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RC-15-2985 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-255980 Permit Number: RC-11-15-2985 Inspection Date: March 31,2016 Permit Type: Residential Construction Inspector: Rodriguez,Jorge Inspection Type: Final Building Owner: . PERAGALLO, DINO&IRENE Work Classification: Alteration Job Address:55 NE 97 Street Miami Shores, FL 33138- Phone Number (305)995-5224 Parcel Number 1132060130990 Project: <NONE> Contractor: RAMI JEDA Phone: (305)970-7079 Building Department Comments Infra o Passed Comments KITCHEN REMODEL INSPECTOR COMMENTS False Inspector Comments Passed (Failed E:1 Correction Needed Ra-inspection Fee No Additional Inspections can be scheduled until ro-ins000:ion fee is paid. For Inspections please call: (305)762-4949 March 30,3016 Page 1 of 1 13'-4° ty N ` i 281® OPEN AREA 10d NAILS NM NV�28 � NEVI NYJH28 NEW (2rL"xl0" STAGG ® 12" O.0 Y • • NEW NVTPSH EXIST CBS PARTITION EXIST CBS WALL (LIVING AREA) (EXIST HOUSE) NEW NON-SEARING (DECORATIVE) WO BEAM DETAIL AT <ITCNEN/DINING AREA N.T.S 155 NE Sl ST MIAMI SNORES FLORIDA .0D� CERTIFICATE OF LIABILITY INSURANCE DA7ZtM "� .! 33/15/2015 THIS OMMI?ICATI=•18 ISSUED A5 A MATTM OF INFORMATION ONLY AND CONV15= 9 NO RIGHTS UPON THE CERTIFICATE HOLDER-TMS GERTIP-KATE DOES KOT AFFIRMATWELY OR NEGATIVELY AMEN06 EXTEND OR ALTER T145 40VI"R IX AFFORDED 13Y THE POLK3FS BELOiNN, TWS CERTIFICATE OF IMMML NCE. DOES NOT CONBTITUTP-A CONTRACT BETWMN THE 188U1KG INSURER(S), AUTHORIZFP REPRESENTATIVE OR PROIIUCEtt,ANDTHE CERTIFWATIR HOLDER. iMPORTANT: If the C811tflcate hooldW is art l5DITIONAL INSURED,On W*V(t }t;—d pe endorsed. If SUBROGATION I WARE,suQ7m to the terms and candltluns of tine polloy,certain P*IIchs may sequirs an sndomemoL A Statement an this certificate does not awfer rFAhts to the certifipata holder in Oen ofsuch endameme s). OAvoucwt ACT TriGm Xaftranae 5olutiocW. mm. CbYip Rhoden 33.6 S8 Wfaaer B7.Vd. Sufte 23.3 (877) 887.4436 PAX (WQTM: 9s2.2625 Isom Ratan. BS. 33432 A EMM ft= l144U ®oO�RA� IIATCA rMIt A•GTtiareatee Xnattrance C11398 WSURM 24139 -4030 86. wricm Aviation, ZUG. at al L/0/8 >lm wi 340 Z Sig ee �oymanb II INSps Trop'lex rNSINI6R fi e ' C YERAC3ES CERTIFICATE NCLWBM Cert ID 13226 RE1►1$tON NUMB t: THIS IS TO CERTIFY THAT THE POI,IOIES OF INSURANCE USTED SMOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATEM NOTWITHSTANDING ANY REQUIREMENT,TOM OR CONDITION OF ANY COAFIRACT OR OTHER DOCUMENT WITH f&SPECT TO WHICH THIS CERTIFICATE MAY BE WGUED OR MAY PERTAIN,'THE INSURANCE AFFORDED INY THIN POLICIES DESCRIBED HEREIN-IS$OBJECT TO ALL THE TERMS, EXCWSION3 AND CONDITIONS OF 813CH POLICIES.IJMIT3 sHOWN IIAAY HAVE BEEN REDUCED BY PAID CLAIMS. Wl1vP8OFINSi> nrC6 POUCYIttUb18ER tY�R LJHA15 ER4A1.GTENERAL UA 17Y EACM OCCUMMN09 0 CLAIMS.d(AD8 �oCCUtt 8 ' PER84NALtiADVI $ .LAGOREGATSLWAf UMPW NERALACiMEGATE 6 pouCY JECT LOC Pt llC75,COMPIOPAG, S OTHER: $ AUTONWILELIAOLMED Em S e WYAUTO BL ED BO»IlvtI�.AIRY(PtyPe►sonl B saBOBB.Y INJi3tY{Pat�ddm>!j S HUeVA"03 �ED PRO 3 S UMAtEIJ.ALIA9000ua Iw40H NGE S DED A @AT8 $ A N[OR!(ER8 COMPMSATM AIM9MNAyQWI.,IAgpny YIN WIP300079301=0 4.'/31/241 12/33/2016 B ANY PROPRj6't'g W.4 Rr�VE A TE FF _ _ MWOED4 EIN I A Sd H A(X:10 T S 1,000. 40 M��OOFOPERATIO{dSOeloW L.L.DSEASE-BAEILFLQYE 3 i,000,044 E.L.D BE-POUMUMIT S 1,400,000 cwar�Si:%PtlDra�oPp�AnONsrLocAT1o91srvENlc3.�{Acorn tar,Aasglenet Rmparldt s:�uao,�,eoweaotroy Irmotospa�a m age is$ psavistd W Teased Omp].gyeen bad not xWb=ntraatoas or non-Leased pmplapeea og a StpivymaUt I2- 24"tACA coverage 099"tive 12/33./2013. Ref: 74-Mi 0•eda MC062208 / X*10yeO Z&Otr David ,Tech, Rami eada, Raohariab &a", Yankav Rap£etein, seak�:•�.a aeea Cl;RTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DE KWMED POLO"in CAIC•LBP tllr rM 7MIR VXRRATION DA•r7: THEROW, NDMcEyaL.L IW DEJY6raL2 IN Dpi SHeses TiYilaga ACCOIitIANCQ UN77t THt:POLIt:1f PRGYISbNS. saildi�g »�artmearo X0050 xE lad xve. AUTN0R=DRagGME=7M ad mi Shores 1731 33238 ®7988-2094 ACORD COLORATION. rights rgierved. ACRD 25(2074f07) The ACORD name and logo am registered masa of ACORLI + Paga I of i L �- ,�� �� sr �da,��El/N 6' ��T�� 3 a ayE£ � �., r� iia __eta t�i � � �•_ Miami Shores Village 10050 N.E.2nd Avenue NE ` s Miami Shores,FL 33138-0000 ;,; ` Phone: (305)795-2204 3 Expiration: 06112/2016 a F z 1- Project Address Parcel Number Applicant 66 NE 97 Street 1132060130990 DINO Sz IRENE PERAGALLO Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell DINO&IRENE PERAGALLO 55 NE 97 Street (305)995-5224 MIAMI SHORES FL 33138- 55 NE 97 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 25,000.00 RAMI JEDA (305)970-7079 �--� Total Sq Feet: 0 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Window Door Attachment Type of Construction:KITCHEN REMODEL Occupancy:Single Family Framing Stories: Exterior: Insulation Front Setback: Rear Setback: Drywall Screw Left Setback: Right Setback: Fill Cells Columns Bedrooms: Bathrooms: Window and Door Buck Plans Submitted:Yes Certificate Status: Review Planning Certificate Date: Additional Info: Review Electrical Review Electrical Bond Retum: Classification:Residential Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Mechanical CCF $15.00 Review Plumbing DBPR Fee $11.25 Invoice# RC-11-15-57895 Review Structural DCA Fee $1125 11/30/2015 Credit Card $200.00 $624.50 Education Surcharge $5.00 12/152015 Credit Card $624.50 $0.00 Permit Fee $750.00 Scanning Fee $12.00 Technology Fee $20.00 Total: $824.50 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 taws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. December 15, 2015 Authorized Signature:Owner / Applicant / Contractor / Agent Date BuildingDepartment p Copy December 15,2015 1 Miami Shores Village Building Department artment Nov 3 ® 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 2014 BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. ExtUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 55 NE 97th St City: Miami Shores County: Miami Dade Zia: 33138 Folio/Parcel#:11-3206-013-0990 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Dino Peragallo Phone#: Address:55 NE 97th St City Miami Shores State: FL ZIP. 33138 Tenant/Lessee Name: Phone#:954-684-2079 Email: dperagallo@whitecase.com CONTRACTOR:Company Name: ?AM/ Phone#: 30 S_q*f0' :?(5-j1 Address: /79,R S /V6 Qr4 Q4 City: N-A l aM) &ems State: Zip: 81 / 9,-Q Qualifier Name: &M1 c�&.& Phone#: SOT— ?w lFqT 5 State Certification or Registration#: GGC O iC2&&k Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: ,,,., Zip: Value of Work for this Permit:$ a s,r w Square/Linear Footage of Work: QW•JD Type of Work: ❑ Addition I Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: K1Tdcw, od Q Specify color of color thru tile: Submittal Fee$ $j'-QU CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 'fOZ— —1 (Revised02/24/2014) • r t 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. 1 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 t the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be p t the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence o c osted notice, the inspection will not be approved and a reinspection fee will be charged. Signature ` Signature OWNER or AGENT CONTRACTOR The for ing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of®G4 b e-r .20 by J�n day of 0,20 by DIA1 D 1064 Irl 6AC-G-b,who is personally known to JA who i kno me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PU ` ♦♦♦��♦0V rKOp'�*'i, Sign ign• a` WA Print OR" l.. 1 uuru x� OTARY • • PAMELA M.8016 N Seal: Seal: (NNetl►Pfd-Bob of Flom : •'� My Comm.Wee Feb 18,2017 = PUBLIC Commission#EE 878448 •moi 1P s'y.�!` 6��'r P♦♦, ou\+'y APPROVED BY L Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) M '012 •aleis wa mi honesVillage Building a artmen 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 CONTRACTORS1 REGISTRATION, IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A.__,K_COPY OF QUALIFIER'S STATE LICENCES & ,�C 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 U I UACERTIFICATE 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. rreararrrarrrrrrrrrrrrererrrrsrreereaarrecarrrrrrr■Orr®aerrrprrrrrr,esererrrraaeeeerearerae BUSINESS DAME:______ PIMI ITb 1)t BUSINESS ADDRESS:_ / q 2 S iu6 Q p(. CITY A/• t4MI ZC4 STATE- _ZIP 3t3 I f9)- BUSINESS PHONE:(3o s ) qg3 4 6 8 6 FAX NUMBER(3o S i `/ Q 3 �6 CELL PHONE(3 S _ -?a-7QUALIFIER'S NAME:__ _ M ( �U A QUALIFIER'S.LIC NUMBER:__ G cr G © 6 a 02 8 _ 002467 • �t�C�f Business�eSS Tax coun ceint -THIS Is tY, State Nora s►ctOf F1o1 i& - DO NOT MY -OCA nOly R"tPr No. Y{R1Ap�1'�EgCH SAL FL 33162 UPIR S e�� �� SEPTEMbEfl3a Q Must Be displayed at.plaoe of bZde6 Pursuant to Cam,Code RAMI 1EDA Chapter 8q art 9&10 . WO*er(s) 196 GES OF sustWESS 1 CGC G AL BUILDING CO NTRACTOR eY.rA siwT Ivacen W AX�L18C7OR' 7hh k Ora = tax Re� $45.00 08/05/2015 aao ' oa oftha ordersn CREDRCgRp_T r�39817 T> RECEIPT NO.above aws uir . a In�B nolderTex��elotis nota licea� 'sPI all PPIYto the b rsln ""n with am`gOY ►e+, al Forge I ercial vehicles-lye• �Nbnao.on,visit +'fade Coda S.88-27& STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL.REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 48'7-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 JEDA, RAMI INDIVIDUAL 17925 N E 9TH PL N MIAMI FL 33162 .K ........... Co_ngmtulationsl With this license you become one of the nearer w... one Wfilon Flo rldlans.licensed by the Department of Business and Profe siorialR n...Our professionals and businesses range n STATIE 0F.FLORIDA­ from arc Niter, to yedt brokers,from boxers to barbeque restaurants, ,BIJaIINESS NES and they kerma Fm's erx"My sem. ULATION Every day we Arlt to Improve the way we do business In order to �1 5/2014.. $arae you tattetr For information mut our services,please tog onto w m.myftrItIalteensecom. There you can find more Infranmation CERTtFIE£fl: ab urt our divisions and the regulations that Impact you,subscribe -JEDA,RAMI x N .W to department newsletters and learn more about the Department's 1 . lNDIVtDt9AL initiatives. t Our mission at the Department is License Efficiently,Regulate Fairly. g" We cons �y strive to serve you`better so that you can serve your customersThank you for doing business in Florida, ts,Ce'eW*'JE... u�nds t tYrau s�tona or Or~>aas FS.; and congratulations on your new licJenset ,` . - ''Faa zrsb c 15MI157 . ._. ...4,, DETACH HERE ttt � QO RNOK FCEIV,tAV#tSl1Ai. F3IwTA Y STATE Qf F'L6R0A 600 T140 r F BUSIN, I AND P ltI E '1,at�l REG L '1�11o1M 4r ON'i'I�A��`G1R dd mect S CER , FIS. h Under' 0ltaptt rX69.[=S M c Sf^"n xpir�t AUG`31,2Lk u1/ Iw sc A" { ke ♦♦{{ 410 .,, �{ ry ♦g ­jp+.y. ,f v •a ' � �. .#''""`t� s=f<: ri P' s.; x ? sib , N k H M ...... _ __02 r "r xi �Aa ^air.„ s ec.„,.M,. ....... ... .... ... .K«x. ..c� ' ISSUED, 0511W014 DISPLAY AS REQUIRED BY LAW SEI!# L1405150t01157 CERTIFICATE OF LIABILITY INSURANCE 10/15/2015' 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. H 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 C A SOUTH FLORIDA CASUALTY, INC. PHONE561 533-6144 (561)533-6170 415 North 4th Street - LADDRES- aine sou ori casua y.com Lantana, FL 33462 INSURER(S AFFORDING COVERAGE NAIC9 Essex Insurance Company 39020 INSURED INSURER B: Rami Jeda 17925 NE 9th Place INSURER D: North Miami Beach, FL 33162 786-266-1787 COVERAGES CERTIFICATE NUMBED 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. INSIR rA TYPE OF INSURANCEIaL POLICY EFF LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000 CLAIMS-MADE ■X OCCUR $ 1 )0 000 MED EXP one rson $ 500 000 MAP00009513 12/12/1412/12/15 PERSONAL&ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY D JECT E]LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY S $ ANYAUTO BODILYINJURY(Perperson) $ ALL OWNED SCHEDULED BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-OWNED $ HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION R AND EMPLOYERS'UABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L DISEASE-EA EMPLOYEE If dSCIeapibe undar DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Sdiedule,may be atiadtedir more apace is required) General Contractor - Rami Jeda CGC062288 ERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES ILL CANCELLED BEFORE g P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 FAX 305-756-8972 AUTHORIZED REPRESENTATIVE ©1988-2013 ACORD CORPORATION.All rights reserved. ACORD 25(2013/04) The ACORD name and logo are registered marks of ACORD v CERTIFICATE OF LIABILITY INSURANCE FDATEIM�EINWr 10/15/2015 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: H 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 TriGen Insurance Solutions, Inc. NH 315 SB Misner Blvd, Suite 213 PHOONE E: (877) 987-4436 No: 561) 952-2625 Boca Raton FL 33432 ADDRESS: certs@trigengroupine.com INSURERS AFFORDING COVERAGE NAIC B MSURERA:Guarantee Insurance an 11398 INSURED (24 8) 71-1030 INSURERS: Trion Solutions, Inc. et al L/C/F AmariTemps Employment II INSURERC: 340 E Big Beaver Road INSURER D: Suite 160 Troy MI 48083 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:Cert ID 7674 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. L NSR TYPE OF INSURANCE AWL SUBR POLICY NUMBER POLICY EFF MP�CY EXP LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO REWO CLAIMS-MADE F�OCCUR PREMISES Me occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JEC ❑ [-�LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY AUTOS AUTOS (Peracxldent) $ HIRED AUTOS NON-OWNED �OPEP n UTOS t)DAMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIMB CLAIMS-MADE AGGREGATE $ DED I RETENTION $ PENSATION A ANIS COM w DEMPLOYERS� YIN 9PC8500002702GIC 1/1/2015 1/1/2016 X PER ER ANY PROPRIETOR/PARTNERIEXECUTIVEE.L.EACH ACCIDENT $ 1,000,000 OFFICERWEMBER EXCLUDED? F N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 if under DESCRIPTION CRIOF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101.Additional Remarks Sclredule,may be attached H more space is requlrer0 Coverage provided to leased employees and not subcontractors of AmeriTemps Employment II. Location coverage effective 1/1/2015 Ref: Rami Jade CGCO62288 / Employee List: David Jeda, Rami Jeda, Zachariah Jeda, Yaakov Ropfstein, Zacharia Jeda CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 10050 NE 2nd Ave. AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 ©1988-2013 ACORD CORPORATION. All rights reserved. ACORD 25(2013104) The ACORD name and logo are registered marks of ACORD Page 1 of 1