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PL-15-3207 (2) f Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-250213 PermitNumber: PL-12-15-3207 Scheduled Inspection Date: July 28,2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: , Work Classification: Septic Job Address:597 NE 93 Street Miami Shores, FL Phone Number (786)763-2813 Parcel Number 1132060141040 Project: <NONE> Contractor: SOUTHERN SEPTIC CONTRACTORS INC Phone: (305)598-8266 Building Department Comments REPLACEMENT F SEPTIC TANK&DRAINFIELD Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed HRS ON FILE Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. July 27,2016 For Inspections please call: (305)762-4949 Page 4 of 35 tfa4. jiA ( �1 • � s3� 5`� E� YG f y � •�r g.., , v -01 lv Fli P E WO lit, t P ! Y P E T13�a7 t 3 t A t� ti;a tin w CM3 7 � v 55 \ tt i / f L-- t57- 2 �I mit No. PL-12.15-3247 �s-IM L®` Miami Shores Village M Pefmif Type:Plumbing Residential 10050 N.E.2nd Avenue NE ���j/ ( yy�� �a g iaepa Work Cl+ + E1bn1 Septia Miami Shores,FL 33138 0000 ' pwmlt 5f it—APPROVED Phone: (305)795-2204 FLORtU4' F Ise t Date: 1141201 __ Expiration: 07/0212016 Project Address Parcel Number Applicant 597 NE 93 Street 1132060141040 IPI HOLDINGS LLC { Miami Shores, FL Block: Lot: Owner Information Address Phone Cell IPI HOLDINGS LLC 1441 BRICKELL Avenue (786)763-2813 MIAMI FL 33131- 1441 BRICKELL Avenue _ ___ MIAMI FL 33131- Contractor(s) Phone Cell Phone $ 2,500.00 Valuation: SOUTHERN SEPTIC CONTRACTORS 1 (305)598-8266 , Total Sq Feet: 300 Type of Work:REPLACEMENT F SEPTIC TANK&DRAINFI Available Inspections: Type of Piping: Inspection Type: Additional Info: HRS Approval Bond Return Final Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 CCF Invoice# PL-12-15-58194 $1.80 12/30/2015 Credit Card $50.00 $623.30 DBPR Fee $2.25 DCA Fee $2.25 01/04/2016 Check#: 1557 $623.30 $0.00 Education Surcharge $0.60 Bond#:2944 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $673.30 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. January 04, 2016 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy January 04,2016 1 ° Ilk ° . b-z3 Miami Shores Village L . CES RID Building Department DEC 3 o 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 ' Tel:(305)79S-2204 Fax:(305)756-8972 BY: Y ° INSPECTION LINE PHONE NUMBER:(305)762-4949 � FBC 201�k� ,BUILDING Master Permit No. ?L l S '3 :4- PERMIT APPLICATION Sub Permit No. BUILDING F-� ELECTRIC r_� ROOFING F� REVISION 7 EXTENSION DRENEWAL PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION [:] SHOP CONTRACTOR DRAWINGS --9 '7l wwa�r JOB ADDRESS: Iv ` - City: Miami Shores County: Miami Dade Zia: T61 ,5s Folio/Parcel#: y r "3Z0�- Q 1� ®L\0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Ty pe: Flood Zone: SFE: FFE: OWNER:Name(Fee Simple Titleholder): :L1'1 O L—D,1 NCS LLX- Phone#:'700b I t'�-2-V5 Address: 1, 'Si V er Si( �. 0 City: W%LVVA;^L'N-0'h State: I✓ Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: ��J�D"L1`L�4-q Phone#: Zoo 5qk$2kb Address: SV'j > 11 City: vtku'Y`,e%A State: Zip: �7�3 � Qualifier Name: Qj�_Ph b C,6 Q c-Z Phone#: �jD� s�t19n�Zbb_ State Certification or Registration#: 0 21 X21 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: State: Zip: Value of Work for this Permit:$ uare/Linear Footage of Work: Type of Work: ❑ Addition Alteration 1 E] New ARepair/Replace E] Demolition Description of Work: ` leA C-P �cvvN '0 sle4A l 1i Specify color of color thru tile: P Submittal Fee$ 6 '00 Permit Fee$ J�- �y CCF$ ` ° �� CO/CC$ rr�� Scanning Fee$ Radon Fee$ - DBPR$ Notary$ ° �J Technology Fee$ Training/Education Fee$ b -coo Double Fee$ Structural Reviews$ Bond$ ST)o , TOTAL FEE NOW DUE (Revised02/24/2014) G03- 30 _ 03, 30 t . z Bonding Company's Name(if applicable) I 'a 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 low 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 i absence of such posted notice, the inspection will not b roved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instru ent w ckn ledged befo me this 1 day of `x'1'-460 .20.4V by 30 day of C ' Q*51�E V ,20 by �► ��iS 1b`I� who is personally kin to who is personally known to me or who has produced as me or who has produced s identification and who did take an oath. identification and who did take on oath. NOTARY PUB NOTARY PUBLIC: Sig Sign: Print: S' Notary Pw ttc-State:0:39797 M Print: �• yComm.ExOres A 017 Seal: %�,, �:s Commtsaion#FF Seal:�, oso Pv® Notary Public Ste or Flwala nn BandedTtr *P Mai t: Sindia Alvarez ! - My Commission F 156750 oras, Expires 09/03/201 •tr•stsesressss+�ssseasssa+strisa+rsrrsssssrsr**or�ii.rses�ra �►sr�aw�a�*ss�a�+a�esg w APPROVED BYz�2 1.,3a,i S Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) PERMIT #: 13-SC-1649465 STATE OF FLORIDA APPLICATION #:AP1217217 DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID: SYSTEM FEE PAID. CONSTRUCTION PERMIT RECEIPT #• we DOCUMENT #: PR999241 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: (IPI Holdings LLC) PROPERTY ADDRESS: 597 NE 93 St Miami, FL 33138 LOT: 23 BLOCK: 56 SUBDIVISION: Miami Shores Sec 2 PROPERTY ID #: 11-3206-014-1040 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 306 ] SQUARE FEET Bed Drainfield SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [x] BED [ ] N F LOCATION OF BENCHMARK: 9.60'NGVD C/L OF 93 ST AS PER SURVEYOR I ELEVATION OF PROPOSED SYSTEM SITE [ 6.00 ][ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 42.00 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: 10.00] INCHES EXCAVATION REQUIRED: [ 36,00 ] INCHES O **THIS PERMIT IS NOT FOR ADDITIONS** *Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. T *Invert elevation of drainfield to be no less than 6.60'NGVD. H *Bottom of drainfield elevation to be no less than 6.10'NGVD. *The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance E with s.64E-6.013(3)(f), FAC. R *This permit includes the abandonment of the existing septic tank. (Comments Continued on Page 2.) SPECIFICATIONS BY: Roberto Rodriguez TITLE: APPROVED BY: TITLE: Engineering Specialist II Dade CHD iao e s DATE ISSUED: 12/29/2015 EXPIRATION DATE: 03/28/2016 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FACPage 1 of 3 v 1.1.4 AP1217217 SE980743 DOCUMENT #: PR999241 The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow of 300 gpd. e NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department,within twenty-one(21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN#A02, Tallahassee, Florida 32399-1703. The Agency Clerk's facsimile number is 850-410-1448. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. CERTIFICATE OF LIABILITY INSURANCE 12130/15D ) 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 CONTACTNAME: JULIO JIMENEZ Jimenez&Co.,Inc. PHONE (305)264-9900- FAx 8000 Coral Way EMAIL (AIC.No): (305)264-5382 ADDRESS: Miami,FL 33155 PRODUCER CUSZOy�F,Q_ID#: Phone (635)264-9900 Fax (305)264-5382 INSURER(S)AFFORDING COVERAGE NAIL# INSURED INSURER A: ARCH SPECIALTY INSURANCE COMPANY 21199 SOUTHERN SEPTIC AND LIFT STATION CORP-SR0021421 INSURER a: MERCURY INDEMNITY COMPANY OF AMERIC 11201 1421 SW 153 PATH INSURERC: FLORIDA CITRUS BUSINESS&INDUSTRIES F 31259 Miami,FL 33194 INSURER D: 305-598-8266 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'INS ADD SUBI POLICY EFF POUCYEXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MMIDD LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000.00 Q COMMERCIAL GENERAL LIABILITY DAMAGE TO RENT PREMISES Ea occurrence $ 100,000.00 A ❑ ❑ CLAIMS-MADE ❑ OCCUR Y AGL0026163-00 MED EXP Any one person) $ 10,000.00 Fly 05/22/2015 05/22/2016 PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00 i Q POLICY ❑ JRO" ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000.00 ❑ ANY AUTO (Ea accident) BODILY INJURY(Per person) $ ❑ ALL OWNED AUTOS BA090000001042 BODILY INJURY(Per accident $ B SCHEDULED AUTOS Y Y 08/02/2015 08/02/2016 PROPERTY DAMAGE ❑ HIRED AUTOS (Per accident) $ ❑ NON-OWNED AUTOS $ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR CLAIMS-MADE AGGREGATE � $ ❑ DEDUCTIBLE $ I -- RETENTION $ _ $ WORKERS COMPENSATION - WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N DHY_U 0 ER C ANY PROPRIETORIPARTNER EXECUTIVE 106-50116 E.L.EACH ACCIDENT $ 500,000.00 1 OFFICERIMEMBER EXCLUDED? Y NIA y 07/17/2015 07/17/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE4$ 500,000.00 if yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) ***Septic Tank System Installation,Service and Repairs**** CERTIFICATE HOLDER CANCELLATION SHOU01RON F E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EATE THEREOF,NOTICE WILL BE DELIVERED IN City of Miami Shores ACCOWI H 11 POLICY PROVISIONS. 10050 NE 2 Ave Miami Shores Village FL 33138... ~AUTHO IRLPIENTATI.'VE I © 8-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09)QF Wh,,20RD name and logo are registered marks of ACORD REGISTERED SEPTIC TANK CONTRACTOR fiiROBERTO RODRIGUEZ 1421 SW 153 PATH MIAMI, FL 33194- SOUTHERN SEPTIC AND LIFT STATION CORP. Business Authorization- SA0121809 SR0021421 Registration Expires on September 30, 2016 Local Business Tax Receipt Mia rni-Dade County, State of Florida -THIS IS NOT ABILL-DO NOT PAY 6963459 LB_Tl� BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES SOUTHERN SEPTIC AND LIFT RENEWAL SEPTEMBER 30, 2016 STATION CORP 6306658 30 SW 57 CT Must be displayed at place of business MIAMI, FL 33144 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED SOUTHERN SEPTIC AND LIFT 196 SPECIALTY PLUMBING BY TAX COLLECTOR CONTRACTOR 45.00 09/29/2015 Worker(s) 1 SEP121809 0224-15-006401 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit or a certification of the holder's qualifications,to do business.Holder must comply with any governmental Of nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec tia-276. MIAWFor more information,visit www.;niam'tdade.gov ollector �ED MIAMI-DADE COUNTY DEPARTMENT OF PERMITTING, ENVIRONMENT AND REGULATORY AFFAIRS 11805 SW 26TH ST. SUITE 207 MIAMI FL, 33175 (786) 315-2880 I STATE CONTRACTOR'S CERTIFICATE OF VOLUNTARY REGISTRATION WITH MIAMI-DADE COUNTY ISSUED OCTOBER 09, 2012 THIS IS TO CERTIFY THAT SOUTHERN SEPTIC AND LIFT STATION CORPI CONTRACTOR CERTIFICATE NO. : SEP0121809 TRADE: PLUMBING REGISTRATION EXPIRATION DATE: 09/30/2016 f HAVING MET THE REGISTRATION REQUIREMENTS OF MIAMI-DADE COUNTY, IS REGISTERED AS A STATE CONTRACTOR IN THE FOLLOWING CATEGORY(S) : 0006 SEPTIC TANK INST WITH ALL WORK TO BE DONE UNDER THE SUPERVISION, DIRECTION AND CONTROL OF QUALIFYING AGENT RODRIGUEZ ROBERTO S.S.N. -4106 ALTERATION, REPRODUCTION OR TRANSFER OF THIS CERTIFICATE IS PROHIBITED. JULIANA H. SALAS, P.E. SECRETARY, CONSTRUCTION TRADES QUALIFYING BOARD SOUTHERN SEPTIC AND LIFT STATION CORP 30 SW 57 CT MIAMI FL 33144 r CERTIFICATE OF LIABILITY INSURANCE 2;30„5°'�"Y' 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($),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 WANED,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 JULIO JIMENEZ Jimenez&Co.,Inc. PHONE 305 264-9900- FAX 305 264-5382 ( ) A/C,No): ( ) _ 8000 Coral WayE-MAIL ADDRESS: Miami,FL 33155 PRODUCOMER CUSTER ID#: - Phone (635)264-9900- _ - Fax (305)264-5382 INSURERS)AFFORDING COVERAGE — NAIC# -_ INSURED INSURER A: ARCH SPECIALTY INSURANCE COMPANY 21199 SOUTHERN SEPTIC AND LIFT STATION CORP-SR0021421 INSURER B: MERCURY INDEMNITY COMPANY OF AMERIC 11201 1421 SW 153 PATH INSURER C: FLORIDA CITRUS BUSINESS&INDUSTRIES F 31259 Miami,FL 33194 INSURER D: 305-598-8266 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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. _ _ IN_ W_VD _ POLICY NUMBER jMM/DDIYYYY MMIDD/YYYY)� _ ___ iNSR Do SUB POLICY EFF POLICY EXP DAMAGE TO RENTED LTR TYPE OF INSURANCE EACH OCCURRENCE LIMITS 1,000,000.00_ GENERAL LIABILITY � COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,000.00 ❑ ❑ CLAIMS-MADE Q OCCUR AGL0026163-00 MED EXP(Any one person) $ 10,000.00_ A Y y 05/22/2015 05/22/2016 ❑ ____ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGGy$ 1,000,000.00 LJ POLICY ❑ PRO- ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 500,000.00 ANY AUTO (Ea accident) BODILY INJURY(Per person) $ —~ ❑ ALL OWNED AUTOS BA090000001042 BODILY INJURY(Per accident $ B i SCHEDULED AUTOS Y Y 08/02/2015 08/02/2016 PROPERTY DAMAGE ❑ HIRED AUTOS (Per accident) $ - ❑ NON-OWNED AUTOS ❑ $ — $ ❑ UMBRELLALIAB ❑ OCCUR EACH OCCURRENCE -_ $ ❑ EXCESS LIAR _F-1CLAIMS-MADEJ AGGREGATE $ ❑ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- Y/N' O T Y STA TER C ANY OFFICER/MEMBER EXCLUDED? N/A 106-50116 E.L.EACH ACCIDENT $ 500,000 00 A E LIABILITY TI II _ _ Y 107/17/2015 07/17/20161 — - -- -- - - (Mandatory In NH) - EL.DISEASE-EA EMPLOYEE$ 500,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT'1 $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) "Septic Tank System Installation,Service and Repairs” CERTIFICATE HOLDER CANCELLATION SHOU01ON F E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EATE THEREOF,NOTICE WILL BE DELIVERED IN City of Miami Shores ACCOWI H THE POLICY PROVISIONS. 10050 NE 2 Ave Miami Shores Village FL 33135... AUTHO I IPIENTATIVE i 19t8-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09)CIF he 4ORD name and logo are registered marks of ACORD c UNANIMOUS WRITTEN CONSENT ACTION OF THE MEMBERS OIC 11111 HOLDINGS LLC IPI HOLDINGS, LLC (the "Company'), a Delaware limited liahihty company. filed its Certificate of Formation on July 180'. -1014. Pursuant to the authority contained in the Delaware Limited Liability Company Act Ithe "Act').the members(the"Members i of the Company do hereby take the following actionsand adopt the following,resolutions by written consent in lieu M"a meeting: CERTIFICATE OF FORMATION RF.SOLVED,that the Certificate of Formation of the Company that%vas filed with the Secretary of State of the State of Dclawure on July Ie.2014.true and comet copy of which is attached hereto as Exhibit A,is hereby approved by the Members and that said Certificate of Formation bre:filed by theManagers of the Company among the permanent records ol'the Company, MANAGERS RESOLVED, that Stewart James Cameron and Nicholaa% Darrell are named as the Managers of the. Company, :and they hereby accept their :appointments to such office and hereby agree to serve as Managers of the Company until their successors are duly elected and qualified or until the earlier of their death,resignation,retirement,disqualification or removal front office. FISCAL YEAR RESOLVED.that the Company adopts a fiscal year ending December 31 for financial and tax reporting purposes. BANKING AUTHORIZATION RESOLVED,that the Managers are herchy authorized and empowered for and on behalf of the Company to designate in writing such banks, trust companies or other financial institutions as depositories for the funds of the Company to be carried in an account or accounts as styled by the Manager in their discretion; and such depository is authorized and requested to accept, horror and pay. without further inquiry and until written notice of the: revocation of such authority granted is received by it, all checks. drafts and other orders for the payment or withdrawal of such funds of the Company, including any instruments payable or endorsed to the order of the Company by 11w Managers.and he it farther RESOLVED,that Manager are hereby authorized to execute and certify any resolutions required by any depository, and such resolutions will he included in this Consent as if duly considered and adopted by said Managers. ORGANIZATIONAL EXPENSES RESOLVED, that the Managers are hereby authorized to pay all fees and expenses related to the organization of the Company. QUALIFICATION IN FOREIGN,JURISDICTIONS RESOLVED.that for the purpose of authorizing the Company to transact business in any state.territory or dependency of the United States or any foreign country in which it is necessary or expedient fair tlae Company to transact business,the Manager-,are hereby authorized to appoint and substitute all necemar! agents or attorneys for service of process.to designate and change the location of all necessary Statutory offices and it)execute,acknowledge.deliver and rile all necessary certificates.reports,powers of attorney and other instruments as may he required by the laws of such state,territory.dependency or country to authorize the Company to transact business therein and. whenever it is expedient for the Company to cease transacting business therein and to withdraw themfrom. to revoke any appointnwnt or agent or attorney for Service of process.and to execute. acknowledge. deliver and file such certificates. reports, revocation of appointment or surrender of authority that may be necessary to terminate the authority of the Company to transact business in any such state,territory.dependency or country. IRS FILINGS RESOLVED, that the Managers of the Company. are authorized in such capacity. for as long as is necessary. to execute on behalf of the Company the Application for the Federal identification Number i form SS4)with the Internal Revenue Service. FURTHER ACTION RESOLVED, that the Mutta-M are hereby authorized to execute, acknowledge. deliver and rifle such other documents and to take such further actions as it may dccnt necessary or appropriate to effect the intent and accomplish the purposes of the preceding resolutions. r-Action is signed this•'�Edttyof-2n -2014.tuix-effecdvcmTot'luiTtt"— 1.4 MEMBER(S)SIGNATURES: IPI A E IANAGEMENT LLP. By: . Name: Title: HAWAr, w r. PqOnrartL, IPI A �ENIENT.i\ By: Stewart lames Cameron, President EXHIBIT A CERTIFICATE OF FORMATION 3 IPI Holdings,LLC 1441 Brickell Ave#1400 Miami,FL 33131 Statement of Authority of the Managers of IPI Holdings,LLC On my oath and under penalty of perjury, I swear that Stewart Cameron and Nicholas Farrell are the duly appointed Managers of IPI Holdings, LLC,a Delaware Limited Liability Company. I certify that we have not been removed as Managers and have the authority to act for and bind IPI Holdings,LLC in business transactions for which this affidavit is given as affirmation of their authority e Signature Name Sworn and subscribed before me the undersigned authority,on fill, Notary Public LI Pubit Stag d porta M Fa" w n"ion EE 887497 s 0172?l2017