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RC-16-3478 Permit NO. RCA 2-16-3478 `S�OREs y, Miami Shores Village Permit Type:Residential Construction 10050 N.E.2nd Avenue NE Pen� ' Work Classification:Alteration Miami Shores,FL 33138-0000 "plNy Permit Status:APPROVED Phone: (305)795-2204 F�OR�Dp Issue Date: 1/5/2017 Expiration: 07/04/2017 Project Address Parcel Number Applicant 85 NE 97 Street 1132060131020 Miami Shores, FL Block: Lot: SANDRA AND RIQUET MORRISI Owner Information Address Phone Cell SANDRA AND RIQUET MORRISEAU 85 NE 97 Street (305)759-2365 MIAMI SHORES FL 33138-2330 Contractor(s) Phone Cell Phone Valuation: $ 6,500.00 ROMAR INDUSTRIES INC (786)295-9198 Total Sq Feet: 0 Approved: In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Review Electrical Date Denied: Review Building Type of Construction: Occupancy: Stories: Exterior: Front Setback: Rear Setback: Left Setback: Right Setback: Bedrooms: Bathrooms: Plans Submitted:No Certificate Status: Certificate Date: Additional Info: Bond Return: Classification:Residential Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $4.20 DBPR Fee Invoice# RC-12-16-62482 $2.92 01/05/2017 Credit Card $ 171.04 $50.00 DCA Fee $2.92 Education Surcharge $1.40 12/28/2016 Credit Card $50.00 $0.00 Permit Fee $195.00 Scanning Fee $9.00 Technology Fee $5.60 Total: $221.04 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constru-10 and zoning. Futhermore, I aphorize the above-named contractor to do the work stated. January 05, 2017 Aut rued Sign re:Owner / Applicant / Contractor / Agent ate Building Department Copy January 05,2017 1 • - CF-TV-ED Miami Shores Village� • DEC 28 lois Building DepartmentY: tA 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 Iq&411 BUILDING Master Permit No.P—C,' 1( -34W PERMIT APPLICATION Sub Permit No. [y(BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [-]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 1r CONTRACTOR DRAWINGS JOB ADDRESS: � 0E 5 'il S+ N loyn s� eJ -�, 3-316'8 City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-320& -013 1090 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: ,�,�,,,,,Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): )(0 0)�% ' `� '1loPhone#:30c'-&03_6)t e f,, Address: J� 's JOE �-2 st City: PaKy)I oqm State: Zip: 3313 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: ���LTw�r�s� ' Phone7 � Address: 333,, City: a State: Zip: Z Qualifier Name: Phone#(r2) 21 S -7195 State Certification or Registration#: /$o- GZJ' Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ V)S("x�•C�-7 Square/Linear Footage of Work: Type of Work: ❑ Addition f❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: I ' 12 r1 Cr_b)r),e D gg P 1aCe_rQf)t_ 2�1 1120P2cb`f- I OZ Specify color of color thru tile: Submittal Fee$ �V� Permit Fee$ a CCF$ �.n` COJCC$ 's— Scanning Fee$ �'--�'r Radon Fee$ `'1 Z DBPR$ [_ Notary$ , Technology Fee$ ` -ice d Training/Education Fee$ - © Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 14 { V -1 (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 commence;WLMust be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In aBence such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this kwho day of0 20 / Lby sday of A/0(/ ` 20 � by lull A "e� LI) 1h 91" `ho is personally known tohas produced as i9or who has produced as identification and who did to a an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: "e Print: Seal: Seal: � •''•' ADNEYQREY r NANN513K'I? E: s R MY MISSION t FF 905430 S. MY Commla3tOM*FF 105369 EXPIRES:Aught 12 2019 frXi't;k.S'Murch 23,201 i3 '31 1&*Mrm&4►N*ry5eMM i;rntRd Yh�a rdW.a.7 Pal:w: ir�er,,�ters ************** ************************************************************** APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search-Application- Miami-Dade County Page 1 of 1 91�a Air"I'APRAIS' ER Summary Report Generated On: 11/23/2016 Property Information Folio: 11-3206-013-1020 Property Address: 85 NE 97 ST Miami Shores,FL 33138-2330 Owner XO MANAGEMENT INC 601 NE 36 ST �F Mailing Address T' MIAMI,FL 33137 USA Primary Zone 1100 SGL FAMILY-2301-2500 SQ 0101 RESIDENTIAL-SINGLE Primary Land Use .. FAMILY: 1 UNIT 1Gx Beds/Baths 1 Half 3/2/0 Floors L � _ Living Units 1 Actual Area 3,112 Sq.Ft Living Area 2,218 Sq.Ft1 -' Adjusted Area 2,623 Sq.Ft Taxable Value Information Lot Size 12,190 Sq.Ft 2016 2015 2014 Year Built 1967 County Assessment Information Exemption Value $50,000 $50,000 $50,000 Year 2016 2015 2014 Taxable Value $307,993 $305,505 $302,684 Land Value $304,872 $231,903 $231,903 School Board Building Value $185,603 $187,125 $183,767 Exemption Value $25,000 $25,000 $25,000 XF Value $3,483 $3,208 $3,249 Taxable Value $332,993 $330,505 $327,684 city Market Value $493,958 $422,236 $418,919 Assessed Value $357,993 $355,505 $352,684 Exemption Vdlue $50,000 $50,000 $50,000 Taxable Value $307,993 $305,505 $302,684 Benefits Information Regional Benefit Type 2016 2015 2014 Exemption Value 1 $50,000 $50,000 $50,000 Save Our Homes Assessment Taxable Value $307,993 $305,505 $302,684 Cap Reduction $135,965 $66,731 $66,235 Homestead Exemption $25,000 $25,000 $25,000 Sales Information Second Homestead Exemption $25,000 $25,000 $25,000 Previous OR Book- Sale Price PaQualification Description Note:Not all benefits are applicable to all Taxable Values(i.e.County, Page School Board,City, Regional). 02/10/2016 $100 29996-0985 Corrective,tax or QCD;min consideration Short Legal Description 07/14/2011 $292,000 27773-2013 Financial inst or"In Lieu of MIAMI SHORES SEC 1 AMD PB 10-70 1 Forclosure"stated LOTS 22&23 BLK 7 01/04/2010 $0 27376-1921 Corrective,tax or QCD;min LOT SIZE IRREGULAR consideration OR 16506-4616 TO 18 0794 4 Financial inst or"In Lieu of 01/04/2010 $100 27158-3208 Forclosure"stated The Office of the Property Appraiser is continually editing and updating the tax roll.This website may not reflect the most current information on record.The Property Appraiser and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at hfp:/twww.miamidade.gov/info/disclaimer.asp Version: http://www.miamidade.gov/propertysearch/ 11/23/2016 Detail by-Entity Name Page 1 of 2 Florida Department of State DIVISfON OF CORPORATIONS On of Fh'461 Department of State / Division of Corporations / Search Records / Detail By Document Number / Detail by Entity Name Florida Profit Corporation XO MANAGEMENT, INC. Filing Information Document Number P03000055769 FEI/EIN Number N/A Date Filed 05/20/2003 State FL Status ACTIVE Last Event REINSTATEMENT Event Date Filed 11/23/2015 Principal Address 601 NE 36 ST 2012 MIAMI, FL 33137 Changed:04/14/2011 Mailing Address 601 NE 36 ST 2012 MIAMI, FL 33137 Changed: 04/14/2011 Registered Agent Name&Address (LOUIS,JOSEPH 601 NE 36 ST 2012 MIAMI, FL 33137 Name Changed: 11/23/2015 Address Changed:04/11/2006 Officer/Director Detail Name&Address Title P, D LOUIS,JOSEPH,JR http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/23/2016 Detail by,Entity Name Page 2 of 2 601 NE 36 ST#2012 MIAMI, FL 33137 Annual Reports Report Year Filed Date 2014 04/18/2014 2015 11/23/2015 2016 05/25/2016 Document Images 052.5/2016--ANNUAL REPORT View image in PDF format 11/23.2015--REINSTATEMENT View image in FDF format 11/13.2014--Amendment View image in PDF format 04/18/2014--ANNUAL.REPORT � View image in PDF tbrma# 06i1112013--AMENDED ANNUAL REPORT View image.in PDF romtat 04/17/2013--ANNUAL REPORT View image in PDF formai 01!11/2012--ANNUAL REPORT View image in PDF format 04,14.,2011--ANNUAL REPORT" View image in PDF format --�1010712010--REINSTATEMENT View image in PDi�4grma# 04242009--ANNUAL REPORT View image in PDF formal 01,242008--ANNUAL REPORT View image in PDF format 04,116/2007--ANNUAL REPORT View image in PDF format 04/11/2006--ANNUAL REPOR I" View image in PDF format 04/13/2005--ANNUAL REPORT View image in PDI forma# 07121/2004- ANNUAL REPORT View image in PDF format, 05i20/2003--Domestic:Profit View image in PDF format Florida o<p;nn:enc of 3c&[e.,eio-:<lon c`Co Jnr;,?cns http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/23/2016 ytiOR16) �Fs 6 sell Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 CONTRACTORS' REGISTRATION Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. ::���PY OF LOCAL BUSINESS TAX RECEIPT C. / COP F�LIABILITY INSURANCE' D. :::::COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE 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 form and Contractor 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. a am BUSINESS NAME: BUSINESS ADDRESS:33a�/,o fJITy� STATE,/ ZIP 31 BUSINESS PHONE: ,go FAX NUMBER(W ) T� CELL PHONE 1, ) �9S-g/9� QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION •L yi CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 WILLIAMS, MICHAELA ROMAR INDUSTRIES INC 3330 SPANISH MOSS TER BLDG#3. UNIT#103 LAUDERHILL FL 33319 Congratulations' i!'f�license you become one Cf the nes, one million Ficrid :,cese3 by ne Cecartment&B`us=^=s=ano _: STATE Or FLORIDA Professional Rec j " Our Grofessionas and businesses range DEPARTMENT OF BUSINESS AND from architects tE ya: ,t rakers frern boxers to barbeque � D TION restaurants.an+o: ,_ _.r=,-ec=`enba=e=: friv strong PROFESSIONAL REGULATION Every day �o CGC15052' ISSUED: 08/03/2016 We work:C?�'" ..`.�'i''c cV�'c CisS?�c55 In Ofder to serve you better. acout cur services. please to onto www.myfloridalicense.com ,i;ere you can lino more CERTIFIED GENERAL CONTRACTOR information about our tiv;_;o-s: a^v t`e regulations t?-at impact WILLIAMS. MICHAELA you,subscribe to and learn mere about ROMAR INDUSTRIES INC 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 IS CERTIFIED under the provisions of Ch.489 FS. serve your customers. Thank you for doing business in Florida, Expre,z„date AUG 31 2C.8 1.160ea+M19:7 and congratulations on your new license! RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION Wx; VZ CONSTRUCTION INDUSTRY LICENSING BOARD rt �,. CGC1506211 tea The GENERAL CONTRACTOR ` Named below IS CERTIFIED 4-a Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 WILLIAMS, MICHAELA ROMAR INDUSTRIES INC _ 3330 SPANISH MOSS TER BLDG#3, UNIT#103- AI IMMMU11 1 CI 797Afl 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 8037 DBA: Receipt#:GENERAL CONTRACTOR (GENERAL Business Name:ROMAR INDUSTRIES INC Business Type:CONTRACTOR) Owner Name:MICHAEL WILLIAMS Business Opened:lo/10/2003 Business Location:3330 SPANISH MOSS TERR State/County/Cert/Reg:CGC1506211 LAUDERHILL Exemption Code: Business Phone:786-295-9198 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 1 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 that it is in compliance with State or local laws and regulations. Mailing Address: MICHAEL WILLIAMS Receipt #04B-15-00008675 3330 SPANISH MOSS TERR Paid 09/29/2016 27.00 BLDG 3 APT 103 LAUDERHILL, FL 33319 2016 - 2017 Dec, 28. 2016 12: 38PM CC&D INSURANCE No. 6264 FP. 1 COR"-' CERTIFICATE OF LIABILITY INSURANCE12%2(MWDD) 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 pollcy(les)must have ADDITIONAL INSURED provlslonE or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and condl(lons of the policy,certain policies may regUlre an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemeni(e). PRODUCER tA- • SHARON CC & D INSURANCE o (954) 791-1930 FAX 791-6563 1215 Sunset Strip ESS:CCdinsurance�yak�00.COm Sunrise, FL 33313 IN3URER(8) AFFORDING COVERAGE NAICr INSURER A?ATLANTIC CASUALTY INS. CO. INSURED ROMAR INDUSTRIES INC INSURER B 3330 SPANISH MOSS TERRACE INSURER C BLDG, 3 UNIT 103 INSURER O: LAUDERHILL, FL. 3331.3 INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 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. INSLTR R TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY P INSD SND POLICY NUMBER MMV00 lW MMfDDYY LIMITS X COMMERCIAL aENERAL LIABILITY EACH OCCURRENCE s 11000, 000 X CLAIMS-MADE F-1 OCCUR PREMISES Me occurrence S 100,000 XDED. F1.1- $500 ACT1849252PC 04/26/3016 04/26/2017 MEDFi(P(Any one person) $ 51000 A X DED. p.D- $500 PERSONALS ADV INJURY s 1, 0001000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000 POLICY❑PRO- Q JECT LOC PRODUCTS-COMP/OP AGG $__i_,__0 0 0 0, 0 0 0 X OTHER:OCCURE'NCE S AUTOMOBILE LIABILITY I LE UMIANYAU17— Es accident OWNED sSCHEDULEDO BODILY INJURY(Per person) j OWNED AUTOS ONLY AUTOS BODILY INJURY(Per ecclden() f HIRED NON-OWNED PROPERTY DAMA AUYOSONLY AUTOSONLY EPeraccldenl S $ UMBRELLA LUB OCCUR T:: EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE g DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORPARTNERIkXF.CVrIVE S OFFICERNAEMBER EXCLUDED? ❑ NIA E.1-FACHACCIDENT (IArnd•UM In e u E.L.DISEASE-EA EMPLOYE $ If yyea describe under DESCRIPTIQN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS/LOCATIONS I VEH(CLES (ACORD 101,Additional Remarks Schedule,may be attached If more sPece Is required) 5ENERAL CONTRACTOR cOC 0150-621x CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG. DEPT. 10050 HE 2ND AVENUE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES, FII, 33318 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. FAX; 305-756-8972 AUTHO D REPRESENTATIVE ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD25(2016103) The ACORD name and logo are registered marks or ACORD 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: 4/6/2016 EXPIRATION DATE: 4/6/2018 PERSON: WILLIAMS MICHAEL FEIN: 611412189 BUSINESS NAME AND ADDRESS: ROMAR INDUSTRIES INC 5610 NW 13 STREET LAUDERHILL FL 33313 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 benerds or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...appy 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 anytime 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 ROMAR INDUSTRIES, INC. *State Certified* General Contractors*Licensed and Insured Lic#CGC1506211 5610 Northwest 13t' Street Lauderhill, FL 33313 Date: YoV 2 t, 20/4 State of P-C " d 0, County ofi rry'-TN Before me this day personally appeared MI(AW W' �k""�ho being duly sworn, deposes and says: That he or she will be the only person working on the pro ect located at: � 4 Sworn to(or affirmed) an subscribed before me on this Z day of Allem&UJ--1 , 20�,by M/L ri ►ike� Q�It c kl,4 ersonally known-+0 t Or Produced Identification Type of Identification Produced Print,Type or Stamp N otary ,Mv o ,AJpll}IEyAWGM .•••` * MY ODIr MIW04 i FF 00 * EXPIRES:hVA 12.2019 ��et IunMllThl�ONyl�N�A� PHONE: 786-295-9198-EMAIL: ROMARINDUSTRIESINC@YAHOO.COM ♦5�►OC.RFS Gl Miami shores Village most OF� ""'1" Building Department 92 - 18 — � 10050 N.E.2nd Avenue �LORIDp` Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance 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 Facts 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 industry may elect to be exempt if: 1. 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 BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this�day of a"0 20,. By �ls who is personally known to •.�produced as identification. Notary,;, JzAaz� N-7 --- --- NADINE GAEENE SEAL: MY COMMISSION#FF 1Q5368 �•,•a-' EXPIRES:March 23 2018 '•�:;pf�t Bonded Thru Notary Public Underwriters � OR Miami Shores Village Building Permit „ no" Y M 10050 NE 2nd Avenue Permit Number: BP2004-1025a~` Phone: 305-795-2204 oRttt Printed:8/4/2004 Page 1 of 1 Applicant: NATHANIEL STRONG Owner: STRONG NATHANIEL JOB ADDRESS: 85 NE 97 ST Contractor Contractor's Address: Local Phone: Parcel # 1132060131020 Legal Description: MIAMI SHORES SEC 1 AMD PB 10-70 LOTS 22 &23 BLK 7 LOT SIZE Fees: Description Amount FEE2004-7866 Building Fee $195.00 Total Fees: $26.48 FEE2004-7867 CCF $4.20 Total Receipts: 0.0$ FEE2004-7868 Notary Fee $5.00 / �- FEE2004-7869 Training and Education Fee $1.40 FEE2004-7870 Technology Fee $4.88 FEE2004-7871 Scanning Fee $6.00 Av0 d �� Total Fees: $216.48 Permit Status: APPROVED Permit Expiration: 1/22/2005 Construction Value: $6,500.00 Work: NEW KIT CABINETS Signed: (INSPECTOR) 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 responisibility for all work done by either myself,my agent,servants or employes. Signed: (Contractor or Builder) BY: