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RC-16-1922 Inspection Worksheet i Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone:(305)795-2204 Fax:(305)7564972 Inspection Number: INSP-267219 PermitNumber: RC-7-16-1922 Scheduled Inspection Date:December 22,2096 Permit Type: Residential Construction Inspector.Naranjo,Ismael Inspection Type:Sinai Owner. MUMFORD,BOBBIE Work Classification:Alteration Job Address,10305 NE 2 Avenue Miami Shores,FL 33138- Phone Number Parcel Number 1121360130390 Project: <NONE> Contractor. PINECREST GROUP INC Phone:(305)251-5470 Building Department Comments REPAIR RAFTERS AS PER SCOPE OF WORK(SEE Infractlo Passed Comments ATTACHED SET OF PLANS)BY GARAGE AREA, INSPECTOR COMMENTS False INCLUDING,SOFFIT WORK. Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-267162 CREATED AS REINSPECTION FOR INSP 263964. not as per plans. 9-13-16 Failed not as per plans. Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re4nspecW fee Is pal Decenber 21,2016 For Inspections please calf:(303)762-4949 Page 8 of 27 I�r Al r© �' - 922 Miami Shores Village P6 Tye Ftss l& t>i tCt t� 10050 N.E.2nd Avenue NErMit nn Miami Shores,FL 33138-0000 . Phone: (305)795-2204 Peit Status:AP ' issuavate:7119/20116' Expiration: 01/1512017 Project Address Parcel Number Applicant 10305 NE 2 Avenue 1121360130390 Miami Shores, FL 33138- Block: Lot: BOBBIE MUMFORD Owner Information Address Phone Cell BOBBIE MUMFORD 10305 NE 2 AVE MIAMI SHORES FL 33138-2056 Contractor(s) Phone Cell Phone Valuation: $ 4,000.00 PINECREST GROUP INC (305)251-5470 Total Sq Feet: 0 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Window Door Attachment Date Denied: Framing Type of Construction:REPAIR RAFTERS AS PER SCOPE Occupancy: Insulation Stories: Exterior: Drywall Screw Front Setback: Rear Setback: Final PE Certification Left Setback: Right Setback: Window and Door Buck Bedrooms: Bathrooms: Fill Cells Columns Plans Submitted:Yes Certificate Status: Review Structural Certificate Date: Additional Info: Review Planning Review Electrical Bond Return: Classification:Residential Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Plumbing CCF $2.40 Review Mechanical Invoice# RC-7-16-60550 DBPR Fee $2.00 07/19/2016 Check#:1472 $209.40 $50.00 DCA Fee $2.00 Education Surcharge $0.80 07/12/2016 Check#:1460 $50.00 $0.00 Permit Fee $120.00 Plan Review Fee(Engineer) $120.00 Scanning Fee $9.00 Technology Fee $3.20 Total: $259.40 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 an ning. Futhermore,I authorize the above-named contractor to do the work stated. July 19, 2016 A orized Signature:Owrier / Applicant / Contractor / Agent Date Building Department Copy July 19,2016 1 00 S_ ___0 V 0 Miami Shores Village _ CMVF11D Building Department Ju 1 z 2016 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 BY: _ Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20(x( BUILDING Master Permit No. Ic_(�I�-�''� PERMIT APPLICATION Sub Permit No. % G— 0`2-7= BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 22 /� r F 1 CONTRACTOR DRAWINGS JOB ADDRESS: /63 C' Iy h �� lV Z City: Miami Shores Countv: Miami Dade zip: Folio/Parcel#: !/ ? 13 �_-01303 i C, Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Floo�d>Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): k.1 ur,foyd LeOl n e I� /1Z4hone#: 310-o?( kS6 Address: /G 3 0 F ea tid city: IG 111 I S�z v S State: Fl zip: Tenant/Lessee Name: Phone#: Email: 6;i + 3 e! CONTRACTOR:Company Name: P1 11rc vPS� Phone#:-305 d2.51- 5 4/7 b Address: /S( 4' 7D S, u) • 93 C� city: e( 2 ( G M- State: 00-,69C,__ Zip: Qualifier Name: �1y U'N V14 cfc e.-_ Phone#: State Certification or Registration M �C_ /_15-1 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address:) City: State: Zip: Value of Work for this Permit:$q06 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ epa' /Replace ❑ Demolition Description of Work: R(?pCe.v. RcAt, C" ti 5 co0e G F WUVK &U . �� Specify color of color thru tile: �, Submittal Fee$M, a Permit Fee$ A� xa ® s CCF$ 2• ® CO/CC$ Scanning Fee$ -13 . C&-) Radon Fee$ ; •C)b DBPR$ 2 'CQ Notary$ Technology Fee$ J ` 20 Training/Education Fee$ 6 , 80 Double Fee$ Structural Reviews$ Bond$ J0 TOTAL FEE NOW DUE$ (Revised02/24/2014) Bonding Company's Name(if applicable) yy�� Bonding Company's Address hl' City State Zip Mortgage Lender's Name(if applicable) N 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_LK&g Signature OWNER or AGENT f1Ncv,°s+ 614TRACTOR _Fua ti; V�4 zrj vrz- The foregoing instrument was acknowledged before,me this The foregoing instrument was acknowledged before me this IS�day of 0/y-*/,?' / 120 6 by 3 day of . ui)f 120 16 by of "Z:s7y who is persoo�nally known to V192 CSL;,-7 who is personally known to me or who has produced CA4/*Id ' ash me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY-PUBLIC NOTARY PUBLI Sign Sign. Print: �vl �'� Print: Seal: Seal: 7 1'_ � WC0mMJ 0NAFFlFJ9t51 •i�,�. �. j i .,E, ...• EMM EmideJ Thru Nary ruYgc UnWmers awta rHr �r� ***. *4lAl+oKA2 � * ***************** **** ********* ** *********** ******************* Notary PubH4•cat omia tos Ange<es county APPRO 4 2019 Plans Examiner Zoning .r Structural Review Clerk (Revised02/24/2014) From: 07/06/2016 11 :08 #381 P.003 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARS} (860)487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 VAZQUEZ,JUAN CARLOS PWECRESTGROUP INC 18672 SW 93RD CT MIAMI FL 33167 Congr atulationsi With this license you booame one of the nearly one million Floridlans licensed by the Department of mess and Professlonat Regulation. Our protsssionale and businesses range DA ORt STATE OF F L from architects to yacht brokers,from boxers to barbeque restaurarrtts, SPARTNI I BUSINESS AND and they keep Fiorlda'a economy strong. PROFESSIOt1E..REGULATION Every day we work to improve the way we do bualneas in orderto serve you better: For lrrFornlagan about our services,please log onto 01512666 y AbUI:I 08!03/2014 www-myflor1d01Icense.catrr. There you can turd more informition t4 about our divisions and Ow re ulatlorls that CERTIFIED B impact You.subscribe a�;cOwTRAcroR tom the nt rimmietters and teemore about DeparhymWe VAZQUr=7 JUAI PtNECRE£sT aR IJP:ING Our mission at the Department Is. License Efficiently,Regulate Fairly, Y. We const ar>t stove to serve you better so that you can serve your customers. kyou for doing business in Florida, IS CERTIFIED under the provisions of Ch 488 PS and congratulations on your new Uoense! EMPMtondaba,AU@34 205 L14flAe30MT3 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRE7rARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD . t CGO16126W � The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2018 VAZQUEZ,JUAN CARLOS. . t.,..•..,`- '.,....- W PINECREST CROUP ING 18672 SW 93RD Cr MIAMI FL 33f57 k ti.r `� `, sq" ''•:U,'.^ QHS• tssMD.' DaM=014 DISPLAY AS REQUIRED BY LAW SEQ# L1408030003M From: 07/06/2016 11 :09 #381 P.004 LOcal BUSIMS "fax Receipt Miami--Dade County, SU00. of Florida -TMs t8 NOTA BILL —00dNoTP4Y 55"45M ..• PINS:L`Ft01JP IMC BCBfpT No. ,;,;>,: :; , 1B6"t;2CP �L sw ga e2iIt' CUTuR $ Or: 1 SAY F7:33157 +alt be QiApj$y :Ab ottIri�s Runi�hrl3o f�ijp(y.c,�yg �i+terai►'»at�i�To 0wMM one.Tv"CW tr PNECRESrGROUPfNC CG 1B42S �11M(3CGNTI�gaM worker(s) i $45.00 09/29/2015 Tiltsissweeshu"Tee idsiyq�ttrme QEOR�D-15-051038 wa ' QW[pYperaft s►aroeu4vlttQ�ttt� gtfstvsaQdsy� Y�eAY ICEIP'fN0 p6ovem�t6eglsA�ddnstl� _� �4" fosse�dtorma8os,vfsi< s From: 07/06/2016 11 :07 #381 P.002 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850)487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 VAZQUEZ,JUAN CARLOS PINECREST GROUP INC 18672 SW 93RD CT MIAMI FL 33157 COngratuiRtional With this license,you become one of the nearly one million Floridan licensed by the Department of Buslrreas and Professional Regulatlon. Our professionals and businesses range STATE OF FLORIDA ftm architects to yacht broksrs,from boxers to barbegrre restaurants, STATE OF , OF BUSINESS AND and they keep Florida's economy gong. PROFESS!.ANAL REGULATION Every day we work to the way-we do business In order toCFC14276Ad3 serve yott better. For nnatYon about our servtoes. one fog onto BSUtD. OA10312U1$ www.myttorldallcerume"am. There you tern find more in on CERTIFIED U about our divisions and the r�utetJons that Impact you,subscribe Iii¢:CQN7F2Ii�G�'{'OR to department newsfettera and}cpm mora about the let's VAZQUR,JUAI11' LC : Initladves. RINECREST GRi rllilG T'„Il ,�•, Our mission at the Department Is:Ucense Efficlantly,Regulate Fatrly. We constant/ 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 Or:489 FS, and cxr�ratuletions an your new ik ttset EVhtim+d-.mar.Me tea DETACH HERE RICK SCOTT.GOVERNOR KEN LAWSON.SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESWONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD c'Fctazrsao The PLUMBING CONTRAC FOR Named below IS CERTIFIED ; Under the provisions Of Chapter 469 FS. Expiration date- AUG 31,2016 VAZQU�,JUAN CARLOS, .:.:M. -` � Q PINEGREST GROUP INC. ll 18872 SW 93RD C T MIAMI FL 39157`` ISSUED: =6=14 DISPLAY AS REQUIRED BY LAW SEQ L140SO30OW205 From: 07/06/2016 11 :09 #381 P.005 aoatr� Local Business Tax Receipt Miami-Dade County, Stag of Florida THtti 18 NOTA SILL -DO NOT PAY L._BT 6356590 PUSIM M NAt MVLOC^VM rAMAWT No. PMR125MROUP INC MUM _ ..%"I s 18672 SW 95 Cr e4�assz EEPnM1kR:.30,2016 CUTLER SAY FL 33157 Mu®t liedtspl arPtac�:*"L� rur�a>n�o,c�►�t,;coda Char,>rei SA-Art.9&10 OVYWHt; BEC.arse cP 8Ll8tNH8@ PINECRB7 Q ww INC' 196 PLUM8INQ CMMCYOR PAYIAGW RKONV D yyprker(s) 1 CFC1427540 OV TAX Cou.9eroa $45.00 (39/29/2015 (2tEDlT u-15--051038 lhisLoaalBmuness7roc taotYa�ot tr yaoeatofehaloo�IBaviueasTaa weft=wow.066"0' ��M��t�eryrhvla�nsosdts�WtMNth)�sb Hahtelris�tou� YtoY6 ! applq>othebnehmas. the t3f;f�PfAitt,a'hoveswsthe�ttayedoe eH oksl•vehtelsa-lV�t-QatleCWts8e0 FwhBotmatioav3eH f r CERTIFICATEL� L DATe(�+�IYYrf) O7/W/2016 THIS CERTIFICATE IS JSSU£D 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 CONSnTUT6 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 SUSROGATION 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 eamncate holderInlieu of such endorsemengs). PRODUCER _.M..., CO Agustin Esti)-las General insurance Group Corp. FF 1305 51-/3461 10350SbV64thSLIL _(780)280-4113 _.5 a0UsH, net Miami,FL 33173 lr�suae)tts)AFFORpING COVERA06 NNC a Pune (7W)2$0-4113 Fax (305)351-8461 _ bleu A: inlemational insurance Co of Hannovar SE 100080 INSURED ` :._.. PINECREST GROUP INCusuRER 18672 Siff!93 a ° Miami FL 33153- F: 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVEFOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERRA 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. I ..O ., IADD UPR P LIC F POLICY•. TYPE OF INSURANCE POLICY NUMaE FMAF/DO _ LIMITS J COMMERCLAL GENERAL L4A(FRJTY _ EACH OCCURRENCE s 11 ,000.00 CLAJMS4AADE g OCCUR N y� �, s 100,000.00 A N AP5570L 02/1012016 02110!2017 b atltP�An one awe S 5.000.00 L_ PERSONAL&ADV INJURY $ 1,000,000.00 GEN`LAWREGATE LIMIT APPUES PER: aeNeRv ASjtdrtEGATE 000.000.00 _ POLICY � ? LOG PRODum-CowwAGG s 2.000.000.00 ✓.OTHER _ 8 AUTOMOBILE LIAML)TY E�NED SINQLE LIMIT �I _. ANYAUTO 0001Y)NJURY(ftpamm)ALL $ �# t AUTOS MEO A ULSO 6001LY FIWNIRY,Per _T.. $ NONX3WNED PROPO �T. HIREOAUTO3 _.. C ALrrQS I AMAE n� s [ UNBIMLA UAS i-OCCUREACFl oecuRRehcE $ - tixrassLlan _._[ .mms-MADE AWREGATE WOR"RSOOKWENSA tOpi PEA Ot AND EAMOVERS'LIABILITY YIN STATUTE ANY PROpRtETbRM>AtTrNERMCUTi E.L.EACH ACC@)ENT $ OFRCERIMEMWA EXCLUDeW N f A I= in N EL DISEASE•EA EMPLOYE F, DESCRIPTION OF OPERAMONS town i ISL.EMSeASS-POLICY U MT g DEWRIPTIQN OF OPERAnONS I.LOCATtOW I VEHICLES(Attach ACORD 101.AdMeae)Rem uM Schedule,It more space Ia mquftd). Pinecrest Group License CGC 1512566,CFC 1427540 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE Miami Shores Vilma THE ACCORDANCE EXPIRATION DATE THEREOF,N0710E WILL TH THE POLICY PROVISIONS BE Da NERED IN $tlAdingDepertrtt8nt ._`. 10050 NE 2 Avenue AUTHORIZED REPRESENTATIVE Miami Soares Vie,FL 33138 I 0198&2014 ACORD CORPORATION: All rights reserved. ACORD 26(2014101)OF The ACORD name and logo are registered matt of ACORD ,44C<>R" CERTIFICATE OF LIABILITY INSURANCE 07/08/20 DATE(MMID6D 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 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 CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. 150 SAWGRASS DRIVE PHONE , 877-266-6850 FAX • 585-389-7426 ROCHESTER,NY 14620 E-MAIL Certs@paychex.com ADDR INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 PINECREST GROUP INC INSURER B: 18672 SW 93 CT MIAMI,FL 33157 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(FA occurrence) $ CLAIMS-MADE[::JDCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ POLICY =PROJECT=LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED SCHEDULED BODILY INJURY(Per AUTOS AUTOS (Per person) HIRED AUTOS AUTOSppWNED BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) $ UMBRELLALws OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'LIABILITY PIWC700085 03/21/2016 03/21/2017 TORY I IMITS FR E.L.EACH ACCIDENT $ 1,000,000.00 ANY PROPRIETOR/PARTNERIEXECUTNE OFFICER/MEMBER EXCLUDED? N E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 (Mandatory In NH) YN/A E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 If yes,describe under DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Pinecrest Group Inc.License CGC 1512566,CFC 1427540 CERTIFICATE HOLDER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Building Department DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 10050 NE 2 Ave PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR Miami Shores Village,FL 33138 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Y �-- ACORD 25(2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From: 07/06/2016 11 :09 #381 P.006 JEFF ATWATER qW CHIEF FtMANCIAL 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: 1/27/2016 EXPIRATION DATE: 1/26/2015 PERSON: VAZQUEZ JUAN C FEIN: 204221427 BUSINESS NAME AND ADDRESS: PINECREST GROUP INC 111672 SW 93 COURT CUTLER BAY FL 33157 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL LICENSED PLUMBING CONTRACTOR CONTRACTOR Punwsstto ChSPW 440.05(14).F.S..an aNtoer of a cmp=fion who*tact gen q�ti0n from hila cnapt®r by tains a w�ar ele�on waver fhb exon mat not recovercf 11ho is or conen Or sefton under fhb ohaptar pursuant to Chapter 440.CRilj F.S..CertH mb"of elecd0n to be exempt,..ap*„Wy wHh@►tha scope of 0te buelttesa or trade Itatad�►the rwtfoe otetedkn to be exempt.Pursuant m Chapter440.OR13).F.S..Notkee or eteWn m be exempt end c"Wketas Ofaterboret0 be eeempt WW ba sublaa to o4oc"=5,at ant time atter ate hang of the no%=orew bwlance of the offaft Ee, tha parson nantad on the natka or oertiflwte n0 tongar meats tha requUements of#"$00004 for bsaanoe cf a ate:The departrnent etuil:mvatce a DFS-F2-DWC-262 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(860)413-1509