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RC-15-1026 (3) Miami Shores Village 10050 N.E.2nd Avenue NW f Miami Shores,FL 33138-0000 "Rx t Phone: (305)795-2204 Expiration: 04/1312016 Project Address Parcel Number Applicant 162 NW 109 Street 1121360100220 CANOR PATO CARLA GRISONI Miami Shores, FL 33168-4317 Block: Lot: Owner Information Address Phone Cell CANOR PATO CARLA GRISONI 162 NW 109 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $47,375.00 HOME OWNER --- -� - _ Total Sq Feet: 168 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Review Building Date Denied: Review Building Type of Construction:GARAGE CONVERSION TO MASTE Occupancy:Single Family Review Building Stories: Exterior: Review Mechanical Front Setback: Rear Setback: Review Mechanical Left Setback: Right Setback: Review Structural Bedrooms: Bathrooms: Review Electrical Plans Submitted:Yes Certificate Status: Review Electrical Certificate Date: Additional Info: Review Electrical Bond Retum: Classification:Residential Review Plumbing Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Plumbing CCF $28.80 Review Structural CO/CC Fee $50.00 Invoice# RC4-15-55382 Review Structural DBPR Fee $21.32 04/30/2015 Credit Card $50.00 $1,792.69 Review Planning DCA Fee $21.32 10/16/2015 Credit Card $1,792.69 $0.00 Education Surcharge $9.60 Permit Fee $1,421.25 Plan Review Fee(Engineer) $120.00 Plan Review Fee(Engineer) $120.00 Scanning Fee $12.00 Technology Fee $38.40 Total: $1,842.69 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 all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhe ,I authorize the above-named contractor to do the work stated. October 16,2015 Authorized Signature:Owner / Applicant / Contractor / Agent Data Building Department Copy October 16,2015 1 ' Miami Shores Village h"�' �-��1 Building Department `D g p OCT 0 9 015 ` 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 [BY: INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2010 BUILDING Master Permit No. _121C t5—t0 24�;' PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [—]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS W CHANGE OF ❑ CANCELLATION ❑ SHOP r CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip• Folio/Parcel#:11-V 316 0110 QZZ0 is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: AJO BFE•: . - FFE: OWNER:Name( ee Simple Titleholder):_ C h�_ PA-1ro Phone#. es-) Address: bz �w " [ ST— City: 1k%Jokkt S t __S State � Zip: Tenant/Lessee Name: Vj t Phone#: Email: CONTRACTOR: , 1� C�om``paany Name:�lJ� n� Phone#:&�7 - � IZ Address: 'T Nw QD Cfj" City: A'L M& i State: Qualifier Name: C-&j?.::Q ©'2�^C•,/FNoa ::T&L�Srks; Phone#: State Certification or Registration#:C ec-1 Z.,1 �(C5. Certificate.of Competency#: DESIGNER:Architect/Engineer: Phone#: Address City State Zip: Value of Work for this Permit:$!PLI .�- Square/Linear Footage of Work: ZW 4 Type of Work: ❑ Addition ip Alteration ❑ New ❑ Repair/Re lace p n ❑ Demolition Description of Work: t/ t `7Z -w4-�J_1.' Specify color color of color thru tile: l 1 ^- �� Submittal Fee$ Permit Fee$ CCF$ CO/CC$ 90 Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ E!U 5— /2AA TOTAL FEE NOW DUE$ (Revised02/24/2014) � 3��. � 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 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. Signatu Signature O r AGENT CONTRACTOR The foregoing instrument was cknowledged before me this The foregoing instrument was acknowledged before me this I —day of F' - ,20 IS',� by k day of_(�C�'b13� .20 (S— J by CA&OvaV'/ ,who is personally known to n el a% GtL.S A-�who is p na y known o I -------------- me or who has produced�bL-:*�t7At (E as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: 4 Sign: Sign: Print:.. Vv�. `e� Print: IL Seal: Seal: EWA W REBECA M.PASTRANA NAF dWASesSI MY COMMISSION 4 EESM24 11tES:Feha=j.22W - EXPIRES:Felaamy 07.2017 F4 A"Room 1� APPROVED BY � Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) • Miami Shores Village PFc7I C It5 Building Department AP R s Zo'5 °3 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 20LO BUILDING Master Permit Nog lt� ' I PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: a 2 N I d a�1 S� City: Miami Shores County: Miami Dade Zip: 33 f Folio/Parcel#: ' 7- (a 0 V ZZ 0 Is the Building Historically Designated:Yes NO Occupancy Type: S Load: Construction Type: x-13 S Flood Zone: A10 BFE: FFE: OWNER:Name(Fee Simple Titleholder): CA,^o1_ I q-T-0 Phone#: 30'� YZ( °O y Address: A-P4 J. A'S A- 3 o J C— City: State Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: lLi� 0t1J(\ Zk, Phone#: Address: City: State Zip: Qualifier Name: Phone#: State Certification or Registration#: 1- Certificate of Competency#: DESIGNER:Architect/Engineer: 0, tt n k rA-( i' Phone#: I S`( 517- zg� 1 / Address: City: State: Zip: Value of Work for this Permit:$-1 d/ 6100 Square/Linear Footage of Work: Type of Work: ❑ Addition ;�(�❑ Alteration El New s 1 ElRepair/Replace ElDemolition Description of Work: [-•�ttY- 01, �wN�UlV Specify color of color thru tile: Submittal Fee$5 O• M Permit Fee$'-3C0 Fad CCF$ CO/CC$ '03 Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ ' TOTAL FEE NOW DUE$ ��� • �'� (Revised02/24/2014) `r 0i ` f 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 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. Signatur Signature OWNER or AG NT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this —6 day of P—'�-- ,20 (� ,by day of ,20 ,by who is personally known to who is personally known to v�T ``�� me or who has produced t� ��� gVD�& me or who has produced as identification and whodid t ke an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: i Sign• Sign Print: Print: Seal: Seal: NotaEN � ate of Florida Sindi MY CFF 15675o 9wwv Expir18 ******************* * * * ******************************************************** S ���JAPPROVED BY Plans Examiner -o Zoning Structural Review Clerk (Revised02/24/2014) , s Miami Shores Village Building Department �m mn 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 OWNER BUILDER DISCLOSURE STATEMENT NAME: /!i''�°� P4-�-O DATE: -3-9 t; ADDRESS: 1'L Z N,AJ 10 1 S i(' t4 i A-p"i I <A,,r AY Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida,F.S 489.103(7).And I have read and understood the following disclosure statement,which entitles me to work as my own contractor;I further understand that I as the owner must appear in person to complete all applications. State Law requires construction to be done by a licensed contractor.You have applied for a permit under an exception to the law.The exemption allows you,as the owner of your property,to act as your own contractor even though you do not have a license.You must supervise the construction yourself.You may build or improve a one-family or two-family residence.You may also build or improve a commercial building at a cost of$25,000.00 or less(The new form states 75,000).The building must be for your own use and occupancy.It may not be built for sale or lease.If you sell or lease a building you have built yourself within one year after the construction Is complete,the law will presume that you built for sale or lease,which is a violation of this exemption.You may not hire an unlicensed person as a contractor.It is your responsibility to make sure the people employed by you have licenses required by state law and by county or municipal licensing ordinances.Any person working on your building who is not licensed must work under your supervision and must be employed by you,which means that you must deduct F.I.C.A and with-holdings tax and provide workers'compensation for that employee,all as prescribed by law.Your construction must comply with all applicable laws,ordinances,buildings codes and zoning regulations. Please read and initial each paragraph. 1. 1 understand that state law requires construction to be done by a licensed contractor and have applied for an owner-builder permit under an exemption from the law.The exemption specifies that I,as the owner of the property listed,may act as my own contractor with certain restrictions even though I do not have a license. Initial 2. 1 understand that building permits are not required to be signed by a property owner unless he or she is responsible for the construction and is not hiring a licensed contractor to assume responsibility. Initial, 3. 1 understand that,as an owner builder,I am the responsible party of record on a permit.I understand that I may protect myself from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own name.I also understand that the contractor is required by law to be licensed in Florida and to list his or license numbers on permits and contracts. Initial 4. 1 understand that I may build or improve a one family or two-family residence or a farm outbuilding.I may also build or improve a commercial building if the costs do not exceed$75,000.The building or residence must be for my use or occupancy.It may not be built or substantially improved for sale or lease.If a building or residence that I have built or substantially improved myself is sold or leased within 1 year after the construction Is complete,the law will presume that I built or substantially improved it for sale or lease,which violates the exemption. Initial 5. 1 understand that,as the owner-builder,I must provide direct,onsite supervision of the construction.,,,/ Initial "Y 6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or residence.It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or municipal ordinance. Initial C-y 7. 1 understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner-builder permit that erroneously Implies that the property owner is providing his or her own labor and materials.I,as an owner-builder,may be held liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while working on my property.My homeowner's Insurance may not provide coverage for those injuries.I am willfully acting as an owner-builder and am aware of the limits of my Insurance coverage for injuries to workers on my property. Initial_ 8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to perform the work being done.Any person working on my building who Is not licensed must work under my direct supervision and must be employed by me,which means that I must comply with laws requiring the withholding of federal income tax and social security contributions under the Federal Insurance Contributions Act(FICA)and must provide workers compensation for the employee.I understand that my failure to follow these may subject to serious financial risk. Initial 9. 1 agree that,as the party legally and financially responsible for this proposed Construction activity,I will abide by all applicable laws and requirement that govern owner-builders as well as employers.I also understand that the Construction must comply with all applicable laws,ordinances,building codes, and zoning regulations. Initial 10. 1 understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service,the United States Small Business Administration,and the Florida Department of Revenues.I also understand that I may contact the Florida Construction Industry Licensing Board at 850.487.1395 or htto://www.mvfloridalicense.com/dbpr/aro/CilbAndex.html Initial- 11. nitial11. 1 am aware of,and consent to;an owner-builder building permit applied for in my name and understands that I am the party legally and financially responsible for the proposed construction activity at the following address: initial Cy 12. I agree to notify Miami Shores Village Immediately of any additions,deletions,or changes to any of the information that I have provided on this disclosure. Initial Licensed contractors are regulated by laws designed to protect the public.If you contract with a person who does not have a license,the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to assist you with any financial loss that you sustain as a result of contractor may be in civil court.It is also Important for you to understand that,If an unlicensed contractor or employee of an individual or firm is injured while working on your property,you may be held liable for damages.If you obtain an owner-builder permit and wish to hire a licensed contractor,you will be responsible for verifying whether the contractor is properly licensed and the status of the contractor's workers compensation coverage. Before a building permit can be issued,this disclosure statement must be completed and signed by the property owner and returned to the local permitting agency responsible for issuing the permit.A copy of the property owner's driver license,the notarized signature of the property owner,or other type of verification acceptable to the local permitting agency is required when the permit is issued. Was acknowledged before me this 3 day of 20 I S By 0ANNQ,P who was personally known to me or who has Produced there License or �RJ1121kk9— as identification. OWNER NOTARY Notary Public State of Honda Sfidia Alvarez • ply Commission FF 158750 ��d> Expires 09/03/2018 t tiiam,yKottEs y�� 1 sea omM i 'Morej Ui&W e 10050 N.E.SECOND AVE. �CORYDp' MIAMI SHORES, FLORIDA 33138-2382 Telephone: (305) 795-2207 Fax: (305) 756-8972 DAVID A. DACQUISTO,AICP PLANNING&ZONING DIRECTOR DEVELOPMENT ORDER File Number: PZ-2-14-201481 Property Address: 162 NW 109x`Street Property Owner/Applicant: Canor Pato Address: 162 NW 109th Street,Miami Shores,33138 Whereas,the applicant Canor Pato Owner),has filed an application for site plan review before the Planning Board on the above property. The applicant sought approval as follows: Special site plan review and approval. Garage conversion attached garage. Whereas, a public hearing was held on March 27, 2014 and the Board, after having considered the application and after hearing testimony and reviewing the evidence entered,fmds: 1. The application was made in a manner consistent with the requirements of the Land Development Code of Miami Shores Village. 2. The conditions on the property and the representations made at the hearing merit consideration and are consistent with the requirements of the Land Development Code. The Board requires that all further development of the property shall be performed in a manner consistent with the site plan, drawings, and the conditions agreed upon at the hearing: 1) Approval is granted as shown on the plans submitted and made a part of this approval to construct a 220 sq. ft.master bedroom addition. 2) Applicant to obtain all required building permits before beginning work. 3) Applicant to obtain all required permits and approvals from the Miami-Dade Department of Regulatory and Economic Resources,Environmental Plan Review Division(DRER,EPRD)and the Miami-Dade Department of Health (DOH/HRS)as required. 4) Applicant to meet all applicable code provisions at the time of permitting. 5) This zoning permit will lapse and become invalid unless the work for which it was approved is started within one(1)year of the signing of the development Page I of 2 DO PZ-2-14-201481 Pato order by the board chair, or if the work authorized by it is suspended or abandoned for a period of at least one(1)year. The application with conditions was passed and adopted this 27th day of March, 2014 by the Planning and Zoning Board as follows: Mr.Abramitis ,Y" Mr.Busta YES Mr. Reese YES Mr.Zelkowitz ABSENT Chairman Fernandez YEs �17- 1 DaV 'chard M. F rnande Chairman,Piannin oard Page 2 of 2 DO PZ-2-14-201481 Pato A�® CERTIFICATE OF LIABILITY INSURANCE OATE(MMlOOtYYYY) 10/7/2015 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 PRODUCtR,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 I(-MAILSS: ONTACT C1aUdia Reutlinger Keen Battle Mead & Company HONE (305)558-1101 Oac (305)&2z 4722 At4,Sla..Ex* --7850 Northwest 146th Street ADDRecreutlinger@kbmco.com Suite 200 INSURER($)AFFORDING COVERAGE NAIC# Miami Lakes FL 33016 IINSURERA:FCCI Insurance Company .. _ 10178 INSURED INSURER B: Oroni, Inc. INSURER C: c/o ABS 999 Vanderbilt Beach Road INSURER D: INSURER E: Naples FL 34108 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 WC 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 1..----- ----`..----- ...__.-_-1ADDL tuait ..-_.. _ .POLICY FFF. ..POLICY EXP TR TYPE'OF INSURANCE ' POLICY NUMBER MMIDDNYYY MMIDDNYYY LIMITS COMMERCIAL GENERAL LIABILITY _ EACH OCCURRENCE _ _$ CLAIMS i ! 6A�vtAG2 f0 RENTCD- -� __! �.�._ PREMISE__(Ea-occurrence)_ .__.__ __ -MADE OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY i,. JE C i LOC PRODUCTS-COMP,OP AGG $ - ---'OTHER: _._. $ AUTOMOBILE LIABILITY COMBINED n SINGLE LIMIT $ _ I ANY AUTO BODILY INJURY(Per persona $ _ ALL OWNED (..._._ SCHEDULED ! BODILY... .. . ..._... _ _._-. ... INJURY(Per accident)i$ NON-OWNED _ _. AUTOS 4.._ AUTOS PROPERTY DAMAGE, $ HIRED AUTOS I ;AUTOS (Per accictont) UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIARtCLAIMS-MADE AGGREGATE $ -- DED RETENTION $ WORKERS COMPENSATION PER 0TH• X S'iATUTE ;_ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERlEXECUTIVE I I i E.L.EACH ACCIDENT _ :$ 119P0,000 OFFICERtMEMBER EXCLUDED? JI N I A A (Mandatory in NH} 001-WC35A-74157 10/1/2015 10/1/2016 EL DISEASE-EAEMPLOYEI $ 1,000,000 tl yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 11000.000 i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schodulo,may be attached if morn space is required) Building Contractor-License#CBC1251654 CERTIFICATE HOLDER CANCELLATION (305)756-8972 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Alex (c)1988-2014 ACORD CORPORATION, Ail rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025 r?man•n