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CC-16-652
1�1 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-272944 Permit Number: CC-3-16-652 Inspection Date: December 13, 2016 Permit Type: Commercial Construction Inspector: Naranjo, Ismael Inspection Type: Final Owner: , BARRY UNIVERSITY Work Classification: Alteration Job Address: 11300 NE 2 Avenue Landon Student Miami Shores, FL 33138-0000 Phone Number Parcel Number 1121360010160-32 Project: <NONE> Contractor: JWR CONSTRUCTION SERVICES INC Phone: (954)480-2800 Building Department Comments DEMOLITION - BUCKY'S COVE ADDITION OF INTERIOR Infractio Passed Comments BAR TO THE INTO EXISTING. INSPECTOR COMMENTS False TO REPLACE PERMIT#CC14-1465 Inspector Comments Passed El Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 December 13,2016 Page 1 of 1 Miami Shores Village ` s 10050 N.E.2nd Avenue NE 0 Miami Shores,FL 33138 0000PTZ h � Phone: (305)795-2204 v � � �� {� 116 Expiration: O2t07J017 Project Address Parcel Number Applicant 11300 NE 2 Avenue Number: Landon Studer 1121360010160-32 BARRY UNIVERSITY INC Miami Shores, FL 33138-0000 Block: Lot: Owner Information Address Phone Cell BARRY UNIVERSITY INC 11300 NE 2 Avenue MIAMI SHORES FL 33161-6628 11300 NE 2 Avenue MIAMI SHORES FL 33161-6628 Contractor(s) Phone Cell Phone Valuation: $ 200,000.00 JWR CONSTRUCTION SERVICES INC (954)480-2800 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:DEMOLITION-BUCKY'S COVE AD Occupancy Load: Tie Beam Stories: Exterior: Slab Front Setback: Rear Setback: Termite Letter Left Setback: Right Setback: Framing Plans Submitted:Yes Certification Status: Store Front Attachment CertInsulation cation Date: Additional Info: Drywall Screw Bond Return: Classification:Commercial Fill Cells Columns Scannin :13 Window and Door Buck Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Celiing Grid CCF $120.00 Review Planning DBPR Fee $90.00 Invoice# CC-3-16-58992 Review Electrical DCA Fee $90.00 03/11/2016 Check*2002207 $78.00 $6,461.00 Review Building Education Surcharge $40.00 08/11/2016 Check*2000042,1 $6,461.00 $0.00 Review Plumbing Permit Fee $6,000.00 Review Structural Scanning Fee $39.00 Review Mechanical Technology Fee $160.00 Total: $6,539.00 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 ELECTRI L,PLU I ,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFF A IT: I ify t t all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction a z ning. F ore,I authorize the above-named contractor to do the work stated. August 11, 2016 Authorize Sig e: er / Applicant / Contractor / Agent Date Building Department Copy August 11,2016 1 Miami Shores Village 713YI: � T�'T Building Department 12a�� 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 I FBC 20 1� BUILDING Master Permit Noml G--G PERMIT APPLICATION Sub Permit No. OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION SHOP CONTRACTORDRAWINGS JOB ADDRESS: 11300 NE 2 Avenue &4 - L--5 V rtrt U<yt l0Vl`--- City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1121360010160-02 Is the Building Historically Designated:Yes NO x Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Barry University, Inc. Phone#: Address: 11300 NE 2 Avenue City: Miami Shores State: FL Zip: 33161 Tenant/Lessee Name: Phone#: Email: C15Y 4-401-f CONTRACTOR:Company Name: JWR Construction Services Phone#: 9544802800 Address: 1311 Newport Center Drive West City: Deerfield Beach State: FL Zip: 33442 Qualifier Name: Jerry DuBois Phone#: 9544802800 State Certification or Registration M CGC034031 Certificate of Competency M DESIGNER:Architect/Engineer: NA Phone#: Address: City: State: Zip: Value of Work for this Permit:$1000.00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Reopen expired permit to close it eo � q — N G5 Specify color of color thru tile: Submittal Fee$ GZ� Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) i 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. i 2 Signature Q6Signature OWNER or AGENT NTRACTOR The foregoing instrument was acknowledged before me this The f egoing instr ent was acknowledged before me this day of 6-d1 U,tAV ,20 11 .by of -f'b(444 l 20 D (tO ,by U � who is personally known to "" c(S who is ersonall S S,►r� L�S N Y P,� Me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY UBLIC: Sign: Sign: Pr t. Print: OVI•-�5 NOW WON W FW" S Jelft J Yeo Seal: LAURA P.TMPSON My Comm bn PR 18"li CorrplassiWt#FF905054 11N?J2014 ' My Commission Exfires 2019 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Act'v® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/28/2015 IS 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 CONTACT NAME: Bateman Gordon and Sands PHONE Extl; ac No. -941-2006 3050 North Federal Hwy E.MA L Lighthouse Point FL 33064 ADDRESS: h INSURER(S) AFFORDING COVERAGE NAIC# INSURER A 8 INSURED JWRCO INSURER B:Ame•sure Mutual Insurance JWR Construction Services, Inc. INSURER C: tc ester Surplus Lines Insurance 10172 1311 W Newport Center Drive,Ste C INSURER D: Deerfield Beach FL 33442 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:30021504 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 TYPE OF INSURANCEADDLISUOR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICYNUMBER MM/DD MM/DD A GENERAL LIABILITY Y Y GL20089651501 3/17/2015 3/17/2016 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $5,000 X CG0001-XCU PERSONAL&ADV INJURY $1,000,000 X CGo001-Contractu GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY Y Y CA13865011301 3/17/2015 3/17/2016 Ea accident $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ $ B X UMBRELLA LIAB X OCCUR Y CU13865031302 3/17/2015 3/17/2016 EACH OCCURRENCE $5,000,000 EXCESS LIAR CLAIMS-MADE I AGGREGATE $5,000,000 DED X I RETENTION$0 I $ A WORKERS COMPENSATION Y WC132928817 1/1/2016 1/1/2017 X WC STATU-R S 0ETH- R AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 A Rented/Leased Equipment CPP13865021301 3/17/2015 3/17/2016 Limit$500,000 Deductible$1,000 C Pollution Liability G27462376002 6/4/2015 6/4/2016 Limit$1,000,000 Deductible$10,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space Is required) General Liability: Blanket Additional Insured including On-going&Completed Operations and Blanket Primary and Non-Contributory,as required by written contract,per FORM CG7048 0913; Blanket Waiver of Subrogation,as required by written contract,per FORM CG7049 1109.Automobile Liability: Blanket Additional Insured and Blanket Waiver of Subrogation,as required by written contract,per FORM CA7171 0508.Umbrella Liability: Blanket Additional Insured and Blanket Waiver of Subrogation,as required by written contract,per FORM CU7467 1107.Workers Compensation: Blanket Waiver of Subrogation,as required by written contract,per FORM WC000313 0484.ALL COVERAGES SUBJECT TO THE POLICY TERMS, CONDITIONS AND EXCLUSIONS JWR Construction is General Contractor CG#CGCO34031 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE BLDG DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • . , C?� ! `� - I ��` Romer,Sheli From: Mike Metzger<Mike@JWRConstruction.cc> Sent: Wednesday, July 20, 2016 3:58 PM To: Romer, Sheli Subject: FW: CC16-652 Attachments: doc10488220160720160332.pdf Sheli, I found the permit card and brought down to Miami Shores Building to show the finals had been signed off but they still want the fees due to the as builts taking so long to be done.See below and attached. Mike From:Arlenis Silvera [mailto:SilveraA@miamishoresvillage.com] Sent: Monday,July 18,2016 3:08 PM To: Mike Metzger<Mike@JWRConstruction.cc> Subject:CC16-652 Hi Mike, As per our phone conversation,the permit CC16-652 must be renewed for us to complete the pending reviews. I The total amount due for the permit renewal is$7174.00. Building permit:$6461.00 Electrical permit:$393.00 Plumbing permit:$320.00 Thank you, Arlenis Silvera Permit Clerk Supervisor Miami Shores Village 10050 NE 2 AVE Miami Shores, FI 33138 305-795-2204 www.miamishoresvilla eg com ACORQ® CERTIFICATE OF LIABILITY INSURANCE 72MM/DATE(MM/DD/YYYI) I� 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 CONTACT Bateman Gordon and Sands PHO E FAX 3050 North Federal Hwy E-MAIL - (A/C.No Lighthouse Point FL 33064 ADDRESS: INSURERS AFFORDING COVERAGE NAIC p INSURER A-Amerosure Insurance Co. 19488 INSURED JWRCO INSURER B .Amerisure Mutual Insurance Co. 23396 JWR Construction Services, Inc. INSURER C-Westchester Surplus Lines Insurance 101 2 ! 1311 W Newport Center Drive,Ste C INSURER D: Deerfield Beach FL 33442 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:1736516607 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. j INSR ADULSUBRPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE I POLICY NUMBER M D M D LIMITS A GENERAL LIABILITY Y Y GL20089651601 3/17/2016 3/17/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENT X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $100,000 CLAIMS-MADE 15F]OCCUR MED EXP(Any oneperson) $5,000 X $0 Ded-BI/PD PERSONAL&ADV INJURY $1,000,000 X CG0001-XCU GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO- LOC $ A AUTOMOBILE LIABILITY Y Y CA13865011401 3/17/2016 3/17/2017Ea accident) $1,000,000 X ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED ti Per accident)AUTOS AUTOS BODILY INJURY( ) $ X HIRED AUTOS Ix NON-OWNED PROPERTYDAMAGE $ AUTOS Per acc dent B X UMBRELLA UAB XOCCUR Y Y CU13865031402 3/17/2016 3/17/2017 EACH OCCURRENCE $5,000,000 4 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X I RErENTION$$0 $ A WORKERS COMPENSATION y WC132928817 1/1/2016 1/1/2017 X I WCSTATU- 0TH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If as,describe under j DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT 1$1,000,000 A Rented/Leased Equipment CPPI3865021401 3/17/2016 3/17/2017 Limit:$500,000 Deductible$1,000 C Pollution Liability G27462376003 6/4/2016 6/4/2017 Limit:$1,000,000 Deductible$10,000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) General Liability:Blanket Additional Insured including On-going&Completed Operations and Blanket Primary and Non-Contributory,as required by written contract,per CG7048 0913;Blanket Waiver of Subrogation,as required by written contract,per CG7049 1109:Blanket 30 Day Notice of Cancellation as required by written contract,perform IL7045 0507 Automobile LiabiliBlanket Additional Insured and Blanket Waiver of Subrogation,as required by written contract,per CA7171 0508 Umbrella Liability:�lanket Additional Insured,as required by written contract per CU7467 1107;Umbrella/Excess Liability policy extends coverage to General Liability(except General Liability per project aggregate),Automobile Liability and Workers Compensation/Employers See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGEO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: JWRCO LOC#: A ADDITIONAL REMARKS SCHEDULE Pagel of 1 AGENCY NAMED INSURED Bateman Gordon and Sands JWR Construction Services,Inc. POLICY NUMBER 1311 W Newport Center Drive,Ste C Deerfield Beach FL 33442 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Liability. Workers Compensation: Blanket Waiver of Subrogation,as required by written contract,per WC000313 0484 ALL COVERAGES SUBJECT TO THE POLICY TERMS,CONDITIONS AND EXCLUSIONS License number:CGC034031 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Y =As WMI, k:" .... ftS- Q.... ... �3 . ..3..w.> auil............. ..... { u' BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895--954-831-4000 44 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#:� coNTRACTOR togs Business Name:`� W R CONSTRUCTION SERVICES IN Burliness Ty PS:CONTR) Owner Name:JERRY W DUBOIS Business Opened:04/01/19 8 5 Business Location:1311 NEWPORT CENTER DR W State/County/Cort/Reg:CGC034031 DEERFIELD BEACH Exemption Code: Business Phone:954-480-2800 Rooms some employeas Machines Professionals 1 For Vending Business Only Number of Machines, Vending Type: Tax amount Transfer Fee ! Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 1 0.00 0.00 0.00 0.00 27.00 0 �d E, THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning WHEN VALIDATEDand zoning requirements.This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. 7i 4 Mailing Address: JERRY W DUBOIS Receipt #ICP-14-00015782 1311 NEWPORT CENTER AR WEST Paid 07/17/2015 27.00 DEERFIELD BEACH, FL 33442 3 . �f s _ 2015 - 2016 t ,4,�o p� DATE(MWOONYYY) CERTIFICATE OF LIABILITY INSURANCE 7282016 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 CONTACT NAME: Bateman Gordon and Sands PHONE FAX 954-941-2006 3050 North Federal HwyE-MAIL - - ac No Lighthouse Point FL 33064 ADDR INSURERS AFFORDING COVERAGE NAIC# INSURER A-Ame isure Insurance Co. 19488 INSURED JWRCO INSURER B-Am risure Mutual Insurance Co. 23396 JWR Construction Services, Inc. INSURER C.WeStCheSter Surplus Lines Insurance 10172 1311 W Newport Center Drive,Ste C INSURER D: Deerfield Beach FL 33442 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1736516607 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INS POLICY NUMBER M D M D A GENERAL LIABILITY Y Y 13120089651601 3/17/2016 3/17/2017 EACH OCCURRENCE $1,000,000 PXCG1000I MMERCIAL GENERAL LIABILITY PREM SES Ea occurrence) $100,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $5,000 Ded-BI/PD PERSONAL&ADV INJURY $1,000,000 -XCU GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY x PRO LOC $ A AUTOMOBILE LIABILITY Y Y CAI 3865011401 3/17/2016 3/17/2017 C=IN0 SINGLE LIMIT Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS x HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ B X UMBRELLA LIAR X OCCUR Y Y CU13865031402 3/17/2016 3/17/2017 EACH OCCURRENCE $5,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE $5,000,000 DED I x I RETENTION $0 $ A WORKERS COMPENSATION y WC132928817 1/1/2016 1/1/2017 X TORY WC LIMIT ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 A Rented/Leased Equipment CPP13865021401 3/17/2016 3/17/2017 Limit:$500,000 Deductible$1,000 Pollution Liability G27462376003 6/4/2016 6/4/2017 Limit:$1,000,000 Deductible$10,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) General Liability:Blanket Additional Insured including On-going&Completed Operations and Blanket Primary and Non-Contributory,as required by written contract, per CG7048 0913;Blanket Waiver of Subrogation,as required by written contract,per CG7049 1109:Blanket 30 Day Notice of Cancellation as required by written contract,per form IL7045 0507 Automobile Liability: Blanket Additional Insured and Blanket Waiver of Subrogation,as required by written contract,per CA7171 0508 Umbrella Liability:Blanket Additional Insured,as required by written contract per CU7467 1107; Umbrella/Excess Liability policy extends coverage to General Liability(except General Liability per project aggregate),Automobile Liability and Workers Compensation/Employers See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGEO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: JWRCO LOC#: AC`ORL7� ADDITIONAL REMARKS SCHEDULE Page, of 1 AGENCY NAMED INSURED Bateman Gordon and Sands JWR Construction Services, Inc. POLICY NUMBER 1311 W Newport Center Drive,Ste C Deerfield Beach FL 33442 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Liability. Workers Compensation:Blanket Waiver of Subrogation,as required by written contract,per WC000313 0484 ALL COVERAGES SUBJECT TO THE POLICY TERMS,CONDITIONS AND EXCLUSIONS License number:CGC034031 ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF FLORIDA cc_1(0 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 GASCH, MARKALLEN GO PLUMBING INC 7927 NW 38TH COURT DAVIE FL 33024 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and9 Professional Regulation. Our professionals and businesses range ' STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque DEPARTMENT OF BUSINESS AND restaurants,and they keep Florida's economy strong. . PROFESSIONAL REGULATION Every day we work to improve the way we do business in order CFC1428760 ISSUED: 07/11/2016 to serve you better. For information about our services,please to onto www.myfloridalicense.com. There you can find more CERTIFIED PLUMBING CONTRACTOR information about our divisions and the regulations that Impact GASCH,MARK ALLEN you,subscribe to department newsletters and learn more about GO PLUMBING INC the Departments initiatives. 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 the provisions of Ch.489 FS. and congratulations on your new license! Expiration date:AUG 31,2018 L1607110000640 DETACH HERE RICK SCOTT GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1428760 The PLUMBING CONTRACTOR ¶: Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2018 GASCH, MARK ALLEN 0 L GO PLUMBING INC 7927 NW38TH COURT 1 DAVIE FL 33024' e aCIS �`s b 1colicn. n7mirmiR IIICPI AV AC RFr)lupi=n RY I AW SEO# L1607110000640 Ll BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm.A-1 00, Ft. Lauderdale, FL 33301-1895—954-831-4000 j VALID OCTOBER 1,2016 THROUGH SEPTEMBER 30,2017 DBA: Receipt#:182-256084 SPR M/CONTRACI"OR Business Name:Go PLUMBING, INC. Business Type:(PLUMBING) Owner Name:MARK ALLEN GAscx Business Opened:o6/12/2013 Business Location:7927 Nva 38 CT State/County/Cert/Reg:CFC1428760 DAVIE Exemption Code: Business Phone: {looms seats Employees Machines Professionals 3 For Vending Business Only Number of Machines: Vending Type: �s' Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid _ 27.00 0.00 0.00 0.00 8.04 0.00 27.00 - _ 'Ai THIS �1 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non-regulatory in nature.You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when If the business is sold, business name has ganged or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. G" Mailing Address: MARK ALLEN GASCH Receipt #04B-15-00007034 7927 NW 38 CT Paid 07/15/2016 27.00 DAVIE, FL 33024 E U.S.A. u 2016 - 2017 UM in inc. 7927 Northwest 38th Court Davie, Florida 33024 954-554-1780 Drop Test Certification Owners Information: Permit Number—CC-7-14-1465 Barry University Buck Stop 11300 Northeast 2nd Avenue Miami Shores,Florida 33161-6628 Contractor: Go Plumbing,Inc. License No: CFC1428760 Type of Installation: New: Upgrade to Existing: X Description work: Installed gas system,for a {4} piece set of kitchen equipment. System Pressure from meter:2LBS Water Column: 10 inches Lock up Pressure:30LBS Test Duration:24 Hours Date of Test:01/19/2015 X/z/"'��' Jan luar�5 Contractor Date Mark Gasch Print Name STATE OF FLORIDA COUNTY OF Broward Sworn to and subscribed before me this 19,day of January 2015,by:Mark Gasch (X)Personally wn )Produced Identification—Type of identification Sign e o otary Pu is (Seal) 1lAi11f K NONAF06 WCOM mWM#EE1ffl0 E*M:.*9%20M sown" J-. :. r<':�ti.. :G, .'F� ,.cr .A' - - ;"k'g". r •c';�": ,.'z;`` ,rr�'r y�rr: .,....�f't- `r.4',:'r 'i. '"€r .a ,..2r-. ,�- :.r.•'�'.'=. ,7'::. "•.�: .. . .� •'F>A. ,.,£4 a*- Y..-,,r,� } -„ ,. r .,,t .+t e - b;e, x w.:-";.9.s .< ... .,,« 1 .5f. i... r.i.L..,. ...Cr. :a'�" ,xa.. � '� t d �� fs?_ "i'_ �),",.Y'S�..t "v.,.a. ,.s. ?a. `.�"$�+, :Y.: .t •�..., �'-`Y3�3P fg�, _,,?rw. F:.z`�.S'Fa<_ ,r., ^.... ,,tL`.�✓�.h.*r} -.. ,'-'t , ... �. ..<:. .,. ,,`�-F '�� _S'�-`Ls� aI1 •s` C�'.'a -�.i t. Y. � rf.,v} '�-,ay. ,i :p+ (( r„ k.. '«.>r. '.. 1:�.n. 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Miami shores Village Inw Building Department Pzkrml RIDp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CERTIFICATE OF OCCUPANCY/COMPLETION CHECK LIST Building permit card. ❑ Surveys (2 copies) Final as built-Required Items: Elevations of buildings showing all intended setbacks from property lines and other existing structures. Ingress+ Egress, required parking spaces, Wheel stops, stripping, and all paving to exterior. ❑ Certificate of Elevation—(Sealed by surveyor). Expiration date required on the form. ❑ Certificate of Insulation. ❑ Certificate of Soil Treatment(Final treatment-original)\ CHAPTER 2913-5 TERMITE PROTECTION: "This Building has received a complete treatment for the prevention of subterranean termites.Treatment is in accordance with the rules and law as established by the Florida Department of Agriculture and Consumer Services." ❑ Health Department Approval Letter(On septic or private water). Note: If the house is on septic tank, approval letter is required from Health Dpt. ❑ Soil Compaction Letter(Density report is required) ❑ Final certification letter from the Engineer/Architect(on masonry, trusses, special structure,etc) ❑ Backflow preventor certificate(Required on commercial projects only) ❑ Declaration of use. (Recorded in Miami-Dade Clerk of Courts) PLEASE NOTE THAT THE SAME ITEMS ARE REQUIRED FOR TEMPORARY CO • Emergency CO(Without 24 Hrs Processing)Additional fee is$80.00. • Temporary CO (Up to 90 days max)$75.00. • Residential CO$150.00 • Residential CC$50.00 • Commercial CO and CC$200.00 M•Ih�e. 1311 W. 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