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PL-17-1637Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 PL -6-171637 t:Type: Pluriit1g sittential CissifrcatIon: Addlt�, $ ration Petrr# Status' 'I i t ilED Parcel Number 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) G&L PLUMBING SERVICE Phone CeII Phone 305-551-5090 (786)225-3648 Valuation: Total Sq Feet: $ 6,000.00 0 Type of Work: NEW BATHROOM AND LAUNDRY Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $3.60 $3.38 $3.38 $1.20 $210.00 $9.00 $4.80 $235.36 Pay Date Pay Type Amt Paid Amt Due Invoice # PL -6-17-64377 06/29/2017 Check #: 3237 $ 185.36 $ 50.00 06/22/2017 Credit Card $ 50.00 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 Building 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) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING ELECTRIC LUMBING ❑ MECHANICAL JOB ADDRESS: g3/ "1 w City: Miami Shores County: Master Permit No. Sub Permit No. ROOFING ❑7fSION PUBLIC WORKS CHANGE OF tot Skid, CONTRACTOR -7-„.„ W-. FBC20I1- 9-05-30 b33 0 EXTENSION ❑ RENEWAL 0 CANCELLATION ❑ SHOP DRAWINGS Miami Dade Zip: r NO Folio/Parcel#: 11 10 1 1333- D Is the Building Historically Designated: Yes Occupancy Type: OWNER. Address: City: Tenant/Lessee Name: Email: 011111)G far <' Load: QUimple Tit! holder): O Construction Type: 00 1 Flood Zone: �1tl-onv) State: r L. BFE: FFE: Phone#:�—'7�LI Li ZP:3i6' CONTRACTOR: Company Name: Address: I.✓ c) City: Qualifier Name: State Certification or Registration #: l ipl� r0 ,+ one#: -1R6-354—b8 trol State: Phone#: Zip: Ll Certificate of Competency #: Phone#: State: i DESIGNER: Architect/Engineer: Address: City: Value of Work for this Permit: $ - bOO O Square/Linear Footage of Work: Type of Work: 0 ddition qq Q/Alteration , ❑ New ❑Repair/Replace 0 Demolition Description of Work: /n) L� �L�Gn.Z11 Penn;_ PI_ 6- 46 S Ch6,re- cord-rzj4o,r Specify color of color thru tile: at d ermit Fee $ ' n C.10 Submittal Fee $ CCF $ : - CO/CC $ Scanning Fee $ Radon Fee $ $ Notary $ Technology F Training/Education Double Fee $ Structural Reviews $ Bond $ 72 -----Ca TOTAL FEE NOW DUE $ I (Revised02/24/2014) SENDER: 'COMPLETE THIS' SECT,IOW' ° '■ Complete Iter'ns 1, 2, and 3. • 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: OcuToeS p1-0,-k6W4ti1G A.6rm-Go A60114 1131f0 SIrJ ltS1-6e`Ri\ NiRN1 33t5} IIIllllllllllllllllllllllll IIIIIIII IIIIIIIIIII 9590 9402 2493 6308 8872 99 COMPLETE,TI-1/5 SECTION'{O�MDELlVER•��y�Y��� 3iA. .r Wn r. y, . A. Sig X ❑ Agent ❑ Addressee C. Date of DjINery B. Rec v by n d Name) i'o' / D. Is delivery ad ifferent from fiem 1 If YES, enter dealvery address bet w: 86-.� es 0 No 2. Article Number (transfer from service label) 3. Service Type ❑ Adult Signature 0 Adult Signature Restricted Delivery ❑ Certified Mail® ❑ Certified Mall Restricted Delivery ❑ Collect on Delivery ❑ Collect on Delivery Restricted Delivery ❑ Insured Mall ❑ Insured Mail Restricted Delivery (over $500) ❑ Priority Mall Express® ❑ Registered Marro ❑ Registered Mail Restricted Delivery 0 Retum Receipt for Merchandise 0 Signature Confirmations, ❑ Signature Confirmation Restricted Delivery PS Form 3811, July 2015 PSN 7530-02-000-9053 Domestic Retum Receipt 11 1 1 ...1481:1A :. ACKING # ,C.I 111 11 ilii 9590 9402 2493 6306 8872 99 United States Postal Service st-Class Malt Postage & Fees Paid USPS Permit No. G-10 • Sender: Please print your name, address, and ZIP+4® in this box• \arcs LLL P�205c35°( - 1 ALLAN L.e, FL. 3300� '1'1'111111'1"111111" 11I11I11I)11111ill1ll1111ttil.11J11111J'$ 0 ,• �. Bonding Company's Name (if applicable) Bonding Company's Address City a Zip Mortgage Lender's Name (if ap • ble) Mortgage Lender's Addr- 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 AGENT The foregoing instrument s ackn •wledged before me this - i dayi1 of �Q ' 20 1 , by r Ori C_ - JYO , who is personally known to me or who has produced identification and wh •; . d take an oath. NOTARY PUBLIC: Sign: Print: Seal: aid MirarlirIVNIC.IVAINIFACTAU APPROVED BY (Revised02/24/2014) MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance Signature The foreg RACTOR s ackn • wledged before me this km/ ,o / 20 l- , by who is personally known to as me or who has produced— V_a as identification and who d • take an oath. NOTARY PUBUC: Sign: Print: Seal: te2 Yn'Plans Examiner MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance Zoning Structural Review Clerk 1 U.S. Postal ServiceTM CERTIFIED MAIL° RECEIPT Domestic Mail Only For delivery information, visit our website at www.usps,com®. Pos 'atjd Certified Fee Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees Postmark Here 04/07/2017 117 Street xNo. ii31G Gk\g5f City State, Z` X33 PS Form 3800, July 2014 See Reverse for Instructions Eagle River Homes LLLP PO Box 3597 Hallandale, FL 33008 Doctor's Plumbing Inc Attn.: Alberto Aguiar 11316 SW 185 Terra Miami, FL 33157 EAGLE RIVER HOMES LLLP PO Box 3597, Hallandale, FL 33008 April 3, 2017 CERTIFIED MAIL Doctor's Plumbing Inc. Attn.: Alberto Aguiar, President 11316 SW 185mTerra Miami, FL 33157 Re: Termination of Services, Permit No. PL -11-15-2946 Property Address: 274 NW 93 St, Miami Shores, FL 33138 This letter serves as notification of the termination of Doctor's Plumbing Inc.'s services associated with the plumbing work at 274 NW 93 St, Miami Shores, FL 33138, Permit No. PL -11-15-2946, effective April 1, 2017. Sincerely, Vice President, Eagle RHGP Inc. General Partner for Eagle River Homes LLLP Detail by Entity Name http://search.sunbiz.org/Inquiry/CorporationSearch/SearchltesultDet... Detail by Entity Name Florida Profit Corporation DOCTOR'S PLUMBING INC. Filing Information Document Number P06000034325 FEUEIN Number 20-4464688 Date Flied 03/08/2006 Effective Date 03/08/2006 State FL Status ACTIVE Principal Address 11316 SW 185TH TERRA MIAMI, FL 33157 Mailing Address 11316 SW 185TH TERRA MIAMI, FL 33157 Registered Agent Name & Address AGUIAR, ALBERTO 11316 SW 185TH TERRA MIAMI, FL 33157 Name Changed: 04/06/2014 Address Changed: 04/06/2014 Officer/Director Detail Name & Address Title P AGUIAR, ALBERTO 11316 SW 185TH TERRA MIAMI, FL 33157 Title VP AGUIAR, YAHY 11316 SW 185TH TERRA MIAMI, FL 33157 The VP ARIAS JR, FERNANDO 2357 W 80TH ST BAY 4 HIALEAH, FL 33016 Title Secretary CONTRERAS ORTEGA, IDALBERTO 19335 SW 117TH CT MIAMI, FL 33177 Annual Reports Pamir" Vaar PULA Mita 2 of 3 4/3/2017 10:23 AM Inspection VVorksheet Miami Shores Village, N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: 756-8972 Permit Number: PL -11-15-2946 Permit Type: Plumbing - Residential Inspection Type: Rough Work Classification: Addition/Alteration b Address' 274 NW 93 Str a+et Miami Shores, FL 3313 Phone Number Parcel Number 05)3004902 010331 120 Phone: ;3© 2-04©0 Building Department Cotntttertts NEW BATHROOM AND LAUNDRY Passed comments led until Permit N. iami Shores Vmage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Owner's Name (F*mple Title Mol Own - s� Asa City: Job Address (Of where work Is being done): City: Miami Shores Contractor's Co n Address: 1.�`k City: Qualifier's Name : Architect/ Engineer of Record Name: Address: City: Phone 1* State: Zip Code; _...._.. _..._ 1 hereby certify that the work has been abandoned and/or the contractor/architect Is unable or unwilling to complete the contract. 1 hold the Building Official and the lami Shores harmless of all legal involvement. Signature The before m L9V 201 Signature Contactor or Architect The foregoing instrument was aknowledged before me this day of , 20 by me or who has produced who is personally known to me or who has produced as Indent) icaden. as indentificacion. Saak MAYERSIFERNANDEZ MY COMMISSION #FF991944 EXPIRES: MAY 12, 2020 Bonded through 1st State Insurance Notary Public: Silk: Sri: f ' BUILDING PERMIT APPLICATION ❑ BUILDING ❑■ PLUMBING 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 ❑ ELECTRIC ❑ ROOFING FBC 20 Itt Master Permit No. RC11530 Sub Permit No.? 5 -2.9 9 ?, ❑ EXTENSION El RENEWAL ❑ REVISION ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR JOB ADDRESS: 274 NW 93 ST Miami FL 33150 ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3101-033-1120 Occupancy Type: Load: Construction Type: Is the Building, Historically Designated: Yes NO X OWNER: Name (Fee Simple Titleholder): EAGLE RIVER HOMES LLLP Address: PO BOX 3598 Flood Zone: BFE: FFE: phone#: (786)443-2320 City: HALLANDALE State: , FL Tenant/Lessee Name: N/A Email: N/A Zip: 33008 Phone#: N/A CONTRACTOR: Company Name: DOCtor PIllt7lbing Inc Address: 2357 W 80 ST BAY 4 Phone#: (305)602-0400 City: Hialeah State: FL Qualifier Name: Fernando Arias State Certification or Registration #: CFC1429344 DESIGNER: Architect/Engineer: N/A Address: N/A Zip. 33016 Phone#: (305)602-0400 Certificate of Competency #: Value of Work for this Permit: $ $6,000.00 Type of Work: ❑ Addition ❑■ Alteration City: N/A Phone#: N/A State: N/A Zip: N/A Square/Linear Footage of Work: 1,600.00 ❑ New v - ❑ Repair/Replace Description of Work: NEW BATH ROOM AND LAUNDRY ❑ Demolition Specify color of color thru tile: Submittal Fee $Sooa4rJ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ f 2if ;r (Revised02/24/2014) CCF $ CO/CC $ DBPR $ _ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE$ r Bonding Company's Name (if applicable) N/A Bonding Company's Address N/A City N/AState N/A Zip N/A Mortgage Lender's Name (if applicable) N/A Mortgage Lender's Address N/A City N/A state N/A Zip N/A 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 AENT The fgregoing instrument was acknowledged before me this Signatur CONTRACTOR e foregoing instrument was acknowledged before me this &C) day of �"�-- , 20 IS , by 9 day of September 6/% f 5 ( , who is personally known to Fernando Arias JR me or who has produced FL bRofE.lZ LIas me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ,2015 by who is personally known to Sign: Print: AIL OA VAtL ,e, Seal: ALINA CARVAJAL MY COMMISSION # EE860269 EXPIRES: December 25, 2016 ********* APPROVED BY (Revised02/24/2014) identification and who did take NOTARY PUBLIC: Sign: Print: Davie Seal: ary P ,lic - State of Florida omm. pires Jan 17, 2016 ommission # EE 160491 **** k****+M*****************4************************* kik*************+ *** )4 -9S Plans Examiner Zoning Structural Review Clerk STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ARIAS, FERNANDO JR DOCTOR'S PLUMBING INC. 7530 SW 36TH ST MIAMI FL 33155 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and team more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! DETACH HERE RICK SCOTT, GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSI NALxREGULATION CFC1429344 ISSUED: -;;07/29/2015 CERTIFIED PLUMBING -CONTRACTOR ARIAS, FERNANDO JR DOCTOR'S PLUMBING=IN IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31, 2016 L1507296660344 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 ARIAS, FERNANDO JR DOCTOR'S PLUMBING INC' 11316 SOUTHWEST1851 MIAMI FL 36'167: n,c.ni Av Ao ncn, ulI r ov I AlAry 'res u , A CA f flelA/1ft* A A inns Tax Roc State of elassimit ftimmettocivrtoot Docnitts Ptteestic Mac COM UAW R 33999 irecron >ra MOW 8"4!9270 OWN* SE C T V i aiXIORS Pt WMA k'IC s crier , Eno{sS Th.s UNA8 .is ton floornoafirNohow wwwwSesame Tex WPM 'to cowellcodwo M the kola's M ++raottsi owasoborooisool twornelore lows am. roweewiNet *Vern is** Tko NECIPT N Wow mow be iLi'sd w a rsM.ewrc:N A GRIT CERTIFICATE OF LIABILITY INSURANCE rDATE(MMIDDIYYYY) 11/02/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FtIGHTS 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 poilcy(Iss) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Polley. certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In 'Mu of such endoraement(s). PRODUCER JvsIn$UranCe Agency 9600 SW 8th St, Suite 27 Miami, FL 33174 Phone (305) 552-5250 Fax (305) 552-5292 INSURED DOCTOR'S PLUMBING INC. 11316 SW 185 TERR ca r (LIANA CASTANEDA PHO No• rI (305) 552-5250 _ADDREm• serttiodelyaldo )vsintwom (305) 552-5292 IRSURIRI) AFFORDING COVERAGE NAM. INSURER A: SCOTTSDALE INSURANCE COMPANY INSURER B : INSURER C INSURER D Miami FL 33157 INSURER E : INSURER F : COVERAGE$ 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 POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TF -RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WM-I 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 SHAWN MAY HAVE BEEN REDUCED BY PAID CLAIIUR- NSR A TYPE OF INSURANCE '[''^i �1 POLICY NUM6f lkj COMMERCIAL GENERAL LIABILITY 150656 D CLAIMS -MADE M OCCUR ❑ GEN'L AGGREGATE LIMfYAPPLIES PER: ❑ POLICY • JPEG 0 LOC El OTHER AUTOLIOBII.E LIABILITY [] ANY AUTO ❑ AUTOS NED ❑ ASCTEDosULED 1 HIRED AUTOS 0 NON -OWNED AUTOS . • UMBRELLA LIAR 0 OCCUR ❑ EXCESS LIAR . p CLAIMS-NMDE DED n RETENTIONS WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y 1 N O FF IGEOPRIWMEMBER I XCLUUDDED7ECUTIvri (Mandatary In NH) I l I yes. describe under DESCRIPTION OF OPERATIONS below imIADD11!YFF VT 1 08/11/2015 fTTN�N1DpJY1rYY1 LOITS 08/11/2016 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TRENTED tSES (Ea ocomsnce) S 100,000.00 MED EXP (Any one person) $ 5,000.00 PERSONAL & Afar INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - cMPtoP AGO $ 1,000,000.00 $ S iMBINEDD SINGLE LIMN BODILY INJURY (Per person) $ OODILY INJURY (Per as ident) $ iOPERTY DAMAGE nraccident) $ EACH OCCURRENCE AGGREGATE $ ❑ � TE ❑ RTH E.L. EACH ACCIDENT $ EL DISEASE - EA EMPLOYEE $ E.L. DI$F,ASE - POLICY LIMIT $ ]ESCRIPTION OF OPERATIONS/ LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remak Schedule, If more apace is required) 'CLIMBING CONTRACTOR :ERT1FICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FL 333138 CORD 25 (2014/01) QF CANCELLATION SHOULD ANY OF THE ABO THE EXPIRATION DATE ACCORDANCE WITH E DESCRIBED POLICIES BE CANCELLED BEFORE , NOTICE WILL BE DELIVERED IN PROVISIONS. $)19 2014 ACORD CORPORATION. Ail rights reserved. The ACORD name and logo are registered marks of 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: 8/13/2015 EXPIRATION DATE: 8/12/2017 PERSON: ARIAS FERNANDO JR FEIN: 204464688 BUSINESS NAME AND ADDRESS: DOCTOR'S PLUMBING INC 7530 SW 36 ST MIAMI FL 33155 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING 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 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 BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Doctors Plumbing Inc. Plumbing Contractor Cell: (305) 602-0400 CFC1429344 Date: State of Florida County of Miami Dade Before me this day personally appeared, Fernando Arias 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 and subscribe before me this Sday of fioyei-792015, by Personally know Produced Identification RY JAVIER PEREZ Notary Public - State of Florida My Comm. Expires Jan 17, 2016 Commission # EE 160491 IVilami 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' Co , ensation Insurance Exemption m 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: ii.� _ !„=iiia =ice Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this ,J day of ' 11.E 20 By(bA°ZTOsz LlZrOwl Ft___ N2\ VE -12._ L►r:. E J Notary: ()--() SEAL: MY COMMISSION # EE860269 EXPIFtES: Decenber 25, 2016 who is personally known to me or has produced as identification. ACORO® CERTIFICATE OF LIABILITY INSURANCE ‘.�.•--- DATE(141M/DD/YYYY) 04/07/2016 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 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 Diaz Insurance Agency, INC P.O. Box 127 Fort Myers Beach FL 33931 CONTACT NAME: Laurie M Diaz o. EA): (239) 765-6571 FAX PNo): (239) 765-5214 E-MAILHHc l ADDRESS: diazinsurance@comcast.net INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ARCH SPECIALTY INSURANCE COMPANY COMMERCIAL GENERAL LIABILITY INSURED IWF CONSTRUCTION AND GLAZING, INC 9345 SW 144 ST MIAMI, FL 33176 INSURER B: COMMERCE & INDUSTRY INSURANCE COMPAN AGL0008218-02 INSURER C : SUNZ INSURANCE COMPANY 01/08/2017 INSURER D: $ 1,000,000 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y AGL0008218-02 01/08/2016 01/08/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENL X AGGREGATE POLICY OTHER: LIMIT APPUES PRO- JECT PER LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE UABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A WCPE00000001 11 6/01/2015 6/01 /2016 PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 B Excess Liability EBU0182421256 01/08/2016 01/08/2017 $4,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached 11 more space Is required) GENERAL CONTRACTOR CGC 1522182 CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES 10050 NE 2 AVE MIAMI CHORES FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD