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CC-14-2747
Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-251821 PermitNumber: CC-12-14-2747 Scheduled Inspection Date: January 29,2016 Permit Type: Commercial Construction Inspector: Rodriguez,Jorge Inspection Type: Final Owner: MANAGEMENT LLC,ADVANCE Work Classification: Alteration CI ACIr1A Job Address:9190 BISCAYNE Boulevard Miami Shores, FL Phone Number Parcel Number 1132060100030 Project: <NONE> Contractor: GOLDEN SANDS CONSTRUCTION MANAGEMENT&MAINT Phone: (305)633-3336 Building Department Comments INTERIOR REMODEL 2 NEW ATMS TELLER ASSIST Infractio Passed Comments INTERIOR AND 1 NEW ATM WITH TELLER EXTERIOR INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. January 28,2016 For Inspections please call: (305)762-4949 Page 29 of 33 (4® 2, GOLDSAN-02 SSIMEON ,d►CORL7° CERTIFICATE OF LIABILITY INSURANCE DATE(M/2D/Y 1/20/2016 6 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 CONTACT NAME: Collinsworth,Alter,Fowler 8 French,LLC PHONE (305)822-7800 Fvc,No:(305)362-2443 8000 Governors Square Blvd Alc No Ext Suite 301 E-MAIL Miami Lakes,FL 33016 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Twin City Fire Insurance Co 29459 INSURED INSURER B:Hartford Casualty 29424 Golden Sands General Contractors,Inc. INSURER C:North River Insurance Company 21105 2500 NW 39th Street INSURER D:Federal Insurance Company 20281 Miami,FL 33142 INSURER E:Catlin Specialty Insurance Co 15989 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 TYPE OF INSURANCE ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MMIDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE lxl OCCUR 21UENQT4514 02/01/2016 02/01/2017 PREMISES Eaoccurrence $ 300,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X]PRO- [] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1,000,000 B X ANY AUTO 21UENOT4516 02/01/2016 02/01/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS EX AUTOS X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 12,000,000 C EXCESS LIAB CLAIMS-MADE 5811063876 02/01/2016 02/01/2017 AGGREGATE $ DED I X I RETENTION$ 0 Gen Aggregate $ 24,000,000 WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE I ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA 21WBQT4513 02/01/2016 02/01/2017 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D Crime 82214761 02/01/2016 02/01/2017 Employee Theft 2,000,000 E Errors&Omissions CPL6899360217 02/01/2016 02/01/2017 E&O/Pollution 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space Is required) For GC License Numbers CGC062617-Mary F.Maguire and CGCO54362-Peter P.Fedele CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE O'/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD I � STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 11100-M1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MAGUIRE, MARY FRANCES GOLDEN SANDS GENERAL CONTRACTORS INC 2500 N W 39TH ST MIAMI FL 33142 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 STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. �� PROFES:SIONAL REGULATION Every day we work to improve the way we do business in order to CGC062617 ISSUED::.;06/17/2014 serve you better. For information about our services,please log onto www.myfloridalleense.com. There you can find more information CERTIFIED GENERAL CONTRACTOR about our divisions and the regulations that impact you,subscribe to department newsletters and learn more about the Department's MAGUIRE,MARY FRANCES initiatives. GOLDEN SANDS GENERAL CONTRACTORS I Our mission at the Department is:License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your "r customers. Thank you for doing business in Florida, IS CERTIFIED under the provisions of Ch.488 FS. and congratulations on your new license! Explu tiondate:AUG31.201e L1406170001002 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD ` ' CGC062617 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 MAGUIRE, MARY FRANCES GOLDEN SANDS GENERAL CONTRACYORSINC _ 2500 N W 39TH ST MIAMI FL 33142 l 4 ■ R, ISSUED; 06/17/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406170001002 001376 -� s Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 4632288 BUSINESS NAMEMOCATION RECEIPT NO. EXPIRES ;OLDEN SANDS GENERAL CONTRACTORS INC RENEWAL SEPTEMBER 30, 2016 2500 NW 39 ST #104 46362511 Must be displayed at place of business MIAMI EL 33142 Pursuant to County Code Chapter BA --Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED GOLDEN SANDS GNRL CONTRACTORS 196 GENERAL BUILDING CONTRACTOR eY TAX COLLECTOR INC CGC062617 $75.00 08/04/2015 Worker(s) 3 ECHECK 15-159287 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit,ora certification of the holders qualitications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above.must be displayed on all commercial vehicles-Miami-Dade Code sec Ba-276. For more information,visit www.miamidade.govfkaxcollector Miami Shores Village �' � - Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 f r'�- _ S�%'��--i Tel:(305)795-2204 Fax:(305)756-8972 �. INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 d0 BUILDING Master Permit Ne CC! 14 ®Z,'1 4-1 PERMIT APPLICATION Sub Permit No. OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL E]PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9190 Biscayne blvd. City: Miami Shores County: Miami Dade zip: Folio/Parcel#:11-3206-010-0030 Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Brite Stone Investment LLC Phone#:305-397-8986 Address:1160 Kane Concourse, Suite 202 City: Bay Harbor Islands State: FL Z;p: 33154 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Golden Sands General Contractors Inc Phone#: 305-633-3336 Address: 2500 NW 39th Street City: Miami State: FL zip: 33142 Qualifier Name: Mary Maguire Phone#: State Certification or Registration#: CGC062617 Certificate of Competency#: DESIGNER:Architect/Engineer: Infinity Engineering Group LLC Phone#: 813-445-4211 Address:1135 Marbella PLaza Drive City: Tampa State: FL zip: 33619 Value of Work for this Permit:$ ( 5 S� r� Square/linear Footage of Work: / / , Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: :QNPr*u-oar iC L (2)PRO aT d'5 -.)/-'ELI✓0L A I ) NFA ATH (jI."f'K T& &L ass. 7 ��( ➢�1 Specify color of color thru tile: Submittal Fee - Permit Fee$ S c' CCF$ n�,�, KJV CO/CC$ Scanning Fee 1 Radon Fee$ X DBPR$dk7 - Notary$ Technology Fee$`G -9 C) Training/Education Fee$ CI . 2 Double Fee$ Structural Reviews$ Q Bond$ 4 TOTAL FEE NOW DUE$ �G (Revised02/24/2014) , t s 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. Signatur ,dl Signature OWNER or AGENT ONTRA OR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this —t} day of ^a 20 1L by �l day of / 1 20by who is`rsonally known to 41 1 'F H6[17 I tP ,who is personally known to Me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NO YPUBLIC: NOTARY PUBLIC: "iii'"� MARIZOL CLARK �pNY nG�i 3�0,.••• Bim: Notary Public,State of Florida My comm.expires Aug. 26,'2018 r==fii iv4•�� Sign: Sign. . ` Commission Number FF 154979 Print: B`'•., ROBERT PHILLIP LISMAN print Seal " MY COMMISSION#FF001132 o` ••,,,ep��o�;.. EXPIRES March 20,20 Seal: (407)398 0153 FloridallotaryService.com 616tst JJ le4WeN 1101881W9j0a grip 901'91 'any segdxe•WW03 An N& °•°�,�o APPROVED BY Lv �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 's CRFs ..i. nil Miami Shores Village L= �y� Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: 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 Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE 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 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: 6a LDC^j Sa.v4 s 6;1WiVF"C &W7nU CjUZ s :6;Vc , BUSINESS ADDRESS: 9S60 Nw 34r st CITY N(t Agl STATE �L ZIP 331 Z_ BUSINESS PHONE: j 0S ) X033-3334. FAX NUMBER(--) CELL PHONE(,S61 ) 'T BY— 75-60 QUALIFIER'S NAME: td A2`( H,4(90165 QUALIFIER'S LIC NUMBER: G 6 G o&Z. G t 7 x'r. •,, MARIZOL CLARK +s r a o1•r' ¢ Inv, LIC +N L.X48 E �gNotar Public;State of Florida c�`��-I My comm.expires Aug. 28.2018 � M260-5 t9 7 9-0Commission Number FF154979 ©' NCEt eke OWEOLA ST I$UlnELAND,FL 3301-5,560[loeOB t1d!i'St SER F .e-s's :ef.3018 ,' A RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION s CONSTRUCTION INDUSTRY LICENSING BOARD CGCO62617 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 i i MAGUIRE, MARY FRANCES Di GOLDEN SANDS GENERAL CONTRACTORS INC 2500 N W 39TH ST MIAMI FL 33142 ISSUED: 06117/2014 DISPLAY AS REQUIRED BY LAW SEO a L1406170001002 006696 Local Business Tax Receipt Miami—Dade County, State of Florida THIS IS NOTA BILL - DD NOTPAY �LBT ) 4632288 BUSINESS NAMIULOCATION RECEIPT NO. EXPIRES GOLDEN SANDS GENERAL CONTRACTORS INC RENEWAL SEPTEMBER A 2015 2500 NW 39 ST #104 4838251 Must be displayed at place of business MIAMI FL 33142 Pursuant to County Code Chapter BA-Art 9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED GOLDEN SANDS GNRL CONTRACTORS 196 GENERAL BUILDING CONTRACTOR BY TAX Cou.6oron INC CGCO62617 $75.00 07/17/2014 Worker(s) 3 ECHECK-14-139978 This Local Baslnese Tax Receipt only continua payment of the Level Business Tex.The Recalpt Is not a floense, pormlt.or a certification of the holders qualiflcadolm,to do business.Holder must amply with any governmental w noagovemarental regulatory laws and requirements which apply to the business. The RECEIPT N0.above most be displayed on all commercial vehicles-Mimi-Dade Code See ge-M For more Infermation,vialtpy mlamldada.aovltexaollomor GOLDSAN-02 SSIMEON ACG7ROm DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/10/2014 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 policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditJons 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 CONTACT NAME: Collinsworth,Alter,Fowler&French,LLC PHONE 305 822-7800 FAX No: 305 362-2443 8000 Governors Square Blvd Arc No Ext:( ) Suite 301 ADDRESS: Miami Lakes,FL 33016 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Twin City Fire Insurance Co 29459 INSURED INSURER B:Hartford Fire Ins Co 19682 Golden Sands General Contractors,Inc. INSURER C:North River Insurance Company 21106 2500 NW 39th Street INSURER D:Federal Insurance Company 20281 Miami,FL 33142 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 TYPE OF INSURANCE ADDLSUBR POLICY NUMBER MOMfDLICYD EFF Myo EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 21UENQT4514 2/1/2014 2/1/2015 PREMISES Ea occurrence $ 300,00 CLAIMS MADE I1 OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY FX-1PRO LOC $ AUTOMOBILE LIABILITY COMEaBINEDdentSINGLE LIMIT $ 1�000�00 aca B X ANY AUTO 21UENQT4515 2/1/2014 2/1/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS X H RED AUTOS X NON-OAUTOSWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB XJ OCCUR EACH OCCURRENCE $ 5,000,00 C EXCESS LIAB CLAIMS-MADE 5811025698 2/1/2014 2/1/2015 AGGREGATE $ 5,000,00 DED FX RETENTION$ $ WORKERS COMPENSATIONX WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVEY/N N/A 21WBQT4513 2/1/2014 2/1/2015 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D Crime 82214761 2/1/2014 2/1/2015 Employee Theft 1,500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,K more space Is required) For GC License Numbers CGCO62617-Mary F.Maguire and CGCO54362-Peter P.Fedele CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 9 p ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Detail by,Entity Name Page 1 of 2 Detail by Entity Florida Limited Liability Company BRITE STONE INVESTMENT LLC Filing Information Document Number L13000177392 FEI/EIN Number NONE Date Filed 12/27/2013 State FL Status ACTIVE Effective Date 01/01/2014 Principal Address 1160 KANE CONCOURSE SUITE 202 BAY HARBOR ISLANDS, FL 33154 Mailing Address 1160 KANE CONCOURSE SUITE 202 BAY HARBOR ISLANDS, FL 33154 Registered Agent Name &Address POLIAKOVA, ANNA 1160 KANE CONCOURSE 202 BAY HARBOR ISLANDS, FL 33154 Authorized Person(s) Detail Name &Address Title MGR POLIAKOVA, ANNA 1160 KANE CONCOURSE, SUITE 202 BAY HARBOR ISLANDS, FL 33154 Title MGMR ADVANCE FLORIDA MANAGEMENT LLC 1160 KANE CONCOURSE, SUITE 202 BAY HARBOR ISLANDS, FL 33154 Title MGMR http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail/EntityName/flal-1... 11/13/2014 i� GOLDSAN-02 SSIMEON A�ORU" CERTIFICATE OF LIABILITY INSURANCE DATE 1 1//27/227/2015 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,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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Collinsworth,Alter,Fowler&French,LLC PHONE 305 822-7800 FAX 8000 Governors Square Blvd Arc No Ext):( ) ac No):(305)362-2443 Suite 301 E-MAIL Miami Lakes,FL 33016 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURERA:Twin City Fire Insurance Co 29459 INSURED INSURER B:Hartford Fire Ins Co 19682 Golden Sands General Contractors,Inc. INSURER C:North River Insurance Company 21105 2500 NW 39th Street INSURER D:Federal Insurance Company 20281 Miami,FL 33142 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. 1�TR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF Map EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE T OCCUR 21UENQT4514 02/01/2015 02/01/2016 PREMISES Ea occurrence $ 300,00 MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 JPRO- POLICY 71 LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 B X ANY q�0 21 UENQT4515 02/01/2015 02/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY eraccdent $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 12,000,000 C EXCESS LIAB CLAIMS-MADE 5811039261 02/01/2015 02/01/2016 AGGREGATE $ 24,000,000 DED FX RETENTION$ 0 $ WORKERS COMPENSATION X PEROTH- AND EMPLOYERS'LIABILITY Y/N STATUTEI ER A ANY PROPRIETOR/PARTNER/EXECUTIVE 21WBQT4613 02/01/2015 02/01/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDE[ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,000,000 D Crime 82214761 02/01/2015 02/01/2016 Employee Theft 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS r VEHICLES(ACORD 101,Additlonal Remarks Schedule,may be attached If more space Is required) For GC License Numbers CGCO62617-Mary F.Maguire and CGCO54362-Peter P.Fedele CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE A kW ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Miami Shores Village °REs y Building Departme fell 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 A jVRimp► Fax: (305) 756.8972 Permit No: Page 1 of 1 Structural Critique Sheet &-Fyo �-,v J-t �. �.�. ON STOPPED REVIEW Plan review is not complete,when all items above are corrected,we will do a complete plan review. If any sheets are voided,remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re-submittal drawings. Mehdi Asraf