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EL-12-1820Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 187381 Permit Number: EL -10 -12 -1820 Scheduled Inspection Date: March 14, 2013 Inspector: Devaney, Michael Owner: GIBON, CHANTEL Job Address: 326 NE 92 Street Miami Shores, FL 33138- Project: <NONE> Contractor: ADT LLC Permit Type: Electrical - Residential Inspection Type:h Work Classification: Alarm Phone Number 305 - 324 -6262 Parcel Number 1132060136470 Building Department Comments burglar alarm Infractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments /t/ 247/ March 13, 2013 For Inspections please call: (305)762 -4949 Page 29 of 37 ($w9 8 6 Miami Shores Village v ` ' Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. PERMIT APPLICATION FBC 20(0 1. ECEll ELD OCT 0 2 712_ Z Master Permit No. EL IL-- d Permit Type: Electrical Phone #.%BJ ✓ ^P' /V6-15P Name (Fee Simple Titleholder): ha iad A 4.60,7 Address: 22 /1/E leG c�7 l City: Riaini t. /2DreS State: 9/o - ._ Tenant/Lessee Name: Phone #: c33J3Y Email: JOB ADDRESS: 3020 ///6:* / 6 92 57/ City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: /J3 ?O Ca 0/3604/70 Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: ,4 7 Z.Z.G. Phone #�Jr�./Z4IO—✓1�.a�3 Address: ��/!eD /7%a'i.S U4y City: _0% /,ZZ 770, / % State: WO/746k Zip: 5340,9 3 Qualifier Name: /ul &6 /C t (CC.,/ tal 1e • Phone #: ( el lv 804)"..3 State Certification Registration #: 72000/G7a'69 Certificate of Competency #: Contact Phone #: 96-49e;(049 - 5 1 : : : a : ? Email Address: aeedeziczed,f e e i a i e . c . DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ (O • Square/Linear Footage of Work: Type of Work: Address ISdAlteration New ❑Repair/Replace ❑Demolition Description of Work: /L%/ af.47 z.'l / 61 • p asO ******** * * * * *** * * * ** * * * * * * ** ** * ** ** * * ** Fees******:******* **** * * ******** *** ** * *** * ** * ** ** Submittal Fee $ 5 °`(-3 Permit Fee $ / 0 6" "® CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 555." ` o0 9 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information' is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to 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 a roved and a reinspection fee will be charged. 0 Signature =. um Signature, 0 eror ent The foregoing instrument was ac owledged before me this �? / C.' H Aa..1'. &[r® , who is personally known to me or who has produced day of .( , 20 11-1-by As identification and who did take an oath. NOTARY PUBLIC: My Commission Expires: Contractor The foregoing instrument was acknowledged before me this" day of , 20 �c rby &22.11C /fAkelail who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: ,�ooa�00000��g �o_ot,A1101� 40 i , � My Commission Expires: o p ON OO�Sd �Up s co ° o � .;� nth Batde9 Tlau Pic Umlerwtltters o ®B ,r ':b0�A,`•••• �� w Q' �e ::�x�: ***** ***:x:x:x:k *:�:�::x *:�:x***** ** x * x �� x x *�x x x x xx x x� x� x� x� �xx� x�x�x� x x� x i�`ee'� c *:c: . APPROVED BY r %2.o/ — Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09) Zoning Clerk Proporiy Information Report } My Home Property Information Report Summary Details: Page 1 of 1 MIAMI•DADE Folio No.: 11- 3206-013 -6470 Property: 326 NE 92 ST Mailing Address: CHANTAL GIBON 326 NE 92 ST EL PORTAL FL 33138 -3134 Prouertv Information: Primary Zone: 1100 SGL FAMILY - 2301 -2500 SQ CLUC: 0001 RESIDENTIAL - SINGLE FAMILY Beds/Baths: 3/2 Floors: 1 Living Units: 1 Adj Sq Footage: 2,371 Lot Size: 9,675 SQ FT Year Built: 1946 Legal Description: MIAMI SHORES SEC 1 AMD PB 10-70 W1/2 LOT 9 & LOT 10 BLK 48 LOT SIZE 75.000 X 129 OR 15268 -4175 1091 1 COG 24861 -1756 08 2006 1 OR 24861 -1756 0806 00 Assessment Information: Year. 2012 2011 Land Value: $139,325 $121,152 Building Value: $207,219 $207,457 Market Value: $346,544 $328,609 Assessed Value: $338,467 $328,609 Exemption Information: Year 2012 2011 Homestead: $25,000 $25,000 2nd Homestead: YES YES Taxable Value Information: Year 2012 2011 Taxing Authority: Applied Exemption/ Taxable Value: Applied Exemption/ Taxable Value: Regional: $50,000/$288,467 $50,000/$278,609 County: $50,000/$288,467 $50,000/$278,609 City: $50,000/$288,467 $50,000/$278,609 School Board: $25,000/$313,467 $25,000/$303,609 Sale information: Sale Date: 8/2006 Sale Amount: $825,000 Sale O /R: 24861 -1756 Sales Qualification Description: Sales which are qualified View Additional Sales 'Close window] 'Click here to Print' This report was created on 9/21/2012 6:07:06 PM for reference purposes only. Web Site © 2002 Miami -Dade County. All tights reserved. http:// gisims2 .miamidade.gov!myhome/proptext_ print .asp?folio = 1132060136470 &cmd = 9/2112012 R ID N HAL SERVICES CONTRACT 063 -2aZ =131 11111111111 N.■,, CONTRACT (� DATED (/ Z ° CUSTOMER' /� 5 T JOB Q 1 ' . LEAD •C pmf"% V ACCOUNT NO '1 1 �� NO _ .SOURCE -" •• •la - r nf• ADT LLC dba ADT Security Services (ADT1. Offife Address www.MyADT.com 1.800.ADT.ASAP1 (1.800.238.2727) - Customer Name �y}j I (°Customer° or °I° or 'me or °my% i s p, IIAJ& 1 1 1 1 Premises' 1 Z6 1' �' z '5TR (✓,T 1 I I Address inVilei ( S,%1 K State -L ZIP 1 ( 3 y Tax Exempt No ' '.. Tax Expire Date . • • - � .. ___..1 Protected Premises Al6 N,r} 0 Traditional Phone ("Other (Qualified) 0 Other (Non - Qualified) Telephone �1 Alternate ?4P i4 fl Telephone 1 t0 t.' 5 O Home ®Cell O Work Alternate r' 3 ! ©BIGF, (� `, O Home O Cell (*Work Telephone 2 t1 S1Ni O Fill in if billing address Is the same Billing sPrP1 1 Address r ifrii/ 1 1 1 City 1 State ZIP 1 , IF FAMILIARIZATION PERIOD IS REJECTED INITIAL HERE. '� (see Paragraph 14 of the Terms and Conditions for explanation) ,. EMAIL lL 1`\1 4,S p K. 1Q vl 4 C. 0 t . Communications Authorization: I authorize products and services to the contact infor 888.DNC4ADT (888.362.4238). Initial here ADT • • provide me with information and updates about the ecurity system and new ADT and third -party .. fo r• rovided by me. I' may unsubscribe or opt out by emailin ,donotcontact @adt.com or by calling, - %) 6q4, Z 336, --6q4, Confirmation of Appointments: I authorize appointments and provide other information ADT to call me using an automated calling device to deliver a pre - recorded message to set/con v �( notices about the alarm system atthe telephone number(g) provided by me. Initial here . =!` and EQUIPMENT TO REMAIN THE PROPERTY OF ADT. All equipment installed by ADT pursuant to this Contract shall be owned by ADT unless ADT has agreed to give me ownership of the equipment in a separate written agreement ADT has the right upon termination of this Contract to remove or disable any or all of the equipment owned by ADT, in which case I will not be able to use the equipment for any purpose. See Paragraph 7 of the Terms and Conditions for more information. I acknowledge and agree to each of the following: (A) This Contract consists of six (6) pages. Before signing this Contract, l have read, understand and agree to each and every term of this Contract, including but not limited to Paragraphs and 18 of the Terms and Conditions. (B) The initial term of this Contract is three (3) years. (C)ADT is not a security consultant and cannot address ail of my potential security needs. ADT has explained to me the full range of equipment and services that ADT can provide me. Additional equipment and services over those identified in this Contract are available and may be purchased fro ADT at an additional cost to me. I have selected and purchased only the equipment and services identified in this Contract (D) No alarm system can provide complete protection or guarantee prevention of loss or injury. Fires, floods, burglaries, robberies, medical problems and other incidents are unpredictable and cannot always be detected or prevented by an alarm system. Human error is always possible, and the response time of police, fire and medical emergency personnel is outside the control of ADT. ADT may not receive alarm signals if communications or power is interrupted for any reason. (6) ADT recommends that I manually test the alarm system monthly and any time 1 change telephone service, by calling 1.800ADT.ASAP or by logging in to www.MyADT.com. (F) this Contract requires final approval by an ADT authorized manager before ADT may provide any equipment or services, and if approval is denied, then this Contract will be terminated, and ADT's only obligation will be to notify me of such tenninatlon and refund any amounts 1 paid in advance. ADT Representative ‘---/ - T e •-.51YNe7/vC Rep. (If Required) ID No. SIN Customer's • pro :: 'riginal Si ature X Required (Must match Customer Name in Section 1 above) c9/ 2.7/ z. NOTICE OF CANCELLATION , THE CUSTOI IER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION 7F THIS RIGHT. I ACKNOWLEDGE BEING VERBALLY INFORMED OF MY RIGHT TO CANCEL AT THE TIME OF EXECUTION 7F THIS CONTRACT AND RECEIPT OF THIS NOTICE. - •• to • - • • • - • FINANCIAL DISCLOSURE STATEMENT THERE IS NO FINANCE CHARGE OR COST OF CREDIT (0% APR) ASSOCIATED WITH THIS CONTRACT. A. NUMBER OF PAYMENTS FOR THE INITIAL TERM IS 36. B. AMOUNT OF EACH PAYMENT IS $ / 7 (TOTAL MONTHLY SERVICE CHARGE FROM BELOW) TOTAL OF PAYMENTS FOR THE INITIAL TERM IS $ % P •`+`•7" (A. TIMES B.) (EXCLUSIVE OF ANY APPLICABLE TAXES, FEES, FINES AND RATE INCREASES) LATE CHARGE - PAYMENT IS DUE PURSUANT TO MY SELECTED BILLING FREQUENCY, PRIOR TO THE START OF SERVICE. MY FIRST BILL/CHARGE WILL BE SENT /MADE SHORTLY AFTER MY SERVICE BEGINS. ADT MAY IMPOSE A ONE -TIME LATE CHARGE ON EACH PAYMENT THAT I5 MORE THAN TEN (10) DAYS PAST DUE, UP TO THE MAXIMUM AMOUNT PERMITTED BY LAW, BUT IN NO EVENT WILL THIS AMOUNT EXCEED 55.00. PREPAYMENT - IF 1 PREPAY THE SEE PARAGRAPHS 2, 7, 15 AND TOTAL OF PAYMENTS PRIOR TO 19 OF THIS CONTRACT FOR THE END OF THE INITIAL TERM ADDITIONAL INFORMATION OF THIS CONTRACT, THERE IS NO ABOUT NONPAYMENT, DEFAULT PENALTY OR REFUND. AND ACCELERATION. 02012 ADT LLC dba ADT Security Services. 1 of 6 Administrative Copy All rights reserved. (06/12) ESLDNT1AL SERVICES CONTRACT ° CONTRACT DATE 41/ 17/ CUSTOMER / V- ACCOUNT NO -11-?363-zoi-1.37 REM gj 2. s---- JOB ryi 1E AD NO MEd SOURCE bection 2. Services to be Provided (continued) 0 Initial/Annual Reaming Munidpal Fee billed separately .. (Subject to change based on local law) Initial/Annual Fee . • . . •,....., M Standard Monthly Service, Burglary Service indudet Customer Monitoring Center Signal Receiving and Notification Service for Burglary, Manual Fire and ManualPolice Emergency " Monthly Service Charge $ L/9- /I 0 Customer to obtain and pay for initiallannual munidpal alarm use permit Failure to obtain and provide ADTwitk• • the municipal alarm use permit registration number could mutt in no munidpal fire/police response to an alarm from the premises ancUor a fine. 4-,r, '.; - • .• . t 4 h e ..5.154) D Standard Monthly Service, Fire/Smoke Detection Service includes: Customer Monitoring Center Signal hring and Notification Service for Fire, Manual Fire acI Manual Police Emergency • t -P -- • . Munldpal Electrical Permit Fee 0 Customer ta obtain,electricai permit .**••• • n Monoxide 0 Flood 0 Low Temp — $ Installation Price $ '?-;717-et D Medical Alert • $ — Taxable Amount . 0) Safewatch Cellguard® S. ....N 4-- • Non-Taxalite Amount $ ii,r-go D SecurityLink** .....- Connection Fee $ 2.-C•01) BO Extended Limited Warranty/Quality Service Plan (QSP) $ Admin Fee $ — D Guard Response Service $ — Sales Tax on Installation* $ 7-7136 Z Monthly Recurring Municipal Fee (Subject to change based on local law) 0 Customer to obtain and pay for munidpal alarm use permit $ — . Totat Installation Charge* $ ()a q/1/ D Other $ — Deposit Received ti 04. # C,71 0 $ Z07.6 0 Total. Monthly Service Charge $ itt91. lei • Balance Due upon Installation* $ 2.67.0 0 *If applicable Sales tax not shown, it will be added to the first invoice. • - j • 0 . Package Name: Includes: Foyer Living Room Family Room Office Dining Room Kitchen Laundry Room Hallway Masfbr Bedroom Master Bath Bedroom 2 Bedroom 3 Bath 2 Basement Garage Price Per Piece Totals I E = Existing Equipment /11 Kr; INSTALLER NOTES Estimated Installation Start Date J77,( /et (35 et-V-r1-4 CeCc 7 vA-.L_A, 7.-iverove"- tA/ r-f-X ! of 6 ©2012 ADT LLC dba ADT Security Services. All rights reserved. (06/12) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 MANGINELLI, GEORGE A ADT LLC PO BOX 811175 ADT LLC - ATTN: LICENSING DEPT BOCA RATON FL 33481 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. f For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and leam more about the Department's 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, and congratulations on your new license! REGULATION DETACH HERE (850) 487 -1395 STATE OF FLORIDA DEPARTMENT OF PROFESSIONAL tz93 EF0001121 AC# 6 L 308 58 BUSINESS AND REGULATION CERT ALARM MANGINELLI:, ADT LLC 12 118186332 C.4ACTOR I IS CERTIFIED under the provieione of Ch.489 Fs Expiration date: AUG 31, 2014 L12051701113 THIS DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING • LINEMARK— PATENTED PAPER AC# 6130858 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEQ# L12051701113 BATCH NUMBER LICENSE NBR 05/17/2012 118186332 EF0001121 The ALARM SYSTEM CONTRACTOR I Named below IS CERTIFIED Under the provisions of Chapter Expiration date: AUG 31, 2014!' MANGINELLI, GEORGE A ADT LLC 6830 SHADOWRIDGE DR SUITE 212 ORLANDO FL 32812 RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A -100, Ft. Lauderdale, FL 33301 -1895 — 954 - 831 -4000 VALID OCTOBER 1, 2012 THROUGH SEPTEMBER 30, 2013 DBA: Business Name: ADT LLC Owner Name: Business Location: Business Phone: Rooms GEORGE A MANGINELLI 10785 MARKS WAY MIRAMAR 954 -2; §6.=51.76 seats Em Receipt #:ELEICT2RIICAL ALARMS /CONTRACT Business Type: (ELECTRONIC SECURITY) Business Opened:06 /29/2012 State /County/Cert/Reg:EF 0 0 01121 Exemption Code: Ines Professionals Number of Machines: For Vending Business Only Tax Amount Transfer Fee NSF Fee 27.00 0.00 0.00 • Penalty Vending Type: Pnoir Ys Collection Cost 0.00 Total Paid 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: ADT LLC ATTN: LICENSING P 0 BOX 811175 BOCA RATON, FL 33481 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 and 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. 2012 - 2013 Receipt #03A -11- 00007863 Paid 09/25/2012 27.00 ACORD CERTIFICATE OF LIABILITY INSURANCE 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(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). I DATE (MM /DDIYYYY) 09/2812012 PRODUCER Marsh USA, Inc. 1166 Avenue of the Americas New York, NY 10036 58880 -ADT-MAIN-12-13 CONTACT NAME: PHONE FAX IA/C. No. Extl: (A /C, No): E -MAIL ADDRESS: INSURED ADT LLC 10785 MARKS WAY MIRAMAR, FL 33025 INSURER(S) AFFORDING COVERAGE INSURER A : Zurich American Insurance Company INSURER B : American Zurich Insurance Company INSURER C : NAIC # 16535 40142 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: NYC - 006454209 -06 REVISION NUMBER: 1 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS POUCY EXP (MM/DD/YYYY) INSR L A A TYPE OF INSURANCE ADDL INSR SUBR VWD POLICY NUMBER GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY II PRO- 7(1 CT Ti LOC AUTOMOBILE LIABILITY X X ANY AUTO ALL OWNED AUTOS HIRED AUTOS GLO 5095899 -00 JMMM/LDO YY 1 09/282012 10/0112013 LIMITS EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) 1,000,000 10,000 PERSONAL & ADV INJURY GENERAL AGGREGATE $ 2.000,000 4.000,000 PRODUCTS - COMP /OP AGG $ 4.000,000 SCHEDULED AUTOS X NON -OWNED AUTOS AL 5095900-00 09/28/2012 10/012013 COMBINED SINGLE LIMIT (Ea accident) $ $ 1.000.000 BODILY INJURY (Per person) BODILY INJURY (Per accident) $ $ PROPERTY DAMAGE (Per accident) $ S UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE A DED 1 RETENT ON $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below EACH OCCURRENCE $ AGGREGATE $ YIN N/A WC 5095897-00 (Deductible) WC 5095898-00 (Reiro) 09282012 09/29/2012 10/012013 10/012013 X ITORY LIMITTS 10TH- TORY E.L. EACH ACCIDENT $ $ E.L. DISEASE - EA EMPLOYEE $ 2,000,000 E.L. DISEASE - POLICY LIMIT 2.000,000 2.000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES BUILDING DEPT 10050NE2AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc- Cynthia Y. KItn YJ ' 01888 -2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORD 25 (2010/05)