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HomeMy WebLinkAboutFolio 2024-2026 Permit - CR 7896 CR 7896 - 9/24/2024 CONTRACTOR REGISTRATION 100 West Dania Beach Boulevard*Dania Beach,FL 33004 /;� ) (954)924-6805*3651,3633 or-3652 Fax(954)922-2687 ( DANrA JFbCH PLEASE PRINT LEGIBLY Type of Contractor "P10‘mbit. Company: Name `�r�;�, `? ,r Office Address 6a.S- C-10Lire City/State/Zip l Ctv ck v1 c. Ft "3 3L1 Le`a Office Phone# SG?c- 'l - 'r5r1 tr Qualifier: Name }. It C LX'rna v'l Office Address 3 a_s- „r V'.r\v- _ City/State/Zip LAAA.lekinv. c4CoQ..- Home Phone# S(o Owner: Name .>•soit ._ A.\n Q vG Office Address City/State/Zip Home Phone# PROVIDE PHOTOCOPIES OF THE FOLLOWING DOCUMENTS Qualifier's Driver's License Lco SS -Sy►-(' - - oFrl- G State: t ay- c .c,, City Business Tax License - - City: -- County Business Tax_Lioense County: ?car" 'pY - L 1 T State License CEcJ4 SSVI Certificate of Competency --- Certificates of Insurance must show the City of Dania Beach as the Certificate Holder General Liability Expiration Date: ti I a-C-- Workers Compensation Expiration Date: s t I tt a I hereby certify that t r stained herein is true and accurate to the best of my knowledge. Qualifier's Signature Date Thhe.foregoing instrument was acknowledged before me this it ate- day of \ n 207`_it By 1---A t(Anr,,Lal v vtnt),v, who is personally know I to MP or has produced as identification and did(or did not)take an oath My Commission Expires: b , OLEYDL B.TORRES MY COMMISSION#HH 197118 Contractor Registration Rey, " '' EXPIRES:November 15,2025 ` 09 26 2017 '•''.£ash;°r: Bo�T�,NotesyPublici3ndennitCrs I Lamm i I 411) ea r OWN .4i co It.) Z a I = =Ce Q W Li) iu O Llj <; ' I/ ` N vi a , 'L1 aG 1I [ -44 ',,, ,$ M ,:,, -'OLU U a J I ! III W � U � oN 0 � � , s }.. W .1* 1' tyre I— :fir , "ii',i Co z 4- LL , Lt1 n E•• co co u 0 W (/) 0 O i ' 0 u-a d itl 1 . ; ; 0 0 '2 0 F— Z Z re = co .0; ? 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O x E r.,,,„, w m D 11r o y o i e `0n A D0 CERTIFICATE OF LIABILITY INSURANCE DATE A E(MM/D z4YY) 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 Keyes Coverage Insurance PHONE Gina Barragato FAX 5900 Hiatus Road we.No,Ex():954-724-7000 (A/C,Not:954-724-7024 Tamarac FL 33321 ADOREss: gbarragatoOkeyescoverage.com INSURER(S)AFFORDING COVERAGE NAIC$ License#:L068199. INSURER A:Arch Insurance Company 11150 INSURED 15152 INSURER B:Westchester Surplus Lines Insurance Company 10172 Bierman,LLC; Dirty Waste Haulers,LLC DBA Raider Rooter INSURER C:Indian Harbor Insurance Company 36940 525 Gator Drive INSURER D: Lantana FL 33462 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER:541754796 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 ADDL SUER POLICY EFF POLICY EXP LIMITSLTR INSD WVD POLICY NUMBER IMM!DDIYYYY) (MMIDD/YYYY) A X COMMERCIAL GENERAL LIABILITY Y Y ZAGLB9251803 5/1/2024 5/1/2025 EACH OCCURRENCE $1.000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $300000 MED EXP(My one person) $10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LMT APPLIES PER: GENERAL AGGREGATE S?000,000 POLICY X 'SCOT- LOC PRODUCTS-COMP/OP AGG $2,000,000 X OTHER. Contractual $ A AUTOMOBILE LIABILITY Y Y ZACAT9282903 5/1/2024 5/1/2025 COMBINED SINGLE LIMIT e lEa accident) 1.000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS jeer accident) X Comp$250 X Coll$500 PIP $10,000 C X UMBRELLA LIAB X OCCUR Y Y SXS006333901 511/2024 5/1/2025 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED RETENTION$ $ A WORKERS COMPENSATION Y 2AWC19973903 5/1/2024 5/1/2025 X ;MUTE EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER EXECUTIVE ELEACH ACCIDENT $1,000,000 OFFICER/MEMBEREXCLUDED? N N/A ----- (Mandatory in NI-I) EL DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $1,000,000 B Pollution Liability Y Y G2830559A 004 4/8/2024 4/8/2025 Each Pollution Limit 1,000,000 General Aggregate 2,000,000 Deductible 2,500 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Plumbing Qualifiers:Michael Lerman:#CFC1430554 City of Dania Building Department is included as an additional insured for ongoing&completed operations on the General Liability&an additional insured on Auto Liability when required by written contract.Waiver of subrogation applies to General Liability when required by written contract.Cancellation applies as per policy terms and conditions CERTIFICATE HOLDER CANCELLATION 60 days notice 110 days for Non-Pay SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Dania Building Department 100 W. Dania Beach Blvd. AUTHORIZED REPRESENTATIVE Dania FL 33004 I ' ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 1 s 1 It I g ' 141) i .*.g7'12W l 1 t flij A:f W. C 4 1 r r \j\\ "' 1 w 1 $ 3 I