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PL-15-2053 �e Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone. (305)795-2204 Fax: (305)756-8872 Inspection Number INSP-241398 Permit Number: PL-8-15-2053 Scheduled Inspection Date:January 13,2016 Permit Type: Plumbing -Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner. SALTZBURG,DONALD Work Classification: Gas Job Address:94 NE 100 Street Miami Shores,FL Phone Number Parcel Number 1132060131180 Project <NONE> Contractor ELITE GAS CONTRACTOR INC Phone: (786)333-0679 Building Department Comments RUN APPROX 70 FEET OF GAS LINE TO CONNECT A Infractio Passed Comments 200 PROPANE GAS TANK(47 GALLON PROPANE)TOA INSPECTOR COMMENTS False COOK-TOP AND BBQ. Inspector Comments Passed Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-Inspection fee Is paid January 12,2016 For Inspections please call: (305)762-4949 Page 3 of 31 4R_A! i WTT invoice #E H. . .. . ..... .. ... .15 ONMOUR INC. licensed & insured Office- 7WA70.4298 FAX 305-381-9907 LIC#:LPG001122 MWX 133218 NWMK FL 330"3.3214 rrelitegaseaol corn P DROP TEST INFORMATION . stomers NOme_�T1P�C��i9�T��IJate__1,�-22_��4�/..S"• Service address--__9q/ 1e' /CSB or city State_ Zip J/i Permit # Monometer Pressure Test Start WC // � Finish WC_j/ Min /s:tii.v Lock Up Lack Up First Stage _ Lock Up 2W stage--/ Lood_ Leak Detection Alt Leak Locations So ip Test-y" Gas left on W Sotisfies coded Order strength_., „ Meter # _ ._.. Reading Tank Reoding _,_- Applicinces_. ~4g, Comments._. This drop hast covers LP/ Nat gas items and equlpnwn# visible and accessible to the service technician and represents the condition existing on the date of inspection. It does not cover latent of manufacturing defects, the Internal working of sealed equipment, or structural components, and cannot be construed to cover future unforeseen happenings. Service Technician Signature. 1R Customer Signature. Cop+ ''* ''$ ;mss b-Z �� (4-26-7-3 ?L- fs- 20 3 MMIDDIYYM W-1 R©� CERTIFICATE OF LIABILITY INSURANCE DATE`12/0812015 B12015 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 endorsement(s). PRODUCER NAME: Automatic Data Processing Insurance Agency,Inc. Pwc.HO N No): 1 Adp Boulevard ADDREss: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE MAIC# INSURERA: Bridgefleld Casualty Insurance Company 10336 INSURED INSURER B: ELITE GAS CONTRACTOR INC INSURER c 1525 W 35TH PL Hialeah,FL 33012 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 422487 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. LTR TYPE OF INSURANCE POLICY NUMBER MMD EFF MEPI EXP LIMITS COMMERCIALGENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO KENTED-- CLAIMS-MADE 7 OCCUR PREMISES Ee occurrence $ MED EXP(Any one person) $ PERSONAL B ADV INJURY $ GERL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY Re- FI LOC PRODUCTS-COMP/OPAGG $ OTHER $ AUTOMOBILE LIABILITY E MBIDt IN LE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accidern) $ AUTOS OS NON--OWNED PROPERTY DAMAGE $ HIRED AUTOS I AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONTH- AND EMPLOYERS'LIABILITYY N X LIABILITY STATUTE ER ANY PROPRIETORIPARTNERAEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OMCERIMEMBER EXCLUDED? rN N/A N 0196-38074 12/20/2015 12/20/2016 (Maansddmy In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 DES.RId OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remaft Schedule,may be attached H more space is required) License No:24437 Gas Installation&Repair CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD { n Florida Department of Agriculture and Consumer Services eFL t5—2055 P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number: 24437 Business Mailing Address Licensed Location Address ELITE GAS CONTRACTOR INC. ELITE GAS CONTRACTOR INC. 1525 W 35TH PL 1525 W 35TH PL HIALEAH.FL 33012-4625 HIALEAH,FL 33012-4625 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a company must be licensed. All LF Gas licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person,firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the department. All licensing requirements must be met by the transferee and a transfer fee of$50 will apply. To apply for a transfer,contact the Bureau of LP Gas Inspections at(850)921-1600. Pursuant to Chapter 527, Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner,or end user upon request when engaged in the business of servicing,testing, repairing,maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here State of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number: 24437 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31,2016 t850 921-1600 Date of Issue: September 1.2015 License Fee: $200.00 Tallahassee, Florida T POST LICENSE Type and Class: 0803 CONSPICUOUSLY Liquefied Petroleum Gas License LP GAS INSTALLER GOOD FOR ONE LOCATION ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license is issued under authority of Section 527.02,Florida Statutes,to: ELITE GAS CONTRACTOR INC, 1525 W 35TH PL ADAM H_PUTN M HIALEAH, FL 33412-4625 COMMISSIONER OF AGRICULTURE ,P3926 sig ` } .,V !r 1hilSr is.11 A+iii, 4AC 655228 13 *AM " i9a CBNTR4CTD IC�iC Q, ¢ 46 625 2'3: T $15#� Mass OWNU R SEC.TYPE OF 81,{t �$ ELITE CAS CONTRACTOR INC 205 LPG INSTALLi rAvatsNT aecElvMD i f'G001122 JW TAX cOLLECTCW �5U.00 09/17/2015 EDITCARD-15-046829 This 1 !business imr�caipt ettig ms pay Businesalex.The Recel: Is not a Rome, pet apuf a ceRificalipa tiftba hoide lr iiicetio Hoiden caipRiy wi8t-arty govemnentai I ot'1tfpNamenml teBniAtory lavv$ niramen "iht the busby '. - . t The 1 iPT N0.above est be dit en aii cmtjn►erciai vs les-Mia s de&eo b-276. I Wr a�18ft►raxation,vise r. 5 � ►�° CERTIFICATE OF LIABILITY INSURANCE ""IGM4i15'' PRODUCER Pmc=Insurance Undue THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 4909 SUN 74th CL ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR • Munni.FL 33155 ALTER THE COVERAGE AFFORDW BY THE POLICIE8 BELOW. Phone(305)740.4480 Fax (305)7404469 INSURERS AFFORDING COVERAGE NAIC III INSURED ELITE GAS CONTRACTOR.INC. INSURER A: ENDURANCE AMERICAN SPECIALTY 1525 W 35 PLACE INSURERS: DIAMOND STATE INSURANCE CO. ROCKHILL INSURANCE CO. HIALEAH,FL 33012 INSURER D. INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED HAVE BEEN RUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERRA 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. [NSA Atm I. ION Im TYPE OF INSURANCE POLICY NUMBER TE MM1p�p� POLICY �T LIMIT$ 09NERAL UARKM EACH OCCURRENCE 1,000,000 DAM®COMMERCIAL GENERAL LIABILITY CBC10001719M 09023/2015 09/2302016 PREIV!lsES Ea RENTEDGE TO 100,000 1111 CLAIMS MADE ® OCCUR MED EXP WW an parson) 51000 A ® ® BUPD$0 DED. PERSONAL&ADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,0001000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 2,000,000 ❑ POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LWt 1,000,000 ® ANYAUFTO 40848602015 08/23!2015 09123/2016 P aoddsntl ❑ ALL OWNED AUTOS BODILY INJURY B ❑ © ScHEDULEDAUTos {Perp!!Iojn ® HIRED AUTOS BODILY INJURY ® NONOWNEDAUTOS (ParacddmQ ❑ PROPERTY DAMAGE er acddeM GARAGELIABILITY AUTO ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN _98 A 11 AUTO ONLY: AGG EXCESS IUMERELLALIABILITY RXSLWGR002573- 09/23/2015 09/23/2016 EACH OCCURRENCE 1,000,000 ® OCCUR ❑ CLANS MADE 00 AGGREGATE 1,000,000 C ❑ PRODUCTS COMP OP 1,000,000 ❑ DEDUCTIBLE CRISIS RESPONSE 250,000 [] RETENTION $ EXCESSgTCgI-AS.CRISIS 50,000 PMMTIOE111PLOYERS'LIABBJTY N AI+tD ❑ RY LEI Ll ?TH- ANY PROPRIETOR I PARTNER I EXECUTIVE YIN EL.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N (MmulaWsy. air In E.L.DISEASE-EA E EMPLOYE bdw E.L.DISEASE-POLICY LIMIT OTHER DESCRIPTION OF OPERA31ONS 1 LOCATi=I VEECI ES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS B PIP$10,000 l! MEDICAL PAYMENTS S 5,000 N UNINSURED MOTORIST$50,000 # COMP KOLL$500 DED.(2005 CHEVY ONLY) 1894 FORD MNS JFTHF26YGRNAMI11 2014 RAM VM 30STRVDGXEEI 191711 2014 VIN d 3CSTRVDGXEE120M PREMISES ADDRESS*1625 W 35 PL HIALEAH,FL 33012 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL VILLAGE OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NORTH EAST 2 AVE THE LEFT,BUT FAILURE To 00 SO 84IAL.IM o OBLIGATION MIAMI SHORES,FL 33138 OF ANY KIND UPON THE INSURER,ITS AG REP AUTHORIZED REPRESENTATIVE ISIDRO GUILLAMA I If ACORD 25(2009!01)QF 0 19M20094CORD CORPORATVK All rights rued. The ACORD n e and logo are rered marks of ACORD Miami Shores Village 10050 N.E.2nd Avenue NE R' Miami Shores,FL 33138-0000 Phone: (305)795-2204 , Expiration: 02/14/2016 Project Address Parcel Number Applicant 94 N E 100 Street 1132060131190 DONALD SALTZBURG Miami Shores, FL Block: Lot: Owner information Address Phone Cell DONALD SALTZBURG 94 N.E.100 ST. Contractor(s) Phone Cell Phone Valuation: $ 1,200.00 ELITE GAS CONTRACTOR INC (786)333-0679 Total Sq Feet: 0 Type of Work:RUN APPROX 70 FEET OF GAS LINE TO C Available inspections: Type of Piping: Inspection Type: Ype: Additional Info: Final Bond Retum: Press Test Classification:Residential Scanning:1 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# PL-8-15-66713 DBPR Fee $2.25 08/142015 Check#:7416 $50.00 $110.70 DCA Fee $2.25 Education Surcharge $0.40 08/182015 Check#:1239 $110.70 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.80 Total: $160.70 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information isurate and that all work will be done in compliance with all applicable laws regulating 1-10 construction and zoning. Futhermore,I authorize the above-named-9mractor to do the work stated. August 18,2016 Authorized Signature:Owner / Applicant / ct&' / Agent Date Building Department Copy August 18,2015 1 i z Miami Shores Village Au4 2015 Building Department BY 90050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Far.(305)756.8972 INSPECTION'S PRONE NUMBER:(305)762A%9 FBC 201 y'rr�� BUILDING Permit No. k? !J 20, 3 PERMIT APPLICATION Master Permit No. RC-12-19'- Permit C/2-1yPermit Type:PLUMBING JOB ADDRESS: 5?�O .VPr ZOO 0'7` City: Miami Shores County: Miami Dade Zip: .33`3 Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Sim le Titleholder): ✓ K 1� �� v`� lede# / cJ /u-1. 1 I J Address: V J City: State: 1 Zip: _��? Tenant/iessee Name: Phone#: Email: CONTRACTOR:Company Name: g•Z/7S'M5 4PA- . 4C7•VR, Xfe- Phone#: 7AC"3 33- Od 7? Address: f 3.2 S 3.S-PL City:— !A L d-W State: F=L Zip: "3301 2 Qualifier Name: eleMOAAO tt*JCVe V Phone#: 7d6-173-/79/ State Certification or Registration#: Z.Y Y3 9 Certificate of Competency#: ContactPhone*: "t-eAR-/7 21 Email Address: RR E�/TE'd 45 & .¢OL• cy.I DESIGNER:Architect/Engineer Phone#: Value of Work for this Permit:$ i 2 O®'ow SquaretLinear Footage of Work: Type of Work: UAddress OAlteration CdNew ORepair/Replace ODemolition Description of work: .ey„d ."I°,P.OX. 7•D pe'"- BF JAW L/NE TO ",awg-cr A 20D"p"P.we dA1 p C_417 1&ce.ayo,¢op.#iyB� To dt e00K l�P �y0 Bd?dZ 444444444444444444444444444444444444 44F�444444il4i�#4444444544444 4444 44 i44i44wj�` �> Submittal Fee$ Perna Fee$ 56• '`'' CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 1 �J. i lb Bones Company's Name(if applicable) Bonding Company's Address City State Zap 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 met 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 Apphcanfi 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 properly is subject to attachment. Also, a certified copy of the recorded notice of commenceme usr be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the s ce of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agentontractor The foregoing instrument was acknowledged before me this ® The forego' instrument was acknowledged before me this Ar day of ®4 .20 t.by 6y0/DV g�cr-sav a 6- day of O ,20 LE,by 2/e ,W2/?d',`� who is personall known to me or who has produced who is pets Uy ka2wn to me or who has produced As identification`!%y*aj%ttake an oath. as identification and who did take an oath. NOTARY PUBLIC: o��''S��••••••.:f b''!Vk- NOTARY PUBLIC: �t�lultlltMNtt//r11 Sign: .•o• Sign: �'• • _ _ :- Print: i JY is 6td? U d Q Print: F. �/S� My Commission Expires: ••'•. e; '•�V'� My Commission Expires: % '•;<y �� hlfi�i► -TO cy—2..3—20/,P '��ii�i*•�TAR��'�\c,� 4###4444##44444#444#4444#44##444444###4#44444444444444444444b4444A##4##444444+644###44###44444444444b444444b# APPROVED BY 0-I rS Plans Examiner Zoning Structural Review Clerk (Revisc&VI J2012)(Revised 07/I0RI7)(Revised 061104200 )(Revised Y15M) Florida Department of Agriculture and Consumer Services Division of Consumer Services 2005 Apaiachee Parkway Tallahassee, Florida 32399-6500 Master Qualifier Mailing Address Licensed Location Address RICHARD HARVEY ELITE GAS CONTRACTOR INC. ELITE GAS CONTRACTOR INC. 1525 W 35TH PL 1525 W 35TH-PL HIALEAH, FL 33012.4625 HIALEAH, FL 33E}12.4625 Cerdficat�e Nutttber , License Nurhber 01122 24437 1 This Master Qualifier Cerfificate i*sued pursuant to Chapter 527, Florida Statutes. This certifiicate is valid only for the person and licdnsed holder'listed. Any changes to the Master Qualifier status (such as transfer car termination,.of et'lodyment);must be reported t4 the-;�urea�t of L P teas Inspection at(85o)92t=1600 immedtateiy. The Master Qualifier Certifioat#10.valid only through the date noted on the Certificate. A notice of renewal will be sent to you in advance of your expiration date. A Master Qualifier Certificate may be renewed if certification of a min ut'n of 1g'(sWeert)hours continuing.education is provided along with the renewal furrnn. If training cannot tie documented,an examination must be taken. if there are any errors on the certificate pleaw submit aA changes in'wriflrtg to: Florida. athwt bt Agriotftte and Consumer Services; . Division of 06rtsu MW Services 200646li chee Parkway Tallahasaee..Florida 323OM6W 0A HM Sults of Florida " Department of Agriculture and Consumer SerV# es NGNYii s> Bureau of tigr`tefi i petroleum Qas inspection be Novwnw e,Inas 1350 921-1800 b�sus t3aa9. JtAy 1a,21115 ( E* : . x11,2118 Tallahassee, Florida mat: 1 MASTER` t'IUALMERI CERTIP104t This Certificote.is issued under jjKj I of Section 527.02,Florida Statutes,to: vat F40r. ��t : 24431 Eta W.roWTRAcT0R INC. 1525 W 35tH PL. =�S:;t F—ft OF ACaFtCULTURE HWLEAH,FL 330124625 Florida Department of Agriculture ano Consumer Services Bureau of Liquefied Petroleum Gas Inspes-tion P.O. Box 6704 Tallahassee. Florida 32399x6700 License Number: 24437 Business Mailing Address Licensed Location Address ELITE GAS CONTRACTOR'NC ELITE GAS CONTRACTOR INC 1525 W 35TH PL 1525'A+35TH PL HiALEAH,FL 33012-4625 f itALEAH FL 33012 8825 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company tocated at the address on the license. Each business location of a company must be licensed. All LP Gas licensees must be i enewed annually. Any lleent#allowed to e)tpire thall be6DMe inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN O N, RB1t1P CHANGE AT 3 1'S BUSINESS LOCATION: This license may be transferred to any person, firm or corporation for the remainder of the current license year upon written request to the department by the original license holder License transfers must be approved by the department. All licensing requirements must be inlet by the transferee and a transfer fee of$50 will apply To apply for a transfer. contact the Bureau of LP Gas Inspections at (850)921-1600. Pursuant to Chapter 527. Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner, or end user upon request when engaged in the business of servicing testing. repairing, maintaining or installing LP Gas systems and/or equipment. For future correspondence, please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services Bureau of Liquefied.Petroleum Gas Inspection P.O. Box 6700 Tallahassee. Flonda 32399-6700 s Cut Here} State of Florida Department of Agriculture and Consumer Services Division of Consumer Services License Number: 24437 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31.2015 F $ � 921-16Q0 Date of issue: Septemt>er 1 2014 ` ) License Fee: $200.00 POST.yti^ao��■lSE Tallahassee, Florida Type and Class: 0803 CONSPICUOUSLY Liquefied Petroleum License LP CAS INSTALLER GOOD FOR ONE LOCATION.ONLY ANY CHANGE OF OWNERSHIP OR SAL15 OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is issued under authority of Section 527.02.Florida Statutes,to: ELITE GAS CONTRACTOR INC. � �... 1525 W 35TH PL. ApAlvl�+ PtIrNAM HIAL SAH, FL 33012-4625 COMMISSIONER OF A+ZR'C'1t_-. C &.- Y:tfr 4 r, 1R,5 i, t t g L ^�i} mg J13 h h "�b. � =5'y{ fE�i_l•�h S "k MSS t^L 2.Y��i''sVr,✓t,f/ ft,.-art .`� f`f S�2diL Y.s"z�5{M y�yf Ya. a" C it.c .fitvs pF y � Cc�if`a, `R f+x 5M f "bks t,t�`T7s xt� £r, �� ' ��ti�av;S a� stt-.E>�.��.� w yy�`yus�'�,^rs��✓? r tmj�y,' � 1 V �x ))s ,�'�rv�r��"1� ti � ' «i r3�'t�+�Yfi}k'�i)�4 { y`y.N��+r� a "xi yfk >� }fir r ua s ' '( av k� 5� A44 et Ys. 4s1s ( tMk ��W �y 'n r--+.x y. RE L ��ay � �r �,, x :✓ .e � fa �r�_: zip �'!F � ,rt a r r. t4 - ss 'ssr d ! �� a •k:4'€�w�3 x; i •'.�. � €� "ham .�t4 !r a ,�2y Mme- CERTIFICATE OF LIABILITY INSURANCE I DATE4' PRObUCER Procan Ireulance Underwriters THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4908 SW 74th CL HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Mhod,FL 33155 ALTER THE COVERAGE Aff9RDW BY THE POLICIES BELOW. Ptaavie(305)740.4460 Fax (3OM740.4469 INSURERS AFFORDING COVERAGE NAIC# INSURED ELITE GAS CONTRACTOR,INC. INSUM A: ENDURANCE AMERICAN SPECIALTY INSURER& TRAVELERS PROPERTY CASUALTY 1625 W 35 PLACE INSURER C: ASCENDANT COMMERCIAL.INS.INC. HIALEAH,FL 33012 jN$Up ZgD, ROCKHILL INSURANCE CO. INSURER I- COVERAGES THE POLICIES OF OJRANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUItaAENT.TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHECH 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 L WrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW MR AWLPal=EFFECTIVE IRD TYPE OF INSURANCE POLICY NUMBER VA GY EXPUtAlIOk umm GENERAL LIABILITY EACH OCCURRENCE 1,000,000 195111m TO RENTED ®COMMERCIAL GENERAL UABI.IIY CBC10001719701 09/23/2014 09/23/2015 PREMISES Ea 100,E ❑❑ CLAIMSMADE ® OCCUR MED EXP Ww one 1mo) 5,000 A ❑ ® B15'D$0 DED. PERSONAL&ADV INJURY 11000,000 ❑ GENERALAGGREGATE 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AM 2,000,000 D POLICY ❑PROJECT ❑ LOC ANYAUTO BA-5AS338BA-14 09!23/2014 09123!2015 ID SINGLE LIMIT 1'000'QDd ❑ ALL OWNED AUTOS BODILY INJURY B ❑ ® SCHEDULEDAUTOS n) D HIREDAUTOS BODILY INJURY ❑ NON OWNED AUTOS (ParawJdw* ❑ PROPERTY DAMAGE El (Per eaddeM GARAGE 1JASIIW AUTO ONLY-EAACCIDENT ❑ ❑ ANYAUTO OTHERTHAN FA A-0 0 i ❑ AUTO ONLY: AGO EXCESSIUMBRELLALIABMMEACH OCCURRENCE 1,000,000 RXSLVItGR001605- 091231'2014 09123/2015OCCU D El ® R ❑CtaLwaDE 00 AGGREGATE 1,000'aw PROD&COMP.OPER 1,000,000 ❑ DEDUCTIBLE CRISIS RESPONSE 250,000 ❑ RETENTION $ EXCESS CAS.CRISIS 50,000 �, COMPENSATION AM LOYMMIJABILM YIN WC-64178-2 09122/2014 09122/2015 IOMFLM ❑ SH- C ANY MEMM� RPARTNU IEXECUTIVE N E.LEACH ACCIDENT 11000,000 Mandatmy la P" ILL DISEASE-EA EMPLOYEE 1,000,000 E.L.DISEASE-POLICY LIMITECK PRCAM i A 1,0 ,000 OTHt9t 1 -T DBSCRIPTION OF OPERATIONS i LOCATIONS t VEHICLES f EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS B PIP$10,000 I1 MEDICAL PAYMENTS$5,000 11 UNINSURED MOTORIST$50,000#COMP KOLL$500 DED.(2005 CHEVY ONLY) 2005 CHEVROLET TRUCK VIN#1GBE4V1275F50353911997 FORD VII#1 FTFE2423VHA1291511994 FORD VIN#1 FTHF25Y5RNA88611J 1989 ISUZU VIN#4KLB4B1R4KXX0I23 PREMISES ADDRESS:9525 W Sri PL MALEAH,FL 33012 License No. LPGO 01 1 22 i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE:DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MNL VILLAGE OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NORTH EAST 2 AVE THE LEFT,BUT FAILURE TO Do SO NO OBIJG ON OR&MILITY MIAMI SHORES,FL 33138 OF ANY IaND UPON THE INSURER, OR REVS 5OW AUTHORRED REPRESENTATIVE ISIDRO GUILLAMA ACORD 25 CAOM)OF 0 1USPbO ACORD CORP TION.AN rights reserved. 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