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PL-16-3202
Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. PL -11-16-3202 Permit Type: Plumbing - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 11129/2016 Expiration: 05/28/2017 Parcel Number Applicant 12 NE 96 Street Miami Shores, FL 33138 1132060130660 Block: Lot: GDS HOLDINGS GROUP LLC Owner Information Address Phone Cell GDS HOLDINGS GROUP LLC 151 N NOB HILL Road PLANTATION FL 33324- (754)244-4697 151 N NOB HILL Road PLANTATION FL 33324- Contractor(s) RCR PLUMBING SERVICES, INC. Phone CeII Phone (305)336-1646 (305)336-1646 Valuation: Total Sq Feet: $ 3,100.00 0 Type of Work: HOOKUP WASHER TO DRAIN PROPERLY. Type of Piping: Additional Info: HOOKUP WASHER TO DRAIN PROPERLY. Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $2.40 $2.25 $2.25 $0.80 $150.00 $3.00 $3.20 $163.90 Pay Date Pay Type Invoice # PL -11-16-62159 11/29/2016 Credit Card 11/22/2016 Credit Card Amt Paid Amt Due $ 113.90 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above-named contractor to do the work stated. November 29, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date November 29, 2016 1 • • Miami Shores Vi l l age Building Department 10050 N.E2nd Avenue, Miami Siores, Rorida33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSDEC11ON UNE PHONENUM BER (305) 762-4949 (�* FBC20(Y RECEIVED xam BUILDING Master Permit No. QI( 7 ec, PERM IT APPLJCATION alb Permit No. - 26 ❑ BUILDING ❑ EB TRIC ❑ FCORNG ❑ REVISON ❑ EXTENSON ❑ FENBWAL 12PLIJM BI NG ❑ M Ba-IANICAL ❑ PUBIJC WORKS ❑ CHANGE OF ❑ CANCELLAl1ON ❑ 9 -IOP OONTPACTOR DRAWINGS JOBADDRM 12 tiE ?6 S City: Miami Siores Cbunty: Miami Dade Zo: -519) Folio/ Parcel#: Isthe Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE FFE OWNER: Name (Fee smple Titleholder): Cnb.5 I1olALvJ - Cn ✓ x_k - Phone#: 151 2—W{ Lf (o1l7Address: 2,35 St. 2 °t, ' Te. '2 1 0 Oty: 140v1AD_SluA Sate: (..--- Op: ?)3 t 3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR Company Name: C PI P UM 19; 4 r C4,1) i c cS Address: '83 °f Sc.(2 je97a Ucc J 16 9 • aty: /94n; gate: i Zp:2 2710 Qualifier Name: gRA., fi bloa/i ,,,,.. Phone#: 30.C -336'16'e/6 Sate Certification or Ragistration #: C t G 1'( Z7 2 7 0 Certificate of Competency #: DESIGNER Architect/Engineer: Fhone#: Address: City: Sate: Zp: Value of Work for this Permit: $ r l LSC) Square/Linear rFF000ttage of Work: Type of Work: El Addition C1 Alteration CI New I q l'epair/Ftplace ❑ Demolition Desaiptionof Work: \- ok.f wA-41 vi/..-- to 10irraa.t/N QYOPe,(((di Phone#: 319s-- 8s- 336 3 q() ecify color of color thru tile: 3ibmittal Fee $ g6 •cki Permit Fee $ /5-t)— OCF$ Z O CO/ CC$ Scanning Fee $ Radon Fee $ Z • 25 DBPR$ 2_ . 2s Notary $ Technology Fee $ • ZC7 Training/Education Fee $ . 80 Double Fee $ Y' aructural Reviews$ Bond $ V9 TOTAL FEE NOW DUE$ (I - A b (Fevised02/24/2014) • Bon ing Compan ' Name (if applicable) Bon ing Oompan ' A re Qty Gate Zp Mor gage Len er' Name (if applicable) Mor gage Len er' A re A Qty gate Zp 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 PLUM&NG, SGNS POOLS FUFI\ACP9 BOILEFB HEATERS TANKS AIROONDITIONB ETC.... O N83'SAFRDAVIT: 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. " ARNING TO 0 NBR YOUR FAILURE TO RIMORD A NONCE OF OOM M ENGEM ENT MAY RESULT I N YOUR PAYING -TWICE FOR I M PFOVBVI BITS TO YOUR PROPERTY. IF YOU I NTB\JD TO OBTAI N R NAM) NG, OONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RBDORDI NG YOUR NOT10EOFO3M M ENGEM SVT." 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 ste 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. OWNER or AGENT The foregoing instrument was acknowledged before me this 11- day of jGUA Ir , 20 16 , by ( i111 !, 'za/tet-, who is=sonally known to mor who has produced as identification and who did take an oath. NOTARYPU' C k,Iia!kii,p'v9 n: Print: '.. r. v 1 .: al: r°`;.`: Property Search Application - Miami -Dade County E T G POPETY A Summary Report Property Information Folio: 11-3206-013-0660 Property Address: 12 NE 96 ST Miami Shores, FL 33150-1716 Owner CHIMI GROUP INVESTMENT LLC GDS HOLDINGS GROUP LLC Mailing Address 235 SE 29 TER 10 HOMESTEAD, FL 33013 USA Primary Zone 1100 SGL FAMILY - 2301-2500 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 3/2 / 0 Floors 1 Living Units 1 Actual Area 1,838 Sq.Ft Living Area 1,524 Sq.Ft Adjusted Area 1,680 Sq.Ft Lot Size 13,000 Sq.Ft Year Built 1940 Assessment Information Year 2016 2015 2014 Land Value $324,852 $246,928 $246,928 Building Value $116,928 $116,928 $117,497 XF Value $2,281 $1,869 $1,891 Market Value $444,061 $365,725 $366,316 Assessed Value $264,358 $262,521 $260,438 Benefits Information Benefit Type 2016 2015 2014 Save Our Homes Cap Assessment Reduction $179,703 $103,204 $105,878 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 1 AMD PB 10-70 LOTS 10& 11BLK5 LOT SIZE IRREGULAR OR 21010-3261 02 2003 1 COC 22266-0689 04 2004 1 Page 1 of 1 Generated On : 11/22/2016 2015 Aerial Photography Taxable Value Information Previous Sale 2016 2015 2014 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $214,358 $212,521 $210,438 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $239,358 $237,521 $235,438 City Exemption Value $50,000 $50,000 $50,000 Taxable Value $214,358 $212,521 $210,438 Regional Exemption Value $50,000 $50,000 $50,000 Taxable Value $214,358 $212,521 $210,438 Sales Information Previous Sale Price OR Book -Page Qualification Description 06/10/2016 $375,000 30113-2326 Qual by exam of deed 04/01/2004 $315,000 22266-0689 Sales which are qualified 02/01/2003 $270,000 21010-3261 Sales which are qualified 03/01/1994 $100,000 16314-2067 Sales which are qualified The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp http://www.miamidade.gov/propertysearch/ 11/22/2016 Detail by Entity Name Page 1 of 2 Florida Department of State 2 7 Ott' Of Fibtkiri wf/:Ur Department of State / Division of Corporations / Search Records / Detail By Document Number / DIVISION OF CoRFORA? oNs Detail by Entity Name Florida Limited Liability Company GDS HOLDINGS GROUP LLC Filing Information Document Number L11000026248 FEI/EIN Number 27-5333256 Date Filed 03/02/2011 State FL Status ACTIVE Last Event LC AMENDMENT Event Date Filed 06/02/2015 Event Effective Date NONE Principal Address 11053 NW 40TH ST SUNRISE, FL 33351 Changed: 06/02/2015 Mailing Address 151 N NOB HILL RD #355 PLANTATION, FL 33351 Changed: 06/02/2015 Registered Agent Name & Address SANDS, GREGORY 151 N NOB HILL RD #355 PLANTATION, FL 33324 Name Changed: 06/02/2015 Address Changed: 06/02/2015 Authorized Person(s) Detail Name & Address Title MGR SANDS, GREGORY 662 nw 89th ave plantation, FL 33324 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/22/2016 Detail by Entity Name Page 2 of 2 Title AMBR SANDS, INDIRA 11053 NW 40TH ST SUNRISE, FL 33351 Annual Reports Report Year Filed Date 2014 03/24/2014 2015 08/11/2015 2016 02/10/2016 Document Images 0211012016 ANNUAL REPORT 08/11/2015 -- ANNUAL REPORT 06/02/2015 -- LC Amendment 03124/2014 -- ANNUAL REPORT 01//24/2013 -- ANNUAL REPORT 08/23/2012 -- ANNUAL REPORT 03/02/2011 -- Florida Limited Liability View image in PDF format View image in PDF format View image in PDF format View image in PDF formai View image in PDF format View image in PDF format View image in PDF format Depart; e :1 JF S ate, Om' irn nt':c,0oratrcns http://search. sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/22/2016 Miami Shares Viflage Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 A. COPY OF QUALIFIER'S STATE LICENCES B, COPY OF LOCAL BUSINESS TAX RECEIPT C. 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. BUSINESS NAME: RC PIM 6i nj he BUSINESS ADDRESS: g?35 S Cry 10 7 aC)( CITY r►r a At STATE D ZIP 3.317 BUSINESS PHONE: ((3C'.5-) 336 J6 4(6 FAX NUMBER ( ) CELL PHONE ( ) QUALIFIER'S NAME: /I:ilkiD rl C° go 4:)01.13 QUALIFIER'S LIC NUMBER: C- G .14/ 2 92 2 0 U 4. I/ 1/4.1 1 1 16.1 % I.. RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 RODRIGUEZ, RAMON CELESTINO RCR PLUMBING SERVICES, INC. 8835 SW 107TH AVE, #169 MIAMI FL 33176 ISSUED: 07/12/2016 DISPLAY AS REQUIRED BY LAW STATE OF FLORIDA tl-1'3 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CFC 1429270 ISSUED: 07/12/2016 CERTIFIED PLUMBING CONTRACTOR RODRIGUEZ, RAMON CELESTINO RCR PLUMBING SERVICES, INC. 1S CERTIFIED under the provisions of Ch.409 FS. Esa.,al.; 1 date • AUG' 31, 2018 L10371207.3:313 SEQ # L1607120000813 Local Business Tax Receipt Miami—Dade County, State of Florida TH{5IS NOT A BILL - DO NOT PAY 7185709 BUSINESS NAME/LOCATION RCR PLUMBING SERVICES INC 18221 SW 100 CT MIAMI, FL 33157 OWNER RCR PLUMBING SERVICES INC C/O RAMON C RODRIGUEZ PRES Worker(s) 1 RECEIPT NO. RENEWAL 7486550 SEC. TYPE OF BUSINESS 196 PLUMBING CONTRACTOR CFC1429270 LBT EXPIRES SEPTEMBER 30, 2017 Must he displayed et place of business Pursuant to County Coda Chapter £iA - Art. 0 & 10 PAYMENT RECEIVED BY TAX COLLECTOR 75.00 07/12/2016 0229-16.007690 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not n license, permit, or n certification of tho holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental rcpuletary laws end requirements which apply to tire business. t, The RECEIPT N0. above must be displayed on all commercial vehicles - Miami -Bade Corte Sec da -276. rt MIAMI DADErto For wore information, visit w4vw mLP!Idj egoviax_Co ee 2 - ® A o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 11/18/2016 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 Complete Insurance Authority Group, Inc. 126 E McNab Road Pompano Beach FL 33060 CONTNAME: ACT Larry Karavasilis ((A c No, Est): (954) 657-8967 FAX No): (954) 960-5093 ADDRESS: larrykaravasilis@ciaginc.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: COVINGTON SPECIALTY INSURANCE COMPANY 13027 INSURED RCR Plumbing Services, Inc. 8835 SW 107th Avenue Suite 169 Miami FL 33176 INSURER B : VBA463434 INSURERC: 06/02/2017 INSURER D : $ 1,000,000 INSURER E : $ 100,000 INSURER F : BER: 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 WTH 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY N N VBA463434 06/02/2016 06/02/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO PREMISES (EaENTED occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE X 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO JECT PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS AUTOSNN-OWNED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY) DAMAGE (Per accident $ $ UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N / A STAT UTE ERH E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Plumbing LLATION Village of Miami Shores 10050 NE 2nd Avenue Miami Shores I FL 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 ...4,- -27 i� - O - ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • ® ACO v CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11/21/2016 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 A&A Underwriters Inc. 8778 SW 8st Miami FL 33174 CONTACT NAME: Pablo M Conde P HO. No. Ext): (305) 220-7447 lac, No): (305) 220-4821 ADDRESS: Pmc©aaunderwriters.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ASSOCIATED INDUSTRIES INSURANCE COMPAt 23140 INSURED RCR PLUMBING SERVICES INC 8835 SW 107th Ave #169 Kendall FL 33176 INSURER B: INSURER C: INSURER D : $ INSURER E : $ INSURER F : 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO PREMISES (EaENTED occurrence) $ CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GE 'L AGGREGATE POLICY OTHER: LIMIT APPLIES JO - RE T PER: LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ _ SCHEDULED AUTOS AUTOS�ED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DDAMAGE Perer accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENT ON $ A WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? Y (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A AWC1068506 07/20/2016 07/20/2017 X STATUTE PER OOTN ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE- EA EMPLOYEE $ 1,000,000 E.L. DISEASE- POLICY UMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) •" "Plumbing CELLATION I Village Of Miami Shores 10050 Northeast 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 7--------),---<._____ ACORD 25 (2014/01) 2014 ACORD CORPORATION. All rights reserves. The ACORD name and logo are registered marks of ACORD