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PL-17-122Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Parcel Number Applicant 112 NE 110 Street Miami Shores, FL 33161-7046 Owner Information Address WILLIAM HARTWELL 1121360040410 Block: Lot: 112 NE 110 Street MIAMI SHORES FL 33161 - Phone Contractor(s) YERBILLAS SERVICES INC Phone CeII Phone WILLIAM HARTWELL (954)294-3397 Valuation: Total Sq Feet: Type of Work: REPLACE GAS TANK WATER HEATER FOR N Type of Piping: Additional Info: REPLACE GAS TANK WATER HEATER FOR N Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $2.25 $2.25 $0.20 $150.00 $3.00 $0.80 $159.10 Pay Date Pay Type Invoice # PL -1-17-62635 01/17/2017 Credit Card 01/24/2017 Credit Card Amt Paid Amt Due $ 50.00 $ 109.10 $ 109.10 $ 0.00 Cell Available Inspections: Inspection Type: Final Press Test Review Plumbing 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 AFFID IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an. , ning. uthermore, I authorize the above-named contractor to do the work stated. January 24, 2017 Aut rize•`• ignature: Owner / Applicant / Contractor / Agent Building Department Copy Date January 24, 2017 1 \\110,( C1 • BUILDING PERMIT APPLICATION 0BUILDING ❑ ELECTRIC Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 RFC VED JA• 172017 BY: at, FBC 2014 Master Permit No. ` L 1-11- I Sub Permit No. ❑ ROOFING ❑ REVISION ❑ EXTENSION D RENEWAL 5 IN PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: 1 2 U G 1 CO City: Miami Shores CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS County: Miami Dade Zip: Folio/Parcel#: Occupancy Type: Load: Construction Type: Is the Building Historically Designated: Yes Flood Zone: BFE: OWNER: Name (Fee Simple Titleholder): V• /ia,yY1 Weis /well Address:s4Alb L _4// S4-• s City: / I`°aA4Pt- /7(t State: F L Tenant/Lessee Name: Email: P. NO FFE: Phone#: q;-%eig-3387 Zip: 7-3if/ �l. h a! i- 0,4 it024404d. tom Phone#: CONTRACTOR: Company Name:q-et2101:i(A) Set2A1(Ces 'Plitt Phone#: 486 4 -1,38S -7A2 Address: ^Z-{ Z 3 St A) ! ? 10C City: Y nY l 0.w( State: T---{.. Zip: " 35/ Qualifier Name: fbQ. Phone#: State Certification or Registration #: CPC- 14 ? 2 i `P Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City:State: Zip: Value of Work for this Permit: $ a5 V Type of Work: ❑ Addition Description of Work: Square/Linear Footage of Work: ❑ Alteration ❑ New L Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ ✓ 0 42O Scanning Fee $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) •g0 Permit Fee $ C61CCF $ CO Radon Fee $ ( 2 S DBPR $ 2 • Z5 Training/Education Fee $ • 2' O Double Fee $ Bond $ TOTAL FEE NOW DUE $ IOCf • CO/CC $ Notary $ IU 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. Signaturee,i2 - OWNER or AGENT The foregoing instrument was acknowledged before 7me this /e day of , 20% / , by Q31/i, who is personally known to WrZwho h s p duce identification and who NOTARY PUBLIC: Sign: Print: Seal: as n oattOSEIT, VALENCIA 'F MY COMMISSION 0 FF921130 EXPIRES November 27, 2019 APPROVED BY (Revised02/24/2014) I-lt-/7 Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of VlAU , 20 ( , by me or who1 as as who is personally known to identification and who did NOTARY PUBLIC: Sign: Print: Seal: Plans Examiner VIBEL VALENCIA MY COMMISSION 9 FF921130 EXPIRES November 27. 2019 407 3a .0153 COW Zoning Structural Review Clerk 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 impi• you, subscribe to department newsletters and learn more abuut 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! RICK SCOTT GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CFC1427286 ISSUED. 08/18/2016 CERTIFIED PLUMBING> CONTRACTOR YERBILLA. JORGE.Ift, YERBILLA SERVICES INC IS CERTIFIED under the proviswns et Ch 489 FS Exp.z.aiion date Atit3 31 '2018 L160818(t100237 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1427286 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31. 2018 YERBILLA, JORGE JR YERBILLA SERVICES INC - MIAMI FL 33'`tSj.ltt"'"'wif'''''e'4 2423 SW 99TH PL r'' 004880 DISPLAY AS REURD Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 5982971 BUSINESS NAME/LOCATION YERBILLA SERVICES INC 2423 SW 99 PL MIAMI FL 33165 OWNER YERBILLA SERVICES INC Worker(s) RECEIPT NO. RENEWAL 6241780 SEC. TYPE OF BUSINESS 196 PLUMBING CONTRACTOR CFC1427286 SEQ # L1608180002067 LBT EXPIRES SEPTEMBER 30, 2017 Must be (splayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 08/15/2016 CREDITCARD-16-047373 This Local Business Tax Receipt only confirms payment of the Local Business Tax, The Receipt is not a license, pemid, or a certification of the holder's qualifications, to do business, Holder must comply with any governmental or nonuovernmental reaulatory laws and ranoiromontR whish nolv to tho boo inooe AC RI® CERTIFICATE OF LIABILITY INSURANCE /Y DATE(MM/DDYYY) 01/17/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA',: !ON 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). PRODUCER First Commercial Insurance Agency P.O. Box 295 Cassadaga FL 32706 CONTACT NAME: Tony Cannizzaro AHC,Nr o. Ext): (386) 775-1781 FAX No): (386) 775-3666 E-MAIL insurance u rr.com ADDRESS: 9 Y©cfl. INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ASSOCIATED INDUSTRIES INSURANCE COMPAI 23140 INSURED Yerbilla Services Inc 2423 SW 99th Place Miami FL 33165 INSURER B : INSURER C : INSURER D : $ INSURER E : $ INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRINSD TYPE OF INSURANCE ADDL SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RENED PREM SESO(Ea occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PO - JET PER: LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENT ON$ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEM ER EXCLUDED? PROPRIETOR/PARTNER/EXECUTIVEANY YYN (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A AWC1060524 03/30/2016 03/30/2017 PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000.00 E.L. DISEASE - EA EMPLOYEE $ 1,000,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 N.E 2nd Avenue Miami Shores, Florida 33138 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 ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Al "[ ' or CERTIFICATE OF LIABILITY INSURANCE ‘4 fa„aomo'''”' DATE(MM/DD/YYYY) 01/17/2017 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). PRODUCER Entrust Insurance 1431 Ponce De Leon Blvd Coral Gables, FL 33134 Phone (305) 265-0112 Fax (305) 265-0101 CONTACT Jason Bryce NAME: PHONE No, Ext): (305) 265-0112 FAX No): (305) 265-0101 E-MAIL info@agencyentrust.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Endurance American Specialty Ins Co N INSURED Yerbilla Services, Inc. 2423 SW 99 Place Miami FL 33165 INSURER B : 03/21/2016 INSURER C : EACH OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E : V COMMERCIAL GENERAL LIABILITY 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 WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL LIABILITY N CBC10001882802 03/21/2016 03/21/2017 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000.00 V COMMERCIAL GENERAL LIABILITY MED EXP (Any one person $ 5,000.00 ❑ ❑ CLAIMS -MADE # OCCUR ❑ PERSONAL 8, ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PECT U LOC PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED im SCHEDULED ❑ AUTOS IIN AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ NON -OWNED • HIRED AUTOS M AUTOS ❑ ■ $ ❑ UMBRELLA LIAR • OCCUR EACH OCCURRENCE $ • EXCESS LIAB • CLAIMS -MADE AGGREGATE $ • DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A ' PER a. STATUTE • EOR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) PLUMBING CONTRACTOR CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) QF © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Budding Department 10050 N.E 2nd Avenue Florida 33138 AUTHORIZED REPRESENTATIVE _ Miami Shores, �'! %�� I ACORD 25 (2014/01) QF © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACGRb® CERTIFICATE OF LIABILITY INSURANCE `...---- DATE (MM/DDNYYY) 01/17/2017 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). PRODUCER First Commercial Insurance Agency P.O. Box 295 Cassadaga FL 32706 CONTACT NAME: Tony Cannizzaro 1A C. No. Ext): (386) 775-1781 NE (a//c, No): (386) 775-3666 E-MAIL nsurance u rr.com ADDRESS: ig y@cfl. INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: ASSOCIATED INDUSTRIES INSURANCE COMPAI 23140 INSURED Yerbilla Services Inc 2423 SW 99th Place Miami FL 33165 INSURER B INSURER C: INSURER D : $ INSURER E : INSURERF: 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 ADDCSUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DDNYYY) POLICY EXP (MM/DDNYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO PREMISES Ea occurrence)E $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS- COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ _ SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? I Y l (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/ A AWC1060524 03/30/2016 03/30/2017 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000.00 E.I. DISEASE - EA EMPLOYEE $ 1,000,000.00 E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PLUMBING CONTRACTOR CERTIFICATE HOLDER CANCELLATION I Miami Shores Village Building Department 10050 N.E 2nd Avenue Miami Shores, Florida 33138 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 a,a^�-_ ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD