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MC-13-1315all Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 ( - ("I--- Inspection Number: INSP - 193376 Permit Number: MC -6 -13 -1315 Inspection Date: February 24, 2014 Inspector: Perez, JanPierre Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: Addition /Alteration Phone Number (863)688 -747_ Parcel Number 1132060100010 Contractor: EXCELL REFRIGERATION INC Phone: (561)585-0342 Buildi!na Deoartment Comments INSTALL COOLERS AND CASES AS PER MASTER Infractio Passed Comments PRPJECT INSPECTOR COMMENTS False Passed Inspector Comments Failed El Correptiom Needed t Re-inspect! G .'. Fee No Additional Inspections can be scheduled until re- inspection fee is paid. For Inspections please call: (305)762 -4949 February 24, 2014 Page 1 of 1 EXCELLR OP ID: JT CERTIFICATE OF LIABILITY INSURANCE 10103113""' 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 CONSTTTUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT: If the certifi holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. N SUBROGATION IS WAIVED, subject to the term 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 endorssme s PRODUCER Phone:561- 683 -8383 P.O. SLATONINSURANCE Fax: 561 - 684599 P.O. Box 220537 West Palm Beach FL 33422 Casey Cunniff, CPCU �E CONTACT PHONE No 1NSU AFFORDING COVERAGE NAIL $ INSURER A: BrIdgefield Employers Ins. Co. EACH OCCURRENCE $ 1,000, INSURED Excel/ Refrigeration, Inc. 605 Whitney Avenue Lantana, FL 33462 =uRER a: Hanover American Ins. Co. 36064 INSURER c: Federal Insurance Company 20281 INSURER o: Hanover American 36064 INSURER E.- Hanover ins. Co. 22292 $ 2,000,0 INSURER F PRODUCTS - COMPIOP AGO I 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. LT R TYPE OF INSURANCE POLICY NUMBER LDSTS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILrIY CLAIMS -MADE FK OCCUR X Broad Form LZJW5297004 PRIMARY AND NON CONTRIBUTORY 07/01/13 07101/14 EACH OCCURRENCE $ 1,000, PREM ES E, = $ 100, MED EV (Arty are person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,00 X Contractual Llab GENERAL AGGREGATE $ 2,000,0 GEML AGGREGATE LIMIT APPLIES PER: POLICY PRO M LOC PRODUCTS - COMPIOP AGO $ 2,000, Emp Ben. $ 1,000,00 D AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS LED NON-OWNED HIRED AUTOS X UTOOS AZJ589075704 07/01/13 07/01/14 C accident) D S N 1 1,000,0 X BODILY INJURY (Per person) $ BODILY INJURY (Per scddent) $ X � acd� DAMAGE $ PIP -BASIC $ 10,00 E X UMBRELLA LU16 EX�SUAB X OCCUR CLAIMS -MADE UHJ877691103 07101h3 07/01/14 EACH OCCURRENCE $ 4,000,00 AGGREGATE $ 4,000, X RETENTION 0 $ A WORKERS COMPEN8ATKIN AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEROMCUTNE YIN OFFICERtMEMSER EXCLUDED? (Mmut torym NH) rc ea, � D I O S N I A 830-0614 EMLOYERS' LU►BILIIY INCL 01101113 01101114 X WC STATU- X OTH- EL. EACH ACCIDENT $ 600, E.L. DISEASE -EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500, C Equipment Floater 06641632 07101/13 07/01/14 RentfLeas 100,0 ILSC.RPTKIN OF OPERATIONS I LOCATIONS i VEN CLES (Attach ACORD 107, Addt mW Rmmft SdmMe, N awry space ls m**m ) Bubliz #794 9050 Biscayne Blvd. Miami Shores, FL 33138 MIAMISH Village of Miami Shores 10050 N.E. 2nd Avenue 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 POLICY PROVISIONS. © 1966 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010106) The ACORD name and logo are registered marks of ACORD Permit Type: MECHANICAL JOB ADDRESS: 09000 FStscayne 15Ivd City: Miami Shores County: Miami Dade Zip: Folio/Parcel# ({ "20(0 -0 {0 -0010 Is the Building Historically Designated: Yes NO X Flood Zone: "138 OWNER: Name (Fee Simple Titleholder):1NuST BANK eTAi. Trt9 %PU�nc yureRMr NO Phone#: Address: P O 150X 32025 City: Lakeland Ste. PI- gip; -3-3802 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Excell R6+r19ewatf0n Phone#: 5(0l "585 "0342 Address: 6009 "+,ney Ave City: lamria State: rL Zip: "462 Qualifier Name: Raymond Taylor Phone#• State Certification or Registration #: CACO224I-3 Certificate of Competency #: Contact Phone#: 6(ol -r —0-342 Email Address: r.rooneyCA excellre+rirm+%on.com DESIGNER: Architect /Engineer: Phone#: Value of Work for this Permit: $ 2(o8'8'TZ Square/I3near Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: Install coolers and cases as per Master OCGIPAZ -1 ,928 Submittal Fee Scanning Fee $ Notary $ Double Fee $ _ Permit Fee $ Radon Fee $ I • DBPR $ Bond $ Training/Educatlon Fee $ Technology Fee $ ;R 0 • ;t C) Review $ TOTAL FEE NOW DUE $ • Bonding Company's Name (if applicable) N/A Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address N/A City State zip 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 approved and a reinspection fee will be charged Signature Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 _, by , who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Expires: APPROVED By Signature Contractor The foregoing instrument was acknowledged before me this � day of 20 1, byii7 who is orally kn to me or who has produced as identification and who did take an oath. 1i Examiner Structural Review Revised 3 /12/2012)(Revised (Y7 /10 107)(Revised 06/10 /2009)(Revised 3/15/09) NOTARY PUBLIC: Zoning Clerk i' Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 193372 Scheduled Inspection Date: August 22, 2013 Inspector: Perez, JanPierre Owner: INC, PUBLIX SUPERMARKETS, Job Address: 9050 BISCAYNE Boulevard Miami Shores, FL 33138- Project: <NONE> Contractor: EXCELL REFRIGERATION INC Comments INSTALL COOLERS AND PASES AS PER STAR PROJECT � �►'' t 40W Permit Number: MC -6 -13 -1315 Permit Type: Mechanical - Commercial Inspection Type: Rough Work Classification: Addition /Alteration Phone Number (863)688 -747_ Parcel Number 1132060100010 Phone: (561)585 -0342 INSPECTOR COMMENTS False v 6 Inspecto mments Pase;� Failed go" Ar Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until P � V " re- inspection fee is paid. August 21, 2013 For Inspections please call: (305)762 -4949 Page 7 of 38 "A V4 0 aw. . ���\ � \. Ml \/ k oml -IkC)M �� � ���\ ���� � \�\ Im BUILDING Miami Shores Village JUN 1 I zot3 p. 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 FBC 2010 1 Permit No. � J 5 PERMIT APPLICATION Permit Type: MECHANICAL Master Permit No. CC- 10- 12 -I°J28 oJOG�O 13�sca ne 151VA JOB ADDRESS: Y � t City: Miami Shores C® Miami Dade gip; 33138 Folio /Parcel# II- 320(0- 010 - 00104' ' Is the Building Historically Designated: Yes NO ^ Flood Zone: OWNER: Name (Fee Simple Titleholder): NOKT'HMN TROT Bic f-7& TRO % PU" OWMMARMT M Phone#. Address: P O ROX N.M2 City: Lakeland State: Zip; 33802 Tenant/Lessee Name: F U AL ` —7011 Phone#: "N. Email: CONTRACTOR: Company Name: Ewe-ell Wet .geration Phone#: ry(ol - 585-0342 Address: 606 Whitney Ave City: Lantana State. F'L 334 02 Zip: o Qualifier Name Raymon J Taylor Phone #: 1 . ��S ® 3 - State Certification or Registration #: CACOZZ413 Certificate of Competency #: Contact Phone#: %01 -585 -0342 Email Address: r- rooney cexeellrefrigeration.eom DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 0 ° -z, Square/Linear Footage of Work. Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: Install coolers and cases as per Master *CC- 10 -12 -Me Submittal Fee $ Permit Fee $ d �'� Y ��CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ TOTAL FEE NOW DUE $ ° L ar 1016 Bonding Company's Name (if applicable) Bonding Company's Address City N/A State Mortgage' Lender's Name (if applicable) Mortgage Lender's Address City N/A 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. l� Signature Signature Owner or Agent The foregoing instrument was acknowledged before me thia� day o �> bye Pr' M�(a 1Z1�> who ' sonally known me or who has produced As identification and who did take an oath. NOTARY PUBLIC: My Commission Expires:a_5 -15* APPROVED BY * MY COMtdt5SION II EE u5b111 tf EXPIRES: February 5, 2015 Bonded Tiuu Budget Notary Services ntractor The foregoing instrument was acknowledged before me this %0 day of 20 J&, by RA~ _ , who is persongLkown me or who has produced as identification and who did take an oath. Examiner Structural Review Revised 3 /12/2012)(Revised 07 /10/07)(Revised 06110nM)(Revised 3/15/09) NOTARY PUBLIC: Sign: Print: t1-a1L My Commission Expires: E-W%EXPURM: �II{ SWABY MSSIOx a EB83n Dawmba 13, 2016 �sh> ffi�a7$ e3, ey8aggaga> gs k�> k$ e> p> k�+ �sk> k> k$a�ksAsp��dt�kds��$�8+��kHedak da'k4��k�k� Zoning Clerk EXCELLR OP ID: JT A`coR' °" CERTIFICATE OF LIABILITY INSURANCE �` ' TYPE OF INSURANCE 06�i10 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, subs to the terms and conditions of the policy, certain policies may require an endorsement. A Statement on this oertlfloate does not confer rights to the certificate holder In lieu of such endorsem s . PRODUCER Phone: 561483 -6383 SLATON INSURANCE P.O. Box 220537 Fax: 561 -6844885 West Palm Beach FL 33422 Casey Cunnlff, CMU NVICT WL Elk MOM No M-OWL S AFFORDING COVERAGE Kwo 07101112 INSURER A -Brld efield Employers Ins. Co. EACH OOC1RRF.NCE $ 1r�. INSURED Excels Refrigeration, Inc, 605 WhitneyAvenue Lantana, FL 33482 n1auRER s: Hanover American ins. Co. 364 INSuwc :Federal Insurance Company 0281 @CLICKER D: Hanover American 38064 INSURER E . Hanover ins. Co. 22282 $ 2,000 INSURER F: PRODUCTS - COMP/OP AGO I COVERAGES 1`F1*`Mf_ATF 1dI1UUFD. "Iew s1I INAMCO. -- - -- ----- - - - - -- --------------- - - -- 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. I TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED IR)UtIES BE CANCELLED BEFORE POLICY NUlIIM Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. U1NT8 B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLARWS -MADE FRI occtm X Broad Form LZJ595297003 PRIMARY AND NON ONTRIBUTORY 07101112 07101113 EACH OOC1RRF.NCE $ 1r�. pREwSw Es oa a $ 100, MED EV (My an person) $ $. PERSONAL & AM INJURY $ 11000, X Contractual Liab GENERAL AGGREGATE $ 2,000 GEN'L AGGREGATE UMIT APPLIES PER: POLICY PRO- LOO PRODUCTS - COMP/OP AGO $ 2,000,00 Ben. $ 1,006, D AUTOMOBILE X X Lu1SLnY ANY Auro ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS X AUTOS J589076703 07101112 07/01113 (ga a erd 11000,00 BODILY INJURY (Perp —n) $ BODILY INJURY (Par a $ $ PIP -BASIC $ 1010 E X UMBRELLA UAB EXCESS Lute X OCCUR CLAIMS•MADE HJ877691102 07101112 07101113 EACH OCCURRENCE $ 4,080+ AGGREGATE $ X rwr 0 $ A WORICERS COMPENSATION AND E®PLOYERq' LIABILITY ANY XBtro r ro EA DR�U'M YIN (MarAdM In NN) urdw DESCRIPTION OF OPERATIONS b X814 LOVERS' LIABILITY INCL. 01 1113 01/01114 X V FATU X OTH E EAai AcaoENr $ �.� E.L. DISEASE -EA EMPLOYEE $ 500100 EL DISEASE - POLICY I IMIT $ �Os C Equipment Floater =41632 07/01112 07/01113 Rent/Leas 100, DESCRIPIM OF OPERATIONS I LOCATIONS I VEHICLES (Afb>ch ACORD 701, AddlftnW Rmmwks SchMW% B more space Is mqulmd) Publix 0794 9050 Biscayne Blvd. Miami. Shores, FL 33138 CERTIFICATE HOLDER t`AMf`CI I AT InA1 MIAMISH SHOULD ANY OF THE ABOVE DESCRIBED IR)UtIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE Wn L BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10060 N.E. 2nd Avenue _ AuTH� ... .. _ Mlarrd Shores, F[. 33138 bT 1888 -2010 ACORD CORPORATION. AN rights reserved. ACORD 25 (20101x'►) The ACORD name and logo are registered marks of ACORD l y r � . •� ""O EXCELLR OP ID.- JT 164,,,,,'x°. R°`a CERTIFICATE OF LIABILITY INSURANCE °"'�( 09/13 07109/13 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) Trust be endorsed. B SUBROGATION IS WANED, subject to the terns and conditions of the policy, cartarin polies may require an endorsement. A statement on this certificate does not confer rights to the certiftsts holder In lieu of such errde�se s . PRODUCER SLAT INSURANCE Phone: �1 P.O. Box 220537 Fact: 581- 684.599 West Palm Beach FL 33422 Casey CunniR, U6 E NO . ma AFFORDING COVERAGE NAIC A lNft ER A. Brldpffeld Emplopirs Ins. Co. GENERAL LiABR.11Y X COMMERCIAL GEN 1ERALLIASIUTY CLms -MADe XI OCCUR X Broad Form INSURED Excel[ Refrigeration, Inc. 605 Whitney Avenue Lantana, FL 33462 INSURER 8: Hanover American Ins. Co. 36064 INSURER C: Federal insurance Company 20281 IIsaRER o: Hanover Amerit:an 136064 aw iRER E. Hanover Ins. Co. 122292 _ MED E P — n $ lox-al 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 LM TYPE OF 04SURANM ADM SUER POLICY NUMBER POLICY EXP LIMITS B GENERAL LiABR.11Y X COMMERCIAL GEN 1ERALLIASIUTY CLms -MADe XI OCCUR X Broad Form L.ZJ505297004 PRIMARY AND NON CONTRIBUTORY 07101113 07/01114 EACH OCCURRENCE $ 10000, $ 100, _ MED E P — n $ lox-al PERSONAL & ADV INJURY $ 1,000, X Contractual Liffi GENERAL AGGREGATE $ 2,000, GENT. AGGREGATE LI FAIT APPLIES PER: POLICY LAC PRODUCTS - COMROP AGG $ Z000, p Sen. $ 1}000, D AUTOMOBILE LaABllnv X ANYAUTO � X HIREDAUTOS X AUTTOS EDED 5$9075704 07/01/13 07101114 1,000, BODILY INJL RY (Per person) $ BODILY INJURY (Per acddwk) $ wwaaddenn -- $ PU%BASIC $ 10, E X UMBRELLA UAS EXCESS LAB X OCCUR CLAIMS-MADE UHJ877699103 07101/13 07101/14 EACH OCCURRENCE $ 4,000, AGGREGATE - $ 4,000, X 0 $ A WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIEr ARTNERIExEcunVE YIN OFFICFR EXCLUDED? pftrAatay in NM) P( less/ NOF T NIA 14 ML.OYERS' LIABILITY INCL. 01109113 01/01114 X A X Mt E.L. EACH ACCIDENT $ E.L. DSEASE- EAEWLOYE ,5001 $ 500, E.LDISFASE- POJCYUMFT $ 5001 C Equipment Fluter 06641632 0710113 0701114 Rent/Leas 100, DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES {Alta¢h ACORO 401, Ad"Onea Remoft Schedule, N more apace 1s required) Re: Pablix 0794 9050 Biscayne Blvd. Miazi- Shores, FL 33138 MUWISH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E. 2nd Avenue Miami Shorty FL 33138 AUTHORIM REPRESENTATIVE 1 I _ ©19111111-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD 08/13/2013 12:48 954- 583 -3995 Dominik Swaby Page 2/2 OP ID: JT DATE (MMIDD/YYYY) 12/26112 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 INSURERS), AUTHORIZED 'EPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. APORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(iesj 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 endorsementlsl_ PRODUCER SLATON INSURANCE P.O. Box 220537 /Nest Palm Beach, FL 33422 Casey Cunniff, CPCU INSURED Excell Refrigeration, Inc. 606 Whitney Avenue Lantana, FL 33462 Phone: 661 - 663 -8383 NaanE `'1 Fax: 561-684-59951 PHONE - - -... —. FAX _ i.ar. No): COVERAGES CERTIFICATE NUMBER: _— TI IS E: Hanover Ins. Co. _.._ X22292 REVISION NUMBER: 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 INSURERS) AFFORDING COVERAGE .; NAIC 4 _ INSURER A : BrldgefieId Employers Ins. Co. "' — tMMID YY , IMMIDD/YYYY LIMITS LIABILITY INSURERS: Hanover American 22292 1,000,00 -' INSURER C:Federal Insurance COanpany :20281 MED EXP (Any one person) $ X Broad FomT II�RII;o4ARY AND NON - -_ INSURER D: Massachusetts Bay lnsurancG Co — COVERAGES CERTIFICATE NUMBER: _— TI IS E: Hanover Ins. Co. _.._ X22292 REVISION NUMBER: 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 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TERMS, INSR •ADDL• POLICY ' -• -- - - -' " "- — LTR ` -TYPE OF INSURANCE EFF POLICY EXP INSR POLICY NUMBER "' — tMMID YY , IMMIDD/YYYY LIMITS LIABILITY GENERAL EACH OCCURRENCE $ B Jl COMMERCIAL TO RENTE15 1,000,00 -' GENERAL LIABILITY I LZJS85297003 07/01/12 07/01113 ,DAMAGE I . PREiv11SES (Ea occurrence_ $ - �.... I CLAIMS-MADE OCCUR I 100,00 MED EXP (Any one person) $ X Broad FomT II�RII;o4ARY AND NON 5,00 _ - PERSONAL & ADV INJURY S Contractual Liab CONTRIBUTORY I I 1,ODO,OO -- I GENERAL AGGREGATE $ I 2,000,00 �X - GEN'L AGGREGATE LIMIT APPLIES PER. i PRODUCTS •COMP /OP AGG j $ i POLICY PRO- LOC - -- �+ - _ I( Emp Berl. $— —I - 2,000,00 ' — 9,000,000 • -�' ! i COMBINED SIN LE LIMIT AUTOMOBILE LIABILITY •, 1,000,00 (Es accide t)_ __.... X 'ANY AUTO AZJ589075703 07101/12 07/01/13 BODILY INJURY (Per person) 5 • I ALL OWNED SCHEDULED - - -- .._. I _ I AUTOS AUTOS I BODILY INJURY (Per accident) $ X I HIREDAUTOS )( NON-OWNED - PROPERTY DAMAGE _- $ - -•" i ( AUTOS Psracddent] -- -- J PIP -BASIC 1$ 10,00 .._ -- - i X 1 uMBRELLA LIAB X OCCUR EACH OCCURRENCE $ E EXCESS LIAR ( - - -- 4,000,00 - CLAIMS -MADE UHJ877691102 07/01/12 07/01/13 AGGREGATE $ 4,000,00 BED - X i RETENTION O $ WORI(ERS COMPENSATION -� ! '•• ..- - -- : WC STATU- X OTH- AND EMPLOYERS' LIABILITY I ( X ' ..LIMITS E(3__- A 'ANY PR OPRIETOR/PARTNER/EXECUT VE YIN I 830- 40114 01/01/13 01/01114 E.L. EACH ACCIDENT _ $ OFFICER/MEMBER EXCLUDED? N 7 A 600_ 00 , _ (Mandatory in NH) EMLOYERS° LIABILITY INCL. E.L. DISEASE - EA EMPLOYEE' $ 11yes, describe under DESCRIPTION F QPERATIONS below E.L. DISEASE- POLICY LIMIT $ 600,000 _ 500,00 C Equipment Floater 0664/632 I I ( 07101/12 ! 07/01/13 Rent/Leas 100,00 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks - -��� Schedule, If more space Is'required) f_[= C9TiCYJ+A•Y� uait, ws"e. TOW NOFJ Town of Jupiter 210 North Military Trail Jupiter, FL 33458 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL HE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUT14ORIZED REPRESENTATAIE leu�l� ©1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/06) The ACORD name and logo are registered marks of ACORD ` A m iv a M. G A X N#141t P.O. 8= 3353. West pt. Ham. Fi. 33402- 3353 ma t irnx coc tgcran www.taxcOUSColpbc aortl Tet (561) 355-2272 ambig waa Ceuntg TYPECIFOUSOMM (NAM 23-0140AAi COMMMSM COMM TAYLOR RAYUM LESM This d mwwd Is vabd only when teceipted by the Tax Colleclo's Office. 82-W EXCEL. REFPJGERATION INC EXCELL REFRIGERATION INC W5 WHITNEY AVE LANTANA, FL 33462 -1641 1r { {ru {111 {1r {r { {s11r {r {ur { {r {1111 {11{111{{ ys � "1 -OCATM AT"" 606 WHITNEY AVENUE LANTANA, FL 33462 CE RTIF"T" s RRMPT MWE PAID AMMA#J ML x CAC=44f3 U12 11 -Q3 w" midi 0400OW4 STATE OF FLORIDA PALM REACH COUNTY 201212013 LOCAL BUSINESS TAX RECEIPT L.BTR Number: 9999 ©2793 EXPIRES: SEPTEMBER 30.2093 Thlbrecelptdoesnotconslituteakanchise, agreement. petrftsiart of authority to perknn the services or operate the business desalmd herein when a ftnr another courtly corms n. state or fixieral paunisslot of author Is fewulmd by county, state of fedenif law. '°41"TW AT" fits WHrTNEY AVENUE LANTANA, FL 33462 rMOFOUSIDEW cram 7Et3i� r r MATE PAID AMT PAID @q ( g 23-0mcwAMCONDn'100MC0347PACTUR I TAYLOR RAW= CA A2M3 UUMMI - i2 Sias 85 This ductoneit is vat only when owe#ftd by the Tax Code's Office. STATE OF FLORIDA PALM BEACH COUNTY 81 -146 201212013 LOCAL BUSINESS TAX RECEIPT EXCELL REFRIGERATION INC LBTR Number: 999902712 EXCELL REFRIGERATION 04C EXPIRES: SEPTEMBER 30.2013 LAN WHITNEY 34 This f does not corm a fuse, LANTANA, FL 334821649 Of adhorrly to parrorm the 1111 1131 111 {n 131111111/111111111111111111 /11 services orthe business dedhefefn when a fiandbe, agrewma or ollm county connnissloiL state or federal pwinission of aut xwly is requinxi by may. she of lwjwW kw. • 0STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487_1395 1940 NORTH MONROE STREET TALLAHASSER FL 32399 -0783 TAYLOR, RAYMOND LESLIE EXCELL REFRIGERATION INC LANTA�NAI�Y AVE FL 33462 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.m Eloridaliaense_com There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and !earn 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 licensel DETACH HERE srAt of tLo�t;n . AC# 6 14 2 9 4. ' DEPARTNIMT * 617 BUSINESS ANU'• PROFESSIONAL ;REGULATION . •:... CACO22413 _ ° °`:. o %a j tZ lis193792 CERTIFIEDf:AIR;`Ct3ND? t3Q1+i'CR' TAYLOR. RAi!kaQNi? jt3LILH;• EXCELL REiCRiT;�bPj.- INC I3 - CERTIFIED under• the grovisioiis of ca.499 as. wwirattoa uatse AUG 31,• 2014 ra20S2900739 JAG# G 14 2 9 4 7 STATE OF FLORIDA., DEPARTMENT OF BUSINESS" AND PROFESSION AL REEG� ATION :CONSTRUCTION INDUSTRY Li ENSIN BO SEW L12052900739 • LICENSE NBR ; 1 05/29/2812. 1118193752 IcACO224: The CLASS A AIR C6NDITI6NINt3 i Named below IS CERTIFIED. - ..., Under the provisions of Chapte Expiration date: AUG 31, 2014 $7. _ TAYLOR r RAYMOND LESLIE ... -• t' �: �_! . - �:=��' ,� ... ' _ EXCELL REFRIGERATION INC 605 WHITNEY AVE j LANTANA FL 3 3 4 6 2 RICK SCOTT: `.° _ KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW