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RC-15-3213 INSPECTION RECORD POST ON SITE Permit No. RC-12-15-3213 Miami Shores Village Permit Type:Residential Construction Cf 10050 N.E.2nd Avenue `see Miami Shores,FL 33138-0000 Work Classification.-Alteration o-* Phone: (305)795-2204 Fax: (305)756-8972 �t"oY�pp► Issue Date: 3131/2016 Expires: 09/27/2016 INSPECTION REQUESTS: (305)762-4949 or Log on at https://bldg.miamishoresvillage.com/cap REQUESTS ARE ACCEPTED DURING 8:30AM-3:30PM FOR THE FOLLOWING BUSINESS DAY. Requests must be received by 3 pm for following day inspections. Residential Construction Parcef #- 1112050270410 Owner's Name: Owner' Prone' (305778-5745 Job Address: 1090 NE 92 Street Total Square Feet: 100 R MiamLShores. FL , Bond Number: 3039 Total Jnb Vahaation: $ 15.000.00 WORK IS Q'_LOVv :D: MONDAY T ARCUGF1 FF.IV k'r,8: 10411-7:00PM. Contractor(s) Phone Prig iary 0uoiotrai.iuv SATURDAY 8:OOAM-6:OOPM. LUZARRAGA CONTRACTORS (305)846-6771 Yes No WORK IS Al,I nea:o: can S 0),76.r 01- IirkiC t.Y:;. BUILDING AND ROCI. -N3 IN?nFCTIONS ARE DONE MONDAY THROUGH FRIDAY. �Ierrc "�no�ot okay.' n e)10t1r'ad° NO INSPECTION WILL BE MADE UNLESS THE PERMIT CARD IS DISPLAYED AND HAS BEEN APPROVED. Pte':"No ANE,:' ADL AvA LABLE IT IS THE PERMIT APPLICANTS RESPONSIBILITY TO ENSURE THAT WORK IS ACCESSIBLE AND EXPOSED FOR iNSPECTiON PURPOSES. NEITHER THE BUILDING OFFICIAL NOR THE CITY SHALL BE LIABLE FOR EXPENSE ENTAILED IN THE REMO\tAL OR F:=F:_f,,< Cd41E,;i CF',aN"MATERIAL REQUIRED TO ALLOW INSPECTION. WARNING TO OWNER: YOUR FAILURE TO RECORD A !NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR iMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOU'R OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDIIiqIF3; YOUR NOTICE OF COMMENCEMENT. INSPECTION RECORD STRUCTURAL ZONING URI.=111a,11 INSPECTION DATE INSP INSPECTION 'DATEl INSPECTION DATE INSP Foundation Zoning Final Stemwall ZONING COMMENTS Rough Slab Water Service Columns 1st Lift 2nd Rough WE Ifw Columns 2nd LiftTop Out Tie Beam Fire Sprinklers Truss/Rafters Septic Tank Roof Sheathing Sewer Hook-up Roof Drains Windows/Doors ELECTRICAL Gas Interior Framing INSP CTION DATE INSP LP Tank Insulation TemporaryPole Well Ceiling Grid, 30 Day Temporary Lawn Sprinklers Drywall Pool Bonding Main Drain Firewall Pool Deck Bonding Pool Piping Wire Lath Pool Wet Niche Backflow Preventor Pool Steel Underground Interceptor Pool Deck Footer Ground Catch Basins Final Pool Slab Condensate Drains Final Fence Wall Rou hHRS Final Screen Enclosure Ceiling Rough Driveway Roug �9' PLUMBING COMMENTS Driveway Base Telephone Rough Tin Ca Telephone Final Roof in Progress TV Rough Mop in Progress TV Final Final Roof Cable Rough Shutters Attachment Cable Final Final Shutters Intercom Rough Rails and Guardrails Intercom Final MECHANICAL ADA compliance Alarm Rou h INSPECTION DATE INSP Alarm Final Underground Pipe DOCUMENT11 Fire Alarm Rough Soil Bearing Cert Fire Alarm Final Rough Soil Treatment Cert Service Work With Floor Elevation Survey ntilation Rough Reinf Unit Mas Cert ELECTRICAL COMM NTS Hood Rough Insulation Certificate lr ,Z Pressure Test Spot Survey4 Final Hood Final Survey �' Final Ventilation Truss Certification — I Final Pool Heater STRUCTURAL COMMENTS Final Vacuum r' a w.° k MECHANICAL COMMENTS INSPECTION DATE INSP Final Sprinkler Final Alarm v - P 1 ,� 7 t* et� La Sin .. •a,,. g, ..f 4hF. �;� 1 a' K-------------------- h 3 Certificate of Completionu Miami Shores Village 4t 10050 NE 2 Ave, Miami Shores FL,33138 ` Tel:305-795-2204 Fax:305-756-8972 r F - Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in k X: compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: ° S Permit Type RESIDENTIAL CONSTRUCTION Bldg. Permit No. RC-12-15-3213 b' Owner MIAMI UP 2 VIEW LLC Contractor LUZARRAGA CONTRACTORS i d g Subdivision/Project NONE Date Issued August 11,2017 Occupancy Construction Type V-B Load N/A Occupancy a Square Footage 100 R-3 Type 4F i Description of INTERIOR RENOVATION Applicable Work Code 2014 FLORIDA BUILDING Location Flood Zone X F.F.E N/A 1090 NE 92 ST 1 Miami Shores FL 33138 i'�IfRE� aaoBuilding Officials Approval Ismael Rairianiro,77,5BO p� , Not Transferable r I xxpR�pl?► POST IN A CONSPICUOUS PLACE j v t Permit r��. ISO" 2-16=�2'l, Miami Shores Village Type .i + sientil Gan$tiiCtsn 10050 N.E.2nd Avenue NE W,16*0W t=a fit rt jtg i� ••• Miami Shores,FL 33138-0000 F� 00tus APPROVE) Phone: (305)795-2204 may. ��lL20�t�_ Expiration: 09/27/2016 3f Project Address Parcel Number Applicant 1090 NE 92 Street 1132050270410 MIAMI UP 2 VIEW LLC Miami Shores, FL Block: Lot: Owner Information Address Phone Cell MIAMI UP 2 VIEW LLC 720 NE 62 Street (305)778-5745 MIAMI FL 33138- Contractor(s) Phone Cell Phone $ 15,000.00 Valuation: LUZARRAGA CONTRACTORS (305)846-6771 Total Sq Feet: 100 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Window Door Attachment Type of Construction:2 BATHROOM REMODEL Occupancy:Single Family Framing Stories: Exterior: Insulation Front Setback: Rear Setback: Drywall Screw Left Setback: Right Setback: Window and Door Buck Bedrooms: Bathrooms: Fill Cells Columns Plans Submitted:No Certificate Status: Review Planning Certificate Date: Additional Info: Fi Review Planning Review Planning Bond Return: Classification:Residential Review Structural Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural Review Plumbing Bond Type-Contractors Bond $500.00 CCF $9.00 Invoice# RC-12-15-58205 Review Plumbing CO/CC Fee $50.00 12/31/2015 Credit Card $50.00 $1,661.50 Review Mechanical DBPR Fee $6.75 03/31/2016 Check#: 1164 $ 1,661.50 $0.00Review Mechanical Review Mechanical DCA Fee $6.75 Bond#:3039 Education Surcharge $3.00 Review Electrical Permit Fee $450.00 Review Electrical Plan Review Fee(Engineer) $80.00 Review Electrical Plan Review Fee(Engineer) $120.00 Review Electrical Scanning Fee $24.00 Review Building Technology Fee $12.00 Review Building Work without Permit Fee $450.00 Total: $1,711.50 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compli ince with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the prol ar authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my or ^!oyes 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 com)liance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated. Mar,-.h 31, 2016 Authorized Signature:Owner / Applicant / Contractor--/ Agent ate Building Department Copy March 31,2016 1 1? 3i Miami Shores Village ( � � 'P ,0 Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4449 FBC 201`i � BUILDING Master Permit No.zcl-5-321-s PERMIT APPLICATION Sub Permit No. BUILDING f--j ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: \(D G1CJ 1yG (\1 S� City: Miami Shores County: Miami Dade Zip: \ Folio/Parcel#: k\ -'S AC`�; -Q 11-6 LA N L) Is the Building Historically Designated:Yes NO � Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): �A n.� y U r L,1 bL�L Phone#: Address: R"5 G \ to\•.1 \CN-NS� TL IF- -N City: I'\ \ k 6. State: Zip: G Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: C-0 A C--\-b-Q� S Phone#: L-4 U Address: City: X-F." -\2-> S c State: V--L. Zip: Qualifier Name: Phone#: 3L k LACE b-1-1 i State Certification or Registration#: C-L \L;C, -4 Q is ® Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: _ Square/Linear Footage of Work: \b U Type of Work: ❑ Addition ® Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 3n��a azCc V-L r-,Ac>EL �� �c� cM 0 r--S A t,-n iL C _ w A S\ tM L`P- ROL co Specify color of color thru tile: c� Submittal Fee$ ' 00 Permit Fee$ !!`4GO • 0�11 CCF$ 1 • 0Q CO/CC$ Scanning Fee$ 1� Radon Fee$ a DBPR$ Technology Fee$ Training/Education Fee$ ouble Fee Structural Reviews$120. o3 P0()•Cx3 Bond$ C (� TOTAL FEE NOW DUE$ • `� (Revised02/24/2014) r ` L l 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$1500,the applicant must promise in good faith that a copy of the notice of commencement and construction lien low 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 issuedin the absence of s ch posted notice, the inspection will not be approved and a reinspection fee will be charged. L Signature Signature OWNER or AGENT CONT?acowledg The foregoing instrument was acknowledged before me this The for going i rument was before me this day of r 20 by12�[day ofCeT,20 15 by who is person ly known to �"j(�—PLu20rLO(,,A who is personally known to me or who has produced as me or who has produced Am n 1�' I ym U cas identification and who did take an ath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: ..„. „ +YP,,, VERONICA VILLAGRA-ROCCA Sin= '�""'••°•°" Sign- ` �`t°a °B%. Public-State of Florida Print: ,” Q Print: B/ivi r(+� i I �. •;x-, *•E MY Comm.Expires#EE 221544Aug 1. 16 Seal: 9AK EXPIRES April 3.2017 �.;�oFa�°o i9 Seal: u,,,,,,,,+ Bonded Through National Notary Assn. :19&0153 FlondallotaryService.com APPROVED BY Plans Examiner Zoning Structural Review Clerk 12AM15 Detail by Frdity Name y `2 Detail by Entity Name Florida Limited Liability Company MIAMI UP 2 VIEW LLC Filing Information Document Number L11000057716 FEl/EIN Number 80-0724518 Date Filed 05/16/2011 State FL Status ACTIVE Last Event LC AMENDMENT Event Date Filed 11/04/2011 Event Effective Date NONE Principal Address 8301 NW 197TH ST MIAMI, FL 33015 Changed: 11/04/2011 Mailing Address 8301 NW 197TH ST MIAMI, FL 33015 Changed: 11/04/2011 Registered Agent Name &Address CHEEMA, BALWANT 8301 NW 197TH ST MIAMI, FL 33015 Name Changed: 11/04/2011 Address Changed: 11/04/2011 Authorized Person(s) Detail Name $Address Title MGR GHEENS, PIERRE 8301 NW 197TH ST MIAMI, FL 33015 Title MGR rwr�wl I JOAN STATE OF FLORIQA­ DEPARTMENT OF _JSINESS AND PROFESSIONAL K. :ULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 4�� °° 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 LUZARRAGA,JORGE RAUL LUZARRAGA CONTRACTORS INC. 115 HARBOR DR KEY BISCAYNE FL 33149 Congratulations! Wifh this license you become one-"e-►ready------ 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 restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. Ot--w. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to CGC1504081 ISSUED: 08/31/2014 serve you better. For information about our services,please log onto www.myfloridalicense.com. There you can find more information CERTIFIED GENERAL CQNTRAGTOR about our divisions and the regulations that impact you,subscribe LUZARRAGA,JORGE`_RAUL to department newsletters and learn more about the Department's LUZARRAGA CONTRACTORS INC. 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.489 FS. and congratulations on your new license! ExpitationdM:AUG 31,2016 u40831000M19 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 0 CGC1504081 The GENERAL CONTRACTOR Named below IS CERTIFIED =ri Under the provisions of Chapter 489 FS. " Expiration date: AUG 31, 2016 _ pHit. o LUZARRAGA, JORGE RAUL LUZARRAGA CONTRACTORS-INC. 115 HARBOR DRIVE • KEY BISCAYNE .FL 33149 • ■ ISSUED: 08/31/2014 DISPLAY AS REQUIRED BY LAW SEQ rt L1408310005018 r—, Local Busie ss Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY Li3T 7002421 BUSINESS NAMEILOCATION M-CEnvT NO. EXPIRES LuzARRAGACONTRACTORS INC RENISIAL SEPTEMBER 30, 2016 115 HARBOR DR 7277825 Must be displayed at place of business VILLAGE OF KEY BISCAYNE FL 33149 Pursuant to County Code Chapter BA-Art.9&10 OWNER SEC.TYPE OR BUSINESS PAYMENT RECEIVED LUZARRAGA CONTRACTORS INC 196 GENERAL BUILDING CONTRACTOR BY TAX COLLECTOR Worker(s) 1 CGC1504081 $45.00 09/14/2015 CHECK21-15-126759 This Local Business Tax Receipt only cooR payment of the Local Business Tex.The Receipt is not a license. pamoit,ar a certification of dm hoWor s goelificadoos,t�budn L Ho der busm y w�azy 9 �1 or mmugavermemal regnia"laws ead nupdroments The RECE PT No.above most be displaW on all commercial v8W des-Niami-Dada Code Sec Be-276. For more information.visit vwrow�amidede 11 Y OP ID:ID ACORO® DATE(NMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 03/30/2016 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 pollcy(les)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 endomeme s. PRODUCER CONTACT E. Combined Underwriters of Miami NH E FAX 8240 N.W.52 Tarr,Suite 408 PHCNNo Ext): Arc No): Miami,FL 33166 EMAIL ADDRESS: PRODUCER LUZAR-1 CUSTOMER ID @ INSURER[SJ AFFORDING COVERAGE NAIC 0 INSURED LUZARRAGA CONTRACTORS,INC. INSURER A:WESTERN WORLD INSURANCE CO. 115 HARBOR DRIVE KEY BISCAYNE,FL 33149 INSURER B: 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. IL R POLICY EFF POLICY EXP TYPE OF INSURANCE IN&WVD POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X NPP8213224 12/17/2015 12/17/2016 PREMISESS DAMAGE (RENTED 100 00 Ea occurrence � $ CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,0011 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- LOC $ CT F AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ NON-OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIABi CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- H- AND EMPLOYERS°LIABILITY Y/N OT TORY LIMITS ER ANY PROPRIETOR/PARTNEWEXECUTTVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101 Additional Remarks Schedule H nmre space Is **CERTIFICATE HOLDER IS LISTED AS ADDITIOAfAI, INSURED — a iii CO CT R CG1CC1504081** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2ND AVENUE ACCORDANCE WITH THE POLICY PROVISIONS. MIAMI SHORES,FL 33138 AUTHORIZED REPRESENTATIVE ©1988 2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHS FINMCIAL 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 fisted below has elected to be exempt from Florida Workers'Compensation km EFFECTIVE DATE: 1/202015 EXPIRATION DATE: 1/19/2017 PERSON: LUZARRAGA JORGE R FEIN: 371560383 BUSINESS NAME AND ADDRESS: LUZARRAGA CONTRACTORS INC 115 HARBOR DRIVE KEY BISCAYNE FL 33149 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 Oft chapter by fMM a certificate of election under this sem may not MOW"bermes or compensation ung thfs dopier.Pursuant to Chapter 440.05(in F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade Rated on tins 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 stall be subject to revocation if,at any Nae after the filing of the notice or the issuance of the certificate, tha person nan, anthe If arcerMcaft no longer meets the requirementsof this section for issuance of a- erica 1 .The departmentshall nwalw a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED OB-13 QUESTIONS?(850)413-1609 0 M Miami Shores Village .... per. Building Department �lpR>IDA 10050 N.E.2nd Avenue 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: er State of Florida County of Miami-Dade The foregoing was acknowledge before me this dayof By V tm- } i.,s who is personally known to me or has produced as identification. NEE e of Florida Notary: gaE 175809 SEAL: 8 - Luzarrunn December 28, 2015 State of Florida County of Miami Dade Before me this day personally appeared Jorge Luzarraga who, being duly sworn, deposes and says: That he will be the only person from Luzarraga Contractors, Inc. working on the project located at: 1090 NE 92 Street, Miami Shores, Florida 33138. Sworn to (or affirmed) and subscribed before me this c', Q day of De f I'Ylib�-r 2015 by Jorge zarr ga /'X"' Personally known — abOr Produced Identification �SPa'r'n�e� VERONICAVILdb JhLAGRA-ROCC'81110A Type of Or Produced l'1(✓�lCIC4 Dr C1L1C Notary Public-State of Florida t . = My Comm.Expires Aug 1,2016 Commission#EE 221544 Bonded Through National Notary Assn. Print, Typor Ste p Name of Notary 115 Harbor Drive,Key Biscayne,R 33149 305-846-6771 luzarraga@blbg.cc www.luzarragacontractors.com