Loading...
MC-17-2498Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. MC -10-17-2498 Permit Type: Mechanical - Residential Work Classification.: A/C Replacement Permit Status: APPROVED Issue Date: 10125/2017 Expiration: 04/23/2018 Parcel Number Applicant 675 NE 93 Street Miami Shores, FL 33138- 1132060141740 Block: Lot: MASEBS LLC Owner Information Address 675 NE 93 Street MIAMI SHORES FL 33138- 675 NE 93 Street MIAMI SHORES FL 33138- Phone Cell Contractor(s) Phone BLUE DIAMOND AIR CONDITION INC (786)286-1294 Cell Phone Valuation: Total Sq Feet: $ 4,500.00 0 Tons: Additional Info: REPLACEMENT A/C 4 TON Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: REPLACEMENT A/C 4 TON Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $3.00 $2.36 $2.00 $1.00 $157.50 $9.00 $4.00 $178.86 Pay Date Pay Type Invoice # MC -10-17-65408 10/19/2017 Credit Card 10/25/2017 Credit Card Amt Paid Amt Due $ 50.00 $ 128.86 $ 128.86 $ 0.00 Available Inspections: Inspection Type: Final Review Mechanical 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 res•onsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBIC , MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAV construction and zo all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating I authorize the above-named contractor to do the work stated. Authorized Sig ^'!e: O -r / Applicant / Contractor / Agent Building Department Copy October 25, 2017 Date October 25, 2017 1 BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC ❑ PLUMBING MECHANICAL 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 ❑ ROOFING RECEIVED CT 2017 BY: 60 FBC 20 )4 -s11' Master Permit No. PAC, `C lTh z4 1 v Sub Permit No. ❑ REVISION ❑ EXTENSION ❑ RENEWAL El PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 7 5 No 1-3 Sr City: Miami Shores County: Folio/Parcel#: Occupancy Type: Load: OWNER: Name (Fee Simple Titleholder): Miami Dade Zip: 3 3 /3S ' Is the Building Historically Designated: Yes NO Construction Type: /' Flood onre: O c. t BFE: �p F611(.1.59'31 FE: �q `"l s`e.LS LL l v'�' Phone#: t�� ( ` �11 5 l Address: 1 G7S 4 L% E1 S�-�'e-e=�({- City: t--<< - t i. --c (€ f State: T(— Zip: 3 (3 g Tenant/Lessee Name: ( Phone#: Email: Qk —d r15 n t �/1&-r?,c-`-C-10(1 CONTRACTOR: Company Name: Oke Jrcm'i'1 C a/c Address: 1/,`f 5/ c J 9T �^ City: / ` ! o. /?1� � /� /� State: f j Qualifier Name: 4/ heC f h g 0,D. -;e )„, . State Certification or Registration #: Certificate of Competency #: e- AC D 4,2 70 3 DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ ` 1 0 d Square/Unear Footage of Work: Type of Work: ❑ Addition ❑ Alteration KNew ❑ Demolition Description of Work: 6-,c,:2_ A f C._ 4 Phone#: 7&le -319—`Ove Zip: 3 3Vjo Phone#: 7S4.' -39c 9ocf'r ❑ Repair/Replace Specify color of color thru tile: Submittal Fee $ v 0 P9►1O Permit Fee $ 1515' CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ I (J (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 'r .--LOWNER or AGENT The foregoing instrument was acknowledged before me this day of -Ptv CSS , 20 1-4— , by CO,4O J AG( 7/0b , who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: as Print: cQ Seal: ************* f DAVID HASSAN Notary Public - State of Florida My Comm. Expires May 30. 2018 Commission # FF 104619 APPROVED BY (Revised02/24/2014) Signature >� v CONTRA R The foregoing instrument was acknowledged before me this �� 2. day of ' UGit 2 , 20 1'1 , by bz_ri ) RoAri jtier , who is personally known to me or who has produced ThlR& ,.-o SO-- 184-0 as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Mu„--I-a Ec • 42nd Seal: ekt,MARTA E. RODRIGUEZ MY COMMISSION # FF902845 EXPIRES: September 28, 2019 **iii**************t#********************************• **** PI ns Examiner Structural Review Zoning Clerk Property Search Application - Miami-Dade County OFFICE OF THE PROPENTV Summary Report Property Information Folio: 11-3206-014-1740 Property Address: 675 NE 93 ST Miami Shores, FL 33138-2906 Owner MASEBS LLC Mailing Address 450 GRAPETREE DR 304 KEY BISCAYNE, FL 33149 USA PA Primary Zone 1000 SGL FAMILY - 2101-2300 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 3/2 / 0 Floors 1 Living Units 1 Actual Area 2,127 Sq.Ft Living Area 1,432 Sq.Ft Adjusted Area 1,818 Sq.Ft Lot Size 11,170.11 Sq.Ft Year Built 1956 Assessment Information Year 2017 2016 2015 Land Value $334,823 $290,239 $268,383 Building Value $131,293 $131,544 $132,723 XF Value $3,504 $3,537 $3,394 Market Value $469,620 $425,320 $404,500 Assessed Value $469,620 $148,272 $147,242 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction Qual by exam of deed $277,048 $257,258 Homestead Exemption $0 $25,000 $25,000 Second Homestead Exemption $39,500 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 3 PB 10-37 LOT 18 & W1/2 LOT 19 BLK 65 LOT SIZE 86.590 X 129 OR 12936-154 0686 1 Page 1 of 1 Generated On : 10/19/2017 Taxable Value Information Previous Sale Price OR Book -Page 2017 2016 2015 County Qual by exam of deed 06/01/1986 Exemption Value 12936-0154 Sales which are qualified $0 $50,000 $50,000 Taxable Value 04/01/1971 $39,500 $469,620 $98,272 $97,242 School Board Exemption Value $0 $25,000 $25,000 Taxable Value l $469,620 $123,272 $122,242 City Exemption Value $0 $50,000 $50,000 Taxable Value $469,620 $98,272 $97,242 Regional Exemption Value 1 $0 $50,000 $50,000 Taxable Value $469,620 $98,272 $97,242 Sales Information Previous Sale Price OR Book -Page Qualification Description 02/23/2017 $492,000 30448-0679 Qual by exam of deed 06/01/1986 $76,000 12936-0154 Sales which are qualified 11/01/1979 $73,000 10564-3260 Sales which are qualified 04/01/1971 $39,500 00000-00000 Sales which are qualified 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 http://www.miamidade.gov/info/disclaimer.asp Version: http://vvvvw.miamidade.gov/propertysearch/ 10/19/2017 2017 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT FILED DOCUMENT# L16000204637 Apr 17, 2017 Entity Name: MASEBS, LLC Secretary of State CC0319740676 Current Principal Place of Business: 675 NE 93 STREET MIAMI SHORES, FL 33138 Current Mailing Address: 675 NE 93 STREET MIAMI SHORES, FL 33138 US FEI Number: 81-4344238 Name and Address of Current Registered Agent: `'QUICENO, DAIANA 675 NE 93 STREET MIAMI SHORES, FL 33138 US Certificate of Status Desired: Yes The above named entity submits this statement for the purpose of changing its registered office or registered agent, or both, in the State of Florida. SIGNATURE: Electronic Signature of Registered Agent Authorized Person(s) Detail : Title MGR Title MGR Name QUICENO, DAIANA Name HERNANDEZ, CARLOS J Address 450 GRAPETREE DRIVE #304 Address 450 GRAPETREE DRIVE #304 City -State -Zip: BISCAYNE FL 33149 City -State -Zip: BISCAYNE FL 33149 Title MGR Name HERNANDEZ, LIGIA LUZ EGEA DE Address 450 GRAPETREE DRIVE #304 City -State -Zip: KEY BISCAYNE 33149 Date I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oath; that I am a managing member or manager of the limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 605, Florida Statutes; and that my name appears above, or on an attachment with all other like empowered. SIGNATURE: CARLOS J HERNANDEZ MANAGER 04/17/2017 Electronic Signature of Signing Authorized Person(s) Detail Date Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. 05 de t 3 Sr Job Address (where the work is being done): City: Miami Shores Village County: Miami Dade Zip Code: 33/ �S ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES 0 NO 0 Contract Attached: YES 0 UNIT BEING REPLACED DATA NEW UNIT )1.4e,..s,Ist, MANUFACTURER Ca i ri{dir A Ag (_ 17 a 1 / W F.D AHU or PKG. UNIT MODEL # 1 jr ti'D iv f o wLoc `?4.j,F} Bro An COND.UNITMODEL# CA /(p /Y4ogs(000 KW HEAT I O 4 (i) NOM TONS 40 ) AHU CU PKG 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3) VOLTS AHU CU PKG PKG UNIT I / ) / PKG UNIT / / 12 Z -re-i EER/SEER 1(a Srr .--- YES YES NO REPLACING DUCTS YES ( N) YES NO REPLACING THERMOSTAT YE NO YES NO NEW 4"CONCRETE SLAB E NO YES NO . NEW ROOF STAND YE NO YES NO NEW RETURN PLENUM BOX YES 140) 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 40 3. Voltage of Circuit (208/240/480): zoS -230 vi C_ 4. Size Disconnecting Means: e Contractor's Company Name: /3w o - �/ L aVYJO 4 of Phone: State Certificate or Registration No. Certificate of Competency No. -AC- 0 41 2. 703 Signature-,// ra �' Date: �f �� — (Qualifier's sig ture) (Revised02/24/2014) BLUE DIAMOND AIR CONDITION INC Date State of County of Before me this day personally appeared -- l r- --- L -L a duly sworn, Deposes and says: That he or she will be the only person working on the project located at: - -- /6 ----de = 7 sr ---------- Contactor signature Sworn to (or affirmed) and subscribed before me this---------- day---- By ay- By Personally know - who, being x OR produced identification— f l)L -g- t2"-=-1 == =- a 4—o Type of Identification Produced - MARTA E. RODRIGUEZ CONLMISSION # FF902845 �• RES: September 28, 2019 Print ,Type or Stamp Name of Notary Notice to Owner — Workers' Com p Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ensation 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. State of Florida County of Miami -Dade The foregoing was acknowledge before me this By liki S6.,c fI-'t'''`�` ce 1 �. Notary: SEAL: 3 day of sSO VSA— , 20_ . wimiuiersonally_knoe or has produced as identification. ij �►�"'"�" DAVID HASSAN I P.' Notary Public - State of Florida I N,, r My Comm. Expires May 30, 2018 I 4 -•;4,,,,ttgoV Commission # FF 104619 I • Miami Shores Viiiage Building Department CONTRACTORS' REGISTRATION 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ✓ COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF 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. BUSINESS NAME: Id ) l a n. oyl oi A r Cor A t t on I r C, • BUSINESS ADDRESS: \32Q. Q3 1- 3 2 S -- CITY N-ici )ea k STATE 4C I ZIP 330 I7 BUSINESS PHONE: ( 7g(0 ) FAX NUMBER ( ) CELL PHONE ( ) QUALIFIER'S NAME: A-1 Ine r i -O R. rt 0(.4 e QUALIFIER'S LIC NUMBER: (ACO 42703 A� oil' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 09/19/2017 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(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 ALL CITY INSURANCE INC. 275 FONTAINEBLEAU BLVD.ptiCeN+e SUITE 190 MIAMI FL 33172- COjE CT INGRID HERRERA FSI. (305)463-9431 FAX .(305)436-6797 MAIL : GMAIL@ALLCITYINS.COM tn. EDDR INSURER(S) AFFORDING COVERAGE NAIC # INSURERA .ASCENDANT COMMERCIAL INSU LIABILITY COMMERCIAL GENERAL LIABILITY INSURED BLUE DIAMOND AIR CONDITION INC 143 EAST 5 STREET Hialeah FL 33010- INSURER B : GL55724-0 INSURERC: 04/04/2018 INSURER D : $ 1,000,000 INSURERS: $ 100,000 INSURER F : $ 5,000 :30 REVISION NUMBER: 00 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 IIJRR SUBR wvn POUCY NUMBER POUCY EFF (MMIDDIYYYY) POUCY EXP (MM/DDIYYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GL55724-0 04/04/2017 04/04/2018 EACH OCCURRENCE $ 1,000,000 DATO REND MI.SFS (Fa oonui rAnce) $ 100,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 EN'LAGGREGATE G—)1( ^ I POLICY UMITAPPLIESPER: PRO - T LOC $ AUTOMOBILE LIABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peramident) $ $ UMBRELLA UAB EXCESS LAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ 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 WC STATU- TORY LIMITS OTH- FR E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N more space is required) �._-- MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVENUE MIAMI SHORES 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 d ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserve. The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHIEF FINANICAL 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: 6/24/2017 EXPIRATION DATE: 6/24/2019 PERSON: RODRIGUEZ ALBERTO FEIN: 272606798 BUSINESS NAME AND ADDRESS: BLUE DIAMOND AIR CONDITION INC 2940 SW 102 AVE MIAMI FL 33165 SCOPE OF BUSINESS OR TRADE: Heating, Ventilation, Air - Conditioning and Refrigeration Systems Installation, Service and Repair, Shop, Yard & Drivers IMPORTANT: 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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CAC042703 The CLASS B AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 RODRIGUEZ, ALBERTO BLUE DIAMOND AIR CONDITION INC 2940 SW 102 AVE MIAMI FL 33165 ISSUED: 09/14/2016 DISPLAY AS REQUIRED BY LAW tit STATE OF FLORIDA �. DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC042703 ISSUED: 09/14/2016 CERTIFIED AIR COND CONTR RODRIGUEZ, ALBERTO BLUE DIAMOND AIR CONDITION INC IS CERTIFIED under the provisions of Ch,489 FS. Expiration date : AUG 31, 2018 L1609140001700 SEQ # L1609140001700