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EL-17-1640Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number Alteration ROVED Expiration: 12/26/2017 Applicant 274 NW 93 Street Miami Shores, FL 33138- 1131010331120 Block: Lot: EAGLE RIVER HOMES LLLP Owner Information Address Phone Cell EAGLE RIVER HOMES LLLP PO BOX 3598 HALLANDALE FL 33008- (305)300-8902 PO BOX 3598 HALLANDALE FL 33008- Contractor(s) Phone K&L ELECTRICAL SERVICES CORP (786)354-6816 CeII Phone Valuation: Total Sq Feet: $ 7,000.00 0 Type of Work: ELECTRICAL WORK Additional Info: ELECTRICAL WORK Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Total: Amount $4.20 $3.68 $3.68 $1.40 $245.00 $3.00 $5.60 $266.56 Pay Date Pay Type Invoice # EL -6-17-64381 06/29/2017 Check #: 3237 06/22/2017 Credit Card Amt Paid Amt Due $ 216.56 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Review Electrical 1 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. June 29, 2017 Authorized Signature: Owner / Applicant / Contractor / Agent Budding Department Copy Date June 29, 2017 1 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 7624949 BUILDING PERMIT APPLICATION ❑BUILDING ELECTRIC ❑ ROOFING PLUMBING ❑ MECHANICAL 0PUBLIC WORKS 01?)Ci JOB ADDRESS: gilt w City: Miami Shores County: JU2 2 2017 FBC 2011 s�th Master Permit No. C 15 30 Sub Permit No. EL- fl - lb4o 0 REVISION EXTENSION ORENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS Foilo/Parcel#: 11-3 I— 11 O Miami Dade Zio: 32)GY" Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: t 1 Flood one: OWNER: Name (F Simple Titleholder): 0619IP-1/Dit i 1)11(1t5 Address: City: � X11 o4et�sl�t State: 1:1.- Tenant/Lessee Tenant/Lessee Name: �C�Vo Email: 01 `Old/1��/' tdl t Vel) op aim CONTRACTOR: Company Name: V -)©I i Sao Address: q4)- 4�'W t_1 Ina �-f nV,;- City: ,la M' I State: . `71, BFE: FFE: Phone#: CirSIPb`� V� Zip: 03Citif Phone#: Qualifier Name: r State Certification or Registrati n #: one#: �V—t3'60 -bc12 one -VI -43'60 x16 0l� Zip: Phone#: �1 Certificate of Competency #: OF t517D 1 DESIGNER: Architect/Engineer: �/ Phone#: Address: qq Value of Work for this Permit: $ .,1—,�/is� . —10 0 (0 Square/Linear Footage of Work: Type of Work: 0 A. . ion L✓J Alt ration J New 0 Repair/Replace R Demolition Description of Work: fYUL(0M b on larin City: State: Zip: Specify color of color thru tile: 2.,U0 Submittal Fee $ *EDO �Q o^C Perm ` $ Scanning Fee $ don Fee $ CCF $ DBPR $ CO/CC $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ 1 TOTAL FEE NOW DUE $ 2 `( Q ' (Revised02/24/2014) O , Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if appli - - Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 ' e job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of suc = • ed notice, the inspection will not be approved d a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instruments ackn.% ledged before me this d y of `/ 20 / , by /► I ho is personally known to me or who has produced rt -2 >� as identification and who did take an oath. NOTARY PUBO Sign: Print: Seal: MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance iii!******iiti!!•* Signature The fore ng / day of CTOR nowledged before me this 20 / , by ho is personally known to me or w 'o has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: -/'___ -isimmizfmirrmEint as MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 "- " Bonded through 1st State Insurance !!!!ii!!i!i!!!!!!!!i!i!!iliiiiiiiiiiiiti!!!!!iilili!! ili ii iiiii!!i!i!i!! i!!ii!! APPROVED BY 2 kuru "dlians Examiner Structural Review (Revised02/24/2014) Zoning Clerk SEND C((O41MPLLTE S SEGZION • Complete items 1, 2, and 3. s Print your name and address on the reverse so that we can return the card to you. • Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: COMPLETE THIS SECTION ON DEL,IVERYY A. Sig X ❑ Agent ❑ Addressee eceivby P(�ro' to )) C. Dpi of very AV E!--tC_,TetcAL sERoiC.E. FEWX P1-eGe►lJ 504 SuJ 120 RUG ,Lo pMl FL 3318y 11111111111111111 I III Ilal II 11111 111 9590 9402 2493 6306 8872 75 s delivery address ent from item 1? Yes If YES, enter delivery address below: ❑ No 2. Article Number (Transfer from service label) 3. Service Type ❑ Adult Signature ❑ Adult Signature Restricted Delivery ❑ Certified Mali® ❑ Certified Mall Restricted Delivery 0 Collect on Delivery ❑ Collect on Delivery Restricted Delivery ❑ Insured Mall ❑ insured Mall Restricted Delivery (over $500) ❑ Priority Mall Express® 0 Registered Mali"' ❑ Registered Mali Restricted Delivery ❑ Retum Receipt for Merchandise ❑ Signature ConfinnatlonTt° ❑ Signature Confirmation Restricted Delivery PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Retum Receipt 11 1 1 USPS TRACKING # 1 1 9590 9402 2493 6306 8872 75 United States Postal Service First -Class Mail Postage & Fees Paid USPS Permit No. G-10 • Sender: Please print your name, address, and ZIP+4® in this box' EAGLE- gD Q FIo,4Es LL.P k Box 3597 wJ vite, 3301 '111111111i1110111111)1,11iIiill)ail§�illfli 0001 8817 4376 U.S. Postal Servicer" CERTIFIED MAIL° RECEIPT Domestic Mail Only For delivery information, visit our website at www.usps.come. MIIPLI P14© !s' P Certified Fee Retum Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) $ 0 . Total Postage & Fees MINIM NEM MIS MEM 0537 22 Postmark Here I14/03/2':17 Sent To meet d o"gr)L1 Su.? 1�O NE_ or PO Box No. Cityy, State, Z!P+4 L 331 Ara PS Form 3800, July 20'.4 See Reverse for Instructions Eagle River Homes LLLP PO Box 3597 Hallandale, FL 33008 AV Electrical Service Inc Attn.: Felix A Negrin 504 SW 120 Ave Miami, FL 33184 Eagle River Homes EAGLE RIVER HOMES LLLP PO Box 3597, Hallandale, FL 33008 April 3, 2017 CERTIFIED MAIL AV Electrical Service Inc. Attn.: Felix A Negrin, President 504 SW 120 Ave Miami, FL 33184 Re: Termination of Services, Permit No. EL -11-15-2947 Property Address: 274 NW 93 St, Miami Shores, FL 33138 This letter serves as notification of the termination of AV Electrical Service Inc.'s services associated•with the electrical work at 274 NW 93 St, Miami Shores, FL 33138, Permit No. EL -11-15-2974, effective April 1, 2017. Vice President, Eagle RHGP Inc. General Partner for Eagle River Homes LLLP Detail by Entity Name http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDet... Detail by Entity Name Florida Profit Corporation AV ELECTRICAL SERVICE, INC. Filing Information Document Number P08000036044 FEI/EIN Number 26-2362255 Date Filed 04/08/2008 State FL Status ACTIVE Last Event CANCEL ADM DISS/REV Event Date Filed 12/01/2009 Event Effective Date NONE Principal Address 504 SW 120 AVE miami, FL 33184 Changed: 08/06/2014 Mailing Address, 504SW120AVE miaml, FL 33184 Changed: 08/06/2014 Registered Agent Name & Address NEGRIN, FELIX A 504 SW 120 AVE miami, FL 33184 Name Changed: 08/06/2014 Address Changed: 08/06/2014 Officer/Director Detail Name & Address Title President Negrin, Felix A 504 SW 120 AVE miaml, FL 33184 Title VP Negrin, Carlos A 504 SW 120 AVE miami, FL 33184 Title Director Socarras, Felix C 504 SW 120 AVE MIAMI, FL 33184 Annual Reports Report Year Filed Date 2 of 3 4/3/2017 10:23 AM Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, Ft. Phone: (305)795-2204 Fax (3115)756-8972 nspecticn Number INSP-258084 Scl-ledued inspection Date. May 05, 2016 Inspector. Devaney, Michael Address. 274 NW 93 Street Miami Shores, FL 33138 - Project <NONE> Contractor: AV ELECTRICAL SERVICE INC Permit Type: Electrical - Residential Inspection Type: Rough Work Classification: Alteration Phone Number (305)300-8902 Parcel Number 31010331120 Phone: (305)218-7347 Building Department Comments ELECTRICAL WIRING Infra+ctio Passed Comments INSPECTOR CQMMENTS False Inspector Comments CREATED AS REINSPECTION FOR INSP-257951. CREATED AS REINSPECTION FOR INSP-257904. BY CARL may 16 no one home at 5:05 be scheduled Eintil calf: (305)76'1,-4949 Page 24 of 40 Permit N. qt -- Owner's Name ( .:.: Tide Hog: Owner'A Ag ress:- City: a Ltalrid OLLe State : Miami Shores Village Building Department 10050 N.E2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT 'U ( ►I P Phone #: Job Address (Of where work is being done):iJl� IV I1V(e/ 1 City: Miami Shores yr Contractor's Company Name: Add 9Z W 1 f) c Qi State: Florid ti_el‘Ptkctf arum Qualifier's Name 'thm A State: klayin Zip Code: `- a Zip Code: e Zip Code: � _ Lic. Number. Architect/ Engineer of Record Name: Phone it Address: City: State: Zip Code: O Describe Work k OTO L� 1 hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the arni Shores harmless of all legal involvement. Signature Contractor or Architect before mem / The foregoing instrument was aknowledged before me Gy this day of , 20 by me or who has produced who is personally known to me or who has produced as indentification. as indenrifcavon. Sign: Seal: MAYERSI FERNANDEZ MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance Notary Public Sign: Seal: K & L ELECTRICAL SERVICES CORP. 447 NW 61ST AVE MIAMI, FL 33126 Date: O(i- D1 - 1l State of Ft County of ry1;c,„ry,: - bMe Before me this day personally appeared fie? 2 . C -Y) a who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 3, N,w 3 411 51- I Gm1 50)1- . /it:). Contractor Signature Sworn to (or affirmed) and subscribed before me this 21 day of gone, .20P}; by )QYC (V1 Cr02 . Personally known OR Produced Identification Type of Ide MAYERSI FERN DEZ MY COMMISSION #FFg91944 EXPIRES: MAY 12, 202C Bonded through 1st State Insurance Notary Stamp Miami Shores Viiiage Building Department 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 parttime 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, parttime 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 projeci. 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: /L/�� k&t4 tA,O R.A Ic Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of `S', . , 20., By fir) C . r vzi I e S . who is personally known to me or has produced Notary: SEAL: c1t^fir"41‘021114iclzia- as identification. MY COMMISSION # ' 1944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 bO Master Permit No. /151 • Sub Permit No. -- S 2f 91 ❑ BUILDING ��j ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PLUMBING ❑ MECHANICAL /P0,LI V\1OKS E CHANGE OF ❑ CANCELLATION ❑ SHOP i d , tr I/ / / /-, CONTRACTOR DRAWINGS JOB ADDRESS: 27'71 N �� .s 7 4x/i 3-/S2D City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically,pesignated: Yes NO Occupancy Type: Load: Construction Type:Flood Zone: BFE; FFE: OWNER: Name (Fee Simple Titleholder): ,i4 64E- ,'4Z' o ' i Phone#: 716'.' A*13 z�&2 Address: City: /414-Z.64.vL472_6— State: I;rl� J , _ Zip: ----A''.3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name 1, e 7c:i ewe �/.,,, - Phone#: 5/S Z/8 73Y7 Address: 5® ...-1.4/ /ze) 42/J City: 14.4.4-i/ State: �� l / i Zip: ,3.1g Qualifier Name: % X' 4.4r�,�a��' Phione# State Certification or Registration #: ./-3,40)1" Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: QgJ City: State: Zip: Value of Work for this Permit: O 00 .-----A5( Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration >❑ New Repair/Replace ❑ Demolition Description of Work: 2 7e 7c )((/- , -� �-✓n 7 Specify color of color thru tile: Submittal Fee $ (1 ` Permit Fee $ 74/3 i .O CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ _ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 2 I ° S -C (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 OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of , 20 by day of , 20 , by , who is personally known to , who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Print: Seal: Seal: ************************************************************************************************************ APPROVED BY Plans Examiner Zoning Structural Review Clerk (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 OWNER or AGE T The foregoing instrument as acknowledged before me this r/� r- ()\(1 day of Cyd 1L� , 20 Ib , by K '01\0 day of ®c �!�I 20 1---C by gorase. (le/Avows , who is personally known to d Signature The foregoing instrument was acknowledged before me this ho is personally known to me or who has produced 1\4L2_ l ie_D- Q =i= as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: b.1-41iLNL- Seal: ******* ALINA CARVAJAL MY COMMISSION # EE860269 EXPIRES: December 25, 2016 identification and who did take an oath. NOTARY PUBLIC: n;�.��ili►' Print: Endanzudait ` alPnirri Seal: ****************************************** es APPROVED BY 0,42:91Z-- V/ -9e -'P' Plans Examiner (Revised02/24/2014) Structural Review Zoning Clerk Local Bust fax Receipt Miami—Dade eduntyr, State of Florida' -THIS* Nor BtL1.-b NOT PAY 6570106 BUST SS NAMEFLOCATION A_ELECTRICAL SERVICE INC b4 SW 120 AVE MIAMI, FL 33184 OWNER AV ELECTRICAL SERVICE INC Worker(s) M COUNTY RECEtisT' NG RENEWAL 6840772 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EXPIRES SEPTEMBER 30, 2016 Mustbe displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 PAYMENT RECEIVED BY TAX C014.ECTOR 75.00 09/21/2015 1 EC3004404 0241-15-003741 This Local nuttiness Tax Ecocide* can&ms payment of the bloat Business Tin. The Receipt is auto license. Permit ora dation oftM.holder's qualreletkee, to do business. Holder mast comply wftb any governmental or nengoverameatai regale[ j laws end req iremems wbicb apply to the business. The RECAP( NO. above -Oat be displayed ea all commercial vehicles - Miami -bade Code See Se -276. Romero information, visit www.miamidade govRaxcofeoter f x, TA ' FLORIDA �`a iEPAR l�NT OF BUSINESS AND fN L REGULATION ,..08/03/2014. CERTIFIED �Et�+ ICAL CO Q+ TOR NEGRIN, AV ELECTRICAL 18 CERTIFIED under the ale Expin:Mon date : AUG 31, 20.16 '°` ®� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YIYY) 11/02/15 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 certlfcate holder Is an ADDITIONAL INSURED, the policy(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 endorsement(s). PRODUCER Jimenez & Co., Inc. 8000 Coral Way Miami, FL 33155 Phone (305) 264-9900 Fax (305) 264-5382 CONTACT JULIO JIMENEZ NAME: A HONN ), (305) 2649900 FAX No): (305) 264-5382 ADDRESS: Julio@jimenezandcompany.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : CYPRESS INSURANCE COMPANY Y INSURED AV ELECTRICAL SERVICES INC 2412 SW 128 AVE Miami, FL 33175 (305) 218-7347 INSURER B : 11/09/2015 INSURER C : EACH OCCURRENCE INSURER D : DAMAGE TO RENTED PREMISES jEa occurrence) INSURER E : V COMMERCIAL GENERAL LIABILITY INSURER F : MED EXP (Any one person) 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. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS A GENERAL LIABILITY Y GFL-1020528-0481 11/09/2015 11/09/2016 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES jEa occurrence) $ 100,000.00 V COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE d OCCUR MED EXP (Any one person) $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ JECT ❑ LOC PRODUCTS - COMP/OP AGG $ 1,000,000.00 $ AUTOMOBILE LUU3ILITY ❑ ANY AUTO ALL ❑ AUTOS OWNED ❑ SCHEDULED NON -OWNED ❑ HIRED AUTOS ❑ AUTOS ❑ ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) n If yes, describe under DESCRIPTION OF OPERATIONS below / A WC STATU- OTH- TORY LIMITS ❑ ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) **** ELECTRICAL WORK WITHIN BUILDINGS***** CERTIFICATE HOLDER CANCELLATION CITY OF MIAMI SHORES BUILDING DEPT 10050 N.E. 2nd Avenue Miami Shores, FI 33138 ACORD 25 (2010/05) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHO- D REPRESENTATIVE © 1988-2010 ACO = ORPORATION. All rights reserved. The ACORD name a logo are registered marks of ACORD IVI iami Shores Viiiage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Com • ensation Insurance Exem • tion 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. f/// —40/Signature% (r State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of b , 20 15 By bAR TCGZ, L(%ii-CkA)t who is personally known to me or has produced �- LI CW, as identification. Notary:' SEAL: ALINA CARVAJAL MY COMMISSION # EE860269 EXPIRES: December 25, 2016 A V Electrical Service Inc. Electrical Contractor Cell: (305)218-7347 EC 13004404 Date: State of Florida County of Miami Dade Before me this day personally appeared, Felix A Negrin who, deposes and says: That he or she will be the only person working in that project located at 274 NW 93 Street, Miami, Florida 33150 Sworn to an subs ibe before me this day of Personally know Produced Identification 2015, by RIANELA MUNOZ MY COMMISSION #FF166123 EXPIRES October 6. 2018 FloridallotaryServire.::om 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: 2/22/2016 PERSON: NEGRIN FEIN: 262362255 BUSINESS NAME AND ADDRESS: AV ELECTRICAL SERVICE INC EXPIRATION DATE: 2/2112018 FELIX A 504 SW 120 AVE MIAMI FL 33184 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR 30 T1 \ 5 -2c1 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 SE EXEMPT REVISED 08-13 QUESTIONS? {B50)413-1609 AC R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER19FICATE 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. CERTIFICATE OF LIABILITY INSURANCE DATE €MM/OD!YYYYi 6/19/2017 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsement(s). PRODUCER ? ADVANTAGE INSURANCE OF AMERICA 4520 NW 7th St • Miami, FL 33126 CONTACT I NAME: aO NO EXE (305) 649-5566taU. No• r(305) 649-5559 ADDRESS jackiebatis ta 749@hotmail.com INSURERISI AFFORDING COVERAGE IC INSURED INSURER A FEDERATED NATIONAL INS CO K & L ELECTRICAL SERVICES CORP 1 INSURER B , INSURER C INSURER 0. 447 NW 61 AVE MIAMI, FL 33126 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 1S SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS Ira TYPE OF INSURANCE I GENERAL LIABILITY X ; COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR I GENT AGGREGATE LIMIT APPLIES PER X POLICY j JECT I i LOC AUTOMOBILE LABILITY ANYAUTO T1 ALL OWNED —1....` SCHEDLE UD ' AUTOS `...... AUTOS 1Att0t. INSR sut+n wvo POLICY NUMBER POLICY EFF I POLICY'E3iIT (MM/DD/Y ) I(MMID(WYYYY) LIMITS GL29860 08/07/16 08/07/17 EACH OCCURRENCE S 1,000,000 1 DAMAGE TO RENTED PREMISES (Ea occurrence; $ 100,000 MED EXP (Anyone person) PERSONAL & ADV INJURY ERAL AGGREGATE PRODUCTS • COMP/OP AGG 5,000 ,000,000 ,000,000 2,000,000 5 HIRED AUTOS ? AAUTOSWNED COMBINED SINGLE UMI) Lite accident) I BODILY INJURY (Per person) $ BODILY INJURY (Per accident): 5 PROPERTY DAMAGE" ;Per accrdenl) IUMBRE.LLA HAS ? !OCCUR EXCESS LIAR i CLAMS -MADE OED j 1 RETENTIONS EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMEER EXCLUDED/ (Mandatory in NH; If yes. describe under DESCRIPTION. OF OPERATIONS below YIN NTA I WC STATU- I OTH-€ T. RY LIMITS ER # E L EACH ACCIDENT � S EL DISEASE - EA EMPLOYES $ E L DISEASE - POLICY LIMIT $ L DESCRIPTION OF OPERATIONS / LOCATIONS t VEHICLES (Attach ACORD 101. Additional Remarks Schedule, if more space is required) ELECTRICAL CONTRACTOR LICENSE # 12E000-107 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2nd Ave Miami Shores F1 33138 SHOU THE ACC E R ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ANCE WITH THE POLICY PROVISIONS. AUT .,'!:►j'#6='D 'xPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved ACORD25(2010/05) The ACORD name and, logo are regist-red marks of ACORD QUALIFYING TRADE(S) FL EC RICAL Ju:rana H Salas E Secretary of the Board Mimi -Dade County rtasfl s hereon Obitiktil-OADIE degoviecortokv *". .. C kW A , 0%. 1 error $ r raw, %r - RICK SCOTT, GOVERNOR KEN LA' ON SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CCNTRACTORS LICENSING BOARD The ELECTRICAL COP./TRACTOR Named below HAS REGISTERED UncIer the provisiOne Of Chapter 489 I5 - Exporalport dale AUG 31 2018 fINDIVIDLIAL MUST MEET ALL LO REQUIREMENTS PRIOR TO CRUZ, JORGE MICHAEL K & L ELECTRICAL SER. 447 NW 61 AVE MIAMI FL 33426 • LICENSING ING IN ANY AREA) ISSUED 4M20,2010 1** DISPLAY AS REQUIRED BY LAW 5LU L 1601200301b15