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MC-15-2425 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-256788 Permit Number: MC-9-15-2425 Scheduled Inspection Date:April 13,2016 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: BRODSKY,MARK Work Classification: A/C Replacement Job Address:1200 NE 105 Street 26 Miami Shores,FL 33138-0000 Phone Number Parcel Number 1122320910060 Project: <NONE> Contractor: EDD HELMS AIR CONDITIONING AND ELECTRIC Phone: (305)653-2530 Building Department Comments REPLACE 3 TONS SPLIT SYSTEM Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid April 12,2016 For Inspections please call: (305)762-4949 Page 47 of 49 Miami Shores Village t 10050 N.E.2nd Avenue NE 3 �45 P3 I L 7T Miami Shores,FL 33138-0000 Phone: (305)79-r-2204 _ Expiration: 03/21/201 -21 Project Address Parcel Number Applicant 1200 NE 105 Street Number: 26 1122320910060 MARK BRODSKY Miami Shores, FL 33138-0000 Block: Lot: Owner Information Address Phone Cell MARK BRODSKY 1287 NE 96 Street MIAMI SHORES FL 33138-2574 Contractor(s) Phone Cell Phone Valuation: $ 4,578.00 EDD HELMS AIR CONDITIONING AND (305)653-2530 Total Sq Feet: 0 Tons: Available Inspections: Additional Info:REPLACE 3 TONS SPLIT SYSTEM Inspection Type: Classification:Residential Final Approved:In Review Review Mechanical Comments: Date Approved::In Review Date Denied: Type of Work: Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3•00 Invoice# MC-9-15-57189 DBPR Fee $0.00 09/29/2015 Chock*6248 $132.03 $50.00 DBPR Fee $2.40 DCA Fee $2.40 09/23/2015 Check#:6247 $50.00 $0.00 DCA Fee $0.00 Education Surcharge $1.00 Permit FM $160.23 Scanninirpee $9.00 Technoicffi Fee $4.00 Total:' $182.03 a Le'1 In consid tion of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertainingiereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. in accepting'�*is permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required WELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERFFIDAVIT: 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. F the ore,I thorize the above-named contractor to do the work stated. ' September 29,2015 tg er / Applicant / Contractor / Agent Date Lid BuilWng Department Copy September 29,2015 1 • . ..• . • . ... .. .• • . • .. .. • • • . . • . • . • . SguR>e� �lv • � Fti o illage �nG u . ... c� artment SEP 2 3 2015 , , „• , ••• Wei: nd Avenue rida 33138 —Y: •. • 3 )795.2204 . . C < Fax:(305)756.8972 UJ AIR CONDITI�WING REPLACEMENT DATA _j c • • . J L • ••• • • • • % • < • •_• • • •• • • C ••' w '•' i i i•• ..PERMIT NUMBER: MC < I TNIs forr i muA kc66 any ALL air conditioning replacement permit applications. Each unit change-out must r' be on its own daia sGe A. Multiple units on single sheets are not acceptable. r rob ss hoe the work Is being done): `� . 16 n �_ �- C 0, i ori Vista ge County: Miami Dade Zip Code: AL( ONIWINSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB - ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means:YES❑ NO❑ ARHI Sheet Attached:YES ® NO❑ Contract Attached:YES UNIT BEING REPLACED DATA NEW UNIT ()-\ MANUFACTURER ){ ZA::S tV_7 AHU or PKG.UNIT MODEL# ,a Rev zD'7 3 COND.UNIT MODEL# �Cet� KW HEAT 7KbcJ NOM TONS AHU 416 CG PKG 1)M.C.A AHUW CU3,j PKG AHU 0CU.30 PKG 2)M.O.P AHU 0 CUA PKG AH2p�( CU PKG 3)VOLTS Ahs CUg?�&KG PKG UNIT / / PKG UNIT !� EER/SEER YES NO REPLACING DUCTS YES YES NO REPLACING THERMOSTAT YES O YES NO NEW 4"CONCRETE SLAB YES YES NO NEW ROOF STAND YES YES NO NEW RETURN PLENUM BOX YES O 1. Minimum Circuit Ampacity(Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): `7' X14 /y 3. Voltage of Circuit(208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: 125 .� Phone:�B� State Certificate or Registration NoJoevagK9 Certificate of Competency No. Signature Date: (Qualifier's signature) (Revised02/24/2014) k f + • ••• • s • ••+ • • • • • • • • • • • • • • ••• "lop, • • • • ••owal • w • • • w •• 00 • + • • • • • Cel" if icate of PCRctinpue.-iot, AHRI Certified Reference Number: 7493AA ; �•�i;atg: 111/4()115 Product: Split System:Air-Cooled Condensing Unit,Coll with Blower Outdoor Unit Model Number: RA1436AC1 Indoor Unit Model Number: RBHP-21 Manufacturer: RHEEM SALES COMPANY,INC. Trade/Brand name: RHEEM; RUUD Region:Southeast and North (AL,AR, DC, DE, FL,GA, HI, KY,LA, MD,MS, NC,OK,SC,TN,TX,VA AK, CO,CT,ID,IL, IA,IN, KS, MA, ME,MI, MN,MO,MT,ND, NE,NH,NJ, NY,OH,OR,PA, RI,SD, UT,VT,WA,WV,WI,WY, U.S.Territories) Region Note: Central air conditioners manufactured prior to January 1,2015,are eligible to be Installed In all regions until June 30,2016. Beginning July 1,2016,central air conditioners can only be Installed in regions)for which they most the regional efficiency requirement. Series n d , t ^I xp !,p lip R r It IIr jiµµ�,tI ! Jill pI i(,!ti.{!� iia, !{¢I(:t �! JS� �:�({1714? 41 { ! ' 1!!1 4 !yh��' ,,:;, (t, ;,,.: h�yl�'!d>,{I�� � ;�. ,�.�r J IJIN1�1.�. PillINw , i,lig , t 1ji i10h Manu Irespor� ible f r th rating off t�gfl ' � I'� !�� ,� ! ! !!t ry=i til!��I� p! I x 'r ' 'gib, I !ti!..!. � 1! j i!'�i >�t� I�� ' w � � Rate �)W i ,gr�p(!Qn !a rice with ibHRI,� t 1 Z ` 99 88!f t..,, }+ igl�� r-t 'g n{,/r! q wource .F�:.t,it�:n: .n. ., 1 ��'�,�,I,G. t pp�, �"fl ,N... A 4. „'H' G,., j! I , (s f e I third Heat Iqu pme(tt an { til alb 4 ,1(, cat o 9 i� ! � r '� ti{( I i I�� It,.e [ i: {��i'I!.e•;:'�14. � t'�::!P,ln;!! i, !�rN���: �!' ;I^i lbt+,yn: r�, {.6 ��,��,,!r, !�i:I:;:!i. ip+i:i'I!I ('�, `3 �"1"11,181121 ��C,)9),1t i�{��, , ! , I !:. ��I jyNlii, ,ry r ,: �, '�•:F: II tt .r,!!!,.. t :"''�++,,I ''111 !, !!' ;_.�I!(�,,�x;�ul,!;+ji I!,1!. '.!I���II'7!��,�t � �!,�!,��tt(�!yI�!y'��i!!��; !� t! �:„I!j,ll��!>•:���i!'�t�!�r�r!11 �`!:I I;�I k,�l:.7ii it��'!'�I:�PII''+rA �p,U"�i4:�� SEER'Ra4ing'(cooling):'"' 15. Q. IEER Rating(Cooling): 'Ratings followed by an asterisk(')Indicate a voluntary rerate of previously published data,unless accompanied with a WAS,which Indicates an Involuntary retails. DISCLAIMER AHRI does not endorse the product(s)listed on this Certificate and makes no representations,warranties or guarantees as to,and assumes no responsibility for, the product(s)listed on this Certificate.AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s),or the unauthorized alteration of data listed on this Certificate.Certified ratings are valid only for models and configurations listed in the directory at www.shridirectory.org. TERMS AND CONDITIONS This Certificate and Its contents are proprietary products of AHRI.This Certificate shall only be used for individual,personal and confidential reference purposes.The contents of this Certificate may not,in whole or in part,be reproduced;copied;disseminated; entered Into a computer database;or otherwise utilized,in any form or manner or by any means,except for the user's Individual, personal and confidential reference. AIR-CONDiTIQNING,HEATING, CERTIFICATE VERIFICATION &REFRIGERATION WSTiTtri The information for the model cited on this certificate can be verified at www.ahridirectory.org,click on`Verity Certificate"link we make lite better- and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which Is listed above,and the Certificate No.,which is listed at bottom right IF" 13086481280034©2014 Air-Conditioning,Heating,and Refrigeration Institute G -'IFICATE NO.: • , r.,�20 ra t ~ Miami Shores Village Building Department SEP 2 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC W4 BUILDING Permit No. PERMIT APPLICATION Master Permit No. 0 Permit Type:MECHANICAL JOB ADDRESS: City: Miami Shores ��gg County: Miami Dade Zip: Folio/Parcel#: /l �C5_12 &7/ zdew) Is the Building Historically Designated:Yes NO Flood Zone: OWNER: ame(Fee S. ple Titleholder): E Phone#: Address: City: State: Zip: TenandUssee 1 ame: Phone#: Email: CONTRACTpOR: ompany Name: rn "h* 4S �* _Phone#- Address: a �/ ��++ City: State: FLI Qualifier Name: are_. Phone#: State Certification or Registration :.3V/q —Certificate of Competency#: Contact Phone#: Email Address: cam DESIGNER:Architect/Engineer: Phone#: "�j to Value of Work for this Permit:$ i ® ' Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: j'e,:,p 1 Aga 73AP[A- F m� �x�xx�x�+�*���a����x�s+�m�e��x�����sx����x� Submittal Fee$ 0 0 Permit Fee$* +s� w�� CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ ��Z • , 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 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the. inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent �4 Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day ofd,20 6 byC U1'-hS id S��_�, day of 5 20 l5 by N�$'(rn Larrabee who is personally known to me or who has produced who' personally kno to me or who has produced V(,1?~N&' 4V Rs identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: w Print: Print: My Commission Exp' "'' STACY CUSAN® My Commiss tg MY COMMISSION#FF1269(3o t/; • j* MY COMMISSION#FF126980 zo:'i� °' EXPIRES August 30,2018 '4Q EXPIRES August 30,2018 (4M M8-0t53 FlorldaNctarySerftexom 3ervice.com APPROVED BY %P Examiner Zoning Structural Review Clerk Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Property Search Application - Miami-Dade County Pagel of 8 : z Address Owner Name Folio SEARCH: 1200 NE 105 ST MIAMI SHORES FL 33138 Suite Q Back to Search Results PROPERTY INFORMATION Folio: 11-2232-091-0060 Sub-Division: VILLAGE DEL MAR WATERFRONT CONDO Property Address 1200 NE 105 ST 26 Miami Shores, FL 33138-2153 Owner MARK E BRODSKY Mailing Address 8228 KERRY CT CHEVY CHASE, MD 20815 Primary Zone 5000 HOTELS&MOTELS-GENERAL Primary Land Use 0407 RESIDENTIAL-TOTAL VALUE: CONDOMINIUM-RESIDENTIAL Beds/Baths/Half 3/2/0 Floors 0 Living Units 1 http://www.miamidade.gov/propertysearch/ 9/23/2015 ProVerty Search Application - Miami-Dade County Page 2 of 8 Actual Area Living Area 1,361 Sq.Ft Adjusted Area 1,361 Sq.Ft Lot Size 0 Sq.Ft Year Built 2006 ti SIN x f" � e �;• �, ,,,max b 9 ?3 7 Featured Online Tools Comparable Sales Glossary Non-Ad Valorem Assessments PA Additional Online Tools http://www.miamidade.gov/propertysearch/ 9/23/2015 Miami Shores Village 10050 N.E. 20d Ave Miami Shores, FL 33138 Re: AIC Permit Application (1200 NE IW St., Unit#26 the "Properly") AGENT AUTHORIZATION To Whom It May Concern: The undersigned herein authorizes, Curtis Brodsky, to represent me in my capacity as the owner of the referenced Property and act as my agent in connection with all matters relating to the above referenced Application. IN WITNESS WHEREOF, the undersigned has caused this agency authorization to be executed this day of September 2015 in the City of Washington, District of Columbia. MARK E. ODSKY CITY OF Washington Washin ) } SS. District of Columbia ) .••••. • I HEREBY CERTIFY that on this day, before me, ate"dittcer d11 '•••'• authorized in the City and the District aforesaid to take acknov'�i'emeats, :••••: the foregoing instrument was acknowledged before me fir••A ARt4 t-* ••••• BRODSKY, who is personally known to me or who has providhti 11ib Driybre: •• ••' License as identification. •. .. �'. .•.•.. WITNESS my hand and official seal at --Washinc iton DC �?ts'-�'Z`•"� ' ...... Day of September 2015 ••• • My Commission Expires. �.•'y.coMe Notary Public, istrict of Columbia m,•RJ t,;• Na. Typed, printed or stamped name of or Notary Public !CT of-0 t Edd Helms CAC 021309 EC 13004829 Air ConCiftning & Ehk—,Mc A Name You Can Trust Since 1975 September 10, 2015 r-.._ Curtis Brodsky 305-608-7088 crbrodsky@aol.com Job site: 1200 NE 105th Street#26 Miami Shores, FI. 33138 Tenet Mark Steven 770-548-5357 Edd Helms air Conditioning is pleased to provide this proposal to replace the air conditioning in your home. 1. Permit and crane service 2. Removal and disposal of the existing equipment 3. Install 3 ton 15 Seer system. 4. Ruud 3 ton Condenser Model: RA1436AJ1NA, Air Handler Model:RBHP21J07SH2 5. Heater 6. Safety Overflow Switch 7. New Digital Vertical Thermostat 8. Reuse existing condenser stand 9. Hurricane Clips 10. Reconnect to the copper, drain line, electrical and duct system 11. All Materials to complete the scope above Warranty: One Year Labor. Ten year warranty on all the parts Units must be registered with in 45 day www.registermyunit.com or parts warranty will only be 5 years.Warranty on thermostat one year parts and labor Warranty hours are Monday through Friday 8am to 5pm excluding holidays. Total for the system above: $4,578.00-$ 128.00 FPL rebate=$4,450.00 Terms$2,225.00 down and$2,225.00 upon start up of new equipment Add for Saturday overtime installation: $650.00 Edd Helms Air Conditioning is authorized to perform the above work and services at the prices and terms specified�erein,All payr%rftiltall be qg in accordance with the terms described above.Customer agrees to pay all court costs and attorneys fees should legal%ep by necessaryVr collections The HVAC system included in this proposal is designed according to industry standards to provide comfort cooling iq pff$ied areas.yhig proposal • does not include the responsibility by EDD HELMS for any procedures to identify,control,eliminate or remove mold irZj�x.Veied or unoccupied spade.V you suspect mold to be a problem,or if you have construction conditions that support the growth of mold,we recommini she CUS COMER take re,64181. actions outside of this proposal to eliminate the problem,remove the mold,and insure a mold free environment.EddoHelmsoir Cond�ienins shall not be responsible for drywall repairs,painting,concrete repairs,or code violations outside of the scope of work.All cancellations must be subr;&;d in wAIN • direct to Edd Helms Group,Inc.three business days before verbal schedule installation date. • • • • • MOLD AND ISSUES RELATED TO INDOOR AIR QUALITY. This contract does not include the j Wolibility by Eld Helms for arty procedures to identify,control,eliminate or remove mold or mildew in any HVAC systems or equipment.If you sus*ect Mogi or mildew tQ be a prgg14jrr,,, or if you have construction conditions that support the growth of mold or mildew,we recommend the CUSTOMER fake remedial fdtlbht butside�of this . proposal to eliminate the problem,remedy the construction conditions,remove the mold or mildew,and insure a mo%"qivironm%nt... :••••: • • • If you have any questions concerning this proposal, please do not hesitate to contact us at your convenience. We thank you for this opportunity to be of service. Sincerely, Ron Thompson Comfort Specialist Customer Signature Cell: 305-970-4711 rthomason@eddhelms.com DOW 17850 N.E.5th Avenue.Miami, Florida 33162.Tel:305-653-2530.Toll Free: (800)329-2530.Fax: (305)653-7933 www.eddheims.com R� CERTIFICATE OF LIABILITY INSURANCE D1,te(InIfDCrYYY,►) 9/15/201 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THS 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 terns 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 endorse s. PRODUCER mrur Bateman Gordon and Sands WL.Eyt FAX 3050 North Federal lighthouse Point FL� IWL INSURERNAFFORDINGCOVERAGE NAIL# INSURERAAmerisure Insurance Co. 194811. INSURED EDDHEI INSURER E;Amerisure Mutual Insurance Go. 23396 Edd Helms Group,Inc. INSURENC: Edd Helms Electric,LLC USD: Edd Helms Air Conditioning, Inc. 17850 NE 5 Avenue wsuRERE Miami FL 33162-1008 1el&IRERF: COVERAGES CERTIFICATE NUMBER:372954496 REVISION NUMBER:- THIS UMBER: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. 6i8R TYPELTR INSURANCEADM MISR EFF POLICY ECP Lam GENERAL LWMUTY Y Y GL20119261301 7/1/2015 7/1!2018 EACH OCCURRENCE $1.0w,000 DAMAGE TO RERTEU— X COMMERCIAL GENERAL LIABILITY PREMISES(Ea 0=00VO) $100 000 CLAIMS MADE P�]OCCUR MED EXP(Any one ) $5,000 XCU/Conbatdual PERSONAL&ADV INJURY $1,000,000 Broad Forth PD GENERALAGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 000 000 POLICY Fx_1 JECT —1 PRO- LOC $ AuToMowwuAsww Y Y CA2001WI401 7/1/2015 7/1/2018as rtt DDDODD X ANY AUTO BODILY$WRY(Per PMM) $ AALL UTOS OWNED SCHEDULED Btddt)BODILY INJURY(Per ao $ AUTOS X HIRED AUTOS X AWNED PROPERTUTOS Y DAMAGE $ • v• B X UMBRELLA W1B X OCCUR Y CU20011491402 7/1/2015 7/1/2018 EACH OCCUSAiNCE •'�S"b00,000 •••••• EXCESS LIAB CLAIMS MADE AGGREWE ' • 0,000 • DEDX IRETENTIONSO *go:** • • 0000#0 AND EMPLOYERS'U A710NU§IJy WC20025011501 7/1/2015 7/1/2018 X O •••••i YIN • ANY PROPRIETORIPARTNEROMCUTIVEEl N/A E.L.FDIC CIBENT • 1$1000,000 OFFICERIMEMBER EXCLUDED? 01mmMm in NN) EL D EIIAPI $1 000,000 • 0 N aIPT10N OF ha roam' OPERATIONS below E.L.D CY 000 L 0 0 • ••000• • • • • • • •0.00• 0000•• DMICICPTION OF OPERATMi LOCAMW I VE==(Attach ACORD 101,AdftI0nW Rm tm Sdnftle Ir nwm sF M reqs •• • • ••• • • ---Document is not complete unless accompanied by the Acord 101. •••' General Liability: Blanket Additional Insured,ongoing and completed operations,as required-written contract,per CG7048 0913. Blanket Primary S Non-Contributory,as required by written corrtract,ppeerr CG 048 0913. Blanket Waiver of Subrogation as required by written contract,per CG70491109. See Attached... 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. 10050 NE 2 Avenue Miami Shores FL 33138 AUIHORAMRE RE8E ATW ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marcs of ACORD AGENCY CUSTOMER ID: EDDHE1 _ LOC#: CO ADDITIONAL REMARKS SCHEDULE Page of Bateman Gordon and Sands Edd Helms Group,Inc. Edd Helms Electric,LLC Foucr NOMM Edd Helms Air Conditioning,Inc 17850 NE 5 Avenue cam --J�-AZCODE Miami FL 33162-1008 EFFEMM DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 30 Days Notice of Cancellation other than non-payment of premium per Notice per Form IL 70 45 05/07 Auto Liabilitiyy: Blanket Adlonal Insured,as required by written contract,per CA7171 0508. Blanket Waiver of Subrogation as required by written contract,per CA7171 0508 Workers!Compensation: Blanket Waiver of Subrogation as required by written contract,per WC000313. Umbrella Liabiiity: Umbrella liability extends coverage to underlying General Liability(excludes the general liability per project aggregate),Auto Liability and Workers Compensation coverage's. General Information: The General Liability policy contains no specific residential exclusions. L COVERAGE IS SUBJECT TO THE POLICY TERMS,CONDITIONS AND EXCLUSIONS QUALIFIER: NORMAN LARRABEE LICENSE#CACO21309 • • 0000 .0000. 0000•. 0000 0000.• • 0000•• . • • 0000.• 0000 .• • • • ••.• • .• 000.0 0000•. . • 0000• •• 00 0• •• 00.0••0 0000•• • • 8000•• • • • • • 0 • • •000•• 0 • • •• s I ACORD 101(2008101) ®2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Invoice Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795-2204 Fax: (305)756-8972 For Inspections please call: (305)762-4949 Return to: Miami Shores Village Permit Number: MC-9-15-2425 10050 N.E.2nd Avenue Involce Date: September 23,2015 Miami Shores, FL 33138-0000 Invoice Number: MC-9-15-57189 Bond Number: Bill To comments: Village Del Mar Village Del Mar c/o Regatt Management 1200 NE 105 Street MIAMI SHORES, FL 33138 Date Fee Name Fee Type Fee Amount 09/23/2015 DBPR Fee Calculated $2.06 09/23/2015 DCA Fee Calculated $2.06 09/23/2015 Permit Fee Percentage $137.34 09/23/2015 Education Surcharge Calculated $1.00 09/23/2015 Scanning Fee Calculated $9.00 09/23/2015 CCF Calculated $3.00 09/23/2015 Technology Fee Calculated $4.00 Total Fees Due: $158.46 :tea Payments r7 z" Date Pay Type Check Number Amount Paid Change r 09/23/2015 Check 6247 $50.00 $0.00 P-moi Total Paid: $50.00 r, r- !`J,1 Total Due: $108.46 C.1J F.� 1) l; Fri Wednday,September 23,2015