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MC-17-49 /' 'MC 1� 1 . o i s r s ° r; Miami Shores Village M 10050 N.E.2nd Avenue NE t11A111 Miami Shores,FL 33138-0000 c _ 3.. 9(fl7j `j +TS Phone: (305)795-2204 _. 1�01 _. Expiration: 08/07/2017 Project Address Parcel Number Applicant 201 NE 95 Street 1132060133920 Miami Shores, FL 33138-0000 Block: Lot: DVS LLC Owner Information Address Phone Cell DVS LLC 9400 NE 2 Avenue (305)756-3711 MIAMI FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 5,000.00 JV&VR SERVICES CORP (786)301-3029 Total Sq Feet: 0 Tons: Available Inspections: Additional Info:BATHROOM EXAUST AND HALLWAY DUCT WO Inspection Type: Classification:Commercial Ventilation Approved:In Review Final Comments: Date Approved::In Review Rough Date Denied: Type of Work:BATHROOM EXAUST AND HALLWA`r Rough Duct Scanning:1 Duct Detector Test Review Mechanical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.00 Invoice# MC-1-17-62558 DBPR Fee $2.25 DCA Fee $2.25 01/09/2017 Credit Card $50.00 $115.50 Education Surcharge $1.00 02/08/2017 Credit Card $ 115.50 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $4.00 Total: $165.50 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. February 08,2017 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy February 08,2017 1 � Miami Shores Village I= -100, Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 b `\40 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201--k BUILDING Master Permit No. C. PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC F-1 ROOFING REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP /�`�� �I C, CONTRACTOR DRAWINGS JOB ADDRESS: 2u City: Miami Shores County: Miami Dade zip: ?J 3q� Is the Building Historically Designated:Yes NO Folio/Parcel#: 320(o"0 k Occupancy Type: Load: Construction 1Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): ��� rL,I-(-- Phone#: -780' I-93 1 ✓ b . Address: 20� City: (Q t-A*l C ,UCs'� State: - Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name3IIV ss-ylt 3.C.C..�-mss G�f Phone#: )-q 5W &.1 Address: 52 G D �f¢4T giz 4y _ City: b tr+ttIcz� State: ��. Zip: z•C Qualifier Name: "Z�o 44• fle 4�;'kiQ Phone#: 7.3-4f !;--y a (;I I Q State Certification or Registration M 47�4C c'l�5-7&? Z/ Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: —5,00 City: State: Zip: Value of Work for this Permit:$ s ej Square/Linear Footage of Work: Type of Work: ❑ Addition Mr Alteration ❑ New ❑ Repair/Replace ❑ Demolition Desai tion of Work: ® /fel 4 Ge' Specify color of color thru tile: r Submittal Fee$ Permit Fee$ CCF$ '�� CO/CC$ Scanning Fee$ 'O J Radon Fee$ �'2S DBPR$ 2.ZS Notary$ Technology Fee$ Training/Education Fee$ •O Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ •50 (Revised02/24/2014) Ri 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 a eeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law broc re will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commence ent must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the a ence of such posted notice, the inspection will not be veed and arei sn pe ' n fee will be charged. Signa a Signature OW or A CO OR The fore )in stru��m((ent was acknowledged before me this The ffo/regoing instrument was acknowledged before me this // - —day of l V���/p lM l2P' 20 4 4 by 1 day of :T 20 �� by Ptgw/v,who is er �'1—Cafcl 0 personally known to me or who has produced as me or who has produced o Q I S-Z®I �D Z-f SC-) identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: UAUA Sign ,��.•• •ti? MY COMMISSION 0 GG 044802 Print: Print " �r;�,1iR� Bonded Tlvu Notary PUbac Utu>�a b, Seal: ;+P EU7ABETH ELORRIAGA Seal: MY COMMISSION#FF953M EXPIRES JanL=y 26.2= IAO/13AN O'b9 M. APPROVED BY ans Examiner Zoning V ML Structural Review Clerk (Revised02/24/2014) f Miami Shores Village Building Department v 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 • a. BUILDING Permit No. PERMIT APPLICATION Master Permit No.GG 3 1 FBC 20 Permit Type: MECHANICAL OWNER:Name(Fee Simple Titleholder): Address N ©1 e4q�� City: N}A-M State: Tenant/Lessee Name: Phone# Email: JOB ADDRESS: City: Miami Shores County: Miami Dade Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: CONTRACTOR:Company Name: � ►�9 C3h9'1 �bcC °,�}°,�° '- 3a�c -Phone#:_IbS'Zli -O'"at Address: 10yO�A City: !n-�PS M o L State: Zip: Qualifier Name: Phone#: 30`Jg-* o�;S State Certification or Registration#: Certificate of Competency#: Contact Phone#: ')J, * S6- '1'Mn Email Address: �s�l.Nlrr e �}C ComL4�y •i�L DESIGNER:Architect/Engineer: Phone#: Value of Work for this Permit:$ - Square/Linear Footage of Work: Type of Work: OAddress OAlteration ONew ORepair/Replace ODemolition Description of Work: �� 1��t2 x �1 �S Submittal Fee$ Permit Fee$ Ly CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Educadon Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 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 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: YOUI -. FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY $ IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YO ERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT, " 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commepeement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. I he absence of such posted notice, the inspection will . and a reingection fee will be charged. F Signature Signature O r or Agent Contractor The foregoing instrument was acknowledged before me this l'� The foregoing instrument was acknowledged before me this day of _J7a a-d..,20 J2L by�UJ_&= &Cts¢,du-A-i day of ,20 ia,by !E_&\ r6 in , 1 ne3 !r who iso rsonal} snow o me or who has produced who is personally known to me or who has produced J-( As identification and who did take an oath. 10t: as identification and who did take an oath. NOTARY PUBLIC: NOTARY PU Sign. Sign. Print: LAytA hoot?.-,e, L)e_V rA&_oTLy' Print: My Commission Expires: a°tPa`PUBS% LAURA BOURNE BURIOfALTER My Commission Ex es: =ftte * MY COMMISSION#DD 859461 ��� � loridaEXPIRES:June 9,2013 48$OFFVOA) BondedThruBudge!NotaryServices ,2018 tC tC 7th $i >$*QQ« 1tt 7k7$ 7tt7t11tt1tt l)< 1kljtl$7t« * $« * Q $ 1k 1k JU APPROVED BY ® b P s Examiner Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Nov. 06.2013 11:24 PAGE. 1/ 1 . A CERTIFICATE OF LIABILITY INSURANCE1 10/18/2013 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the t:ertificata holder la an ADDITIONAL INSURED,the polloy(les)must be endorsed. If SUBROGATION IS WAMD,subject to the terms and 0011 10116 Of the policy.certain poBeles may require an endorsement. A stotement On this certificate does not confer rights to the certificate holder in lieu of such endoreemenMo. PRODucaRCKHrrAcrDawtd M. Lopax Eastern Insurance Group, Inc. (305)595•-3323IM. e303)sos-713a 9570 OR 107 Avenue Mascar@easternineura.nce.not Sulto 104 At+f rind t:OV agm HMO Miami FL 33176 INME10RA,1lesociated Industries Ins. INSURED INiURaR B Palmetto BOY Air.•,Conditioning Service, Inc. HlsuReRo: 11271 SW 191. Terrace alauReRe: Miami FL 33157 aasuaeR P; COVERAGES CERTIFICATE NUMBERM4at er 13-14 REVISION NUMOOR: 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, TYPE OF INSURAN00Luwffrs ►L 00410tLIAMUTY Alm 1=ACN oc�.IRRaNaa a coawERM"GENERA(,LIABILITY PUAW R s a CLNMSAIADH OCCUR MED EXP one pMtwja PERSONAL A AW INJURY a GENERAL AGGRRM-M a 6I!1VL AGGREGATE LMATAPPUES PFR; PRODUCTS.COMPADP AG6 $ POLIOY PRO. LOC a AUTOMMUZ LIAMUTY IT ANY AUTOALLCANWKCILY INJURY(Per pereon) a AUTO$ D �18DlA.E01 SWILYINJURY(WraaoldwO S Yoe tdREDAuros p�+���0 a '""Aa a °� M4 UR S s(casa UAe OIAiMS MAp6 A00R1:6A7F_ a A Vlonjam cowax"MON S ANa 10&U W10W LlAft1UWX APROPRIET0R PA�UTIVE Y/N NY (l Iltcey�I wi)EXtX llDED7 1:1N/A LMU1024637 /30/2033 /30/20�1< E.L EAgi ACCIDENT a 1 000 000 IPYee.Q"-161be UrAw E.L.DISEASE.EA 04q.0YH a y oao 000 D P11tlN OF OPERATION.s•bokn„ F.L.LSFABE- LMT; a 11000.00 DESMPTM OP OPERA7K=I LOCATION&/VMWLRS(Attach,AOORD 701.Addwwm RemmYsseloedt ,N Aeon space N Air Conditioning Contractors rpWna) CERTIFICATE BOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TmEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLIcY PROVISIONS. Building Department 10050 NE 2 Avenue AUTN0RWWRM""Hq TATIVE Miami shores, FL 33138 Avid Lopez/AMI - --� ACORf)ZS(2010/OS) *11 986-2010 ACORD CORPORATION. All rights reserved. INRr12Rnmerutm Th.AMPn nama aeul Innn arm rA"iatn.w{.narlro n!Aetm 1 �', �� � v' �� �, �...- I �' i r I i �, Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores,Florida 33938 Tel:(305)795.2204 Fac(305)756.8972 Notice to Owner—Workers' Com ..neation Insurance Exel i tion man Florida Law requires Work®'Compensationmsntance coveaaga ceder Chapter 440 of the Florida Statutes. Fra Stat§440.05 allows corporate officers in the construction industry to exempt themselves from this requircment for any conswxtion project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer feats Broahmw: An employer in the construction industry who employs one or more part-time or fall-time employees,including the owner,mast obtain workers'compensation coverego. Corporate oificars or members of a limited liability company(LLC)in the construction industry may elect to be exemptiE 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement atteaCwg to the-in;—10 p=ent ownership; 2. The oifrcar is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members am allowed to be exempt Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revolted by the Division. Your contractor is regtiwtwg a permit under this workers'compensation exemption and has aclmowledge that he or she will not use day labor.Part-lima employeas or subcontractors for your project.The contractor bas provided an affidavit stating that he or she will be the only person allowed to work on your projeaL In these circumstances,Miami Shores Village dans not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part time employees or subcontractors. BY SIGNING B OWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENT Si Owner State of Florida County of Miami-Dade {, The foregoing was acknowledge before me this 3 d day of s ,20L BY s� t?q �� wbo is oarsonally known to me or has produced as identification. y� Notary STM ELp SEAL: W /iF9 tmriasatras 21L 2= cur '4c R CERTIFICATE OF LIABILITY INSURANCE D 1 2130/201 6 Y) `,.../ 12/30/2016 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(les)must be endorsed. If SUBROGATION IS WANED,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 ALL CITY INSURANCE INC-ACI CONTACT CARMENRODRIGUEZ 275 FONTAINEBLEAU BLVD. PHONE 305 463-9431 F 305 436-6797 SUITE 190 E-MAIL GMAIL ALLCITYINS.COM MIAMI FL 33172 INSURERS AFFORDING COVERAGE NAIC# INSURERA.UNITED SPECIALTY INSURANC 12537 INSURED INSURER B: PRIORITY CONSTRUCTION MANAGEMENT, INC. INSURER c: 4631 NW 5 ST INSURER 0: MIAMI FL 33126- INSURER E: COVERAGES CERTIFICATE NUMBER:05 REVISION NUMBER:00 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 PD POLICY NUMBER OLICY EXP LIMBS A GENERAL LIABILfTY TAM-0005197-02 08/24/201608/24/2017 EACH oOCURRENCE $_ 1-000.000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS-MADE F_X1 OCCUR MED EXP(Any oneperson) $ 5,000 X A/I BLANKET PERSONAL BADV INJURY 1,000,000 GENERAL AGGREGATE 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP OP AGG 1,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY Y_/N_ ANY PROPRIETOR/PARTNER/EXECUTVEI N/A E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? U (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE D es,describe under SL JIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CONTRACTOR LICENSE#CGC 058991 CERTIFICATE HOLDER CANCELLATION Al COMMWJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING&ZONING DEPT. ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE 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 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND I! i4 PROFESSIONAL REGULATION CGCO58991 ISSUED:_';06/05/2016 CERTIFIED GENERAL CONTRACTOR: DE ARMAS,OMAR FELIX - PRIORITY CON9rktjcTt0 N MANF.ItGFMENT ,- IS CERTIFIED under the provisions of Ch.489 FS. E bnQBle AUG31.2D1s L160S 1302 I M 1 003714 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY 3732840 RECEIPT NO. EXPIRES BUSINESS NAME/LOCA'nON SEPTEMBER 30 2017 PRIORITY CONSTRUCTION MANAGEMENT INC RENEWAL , 3897734 Must be displayed at place of business 4631 NW 5 ST Pursuant to County Code MIAMI FL 33126 Chapter 8A—Art.9&10 SEC.TYPE OF BUSINESS PAYMENT RECEIVED OWNER TAX CTOR PRIORITY CONSTRUCTUION MGMT INC 196 CGCO 89SERAL BUILDING CONTRACTOR $45.00 07/20/2016 Worker(s) 1 FPPU06-16-019779 • This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license. permit or'. r a certification of the holder's qualrficaaons,to do basin m Holdere bus business with any governmental or nongovernmental regulatory laws and requirements which apply The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec ga-276. colle r For more inrfonnatien,visit wwwmiamidede aovR_�_ •�°an vra • JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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 law. EFFECTIVE DATE: 8/12/2015 EXPIRATION DATE: 8/11/2017 PERSON: DEARMAS OMAR F FEIN: 650697046 BUSINESS NAME AND ADDRESS: PRIORITY CONSTRUCTION MANAGEMENT INC 4631 NW 5 ST MIAMI FL 33126 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14),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(12),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 on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 4631 aU 5' at Mwm, R 33126 . 786-299-2776 State of Florida County of Miami- Dade Before me this day personally appeared Omar de Armas who, being duly sworn, deposes and says: That he will be the only person working on the projected located at 201 NE 95th Street, Miami Shores, FL 33138 S4-- Sworn to (or affirmed)and subscribed before me this day of (Rmv. 20j 1oby Personally Known Pri t,Type or Stamp Name of Notary EIIZgg��N ura� M•COMMU SM 0 ff833536 • EXPMS Jamuwy 25.2C20 goon:iee�•sa am