally known to who is personally known to me or who has produced �✓��er Li C�h ICL as me or who has produced s�ti,. u. M^^ r as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC; NOTARY PUBLIC: Sign: i Print: L h 'Z— Ji Print: L- "c Seal: Seal: tM� _ JOSS F.B V4W r MY COMMISSION N FF 232328 EXPIRES:June 18,2019 p�`�"v�'•% � ,E - BOnde�ThN NOW ,..N` TERESA NUNEI-APONTE ryP0411rdO�� J t Pt �'My�CO m.�xpires Jan .2s01� *sssss*sssss*sssss*ssssssssss*s*****ss**s**ss**s**** ssssss*ssssss CWF Commission N FF AP �l Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 5t1lOREs L♦! t e... NUP" Miami shores Village h� oy Building Department F�ORiDp' 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. L�COPY OF QUALIFIER'S STATE LICENCES B. _ '��OPY 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 must specify the description of operations or contractor license number. ........................................................................................... BUSINESS NAME: Fera Plumbing BUSINESS ADDRESS: 1860 NW 83 Terrace CITY Pembroke Pines STATE FI ZIP 33024 BUSINESS PHONE: (954 1 658-8086 FAX NUMBER(954 589-1621 CELL PHONE (_954 ) 658-8086 QUALIFIER'S NAME: William A. Trummert QUALIFIER'S LIC NUMBER: RF0040483 DBA: r Receipt#:P8U2MBING/LLWN SPRNKL/CONTRACTOR Business Name: - 54189 FERA PLUMBING INC Business Type:(MASTER PLUMBER) Owner Name:WILLIAM A TRUMMERT Business Opened:03/07/2013 Business Location:1860 NW 83 TER State/County/Cert(Reg:79CMP512X/CFC1429148 PEMBROKE PINES Exemption Code: Business Phone:95 4-6 5 8-8 0 8 6 Rooms seats Employees Machines Professionals i For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 2.70 0.00 1 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has Changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: FERA PLUMBING INC Receipt #O1A-14-00000367 1860 NW 83 TER Paid 10/29/2014 29.70 PEMBROKE PINES, FL 33024 2014 - 2015 RRnwARn rn111UTV i nrA1 Q1101k11e00 TAv erne-le+r CERTIFICATE OF COMPETENCY . . DRtVER LICA SL ^:ASS E �. T T656-9' i-X12-1 4-0 A' WILLIAM ART)- �'T f TRUMMERT Alk ISM MW 83RD MBTEf PK PMIES,FL 33024-477 Doe 04 001-tSt2 SEX M I @uM-8683-211/8HG7 s-» EXatptb MASTER PLUMBER alta-mte sT,A FERA PLUMBING, INC r,,Q-o*Crc; ti:- CC#79-CMP-512-X Ref. 13244010 Expires 8/31/2015 Ctrl#15-23674 STATE OF FLORIDA >'` ic4 STATE OF FLORIDA PDEPARTMENT OF ROFESSIONAL BUSINESS AND DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION RF0040483 ISSUED: 02/11/2014 CFC1429148 ISSUED: 09/30/2014 REGISTERED PLUMBING CONTRACTOR CERTIFIED PLUMBING CONTRACTOR TRUMMERT,WILLIAM A TRUMMERT,WILLIAM A FERA PLUMBING,INC. FERA PLUMBING,INC. (INDIVIDUAL MUST MEET ALL LOCAL LICENSING REQUIREMENTS PRIOR TO CONTRACTING IN ANY AREA) HAS REGISTERED under the provisions of Ch.489 FS. IS CERTIFIED under the provisions of Ch-489 FS. Expiration date:AUG 31,2015 0402110007591 Expiratim date:AUG 31.2016 L1409300000579 CERTIFICATE OF LIABILITY INSURANCE DATE(MM'DD/YYYY) C820/2015 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(ies)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 JOSEPH F LRACCIO NAME J&J I-isurar,ce Assodates aC,NN,Ext): !954)893-5558 (AIC.No) (J54)893-1174 E-MAIL u)S1'c Dello�(a."net 7031-B Tat St ADDRESS. .1- �- Hollywood.FL 33024 INSURERS)AFFORDING COVERAGE NAIC k Phone (954)893-5558 Fax (954)893-1174 INSURER A: COLONY INSURANCE COMPANY INSURED INSURER B: FERA PLUMBING INSURER C: 1860 NW 83 PLACE INSURER D: INSURER E HOLLYWOOD FL. 33024 INSl1RER F COVERAGES CERTIFICATE NUMBER' REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BFLOW HAVF BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 1 HE POLICY PERIOD INDICATED NC[WITHSTANDING ANY RFOU'REMENT.TERM OR CONDITION OF.ANY CONTRACT OR 07HER DOCUMENT WITH RESPECT TO WdICH I HIS CER I IFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POI ICIFS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERLIS EXCLUSIONS AND CONCiT ONS CF SUCH POLICIES LIMI rS SHOWN MAY HAVE GLEN REDUCFD RY PAID Ci ARMS INSR ADDLSUBR POLICY EFF POLICY EXP TYPE OF INSJRANCE LTR INSR WVD POLICY NUMBER (MM!DDIYYYY) (MIAIDDf1'YYY) LIMITS GENERAL LIABILITY I ACH OCCURHENCI 500.000.00 coNUA:Rcl,;l.GE N[i.nl I Inisl I Iv OAI.IACF To Ri Ni F:) 100.000.00 PREMtISFS IEa G!AINIS MAW / occuR !.L I)l XP..n:y::..... ...:.... s 5000.00 A GL-4160510 01!14/2015 01/14/2016 i­R;oNAE :ADV IN.,I RY _ 500.000.00 G NI RAt AGGRi_GAI1_ 1 000 000 00 6rN L n66 tF;';A11_;-Intl1 APPI IIS PFR PRGDUc-S COMP;oP A-sc, 53C.000.00 ?Eao � Pi n ICY JLC I Of, AUTOMOBILE LIABILITY C;YAISINEi)rLNCI i _itJIT ANYAIIO H�CIL�INiURY P- _.. Ail O%INPD SCFFOULFD .211.Y'dd.itl'r2Y i- , AUTOS AlI OS - NqP;-(IL JV CO P-2CPERTY:7AMA(31 HIRI".DA ITI)R AI_I1CS j-"!.':•,..: _ UMBRELLA LIAR ()C('UR i ACH OCCURRENOE - EXCESS LIAB 11AA1c_NIADI AGGRFGAIF DED P I-NIIONS WORKERS COMPENSATION ''E2 01I- AND FMPI OYERS'LIABILITY YIN 57471 I IF 1-it ANYPROP10 IOR PAIR iNFP; XLCU V1 .-. I. E-ACI ACC0 NI _ Oi--I CCRiMIJ18F rt i XC'[UDI.J° NIA (Mandatory in NH) Ii DiSFASI EA FMPLOYF F I ,,. n: D!SCRIP! 01 OP:.iIA II(INS,..-:- F� Dlo'EASI--POLICY I.MAIF DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) PLUMBING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VI!LAGE BLDG DEPT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2 AVE ACCORDANCE WITH THE POLICY PROVISIONS. 41 MIAMI FL 33138 AUT HCRIZED REPRESENTATIVE 1 JOSEPH F BRACCIO i ----- G 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01)QF The AC0110 name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE T s20/2015 Producer: Plymouth Insurance Agency This Certificate is issued 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 or alter the coverage afforded by the policies below. Holiday. FL 34691 (727) 938-5562 Insurers Affording Coverage NAIC = Insured: South East Personnel Leasing. Inc. &Subsidiaries 2739 U.S. Highway 19 N. Holiday. FL 34691 Coverages D; _ Type of insurance Policy Number �IA. DVY) ptr' Drl'Y) GENERAL LIABILITY - Commerc'al Geae�a� iab!:qty Caims Made � occur Ge^.era;aggregate::-I,;t oc.',es per AUTOMOBILE LIABILITY EXCESS/UMBRELLA LIABILITY -- 13` A Workers Compensation and �h'C 7'949 01�01'20'5 C'vo112016 XEmployers'Liability Liability NO �as�z a ;oae� other Lion Insurance Company is A.M.Best Company rated A-(Excellent). AMB# 12616 Descriptions of OperationstLocationslVehicleslExclusions added by Endorsement/Special Provisions: ,iD. Fera Plumbing,Inc. _ •,nly up i .to n]ur e-, �, u, __,,�tl d ;<�r_ __.. :.tc.&s .. _3r'r ,ct, ate,ayre;�;, cr _ Project Name: Begin Date 3/1412013 CERTIFICATE HOLDER CANCELLATION 4GOR0$ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) �� 02;09;2016 ` 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(ies)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 BRAD BRACCIO NAME; PHONE 9541893-5558 FAx 954 893-1174 J&J Insurance Associates (AIC.No, EXt) ( (A c,No) 7037-6 Taft St. ADDRESS: jI_inst@bellsouth net Hollywood,FL 33024 INSURER{S)AFFORDING COVERAGE NAIC tl Phone (954)893-5558 Fax (954)893-1174 INSURER A COLONY INSURANCE COMPANY INSURED - - INSURER B: _ FERA PLUMBING INC INSURER c 1860 NW 83RD TERR INSURER D INSURER E HOLLYWOOD FL 33024 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE .__INSR. WVD. POLICY NUMBER. (MM/DDIYYYY) (MMIDDfVYVY). . _. © COMMERCAL GENE RAS L IABD."! EACH OCCURRENCE _ 5 500.000.00 DAMAGE TO RENTED S 1 00.000.00 ❑ CLAIMS-MADE 7,/ OCCUR PREMISES;Ea occurrence] ❑ MED EXP(Any one Person S 5.000.00 A GL-4160510 01/1412016 01/1412017 PERSONAL&ADV NJI,RY s 500,000.00 GE1, AGGREGA'E-IMiT APPLIES PER GENERAL AGGREGA'E c- 1.00000000 ❑ POLICY ❑ EO. El LOC PRODUCTS COMP/OP AGG S 500000 00 ❑ OTHER $ OMBIN AUTOMOBILE LIABILITY t;Ea accoSINGLE LIM:' acidenen t; $ ❑ A=JY A l BODILY INJURY;Per person; ALLOWNEC HED' ED❑ v AUTOS ❑ At. CS BOD 'udFiRY iPer accde,iq S NON-Cl-,E:; PROPER-1Y DAMAGE S ❑ HIRED AU'OS ❑ AI-TCS 05 accident; ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE S ❑ EXCESS LIAB ❑CLA.MSMADE AGGREGATE S ❑ DIED [IRE-ENTIO%S _.. -__ WORKERS COMPENSATION PIR AND EMPLOYERS'LIABILITY YIN ❑.S.A'J?E___ ❑SR' _ ANY PROPRIF7CR%=ARTNER!EXEC.I?vE E. EACH ACC_DENT S_. OFFICER/MEMBER EXCL EDl NIA EL DISEASE-EA EMPLOYE S (Mandatory in NH) -. -.. _._. __.. If yes describe under DESCRIPTION OF OPERA-C',S belov� E L DISEASE-POLICY-!MTS DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 107 Additional Remarks Schedule,if more space is required) CFC-1429148 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE MIAMI SHORES FL 33138 AUTHORIZED REPRESENTATIVE _ BRAD BRACCIO _ s;198 44 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01)QF The ACORD name and logo are registered marks of ACORD Date CERTIFICATE OF LIABILITY INSURANCE 2/9/2016 Producer: Plymouth Insurance Agency This Certificate is issued 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 Holiday, FL 34691 or alter the coverage afforded by the policies below. (727) 938-5562 1 Insurers Affording Coverage NAIC# Insured: South East Personnel Leasing, Inc. &Subsidiaries insurer A: Lion Insurance Company 11075 2739 U.S. Highway 19 N. Insurer e: Holiday, FL 34691 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. INSR ADDL Policy Effective Policy Expiration Limits LTR INSRD Type of Insurance Policy Number Date Date (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence Commercial General Liability Damage to rented premises(EA Claims Made ❑ Occur occurrence) Med Exp Personal Adv Injury General aggregate limit applies per: Policy11Project 11Products General Aggregate Products-Comp/Op Agg AUTOMOBILE LIABILITY Combined Single Limit (EA Accident) Any Auto All Owned Autos Bodily Injury (Per Person) Scheduled Autos Hired Autos Bodily Injury Non-Owned Autos (Per Accident) Property Damage (Per Accident) EXCESS/UMBRELLA LIABILITY Each occurrence Occur ❑Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2016 01/01/2017 X WC Statu- OTH- Employers'Liability I tory Limits ER Any prop;ieter/partner/executive officer/member !HI I E.L.Each Accident $1,000,000 excluded? IVo I E.L.Disease-Ea Employee $1,000,000 If Yes,descripe under special provisions below. E.L.Disease-Policy Limits - $1.000,000 Other Lion Insurance Company is A.M.Best Company rated A-(Excellent). AMB# 12616 Descriptions of Operations/LocationsNehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 92-67-235 Coverage only applies to active employee(s)of South East Personnel Leasing,In_.&Subsidiaries that are leased to the following"Client Company": Fera Plumbing,Inc. Coverage only applies to injuries incurred by South East Personnel Leasing,Inc. &Subsidiaries active em)loyee(s),while working irl:Fl. Coverage does not apply to statutory employee(s)or independent contractor(s) )f the Client Company of any other entity. A list of the active employee(s)leased to the Client Company can be obtained b� faxing a request to(72.')937-2138 or by calling(727)938-5562. Project Name: ISSUE 02-08-16(TD)/REISSUE 02-09-16(TLD) Bealin Date 12/3/2015 CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES Should any of the above described policies be cancelled before the expiration date thereof,the issuing insurer will endeavor tc mail 30 days written 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. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138