BBP-13-2257Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-200513 Permit Number: BPP -10-13-2257
Inspection Date: April 03, 2015 Permit Type: Pools/Whirlpools/Hot Tubs
Inspector: Naranjo, Ismael
Inspection Type: Final
Owner: OLIVA, TERESA Work Classification: Addition/Alteration
Job Address: 301 GRAND CONCOURSE
Miami Shores, FL 33138- Phone Number (305)807-1210
Parcel Number 132 50
Project: <NONE> -�
Contractor: PALM BEACH DESIGNER POOLS INC Phone: (561)308-2302
Buildina Denartment Comments
BUILD SWIMMING POOL AND SPA
Infractio Passed Comments
INSPECTOR COMMENTS False
Passed
Inspector Comments
Failed El
S
Correction
Needed
❑
�i
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
For Inspections please call: (305)762-4949
April 03, 2015 Page 1 of 1
�-� Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-231233 Permit Number: BPP -10-13-2257
Inspection Date: March 30, 2015 Permit Type: Pools/Whirlpools/Hot Tubs
Inspector: Dacquisto, David
Inspection Type: Survey Final
Owner: OLIVA, TERESA Work Classification: Addition/Alteration
Job Address: 301 GRAND CONCOURSE R I,
Miami Shores, FL 33138-
fine Number (305)807-1210
U' Feel Number 1132060133850
Project: <NONE>
Contractor: PALM BEACH DESIGNER POOLS INC �. Phone: (561)308-2302
Buildino Denartment Comments
BUILD SWIMMING POOL AND SPA
Infractio Passed Comments
INSPECTOR COMMENTS False
Passed
Inspector Comments
Failed El
Correction ❑
Needed
Re -Inspection
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
For Inspections please call: (305)762-4949
March 30, 2015 Page 1 of 1
BOUNDARY SURVEY
SCALE: 1" = 20' n,4P
6
//2' /.,a/ I
PD.
l/2, l.P.
PD.N w// / 5' W.F.
l/2' LP.
5' W.P. 3' C. 5.5. Wail * W..A
L
51 W.
13'GH.5. Wall* W.F.
4*
R
N
Y001
Mow
TWO STORY
Res. # 30 /
i v � r
8 .89' %v (M) a e 4 d• e
a d'
A e d, .
a
ea .e
NE 94 t ...5 t.
52' Asphalt Pavement
:......._.75� .. TOTAL R/W
3
1
PD.
PK Mad A
Pod Equrpmmlb
5' W.F
290.
G .
a
01 d e
zoP) -fs -
, 7� � r s-�,
-7,4s
��1
NOT TO SCALE "
PROPERTY ADDRE55: 301 Grand Concourse Miami Shores, FL. 33138
LEGAL DE5CRIPTION: Lot 25, Block 28, of MIAMI 51-10RE5 5ECTION 1, according to
' "the plat thereof a5 recorded In Plat Book 10, at Page 70, of the Public Records of
Miami Dade County, Florida.
NOTE:
ELEVATIONS ARE REFERRED TO MIAMI DADE COUNTY BM# N-568 ELEV.= 9.G5 OF N.G.V.D. OF 1929
e . a
I
LEGEND AND ABBREVIATIONS
A= ARC DISTANCE
M/L= MONUMENT LINE
NE 95th St.
2
nl
/3
/4
-
/
2
r%
OS =SANITARY SEWER
CA .= CATCH BASIN
a
/5
3 Goy
(C)= CALCULATED
P.O.C.= POINT OF COMMENCE
4
a
Is
CIO
O POLE
/7
4D
(R)= RECORD
= LIGHT
\4
CONIC.= CONCRETE
RES.= RESIDENCE
® = FPL TRANS.
D.M.E.= DRAINAGE MAINT. EASEMENT
NE 94th St. OSP
��1
NOT TO SCALE "
PROPERTY ADDRE55: 301 Grand Concourse Miami Shores, FL. 33138
LEGAL DE5CRIPTION: Lot 25, Block 28, of MIAMI 51-10RE5 5ECTION 1, according to
' "the plat thereof a5 recorded In Plat Book 10, at Page 70, of the Public Records of
Miami Dade County, Florida.
NOTE:
ELEVATIONS ARE REFERRED TO MIAMI DADE COUNTY BM# N-568 ELEV.= 9.G5 OF N.G.V.D. OF 1929
e . a
I
BASED ON THE FLOOD INSURANCE RATE MAP OF THE FEDERAL EMERGENCY AGENCY REVISED ON 9-11-09 THE HEREIN
DESCRIBED PROPERTY IS SITUATED WITHIN:
ZONE X - BASE FLOOD ELEV. WA. COMMUNITY NUMBER 120652 PANEL NUMBER 0302 SUFFIX L
LEGAL NOTES
THIS SURVEY DOES NOT REFLECT OR DETERMINE OWNERSHIP. EXAMINATION OF THE ABSTRACT OF TITLE WILL HAVE TO BE MADE TO
DETERMINE RECORDED INSTRUMENTS IF ANY AFFECTING THE PROPERTY. THIS SURVEY IS SUBJECTTO DEDICATION LIMITATIONS
RESTRICTIONS RESERVATIONS OR EASEMENTS OF RECORDS. LEGAL DESCRIPTION PROVIDED BY CLIENT. THE LIABILITY OF THIS SURVEY
IS LIMITED TO THE COST OF THE SURVEY. UNDERGROUND ENCROACHMENTS, IF ANY, ARE NOT SHOWN. THIS FIRM HAS NOT ATTEMPTED
TO LOCATE FOOTING AND/OR FOUNDATIONS AND/OR UNDERGROUND IMPROVEMENTS OF ANY NATURE. IF SHOWN BEARINGS ARE
REFERRED TO AN ASSUMED MERIDIAN. IF SHOWN ELEVATIONS ARE REFERRED TO N.G.V.D. OF 1929. THE CLOSURE IN THE BOUNDARY
SURVEY IS ABOVE 1: 10000. THIS SURVEY IS NOT INTENDED FOR NEITHER DESIGN NOR CONSTRUCTION PURPOSES. FOR THOSE
PURPOSES A TOPOGRAPHIC SURVEY IS REQUIRED.
CERTIFIED TO: DATE OF FIELD WORK: M;rcil /5r 20/5
Teresa 0/Iva TX REVISED ON:
L° lffyun(o 12o (Mug
Professional Land Surveyor & Mapper
14317 S.W. 45th Terrace Miami, Florida 33175
Tel: (305) 552-7504 Fax: (305) 229-8068
I hereby certify that the attached Sketch of Surv•Ay of tho herein
described property Is to the best of my knowledgd and bAillaf, a true
and correct representation, of a fir.4d sur ve, perfor-ned under my
direction. And also meets the Minimum Technical Standa^:s as set
forth by the Florldq Board of Professional Surveyors end Mappers in
chapter 5J-17.050 thru 5J-17.0§2 F.A.G. j;ursuant.to Section 472.027
F. S.
RTURO R, TO RAC P.S.M..'.'102 .
Not validlout,
the signatureand the orig'nal ambosed seal of a
Florida Licensed Surveyor and Mapper.
LEGEND AND ABBREVIATIONS
A= ARC DISTANCE
M/L= MONUMENT LINE
= ELEVATION
=CATCH BASIN
AC= AIR CONDITIONED UNIT
B.0 = BLOCK CORNER
CA= OVERHEAD UTILITIES
P.C.P.= PERMANENT CONTROL POINT
® =WATER METER
OS =SANITARY SEWER
CA .= CATCH BASIN
P.O.B.= POINTO OF BEGINNING
w
(C)= CALCULATED
P.O.C.= POINT OF COMMENCE
C'0-3 = POWER POLE
= WATER VALVE
CL= CLEAR
R= RADIUS
O POLE
® =TV BOX
C.L.F.= CHAIN LINK FENCE
(R)= RECORD
= LIGHT
CONIC.= CONCRETE
RES.= RESIDENCE
® = FPL TRANS.
D.M.E.= DRAINAGE MAINT. EASEMENT
RRIGHT-OF-WAY
NV=
®=FIRE HYDRANT
ENC.= ENCROACHMENT
TYP.= TYPICAL
FD= FOUND
U.E.= UTILITY EASEMENT
® = CONC. POWER POLE
F.F.ELEV.: FINISHED. FLOOR ELEVATION
W.F.= WOOD FENCE
®_ MANHOLE
I.F.= IRON FENCE
W.M.= WATER METER
L.F.ELEW LOWEST FLOOR ELEVATION
0= DIAMETER
JOB NUMBER: l 50342
(M)= MEASERED
(j= CENTER LINE
BASED ON THE FLOOD INSURANCE RATE MAP OF THE FEDERAL EMERGENCY AGENCY REVISED ON 9-11-09 THE HEREIN
DESCRIBED PROPERTY IS SITUATED WITHIN:
ZONE X - BASE FLOOD ELEV. WA. COMMUNITY NUMBER 120652 PANEL NUMBER 0302 SUFFIX L
LEGAL NOTES
THIS SURVEY DOES NOT REFLECT OR DETERMINE OWNERSHIP. EXAMINATION OF THE ABSTRACT OF TITLE WILL HAVE TO BE MADE TO
DETERMINE RECORDED INSTRUMENTS IF ANY AFFECTING THE PROPERTY. THIS SURVEY IS SUBJECTTO DEDICATION LIMITATIONS
RESTRICTIONS RESERVATIONS OR EASEMENTS OF RECORDS. LEGAL DESCRIPTION PROVIDED BY CLIENT. THE LIABILITY OF THIS SURVEY
IS LIMITED TO THE COST OF THE SURVEY. UNDERGROUND ENCROACHMENTS, IF ANY, ARE NOT SHOWN. THIS FIRM HAS NOT ATTEMPTED
TO LOCATE FOOTING AND/OR FOUNDATIONS AND/OR UNDERGROUND IMPROVEMENTS OF ANY NATURE. IF SHOWN BEARINGS ARE
REFERRED TO AN ASSUMED MERIDIAN. IF SHOWN ELEVATIONS ARE REFERRED TO N.G.V.D. OF 1929. THE CLOSURE IN THE BOUNDARY
SURVEY IS ABOVE 1: 10000. THIS SURVEY IS NOT INTENDED FOR NEITHER DESIGN NOR CONSTRUCTION PURPOSES. FOR THOSE
PURPOSES A TOPOGRAPHIC SURVEY IS REQUIRED.
CERTIFIED TO: DATE OF FIELD WORK: M;rcil /5r 20/5
Teresa 0/Iva TX REVISED ON:
L° lffyun(o 12o (Mug
Professional Land Surveyor & Mapper
14317 S.W. 45th Terrace Miami, Florida 33175
Tel: (305) 552-7504 Fax: (305) 229-8068
I hereby certify that the attached Sketch of Surv•Ay of tho herein
described property Is to the best of my knowledgd and bAillaf, a true
and correct representation, of a fir.4d sur ve, perfor-ned under my
direction. And also meets the Minimum Technical Standa^:s as set
forth by the Florldq Board of Professional Surveyors end Mappers in
chapter 5J-17.050 thru 5J-17.0§2 F.A.G. j;ursuant.to Section 472.027
F. S.
RTURO R, TO RAC P.S.M..'.'102 .
Not validlout,
the signatureand the orig'nal ambosed seal of a
Florida Licensed Surveyor and Mapper.
.SM SM 3 - 6 5 0
Miami Shores Villages a
Building Department
Gre � .� �uaj
90050 N.E.2nd Avenue, Miami Shores, Florida 33138
13 Tel: (305) 795.2204 Fax: (305) 756.8972 Y. o
INSPECTIONS PHONE NUMBER: (305) 762.4949
q.r�
BUILDING � Permit No. FBC 20
PERMIT APPLICATION Master Permit No. 3 P P SOZ
7
Permit BUILDING ROOFING
JOB ADDRESS: l . it (_ 9 V.,
City: Miami Shores County: Miami Dade Zip:��
Folio/Parcel#: 1 <v � j Ob 1% 1 _� '-'AX,
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): Tc bac , Phone#:
Address:
City: Ni1.0 R -Gs State: Zip:
Tenant/Lessee Name: Phone#.
Email:
CONTRACTOR: Company Name: �Q V
Address: _ � uo .-_ �_ 1 gi tkv t,
City:
Qualifier Name:
,1 1 -3 n_ 2,30 L
State Certification or Registration #: C �� I 4-t) pi Certificate of 5qompetency #:
Contact Phone#: �Daf— 0 �5 -3 ti 7i Email Address: r ~i�- P 5 C
DESIGNER: Architect/Engineer: c �' �- F; '(' r Phone# 65- T-.
Valve of Work for this Permit: $ s � D uare/Linear Footage of Work:
Type of Work: OAddition OAlteration ew ORepair/Replace
. gg
Description of Work: l� _ (< �iN r 144G_ 1_� �i2D 61- 'G710 el- __D-e-�
Color thru tile:
Submittal Fee $ Permit Fee $ t5f 15'5: CCF $ CO/CC $
Scanning Fee $
Radon Fee $
DBPR $ Bond
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
ODemolition
TOTAL FEE NOW DUE $ '
-- 4D�o
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
zip
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
MPROVEVIENTS 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 properly 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 appr o ed and a reinspection fee will be charged
Signature Signature
Owner or Agent Contractor
The fore oin instrument was acknowled ed before this ��
g g �'N'' The foregoing instrument was acknowledged before this �'
day of _ , 20 , byQtc.SdL V Ni Q day of o6 20 , by '� to ��?¢o `!
who is personally known to me or who has produced FL who is personally known to me or who has produced
L 644r�� , As identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC:
f 1 I(ERV 913 DOSTALY
10
Notary Pubk State of Ftmida
Sign: comm
1t a ��� S My cximm. a rg Feb. 7, 2016
Mai
Print: frl
My Commission Expires:
BbltL4
APPROVED BY --V l / Plans Examiner
Cd ` Structural Review
(Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/1909)
NOTARY PUBLIC:
V (' ,,0 • 1(F2Y 04 DOSTALY
Sign: No" Pubk State of FloWe
_ m ons EE 167413
Print: l 2010
My Commission Expires:
„�— Zoning
Clerk
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LIC CARD
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT)
D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION)
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
COMPLETE CONTRACTOR'S INFORMATION
BUSINESS NAME: F.4Im ec - 4L4 , C.' i r- c-'4-1 TOO
BUSINESS ADDRESS: I % c L;7 CITY
STATE ''1-- ZIP CODE_
BUSINESS PHONE:( * ) 309 -2,3®-Z- FAX NUMBER (_)
CELL PHONE Z.3 02- QUALIFIER'S NAME:
QUALIFIER'S LIC NUMBER:
E-MAIL ADDRESS OF APPLICABLE):
Created on 3119109 BY MLDV 1 RV 31209 MLDV
STATE OF FLORIDA
- DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 RTH�
1TALLAH SSEEMONROE STRELT32399-0783
TODOROV, EMANUEL A
PALM BEACH DESIGNER POOLS, INC.
443 34TH ST
WEST PALM BEACH FL 33407
DETACH HERE
C:. STATE OF FLORIDA- .
i 61338`"�
I~iF:PARTiKSNT .QF SUSS SS PROFSS. IOC RI4ULATION
CONSIDC'I'TCCN; INDUSTRY LTCE3MG, SOliiRD : gEf#L120
CENSW
STAFF OF FLORIDAAC# Is 1-33a8.91
Congratulations! With this license you become one of the nearly one million
DEPARTMENT OF-.$USII85 AiSD
Floridians licensed by the Department of Business and Professional Regulation.pRpgg4y�,GbLATZ0N
Our professionals and businesses range from architects to yacht brokers, from
a 1
boxers to barbeque restaurants, and they keep Florida's economy strong.
r 0' 7 ` ix$18661
C1�C14S730��85' I
Every day we work to Improve the way we do business in order to serve you better.z
For information about our services, please log onto www.myfloridalicense.com
: LERT OO�RIF C."QNTR <.
There you can find more information about our divisions and the regulations that
TDDPR0V::, �
impact you, subscribe to department newsletters and team more about the
PAt; $EACH° ;, # i►S, TKC
Department's initiatives.
va
TODORQV , ' i3M Ni7EL A
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!
._ =ssxT=Fxi Wooer _rte p;ooieiQas ag -Ch 4I39 as
WEST PALM BEACH FL 334.07 :y
i �¢� alta. AUG 31, 2a3, t.aaseosslf
L
1
DETACH HERE
C:. STATE OF FLORIDA- .
i 61338`"�
I~iF:PARTiKSNT .QF SUSS SS PROFSS. IOC RI4ULATION
CONSIDC'I'TCCN; INDUSTRY LTCE3MG, SOliiRD : gEf#L120
CENSW
v 7 Y
818662`<
CPC1455080
! 'T.he. COMMETTCIATs P66tiSPA C".QNTR. G r
Named bo1ow ISCERTIFIED r
Under the..'.—r.6va.sion a* of :Ch:apt�;�
Expiration date: AUG 31, 2014 s , } � Vt
4 M1
TODORQV , ' i3M Ni7EL A
i
1A3M3'R C ,":- ICER PO4LS
✓ .,ti x d✓
WEST PALM BEACH FL 334.07 :y
NICK SCOTT
MEN LA@1fS70N
GCV'ER>+TOR
SECRETARY "
DISPLAY AS REQUIRED BYLAW
1800837
10-30-2012
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation lawn.
EFFECTIVE DATE: 12/1212012
PERSCIN: TODOROV
FEIN: 300650560
BUSINESS NAME AND ADDRESS:
PALM BEACH DESIGNER POOLS INC
443 34TH STREET
WEST PALM BEACH FL 33407
SCOPES OF BUSINESS OR TRADE:
1— SWIMMING POOL CONSTRUCTION—NOT
EXPIRATION DATE: 12/12/2014
&MANUEL
IWORTANT: Pursuant to Chapter 440 . 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this
section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(17), F.S., Certificates of election to be exempt... apply only within the
scope of the business or trade listed on the notice of election to be exempt Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation If, at any time after the filing of the notice or the issuance of the certificate, the person named an the notice or
certificate an longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW .o
EFFECTIVE: 12/12/2012 EXPIRATION DATE: 12/12/2014
PERSON: ENANUEL TODOROV
FEIN: 300650560
BUSINESS NAME ARID ADDRESS:
PALM BEACH DESIGNER POOLS INC
443 34TH STREET
WEST PALM BEACH. FL 33407
SCOPE OF BUSINESS OR TRADE:
1- SWIMMING POOL CONSTRUCTION -NOT
IMPORTANT
F Pursuant to Chapter 440.05(141, F.S., an officer of a corporation who
O elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
Pursuant to Chapter 440.05021, F.S., Certificates of election to be
H exempt_. apply only within tate scope of the business or trade listed on
E the notice of election to be exempt
R
E Pursuant to Chapter 440.05031, F.S., Notices of election to be exempt
and certificates of election to be exempt shall be subject to revocation
if, at any time after the filing of the notice or the issuance of the
certificate, the person named on the notice or certificate no longer meets
the requirements of this section for issuance of a certificate. The
department shall revoke a certificate at any time for failure of the
person named on the certificate to meet the requirements of this
section.
QUESTIONS? (850) 413-1609
CUT HERE
- Carry bottom portion on the job, keep upper portion for your records.
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
PALMB-4 OP ID: TF
'`'k �r CERTIFICATE OF LIABILITY INSURANCE
091181 ��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(SJ AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terns 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 Phone: 321-397-3870
Insurance By Ken Brown, Inc.Fax: 321 397-3�
PO Box 94131117
Maitland, FL 32794-8117
Customer Service Unit
cT
rv0ME:
P F
Na No :
a�REss:
INSURERS) AFFORDING COVERAGE MAIC i
oSuRERA:Amerisure Mutual Ins. Co 23396
INSURED Palm Beach Designer Pools Inc
443 34th St
West Palm Beach, FL 33407
INSURER B: Amerisure Ins Com pany 19488
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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
IN 11
TYPE OF INSURANCE
ADDL
UUBN
POLICY NUMBER
POLICY
POLICY EXP
LIMITS
A.
GENERALLIABILr1Y
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE a OCCUR
GL20735210202
11H712012
11/1712013
EACH OCCURRENCE $ 1,000,0001
_
RENTED
PREMISES Ea occurrence $ 100,00
MED EXP (Any one person) $ 5,wm
PERSONAL & ADV INJURY $ 1+wor
GENERAL AGGREGATE $ 21000+
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PR LOC
PRODUCTS- COMPIOP AGG $ Zr�r
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNEDSCHEDULED
AUTOS AUTOS
NON-OWNED OS
HIRED AUTOS AUT
O 1NE SINGLE LIMIT(Ea $
acddenQ
BODILY INJURY (Per person) $
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
UMBRELLA I"
EXCESS 1-1118
OCCUR
CLAIMS -MADE
EACH OCCURRENCE $
AGGREGATE $
DED RETENTION $
$
WORIQBiB COMPENSATION
AND EMPLOYERS' LIABILITYB ANY PROPRIETORIPARTNERfE�CUTIVE YIN
OFRCERIMEMBER EXCLUDE]?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N f A
C207411602
12/29/2012
1 ?12912013
X W 5TA LJ- OTH-
ER
E.L. EACH ACCIDENT $ 100,
E.L. DISEASE- EA EMPLOYEE $ 100,
E.L. DISEASE - POLICY OMIT $ 500, 000
DESCRIPTION OF OPERATION d LOCATIONS f VEMCLES (Attach ACORD 101, Additional Remarks Schedule, If more apece Is required)
CERTIFICATE HOLDER CANCELLATION
MIAMSHO
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Mian i Shores Village Bldg
9 g
THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Dept
10050 NE 2nd Ave
Miami, FL 33138
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
PREY YR. $ - 00 uc. FEE $ 38.25
$ _.100 PENALTY $ .00
$ : QO OOL FEE $ • 00
$ .00 TRANSFER $ .00
TOTAL 26.25 TOODOROV, ZMAUMM A
IS HEREBY LICENSED TO ENGAGE IN THE SLISINESB. PROFMON OR OCCUPATION FWA MRCS DWXGftR P00LS,
OF 110OL./8PA COI+ T"CTOR 1500 ow SWARAVE Tffi
AT LOCATION L$TED'FORTHE PERIODBEGINNING ONTHE BART, rL ' 34997
19 DAY OF SRPT&1MRR 20 13
AND ENDING SEPTEMBER 30. 2014 804 2012 01125.0001 PAID
INC
THIS FORM BECOMES A RECEIPT ONLY WHEN VALIDATED BY RECEIPTING MACHINE.
ANYONE DOING BUSINESS WITHOUT A VALID BUSINESS TAX RECEIPT IS
SUBJECT TO A $250 FINE. IF NOT PAID BY OCT. 1, A DELINQUENT PENALTY OF '100/0
FOR THE MONTH OF OCTOBER, PLUS A 5% PENALTY FOR EACH MONTH
THEREAFTER UP TO 255/6, PLUS COLLECTION COSTS WILL APPLY.
NOTE -A PENALTY IS IMPOSED FOR FAILURE TO KEEP THIS BUSINESS TAX
RECEIPT EXHIBITED CONSPICUOUSLY AT YOUR ESTABLISHMENT OR PLACE
OF BUSINESS.
9
From:Janice Keppeler FaxID:InS by Ken Brown Page 2 of 2 Date:22812014 12:57 PM Page:2 of 2
PALMBA OP ID: JK
CERTIFICATE OF LIABILITY INSURANCE
a.vvCRia{7r0 CERTIFICATE NUMBER' DC\/ICIAAI AIIInnQCo.
•vm ucr�.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE
DATE
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
1 4"'
02/28/2014
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 pollcy(les) 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
Insurance By Ken Brown, Inc.
PO Box 948117
Maitland, FL 32794-8117
Customer Service Unit
NCONTACT
AME.
PHONE
Ass:(AIC'No
ADD
INSURER(S) AFFORDING COVERAGE NAIC f
LIMITS
INSURER A:Amerisure Mutual Ins. Co 23396
GENERAL LIABILITY
INSURED Palm Beach Designer Pools Inc
1900 SW Belgrave Terrace
Stuart, FL 34997
INSURER 13:Amerisure Ins Company 19488
INSURER C:
INSURER D:
INSURER E :
A
INSURER F :
a.vvCRia{7r0 CERTIFICATE NUMBER' DC\/ICIAAI AIIInnQCo.
•vm ucr�.
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,
AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
IV
�TRR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
MMIDp
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,00
A
X COMMERCIAL GENERAL LIABILITY
GL20735210302
11/17/2013
11/17/2014PREMISES
Ea occurrence $ 100,000
FRI
MED EXP (Any one person) $ 5,000
CLAIMS -MADE OCCUR
X Pool Pop
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS- COMP/OP AGG $ 2,000,000
X POLICY PRO- LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
Ee accident $
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
BODILY INJURY (Per accident) $
AUTOS AUTOS
HIRED AUTOS NON -OWNED
AUTOS
PROPERTY DAMAGE $
PER ACCIDENT
$
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESSLWB
CLAIMS -MADE
AGGREGATE $
DED RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
WCSTATU- OTH-
X
B
�ICER/PMREIMBER EXCLUDED? CUi1VE YIN
NIA
C2074116-03
12/29/2013
12/29/2014
E.L. EACH ACCIDENT $ 100,000
(Mandatory In NH)
Ityes, describe under
E.L. DISEASE - EA EMPLOYEE $ 100,000
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required)
308-756-8972
rCOr CIPr Arc Uri, -
MIAMISH
Miami Shores Village Building
Department
10050 NE 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.
AUTHORIZED REPRESENTATIVE
US lsse-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD