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EL-12-1950Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 180155 Permit Number: EL -10 -12 -1950 Scheduled Inspection Date: January 22, 2013 Inspector: Devaney, Michael Owner FENWICK, JAMES AND SUZANNE Job , ddress:154 NW 111 Street ' Miami Shores, FL 33168 -4323 Project <NONE> Contractor: JAKE'S ELECTRIC, INC Permit Type: Electrical - Residential Inspection Type: Final Work Classification: Addition /Alteration Phone Number (786)238 -7844 Parcel Number 1121360030450 Phone: (305)796 -6237 Building Department Comments ELECTRICAL OUTLETS REPLACEMENT 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 January 18, 2013 For Inspections please call: (305)762 -4949 Page 6 of 27 Miami Shores Village 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 APPLICATION Permit Type: Electrical JOB ADDRESS: 1 4. OCT 17 2012 BY: FBC 20tt3 Permit No. I 2 ! '5 O Master Permit No. City: Miami Shores County: Miami Dade Folio/Parcel #: Lot <r>% o / G&i li; fi01 Is the Building Historically Designated: Yes g\rZA 0 E. FE. wrc OWNER: Name (Fee Simple Titleholder) Address: t S 4, , r\ Sg Zip: 3 1 b� - eicT.N...St a N/ Flood Zone: Phone #:1 2-3 City: (')¼\-\ S Ko2€$ Tenant/Lessee Name: o 1 Email: State: FL- Zip: i S Phone #: CONTRACTOR: Company Name: ,Cc S EL���e-N, Address: 4- \ 0 AcD 6N.1. v 1/4.r € City: 6A < A PA i' C10% State: V Zip: 3 3\ LL 0 Qualifier Name: ZI (oo rc, )05 tm State Certification or Registration #: 6311 t 000 ti 75-- Certificate of Competency #: Contact Phone #: j .W4 037 Email Address: �/ q50 9 h /%iso ► ° 20e-6- DESIGNER: Architect/Engineer: Phone #: 1 1 Phone #: 3°5— 3 Phone #: ®c 7? 43 Value of Work for this Permit: $ 8 0 5 44 Square/Linear Footage of Work: Type of Work: DAddress OAlteration `°New ORepair/Replace Description of Work: T t_i✓cc -CA L ODemolition ****+ r***+ x****** x: *x:: **+ x**+ x**** *+ x: x******* Fees******* ***+ x******* ****** ****s:******* ** ****** Submittal Fee $ Permit Fee $ /1-5—eP P' C7 Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ 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 . osted notice, the inspection will not be approved and ' spection fee will be charged. Signature The f day o who is pe $nstrument was ac (20 , by sonall known • me or who has produced Own r or A t owledged be e (i ' 4 Signature The fo NOTARY PUBLIC: Sign: Print: My Commission Expires: o is pers entification and who did take an oath. * * * * * * * * * * * * * * * * * * * ** APPROVED BY Zm /� Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NO Sign: Print: My Commission E Contractor trume was ckno<./i ged eforee , 201 by {`'nv nally known to me or who has produced ..., #,'7 ARY PUBLIC: ation and who did take an oath. Ct.hl1DI ' My Comm. State of Florida y ', No a Expires Sep • Commission # EE 128810 Assn. Bonded Through National Notary * * * * * * * * * * * * * * * * * * * ** Zoning Clerk Jake's Electric, Inc. 4410 Adams Ave Miami Beach, FL 33140 Tel: 305.532.5070 Fax 305.538.7697 Beep: 305.475.7000 Email Jake @JakesElectric.com Text ClickHere.Nextel Messaging Page 1 on AV8S9 c�S,��� (C ADD SMOKE/CARBON MONOXIDE DETECTORS. ANY AND ALL CLOTH AND RUBBER INSULATED CONDUCTORS TO BE REPLACED. 5 E <-11\? v.I \\/,4 <Zere wen L.-iv/Nits L) A-?vl 7 Stye ?F_„s reoE$LARInA AC#' -6 3s 5 Fp TIE c F BITSINEgS AND L?ROtESSQNkli REG L TION 1.4.2 118198703 RACTOR. •:.CERTIFIER =A pr `Pzpvis4.00 of Ch: 4.89 Fs �xati3on data• . UG .3L 2014 I1206.0'5t03.2'34 Construction °p Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 94E000475 JAKE'S ELECTRIC INC D.B.A.: COHEN JACOB 10 of Miami -Dade County Is certified under the provisions of Chapter RECEIPT 2013 FIRST -CLASS FLORIDA. U.S. POSTAGE 013 PAID F BUSINESS. MIAMI, FL 8A, ART. 9 & 10. PERMIT NO. 231 327021-2 THIS IS NOT A BILL -- DO NOT PAY RENEWAL • Busman FE weivil8N INC OPERATING IN DADE COUNTY OWNER JAKES ELECTRIC INC Sec1T96 tLt1:1 tICAL CONTRACTOR THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUALIFICA- TIONS. PAYMENT RECEIVED MIAMI -DADE COUNTY TAX COLLECTOR: 07/18/2012 09010063001 000075.00 SEE OTHER SIDE RECEIPT NO. 340684-0. CC B 94E000475 WORKER /S 2 DO NOT FORWARD JAKES ELECTRIC INC JACOB COHEN PRES 4410 ADAMS AVE MIAMI BEACH FL 33140 1 11Jltli . lull /!lf5(37Dtth13Dl1m didfb}F3F:fl7dfft,1,4 4 1 MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. • 1st FLOOR MIAMI, FL 33130 2011 MUNICIPAL CONTRACTOR'S 2012 FIRST -CLASS TAX RECEIPT U.S. POSTAGE MIAMI -DADE COUNTY - STATE OF FLORIDA PAID PURSUANT TO COUNTY CODE SEC. 10 -24 MIAMI, FL EXPIRES SEPT. 30, 2012 PERMIT NO. 231 THIS IS NOT A BILL - DO NOT PAY RECEIPT NO. 30- 3406840 CC NO: 94E000475 BUSINESS NAME / LOCATION JAKES ELECTRIC INC OPERATING IN DADE COUNTY OWNER :JAKES ELECTRIC INC SEE BACK OF RECEIPT FOR A LIST OF NON- PARTICIPATING MUNICIPALITIES Receipt holder must register in the city where work is to be done. PAYMENT RECEIVED :=1341rDO5N/2 T01 1 02210005001 000200.00 RECEIPT HOLDER MAY DO BUSINESS AS ACONTRACTOR AS SPECIFIED HEREON. ELECTRICAL CONTRACTOR DO NOT FORWARD JAKES ELECTRIC INC JACOB COHEN PRES 4410 ADAMS AVE MIAMI BEACH FL 33140 49, 1 111i2A J I11ky Ij1J1,11. `` llJ31t 1 STATE OF FLORIDA DEPARTMENT OF'BU'SINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399 -0783 COHEN, JACOB JAKE'S ELECTRIC -INC 4410 ADAMS AVENUE MIAMI BEACH FL 33140 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.. 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 learn 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! (850) 487 -1395 STATE OFF LORIDA AC# 6b528i6 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION DETACH HERE EC13002503 U6 -5112 118198703 CERTIFIED ELECTRICAL CONTRACTOR COHEN, JA.CCOB JAKE'S ELEC' 'Ric IS CERTIFIED under the provisions of Ch.489 BS 4xgiration date: AUG 31,.:20.14 .. IA2060501234 THIS_; DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING.■.LINEMARK"' PATENTED PAPER STATE OF FLORIDA, PARTMENT OF 'ii~S I TESS ' AND PROFESSIONAL REGULATION ELECTRICAr, CONTRACTORS LICENSING. BOARD SEQ#I,12060501234 06/05/2012 1.18198703.: , EC130`0255 The ELECTRICAL CONTRACTOR ..: Named below IS CERTIFIED.:` Under the provisions of :;Chapter -. Expiration date: AUG 31, 2014 COHEN, JACOB JAKE' S ELECTRIC INC 4 410 ADAMS AVENUE MIAMI BEACH RICK SCOTT:. GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY `'' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 10/03/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THECERTIFICATE 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 poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Jackson Insurance Agency 2075 West 76tth Street Hialeah, FL 33016 Phone (305) 824 -3464 Fax (305) 822 -8535 CONTACT HEATHER ARIAS NAME: (A/C. No. Extt: (305) 824 -3464 FAX No): (305) 817 -1610 ADDRESS: HARIAS©jacksonagency.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : ASCENDANT COMMERCIAL INSURANCE INSURED JAKE'S ELECTRIC, INC. 4410 ADAMS AVENUE MIAMI BEACH„ FL 33140 (305) 796 -6237 INSURER B : TRAVELERS INSURANCE 06/01 /2012 INSURER C : BRIDGEFIELD INSURANCE EACH OCCURRENCE INSURER D : V COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE V OCCUR ❑ INSURER E : $ 100,000.00 INSURER F : $ 5,000.00 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. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR MD POLICY NUMBER POLICY EFF (MM /DDIYYYY) POLICY EXP (MM /DD/YYYY) LIMITS A GENERAL LIABILITY GL -38726 06/01 /2012 06/01 /2013 EACH OCCURRENCE $ 1,000,000.00 V COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE V OCCUR ❑ DAMAGE S RENTED PREMISES (Ea o SES (Ea ccurrence) $ 100,000.00 MED EXP (Any one person $ 5,000.00 PERSONAL &ADVIIJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: Vf POLICY PRO - JFST LOC PRODUCTS - COMP /OP AGG $ 1,000,000.00 $ B AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ❑ AUTOS OWNED v SCHEDULED HIRED AUTOS NON -OWNED L i ❑ AUTOS ❑ ❑ BA- 9A70767A- 12 -SEL 03/28/2012 03/28/2013 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 100,000.00 BODILY INJURY (Per accident' $ 300,000.00 PROPERTY DAMAGE (Per accident) $ 300,000.00 $ C ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' UABIUTY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A 830 -31196 01/24/2012 01/24/2013 , TORY L STATU- MRS ❑ OT E.L. EACH ACCIDENT $ 100,000.00 • OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N E.L. DISEASE - EA EMPLOYE $ 100,000.00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) CERTIFICATE HOLDER ANCELLATION I NORTH MIAMI- COMMUNITY PLANNING AND DEVELOPMENT DEPARTMENTS 12340 NE 8TH AVE N. MIAMI, FL 33161 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - < i.. —.---- ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Prepared by : Record and Return To: Lisa A. Douglas Preferred Title & Escrow, Inc. 2525 Embassy Drive, Suite 2 Cooper City, Florida 33026 File Number. 12-412 Record G. Return to: Preferred Title G. Escrow. 2525 Embassy Drive #2 Cooper City. P133026 1111111111111111 11111111111111111111111111111 C FN 201280684624 OR 8k 28288 Pa 0668/ (laa) RECORDED 09/26/2012 16158/25 DEED DOC TAX 1,620,00 HARVEY MIN, CLERK OF COURT t4IAtI —DADE COUNTY, FLORIDA LAST PAGE General Warranty Deed Made this September 7, 2012 A.D. By Jiam Gonzalez, a married man, joined by his spouse, Sonsire Gonzalez whose post office address is: 118 NW Swann Mill Circle, Port St. Lucie, F134986, hereinafter called the grantor, to James H. Fenwiek and Suzanne Fenwlck, husband and wife, whose post office address is: 154 NW 111th Street, Miami Shores, Florida 33168, hereinafter called the grantee: (whenever used herein the term "grantor' and " grantee° include all the parties to this instrument and the heirs, legal mpresentadves and assigns of individuals, and the successors and assigns of cerpoathes) Witnesseth, that the grantor, for and in consideration of the sum of Ten Dollars, ($10.00) and other valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, releases, conveys and confirms unto the grantee, all that certain land situate in Miami -Dade County, Florida, viz: Lot 13, Block 220, Miami Shores Extension, according to the map or plat thereof as recorded in Plat Book 43, Page(s) 40, of the Public Records of Miami -Dade County, Florida. Parcel ID Number: 11-2136-003-0450 Together with all the tenements, hereditanients and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with said grantee that the grantor is lawfully seized of said land in fee simple; that the grantor has good right and lawful authority to sell and convey said land; that the grantor hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever and that said land is free of all encumbrances except taxes accruing subsequent to December 31, 2011. In Witness Whereof, the said grantor has signed and sealed these presents the day and year first above written. Signed, sealed and delivered in our presence: State of Florida County ofBroward The foregoing instrument was acknowledged before me this 7th day of September, 2012, is/are personally known to me or who has produced driver license as identification. DEED Indivhdaal Warranty Deed - Legal on pace Closers' Choice Book28288 /Page668 CFN #20120684624 Page 1 of 1 OCT/17/2012/WED 11:52 AM Jackson Agency FAX No, 305-822-8535 P, 001/001 e-"''g, `° ' x�` CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/17/12 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 CONSTITUTEA 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 teens and conditions of the policy, certain policies may require an endorsement. A statement on thls certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Jackson Insurance Agency 2075 West 76tth Street Hialeah, FL 33016 Phone (305) 824-3464 Fax (305) 822 -8535 NAME: HEATHER ARIAS PHONE C Lo Ext): (305) 824-3464 FAX No): (305) 817 -1610 ADDRESS; HARIASQacksonagency.com INSURER(S) AFFORDING COVERAGE NAIC f INSURER A: ASCENDANT COMMERCIAL INSURANCE GENERAL LIABILITY INSURED JAKE'S ELECTRIC, INC. 4410 ADAMS AVENUE MIAMI BEACH„ FL 33140 (305) 796 -6237 C.AU= aersec ...- .,�...... -.._ ...... - -_ INSURER e : TRAVELERS INSURANCE GL -38726 INSURER C: BRIDGEFIELD INSURANCE 06/01/2013 INSURER 0 : $ 1,000,000.00 INSURER E : DAMAGE TO RENTED PREMISES INSURER F El II CLAIMS MADE OCCUR • THIS INDICATED. CERTIFICATE EXCLUSIONS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR INSR wBR WVD POLICY NUMBER POLICY_ EFF (MMM/DEFF (MMMiCY_EX_P_ D�YYYY) LIMITS A GENERAL LIABILITY GL -38726 06/01/2012 06/01/2013 EACH OCCURRENCE $ 1,000,000.00 Q COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES $ 100,000.00 El II CLAIMS MADE OCCUR (Ea occurrence) MED EXP (Any one person) $ 5,000.00 II PERSONAL & ADV INJURY $ 1,000,000.00 ■ GENERAL AGGREGATE $ 2,000,000.00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 1,000,000.00 n POLICY ❑ jEa ❑ LOC $ B AUTOMOBILE LIABILITY BA 9A70767A- 12-SEL 0328/2012 03/28/2013 COMBINED SINGLE LIMIT (Ee accident) $ • ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ 100,000.00 ❑ AUTOS V AUTOS NON -OWNED BODILY INJURY (Per accident) $ 300,000.00 ❑HIRED AUTOS • AUTOS PROPERTY DAMAGE (Per accident) $ 300,000.00 ■ ■ C • UMBRELLA LIAB • OCCUR EACH OCCURRENCE $ II EXCESS LIAB El CLAIMS -MADE AGGREGATE III DED 1 RE 1 tNTION $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILRY Y / N ANY ICPROPRIETOR/PARTNER/EXECUTIVE R N / A 830 -31196 01242012 01242013 $ 0 T\ O C RY LIM STATU ITS R ❑ E E.L. EACH ACCIDENT $ 100,000.00 (Mandatory In NH) N If E.L. DISEASE - EA EMPLOYEE $ 100,000.00 yes, describe unde DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (201W05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD