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RC-16-1258 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-269232 Permit Number: RC-5-16-1258 Scheduled Inspection Date: October 27,2016 Permit Type: Residential Construction Inspector: Mesa, Michel Inspection Type' Owner: JIDY,ALFREDO Work Classification: Alteration Job Address:8745 NE 4 Avenue Road li::�v\A L Miami Shores,FL Phone Number Parcel Number 1132060460880 Project: <NONE> Contractor: FORTIS CONSTRUCTION GROUP LLC Phone: (786)252-3770 Building Department Comments EXISTING KITCHEN TO BE LEGALIZED tnfractlo Passed Comments INSPECTOR COMMENTS False TO REPLACE PERMIT#RC15-1834 08-01-2016 According to the letter provided by Alvaro Tellez, P.E dated June 23, 2016 the walls built for the kitchen renovation do not comply with the requirements of the code nor with Diggs Lac The contractor was advise that he needs- Nopeoc,ontments finishes, including the drywall e cpT@e was also th EINSPECTION FOR INSP-258568. pass all Miami Shores Village its `ons for the Fi�j permit will have to i required. Correction Needed Re-Inspection Fee No Additional inspections can be scheduled until re-inspection fee is paid October 26,2016 Page 17 of 29 For Inspections please call: (305)762-4949 12� 00"'f"- - Miami Shores Village a P It?>Ef 7"jEpe RsSldEbfltt CE3 truction, 10050 N.E.2nd Avenue NE . sWtOass tersttOtt Miami Shores,FL 33138-0000 r dL , 115: P ; Phone: (305)795-2204 . �'ioi iuP ee:5/2312011, Expiration: 11/19/2016 Project Address Parcel Number Applicant 8745 NE 4 Avenue Road 1132060460880 Miami Shores, FL Block: Lot: ALFREDO JIDY Owner Information Address Phone Cell ALFREDO JIDY 1312 15 Terrace MIAMI BEACH FL 33139- 1312 15 Terrace MIAMI BEACH FL 33139- Contractor(s) Phone Cell Phone Valuation: $ 2,500.00 FORTIS CONSTRUCTION GROUP LLC (786)226-4264 Total Sq Feet: 0 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Window Door Attachment Type of Construction:EXISTING KITCHEN TO BE LEGALI Occupancy: Framing Stories: , Exterior: Insulation Front Setback: Rear Setback: Drywall Screw Left Setback: Right Setback: Window and Door Buck Bedrooms: Bathrooms: Fill Cells Columns Plans Submitted:Yes Certificate Status: Review Electrical Certificate Date: Additional Info: Review Building Review Planning Bond Return: Classification:Residential Review Structural Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Mechanical CCF $1.80 Review Plumbing DBPR Fee $2.00 Invoice# RC-5-16-59724 DCA Fee $2.00 05/10/2016 Credit Card $50.00 $67.80 Education Surcharge $0.60 05/23/2016 Credit Card $67.80 $0.00 Permit Fee $100.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $117.80 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 foregoin information is accurate and that all work will be done in compliance with all applicable laws regulating construction and ning. uth rmor , uthorize thbove- ed contractor to do the work stated. May 23, 2016 W7u'thoP6ed Signature:Owner / Applicant / Contractor / Agent ate Building Department Copy May 23,2016 1 * � � ►� Miami Shores VillagecE Building Department 7BY: Y ° 2x16 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 20 BUILDING Master Permit No. (�,= PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION (RENEWAL ❑PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP //�/ CONNTTRAeCTOR DRAWINGS JOB ADDRESS: /Wy(f ` 1d 7 City: Miami Shores County: Miami Dade Zi : � Folio/Parcel#: 113-., Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): /�-L��D ��57� Phone#: Address: City: /—I/A>4t u(— ?<f State• �- Zip: 3� Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name :y0fZ775 6-ZOUP CGC- Phone#: Address: <f7, -�ZS l�� City: z State: Zip: Qualifier Name: 49W,! ti , /'4 0°Z Phone#: State Certification or Registration#: Z 3 41 Z Z Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: --y Value of Work for this Permit:$ �f Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: ) 5 it h-,E5' Specify color of color thru tile: Submittal Fee$ O ` Permit Fee$ " CCF Zl CO/CC$ Scanning Fee$ Radon Fee$ C*�'3 DBPR$ OLl Notary$ � Or Technology Fee$ Training/Education Fee$ 0 r0c) Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (RevisedO2/24/2014) 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. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of �` L ,20 by day of /�-/ ,20 �� by who is personally known toCis rsonally known o me or who has produced J 3b ao�«FBF/�!D 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: Sig �L � �PQ�e \�1a '�°' Sign: -cc-1 \ Q 'L1• Pgg Print: o�\�. a Print: G 000- \a� \e Q�aC�oo P Seal: „�„�,,,, ° '00 r� o Seal: ,,.,�Pue"�•. %I)WO ubgio0 c+wusuC%, �O°t�`r�o°0 '�°P ��O': Commis ExP�<es�allo�acY a`' r000 ona� ##############•8#iK##'ilk ###### ### ### ################################�k�########################### APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) OR .5"Q o Miami Shores Village Building Department I� Rr0 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. / — ) Owner's Name (Fee Simple Title Holder)- �� `�� Phone#: Owner's Address: /':3/Z /s 71-e--z_ City: State : `r�'L Zip Code: 33,13! Job Address (Of where work is being done): 4�- City. Miami Shores_ State:—Florida Zip Code: Contractor's Company Name: 4=��2 c Gt! �� ' / i�7k�S Phone#: 'DJ J G'I� - Z ZD Address: _q 9 -2-0 � c City: 1-7 7/ 14 /---/( State: -;P:::7'L Zip Code: Qualifier's Name: �//� c14 �� Lic. Number�� Architect! Engineer of Record Name: Phone# Address: City: State: Zip Code: Describe Work - I hereby certify that the work has been abandoned and/or the contractorlarchitect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless of all legal ji vement. Signature 's Signature Owner or Agent Contractor or Architect The foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me _ this 217 day of /�Y4 20/6,by ' this /0 day of o 20/6 by�'� Who is personally known to me or who has producedo is persona known to me or who has produced 7L 7� � as indentification. as indentification. Notary Public: Notary Public- Sig: Seal: S ussV AieioN Ieuoin y8nojgi popuog JULIAN A CARDONA .a,+ .. 6lOZ'tZ uep se�ldx3•wwop AW Notary Public-State of Florida 016161 JA#uolsslwwoO =. ►." Commission#FF 191910 epliou io eivis-ollQnd ARION t..4, • =c ' = My Comm. Expires Jan 21,2019 @i vN0vo V NVnnf �ej'd ^i,tinnal Notary Assn • Bonded'h.' Y ®mss G �xc.193z d ..a, w®®®t" Miami 0hores Village Building ��R1l�A 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ZCOPY OF QUALIFIER'S STATE LICENCES B. r// COPY OF LOCAL BUSINESS TAX RECEIPT C. V COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. meevem®n®®®®®®m®_®c®®�®-■®®®®®®■®ammsr®®®®■o�■®®aremnno©ooanoonn®000anemoon©o®an®anon®n®nnnnfle BUSINESS NAME: rcla-7-7 s BUSINESS ADDRESS: 92 &U l /B W CITY STATE ZIP 95/-;�Z BUSINESS PHONE: ( FAX NUMBER /( 96P) 222 o?2j CELL PHONE(M� QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: °��'`� 1J Z 3-11 Z z o� STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 2 � CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 " ate 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MORALES,AGUSTIN E FORTIS CONSTRUCTION GROUP LLC 8725 NW 18TH TERRACE STE 308 DORAL FL 33172 Congratulations! With this license you become one of the nearly -- '=2 one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range fla. STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMUEN -OF�BUSINESS AND and they keep Florida's economy strong. " �, PROF S[O,NAWIqJLATION Every day we work to improve the way we do business in order to CGC1523422SUEDfl7/16/2015 serve you better. For information about our services,please log onto4� -j -4, www.myfloridalicense.com. There you can find more information CERTIFIEDG I�CNT,RACT r about our divisions and the regulations that impact you,subscribe t v " ' to department newsletters and learn more about the Department's t MORALES,ACS }�M1LI {+ 5" FORTIS CONST�C�I�SN GRO1P L initiatives. F € y� .t Our mission at the Department is: License Efficiently,Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under.Yhe Rrovisions of Ch.488 FS. and congratulations on your new license! exp� bn��ea, quc s�,2o1s L1507160000241 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION E. -- - CONSTRUCTIO.N,INDUSTRY LICENSING BOARD }. CGC1523422 The-GENERAL CONTRACTOR ' F Named below IS CERTIFIED_-_ Undhe provisions of Chapter-489 F er tS ,_ _ Expiration date AUG 31;2016:.. p IyIORALES;AGUSTIN E_ - ` ti � a FORTIS CONSTRUCTION G1OUF _ 8 �5 NW 18TH TERRACI; g a DOFAL ® MCI=n-_ n711R19n1F nISPLAYAS REQUIRED BY LAW SEQ# L1507160000241 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY LBT 7188129 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES FORTIS CONSTRUCTION RENEWAL SEPTEMBER 3O, 2016 GROUP LLC 7469200 8725 NW 18TH TER SUITE 308 Must be displayed at place of business DORAL, FL 33172 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS FORTIS CONSTRUCTION GROUP 196 GENERAL BUILDING BYTAX CONT LLECTOR LLC CONTRACTOR 45.00 07/16/2015 r/r�Arl ISTIN Mr1RA1 FS MrP Worker(s) 1 CGC1523422 0224-15-005338 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is nota license, permit,ora certification of the holders qualifications,to do business.Holder must comply with any governmental or 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 8a-276. hIl/utls For more information,visit www.miamidade.acy/texcollector PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - IMPORTANT STATE OF FLORIDA Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation DEPARTMENT OF FINANCIAL SERVICES who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or DIVISION OF WORKERS'COMPENSATION �„ � F compensation under this chapter. CONSTRUCTION INDUSTRY EXEMPTION O CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L Pursuant to Chapter 440.05(12),F.S.,Certificates of election to WORKERS'COMPENSATION LAW D be exempt...apply only within the scope of the business or trade EFFECTIVE DATE: 720/2015 EXPIRATION DATE: 71192017 listed On the notice of election to be exempt. PERSON: MORALES AGUSTIN E H Pursuant to Chapter 440.05(13),F.S.,Notices of election to be FEIN: 473936795 E exempt and certificates of election to be exempt shall be BUSINESS NAME AND ADDRESS: R subject to revocation if,at any time after the filing of the notice FORTIS CONSTRUCTION GROUP LLC E or the Issuance of the certificate,the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke 8725 NIN 18 TERRACE UNIT 308 a certificate at any time for failure of the person named on the DORAL FL 33172 certificate to meet the requirements of this section. SCOPES OF BUSINESS OR TRA LICENSED GENERAL CONTRACTOR — DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 Date: May 05, 2015 State of Florida County of Miami Before me this day personally appeared Agustin Morales who,being duly sworn deposes and says: That he or she will be the only person working on the project located at 8745 SW 4 Ave Miami Shores, FL 33138 Sworn to(or affirmed)and subscribed before me this 05 day of May. 2016 by Agustin Morales Personally Know m OR produced identification Type of Identification Produce JULIAN A CARDONA ., Not Xpublic-State of Florida &4n-#FF 191910 P Fait In Bonded through National Notary Assn. Notary rORT11% OONTRUOTIOn GROW I,IO 8725 nW 18 TER Suite $08 0,P)ran1®f1®ridn 33172 786.S39.9008 Direct 786.2S2.3770 OFFice 1.888.222.0729 Foca ,... „,„ Miami shores Village Building Department �ORIUA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this 05— day of ,20_/ By who is personally known to me or has produced as identification. Notary: JV�'�PN• S�a�e X919, b�9 SEAL: - • ►o_ aed .......... f ZSR epc DATE(MUDMV" CERTIFICATE OF LIABILITY INSURANCE 05/12=6 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 ceeAftcate holder Is an ADDITIONAL INSURED,the poficyfles)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an andorsement.A statement on thiseerlificate,does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CT MARTAALONSO norida Bankers Insurance P&LE ..W. . (3015MXitA93 Fax o {2105)262-0679 7278 SW 8 Steel mana@ooridabankersinsurance.com Miami,FL 33144 J N"9VERAtNAIcA - Phone (305W66-6493 FaX 30 262-0879 IMURERA: UNITED SPECIALTY INSURANCE CO- .............. ...... INSURED wamit a: EVASTON INSURANCE CO. FORTIS CONSTRUCTION GROUP LLC. INSWMR C., 8725 NW IS Terr #308 INSURER D, —--------.—............... INSURER E: DORAL Fl- 33172 INSURER F: COVERAGES CERTIFICATE NUMBER:- REVISION NU PHIS 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 POLtC4ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AMfUl, POLICY EXP INSR TYPE OF INSURANCE 'Wj POLICYNUMSER I Man 1111MID-0111"IMM LIMITS 4" - COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ i'600,00600 ❑ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Me occurrence) $ 100,00OZO MED EXP(Any one Mew) $ 5,000.00 rA N N B#1501660 110121/2015 IW1/2016 PERSONAL&ADV INJURY $ 1,000,000.00 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000.00 OPOLICY W JPERCOT- 0 LOG PRODUCTS-Compiop AGG $ 2,0W.W0.00 0 OTHER $ AUTOMOINL9 LIABILITY MUDS114GLELIMIT ❑ $ ANY AUTO BODILY INJURY(Per Person) Fj ALL OWNED ❑ SCDU HELED —66DILY INJURY(Peramidentj $ B ❑ AUTOS L-J AUTOS OPaR DAMAGE $ . 1Z HIRED AUTOS E] AMUTNO-05"Fo fpFW M) El UMBRELLA LIAS 0 OCCUREACH OCCURRENCE $ 1,000,000.00 ...........I -.— B p ExcEss Lim OCI-AIMS-MADE N N B#1501660 10/21/20iS 10/21/2D16 AGGREGATE S 1,000,000-00 0DED 0 RETENTION$ A INORKERS COMPENSATION SPERC AND EMPLOYERS'LIABILITY YIN A LITE ANY PROPRIETO"ARTNERIEXECUTIWF-� E.L.EACH ACCIDENT OFFICERNEMBER EXCLUDED? MIA (Mandidwy In NH) E.L.DISEASE-EA EMPLOYE H yes.deacdtte under E.L DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below ............... DEW . LOCATIONS (Attach ACORD W,Add0mi flestaft Sche"e.9 amarespace Is required) 40PTM OF OPERAVONS I LOCA CGC1523422 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE VILLAGE MIAMI SHORES THE EXPIRATION VA DATE THEREOF,NOTICE WILL BE DELIVERED IN OF ACCORDANCE VMW THE POLICY PROVISIONS. BUILDING DEPARMENT 10050 NE 2 AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES,FL 33138 1988-2014 ACORD CORPORATION. All rights resmed. A25(2014101)OF The ACORD name and logo are registered marks of ACORD CORD ...........-