DS-16-2611 y Permit NO-
Miami Shores Village Permit 7'ppe �tiVeWayS/Si13ikstSia
10050 N.E.2nd Avenue NW W,,6r,�esCetfo .Aloe/Ae*14.�
Miami Shores,FL 33138-0000 Status APPIRdVib
r
y�PN � Phone: (305)795-2204 ' " -
�coRmA
6, Expiration: 03/26/2017
tssue. :9/271�t}1
Project Address Parcel Number Applicant
9105 NW 1 Avenue 1131010160110
IDRIZ AND SANDA KOVACEVIC
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
IDRIZ AND SANDA KOVACEVIC 9105 NW 1 Avenue (305)496 8914
MIAMI SHORES FL 33150-2248
9105 NW 1 Avenue
MIAMI SHORES FL 33150-2248
Contractor(s) Phone Cell Phone
Valuation: $ 6,500.
77
PREMIER CONSTRUCTION AND PAVE (954)441-4224 00
Total Sq Feet: 1375 I.
Approved:In Review Available Inspections:
Comments: Inspection Type:
Date Approved::In Review Final
Date Denied: Foundation
Type of Work:CONCRETE DRIVE WAY Additional Info:CONCRETE DRIVE WAY Review Planning
Bond Return:CONCRETE DRIVE WAY Classification:Residential Review Planning
Scanning:3 Review Planning
Review Building
Review Building
Review Building
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
Bond Type-Contractors Bond $500.00 Invoice# DS-9-16-61429
CCF $4.20 10/04/2016 Check#:3036 $674.70 $0.00
DBPR Fee $2.25
DCA Fee $2.25 Bond#:3227
Education Surcharge $1.40
Permit Fee $150.00
Scanning Fee $9.00
Technology Fee $5.60
Total: $674.70
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AF VIT: I cert��all th f going information is accurate and that all work will be done in compliance with all applicable laws regulating
construction an orn FuthI a rizethe above-named contractor to do the work stated.
October 04, 2016
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
October 04,2016 1
Miami Shores Village
Building Department SEP 21 2816
10050 N.E.2nd Avenue,Miami Shores,Florida 33138 '�_41 D
Tel:(305)795-2204 Fax:(305)756-8972 13y:
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20114
BUILDING Master Permit No.DS 0xV (U
PERMIT APPLICATION sub Permit No.
❑BUILDING ❑ ELECTRIC Ej ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
PLUMBING ❑ MECHANICAL [—]PUBLICWORKS F-1 CHANGE OF ❑CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
10B ADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): 2ZAI Z ��/VAe'1P_y1z- Phone#:
Address:. W
City: < State: Zip:
Tenant/Lessee Name: Phone#:
Email: �� /J� �{
CONTRACTOR:Company Name: �in/�P� �,�(�''l0✓] 7 APhone#:�,1� -�y '
Address: � #V-(-
City: __FA—vie- State: & Zip: J 333y
Qualifier Name: / Love, Phone#:
State Certification or Registration#: ertificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ �—o Square/Linear Footage of Work: 3 7�
Type of Work: ❑ Addition ❑ Alteration
jj ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: .0/l u✓�✓ ��
S 1.,AQ4 JAN,
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$ u —1
TOTAL FEE NOW DUE$
(Revised02/24/2014)
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$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
_W---
WNER or AGENT NTRACTOR
The foregoing instrument was acknowledged befor me this The foregoing instrume t wapack owledged before me this
day of 20 by day of E 20 �h by
I-I Z �rsy/a�1/JL who is p sonally own to / who is p sonally kn wn to
me or who has produced as me or who has pr duced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print:
Seal: Cal'paus„
SANDY
ROMERO
S A N O� H i M E w Notary Pubk State o1 FE201*9*
�`�* ��� �r�#'aAiI��P�$b4*�Sd�skae�l�Ffs •**re****�**�x*r*s *, ** *COmmISSIon a FF 915708 'a,,, ;� my Comm.Ex I s
By Comm.Expires Sep 7,2019
vFn Y Plans Examiner oning
Structural Review Clerk
(Revised02/24/2014)
E
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
LYMAN, MICHELLE
PREMIER CONSTRUCTION AND PAVERS
4200 SW 141 AVE
DAVIE FL 33330
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 DEPARTMENT OF BUSINESS AND
restaurants,and they keep Florida's economy strong. ,:. ..'" PROFE ,SIQN4L•RE+CULATION
Every day we work to improve the way we do business in order CBC1256001SUE1 :__ 06102/2016
to serve you better. For information about our services,please
log onto www.myflofidalicense.com. There you can find more CERTIFIED BU CONTRAC�"bR
information about our divisions and the regulations that impact LYMAN,MICHE,IX
you,subscribe to department newsletters and learn more about PREMIER CONST UCTI¢N PAVERS
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, Is.CERTIFIED under the provisions of ch..4e9 FS.
and congratulations on your new license!
dare,AUG 37,2018 Lsosozaoo„off
DETACH HERE
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD fid' x
CBC1256001
The BUILDING CONTRACTOR
Named below IS CERTIFIED
Under the provisio6s ofChapter 489 FS. h
Expiration date:AUG 31,2018
UE Lei
LYMAN, MICHELLE
-PREMIER CONSTRUCT11?, D PAVERS `S
,(200 SW 141 AVE ` •z . ` �.._,. .� ., ,
j DAVIE FL 33:336
ISSUED: 06/02J2016 DISPLAY AS REQUIRED BY LAW SEQ# L16*06020001106`
i
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm.A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000
VALID OCTOBER 1,2016 THROUGH SEPTEMBER 30,2017
Cg PREMIER CONSTRUCTION AND PAVERS Receipt 'GE ERAL4CONTRACTOR (BUILD Mr.
Business Name: Business Type:
yOzaTRACTOR)
Owner Name:LYMAN MICHELLE/QUAL Business Opened:08/11/2009
Business Location:4200 SW 141 AVE
tate/COtf rttylCertlReg:CBC 12 5 60 O 1 =;
DAVIE Exemption Code: x
Business Phone:
Rooms seats Employees Machines Professionals
2
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid
27.00 0.00 0.00 0.00 0.00 0.00 27.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non-regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements.This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location.This receipt does not indicate that the business is legal or that14
it is in compliance with State or local taws and regulations.
Mailing Address:
PREMIER CONSTRUCTION AND PAVERS Receipt #52A-15-00008610
4200 SW 141 AVE Paid 07/26/2016 27.00
DAVIE, FL 33330
2016 ® 2017
pq, g ®..®,p..m_ _ ...y' �p
....i.c 1 A Q J ire,=Sri.i°w °r v X Ww► .C�. .A.PA°"
r
y >
JEFF ATWATER
CHIEF FINANCIAL OFF;CErR STATE OF FLORIDA
DEPARTMENT OF =INArNCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
*
CERTIFICATE OF FLECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW".
CONSTRUCTION INDU>,TRY EXEMPTION
This certifies that the Individual listed velour has elects(i to be exempt+tom Florida Workers'Compensation law
EFFECTIVE DATE: 1/28/2016 EXPIRATION DATE: 1/27/2018
PERSON: LYtt AN MICHELLE
FEIN: 20551€1821
BUSINESS NAME AND ADDRESS:
PREMIER ENTERPRISE tall+SUP DF SOUT.-i FLORIDA INC:
PREMIER CONSTRUCTION AND PAVERS
4200 SW 141 AVE
DAVIE FL 33330
SCOPES OF BUSINESS OR TW. .�E:
LICENSED BUILD:NG
CONTRACTOR
Pursuant to Chapter 440.06(11),F.S.,an offlcar w a ccrpora$)n who elects exemptir-n from this chapter by Ming a certificate of eterticn under this section
may not recover benefits or compcim.tion uiviar this chapte Pursuant fQ Chspter 4,10.061(12',F.S. Certificates of alp tton to be exemgi...apply only
within the scope of the business a,tre9e Isted on the rofae of eleclion tube exectpt Pursuar t 5o Chapter 440.05((3),F.S.,Nd Aicea of election to tie
exempt and certificates of election to tie exerrg t shall be suLrjact to revocatkon if,at any tine Osr the fling of the notim 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 certificafe.The department shaft revoke a
DFS-F2-DWC-252 CERtl=-,li;.:aTt:CF E'_ECTION TCr BE EXEA4PT Fil_`JISED 08- 3 QUESTIONS?(850}413-IW9
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"foo'0 18.00'ASPHALT PAVEMENT 1 1
`�^utivU�T ■ 1 C.
Miami Shcres Village
APPPO'vED BY DATE
Cave, ZONING DEPT
Property Address:
9105 N.W.1 AVENUE
MIAMI SHORES,FL 33150ISE UI ALA UERAL
n..__rOI/ro eL•RUM&T±_! WERE®+cERTIrr THAT THMSOUNDARr SURVEY s A TRUE AND - ul-C ANv l-C I,N f HL L--S AND REGULATIONS
CORRECT REPRESENTATICN OFASURYEY PREPARED UNDER MY OIRECT"I THIS COHPLJE£AIT.I
THE FAW WUM TECHNY_'AL STANDARDS AS SES FT7RTH BY THE STATE OF FLORIDA BOARD OF
PROFESSK)sm LAND SURLIF. Ire 6,0176 FLORIDA ADMINISTRATIVE CODE PURSUA141
To4Ta+7 FLOAOASTAryRS \meq
( MIGUEL ESPINOSA LAND SURVEYING,INC.
10665 SW 190TH STREET
SIGNEDSUITE 3110
FOR THE FIRM MIAMI,FL 33157
MIGUEL E
STATE OFFLORlO� y, PSM NO srol PHONE:(305)740-3319
QAfi L1ML"
FAX:(305)669-3190
E'•:i E h P£S.IG 4rtr•Eylr-gfEG E..F aC 9F L NE.+`a LB#:6463
G1S.16Vg4 .•♦ a
Accepted By:
Survey:A-26112 Page 1 of 2 Not valid without all pages.
°
Surveyor's Legend
PROPERTY LINE
STRUCTURE
FMO FOUND IRON PIPE/ B.R. BEAMING REFERENCE TEL TELEPHONE FACILITIES
® CONC.BLOCK WALL PIN AS NOTED ON PIAT A CENTRAL ANGLE OR DELTA U.P. UTILITY POLE
—X—X— CHAIN-LINK FENCE OR WIRE FENCE LB/ uCENSE/-BUSINESS R RADIUS OR RADIAL E.U.B. ELECTRIC UTILITY BOX
--/Hi-- WOOD FENCE LS/ LICENSE If-SURVEYOR MD. RACK THE SEP. SEPTIC TANK
Tom^ UM FENCE CALL CALCULATED POINT K.R. NON RADIAL D.F. ORAINFIELO
-- EASEMENT SET SET PIN TYP. TYPICAL A/C AIN CONDITIONER
CENTER LUNE A CONTROL POINT
I.R. IRON ROD g/W SIDEWALK
® WOOD DECK CONCRETE MONUMENT I.P. IRON PIPE DWY DRIVEWAY
�y, � BENCHMARK M" NAI.k DISK
SCR. SCREEN
CONCRETE ELN ELEVATION
PK NAIL PARKER-KALON NAIL GAR GARAGE
®
ASPHALT P.T. POINT OF TANGENCY
O.H. DRILL HOLE ENOL ENCLOSURE
P.C. POINT OF CURVATURE 0 WELL N.T.S. NOT TO SCALE
BRICK/TILE P.R.Y. PERMANENT REFERENCE MONUMENT ® FIRE HYDRANT F.F. FINNISHED FLOOR
WATER P.C.C. POINT OF COMPOUND CURVATURE ® M.X. MANHOLE T.O.B. TOP OF BANK
P.R.C. POINT OF REVERSE CURVATURE O.H.L. OVERHEAD LANES E.O.W. EDGE OF WATER
/'`-- APPROXIMATE EDGE OF WATER P.O.B. POINT OF BEGINNING TX TRANSFORMER E.O.P EDGE OF PAVEMENT
® P.O.C. POINT OF COMMENCEMENT CATV CABLE TV RISERONCRETE VALLEY CUTTER
COVERED AREA C.V.G.cvo
P.C.P. PERMANENT CONTROL POINT M.Y. WATER METER B.S.L. BIR DIXG SETBACK LINE
Q TREE Y FIELD MEASURED
P/E POOL EQUIPMENT S.i.L SURVEY TIE LINE
POWER POLE P PLATTED MEASUREMENT CONC. CONCRETE SLAB CENTER LME *we*
® CATCH BASIN D DEED ESNT EASEMENT RM. RIGHT-OF-WAY •
C.U.E. COUNTY UTILITY EASEMENT C CALCULATED D.E. QRADIABE EASEMENT • 0 •e f e 969096
LE./E.E. INGRESS/EGRESS EASEMENT L.M.E. LAM INE LANDSCAPE YAMT.ESMT. P•U.E. Y EASEMENT
LB.E. lA1PoSGPH BUFFER CASEMENT Cy,E•GNAL fAINTENANCEe�ASFiI�e ••
U.E. UTILITY EASEMENT R.O.E. ROOF OVERHANG EASDWTY
L.A.E. LIMIT®ACCESS CA1iE1ffNT A.E.•••NY•R•EASEINENT •••• 966666
• • •
9105 N.W.1 AVENUE
••eeff
MIAMI SHORES,FL 33150 •••••• •• • • •
•••• 0f •eess
fees** ••• •••••
General Notes: •
N •• •• •efe.e
0 c e ± ° 0 1. The Legal Description used to perform this Bondy*A#supplted by • f•
C Y t 0 w.." others. This survey does not determine or is nolo hAly q�+nerehip.• ••••••
A T 2. This survey only shows above ground improvements. Undergro•ntl•• •
utilities,footings,or encroachments are not located on thlb survey milp. • e
T feeee•
�' 3. If there Is a septic tank,well,or drain field orRF�s sErv�r,the locagp�f f e
I ° Q wti"d o of such items was shown to us by others end the i i1mation was nota e f
0 "n °�9 $ verified. •e •
g 4. Examination of the abstract of title will have to be made to determine
N i '� recorded instruments,if an effect this property.
C were not abstracted for easement or other creel ded encumbrances nces of In
M A shown on the plat
A "-®. L 5. Wall ties are done to the face of the wall.
P r E 6. Fence ownership is not determined.
e 7. Bearings referenced to line noted B.R.
t p r F r 6. Dimensions shown are plotted and measured unless otherwise
shown.
Community Number: MIAMI SHORES VILLAGE/120652 9. No identification found on properly comers unless noted.
10. Not valid unless sealed with the signing surveyors embossed seal.
Panel Number. 12086CO302L 11. Boundary survey means a drawing and/or graphic representation of
the survey work performed in the field,could be drawn at a shown scale
Suffix: L and/or not to scale.
Date of Firm Index: 9/11/2009 12. Elevations N shown are based upon NGVD 1929 unless otherwise
noted.
Flood Zone: X 13. This is a BOUNDARY SURVEY unless otherwise noted.
Base Flood Elevation: N/A 14. This survey is exclusive for the use of the parties to whom it is
Date of Field Work: 10/26/2011 certified.The certifications do not extend to any unnamed parties.
Date of Completion: 10/27/2011
Certified o: I I LF-INSURANCE AGENCY,INC.,OLE)REPUBLIC NATIONAL
TITLE INSURANCE COMPANY ISSUED THROUGH ATTORNEY'S TITLE FUND SERVICES,LLC,WELLS FARGO BANK NA,
Its'successors and/or assigns as their interest may appear.
Legal Description:THE SOUTH 85 I-Et I Ut-LOT 10 AND THE WEST 5 FEET OF THE SOUTH-85 FEET OF LOT 12,OF
MIAMI SHORES MANOR,ACCORDING TO THE PLAT THEREOF,AS RECORDED IN THE PUBLIC RECORDS OF MIAMI-
DADE COUNTY,FLORIDA.
PRINTING INSTRUCTIONS• MIGUEL ESPINOSA LAND SURVEYING, INC.
Nle viewing the survey in any Acrobat Reader,select the 10665 SW 190TH STREET
File Drop-down and select"Print°
Select a color printer,if available,or at least one with 8.5"x SUITE 3110
14"paper. MIAMI, FL 33157
Select ALL for Print Range,and the#of copies you would like PHONE:(305)740-3319
o print out. FAX: (305)669-3190
Under the"Page Scaling"please make sure you have
selected"None." LB#:6463
Do not check the"AutoRotats and Center"button.
Check the"Choose Paper size by PDF"checkbox.
Click OK to Print.
Survey:A-26112 Page 2 of 2 Not valid without all pages.
� OR�,s y�!
Miami shores Village
Building Department
10050 N.E.2nd Avenue
'117%2.es�TeWo' Miami Shores, Florida 33138
�tOR1pA Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF(FLORIDA)
COUNTY OF(DADE)
The undersigned Affiant, —S14Z 4PI'A69VI�does hereby attest that
(Property owner)
The attached survey,performed by
Gf ,�/ (Name of su eyor's company)
For address: `/(Zr //W �s� �6
Performed on (date of survey)is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7)years old old. The Affiant, as property owner,further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structur s may a ct final inspections as applicable to this or other permits.
Furth ,Affiant y eth ught.
�f z4VAWIC
Prop 0 er Signature , Property Owner Print Name
SWORN TO A"personally
SCRIBED before me this day of
Affiant is 1/ known to me, produced as identification.
1% 1jblic-State of Fl]2019
Commission#FF 9157
iwi OP`
Revised on 5122/2009/Revised on 6112109 '%.',Foa F��?:' My Comm.Expires Sep 7,
nua•
M85P11EMILK
COMMERCIAL
` RESIDENTIAL
Date:9/20/2016 MICONSTRUCTION AND PAVERS, INC.
State of Florida
County of Miami Dade
Before me this day personally appeared Michelle Lyman who, being duly sworn,deposes and says:
That he or she will be the only person working on the project located at:
9105 NW 11 Ave
Miami Shores, Fl.33150
Sworn to (or affirmed) and subscribed before me this 191'day of September. 2016, by Michelle Lyman
er
onally Known-
•. SANDY ROMERO
. Notary Public-State of Florida
�g Commission#FF 915708
�'•.,,� .� My Co Exptr Sep 7,2Q19
Pri t,Type 4 Stamp of Notary
Office 954-441.4224 - Fax 954-6934703 Email: premierenterprisegroup@yahoo.com
Premier Enterprise Group of South Florida Inc Building Contractor - Licensed&insured CSC 1256001
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305)795.2204
Fax: (305)756.8972
Notice to Owner® Workersz Compensation Insurance Exem tion
-111111111111M -
Florida Law requires Workers' Compensationinsurance coverage under Chapter 440 of the Florida Statutes. Fla.-Stat- § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer pacts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees,including the owner,must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction
exempt if: industry may elect to be
L The officer owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attesting to the minimum 10 percent ownership;
2. The officer 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 are
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 revoked by the Division.
Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use
day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of
workers compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BE W YOU ACKNOWLEDGE THAT YOU RAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature: j�l Z- 40VA Ce,VIL
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this--;LZ day of 4 20A
By. Z&2 161/,eG2a/!C, who is
y mo to me or has produced
as identification.
Notary
SANDY ROMERO
• �,; Notary Public-State of Florida
Commission & F
YComm Expires Sep 7.2019