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FW-17-2762P\in- 2-7(02 Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 1144 NE 101 Street Miami Shores, FL 33138- Owner Information Permit Permit NO. FW -11-17-2762 Permit Type: Fence/Wall Work Classification: Wire Fence Permit Status: APPROVED Issue Date: 11/2112017 Expiration: 05/20/2018 Parcel Number Applicant Address 1132050190260 Block: Lot: 1144 NE 101 Street MIAMI SHORES FL 33138- 1144 NE 101 Street MIAMI SHORES FL 33138- DAISY ABELEDO Phone Cell Contractor(s) Phone MILIANI CONSTRUCTION CORP (305)542-5075 CeII Phone Valuation: Total Sq Feet: $ 2,370.00 110 Approved: Comments: Date Approved: : Date Denied: Type of Construction: Wire Fence Classification: Residential Additional Info: CHAINLINK FENCE TO BE MOVE CL Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee - Wire & Wood Scanning Fee Technology Fee Total: Amount $1.80 $2.00 $2.00 $0.60 $110.00 $9.00 $2.40 $127.80 Pay Date Pay Type Amt Paid Amt Due Invoice # FW -11-17-65711 11/21/2017 Check #: TEMP $ 77.80 $ 50.00 11/21/2017 Check #: 10651 TE $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Building Review Planning 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 a jar.ni . e, I thorize the above-named contractor to do the work stated. orized ' ignature: Owner / Applicant / Contractor / Agent Building Department Copy November 21, 2017 Date November 21, 2017 1 RECEI VED OrelemdN0V 212017 TRIDENT T1iU • 10. 20' 270.43' B.C. F.I.P. 1/2" (NO L0.) FLP. 1/2" (NO I.D.) LOT 4 BLOCK 177 117.87' (R&M) 0 K 0 0 p m y Q' y (-) ' LO,T 2, BLOCK 1.77. 0 'pA C 'l (11., r F.LP. 1/2" L (NO I.O.)44. �_ r t*„ �6— — .00— FtSctu i .D` III 4 • CONC 12.0'• t 4.0 020' F.I.P. 1/2" (NO 1.D.) ASPHALT PAVEVENT..:B LOT 12 BLOCK 177 Notes: NO VISIBLE ENCROACHMENTS ON THIS PROPERTY. LOT 13 BLOCK 177 LOT 14 BLOCK 177 Fences Good Side Out. The vertical and horizontal supporting members of a fence shall face the interior of the plot on which the fence is located and the finished side shall face the adjoinin lot or any abutting nab! v, Property Address: 1144 NE 101 ST MIAMI SHORES, FL 33138 nlineLand SURVEYORS,INC. :� • :•n ;(I ,•7.1/;•::. UE ,TY�T THIS BOUNDARY SU'; VEY IS A TRUE PND CORRECT REPRESENTAtTION 6Ai A I:URVEY PREPP E'BUNDERMV • • - TION. THIS COMPUES WITH THE MII�IMbbM HI•CALST¢NDARDS, AS SET FORTH BY THE STATE OF FLORIDA BOARD OF PElUFEE,S61 ' I:AN�S•U YORS IN CHAPTER 61017-6, FLORIDA ADMINISTRATIVE C(�bEN E UAtUTg473.laAFL'VRIDA STATUES. v • • rs, SIGNED f' ....... ' FOR THE FIRM FERNANDO V. G0( P.S.M. No. 5259 STATE OF FLORIDA ' STATE OF , FLOR`:.Dq NOT VALID WRHOUT AN AUTHENTIC ELECTRONIC SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL, AND/OR THE SIGNATURE AND/OR THE ORIGINAL RAISED SEAL OF A LICENSED SURVEYOR AND MAPPER. THE SEAL APPEARING ON THIS DOCUMENT WAS AUTHORIZED BY FERNANDO V. GOMEZ, P.S.M. NO. 5259 ON THE SURVEY DATE NOTED Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHAIN LINK FENCE DESIGN DETAIL (ACCORDING TO THE F.B.C. SECTION R4408.11) TABLE R4408.11 CHAIN LINK FENCE MINIMUM REQUEREMENTS Fence Height (ft) Terminal Post Dimensions (in inches) (o.d. X wall thickness) Line Post Dimensions (in inches) (o.d. X wall thickness) Terminal Post Concrete Foundation Size (diameter X depth) (in inches) Line Post Concrete Foundation Size (diameter X depth) (in inches) Upto4 23/8x0.042 15/8x0.047 10x24 8x24 Over 4 to 6 2 3/8 x 0.042 1 7/8 x 0.055 10 x 24 8 x 24 For SI: 1 inch = 25.4 mm. NOTES: 1. This table is applicable only to fences with unrestricted airflow. 2. Fabric: 121/2 gauge minimum, Black or'Gfeen.7 3. Tension bands: Use one less than the height of the fence in feet evenly spaced. 4. Fabric Ties: Must minimum the same gauge of the fabric. 5. Fabric Tie Spacing on the Top Rail: Five ties between posts evenly spaced. 6. Fabric Tie Spacing on Line Posts: One less than height of the fence in feet, evenly spaced. 7. Either top rail or top tension wire shall be used. 8. Braces must be used at Terminal Posts if top tension wire is used instead of Top Rail. 9. Post Spacing: 10 foot (3m) on center maximum. 10. Post shall be embedded to within 6 inches (152 mm) from bottom of the foundation. 11. In order to follow the contour of the land, the bottom of the fence may clear the contour of the ground by up to 5 inch (127 mm) without increasing table values to the next higher limit. NOTICE TO PROPERTIES WITH POOLS: If the fence is to meet the criteria as a pool barrier, the fence shall not be climbable and all rails must be placed facing the inside of the property. Pedestrian gates shall have self-closing and latching devices installed at the minimum of 54" above ground. For further details see Section R4401.7.1 of FBC. CONCUR Created on 5/22/2019 MLD !./22/2015 STATE OF (FLORIDA) COUNTY OF (DADE) Miami Shores Viiiage Building Department SURVEY AFFIDAVIT 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 The undersigned Affiant, bki5 Y A-f2Q—(=ued) , oes hereby attest that (Property owner) The attached survey, performed by ON u_ ioe LA,\ 5u2vt'yci-S ( /off (Name of surveyor's company) r II�j For address: )15—I N N � pt �� r H� f 51-10(1--, , f z Performed on .5� Z ( IZ (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits. urthe Affian say ethn.ught. Property Owner Signature bAis ( ISE,c3 Property Owner Print Name SWORN TO AND SUBSCRIBED before me this 13 day of Mti\A> eaa Affiant is personally known to me, produced 7-1., '. e- L►Q_-tas identification. Revised on 5/22/2009/ Revised on 6/12/09 Notary o tT P6e% Notary Public State of Florida Sindia Alvarez My Commission FF 156750 4oro, Expires09/03/2018 �n�l"tr'\.iti.h.J'...'.JL.ti.J►.V. 1l.Ji..e._x.s� ... { { { Miami Shores Village RECEIVED Building Department NOV 21 1011 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 •1 Tel: (305) 795-2204 Fax: (305) 756-8972 `� %' i INSPECTION LINE PHONE NUMBER: (305) 762-4949 Cit-ci 5 FBC201 i BUILDING Master Permit No A-31 1--23C/2— PERMIT 2i 2_PERMIT APPLICATION Sub Permit No. gBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 11yL\ ST City: Miami Shores tCounty: Miami Dade Zip: 3 t Folio/Parcel#: 1 '3 Z '7 —0 t�" 0.Z -CO Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): L : S 4 b4S%..12- O Phone#: ? S - S a-5 P g, Address: 114 C-1 'NE- 1 0 S Cit S�, '1 --- Zip:3 3 k 3 y: � � �, .rh i Cie Q S State: Tenant/Lessee Name: _ Phone#: Email: y,� /�, G� c� CONTRACTOR: Company Name: l'eq �%Mr c k 3 6%4' %Phone#: l 5�7✓ Address: 2051 k) \A/ ��7` Ave- City: vim City: 72.7(,,,.,-,s. State: `--- Gam- Zip: (S.-?> ( ( 7 Qualifier Name: � t M `�n� CA..�� Phone#: `3 t� 7� 51.7„�J D7S State Certification or Registration #: C v -' LS 7- 4-10 33 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 2370�� Square/Linear Footage of Work: ` \ D Type of Work: ❑ Addition 01 Alt ation ❑ New ❑ Repair/Replace ❑ Demolition r/ �.f Description of Work: ��6 L n 4) It 9C€ ko c- ve_ Nco \ c �e ( ,eu Ce(c70-. 5r1- Specify color of color thru tile: Submittal Fee $ �- tCD Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) Bonding Golfipany'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 AGENT Signature The foregoing instrument was acknowledged before me this i3 day of /.4 C ry , 20 (—) , by o is personally known to CONTRACTOR The foregoing instrum nt was acknowledged before me this day of 0Ve%"1-er' , 20 I 7 , by 0 L t. Z!W a who is personally known to me or who has produced—TVA a- (%`� was me or who has produced 10' L Ge--)Ceas identification and who did take an oath. NOTARY PABLIC: Sign: Print: Seal: AW c2- 'es Notary Public State of Florida Sindia Alvarez c My Commission FF 156750 cKc=* Expires 09/0 /2018 *************** APPROVED BY (Revised02/24/2014) identification and who did take an oath. NOTARY PIABLIC: Sign: Print: Seal: ************ Plans Examiner Structural Review "+ a RAQUEL HARRIS 14. : Commission # GG 066867 l ^ ha 4 Expires July 24, 2021 •.f,„"..• Bonded Nu Troy Fain Insurance 800485.7019 >k � IZoning Clerk 11/16/2017 Property Search Application - Miami -Dade County OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11-3205-019-0260 Property Address: 1144 NE 101 ST Miami Shores, FL 33138-2607 Owner NANCY VALDES JTRS DAISY ABELEDO JTRS Mailing Address 1144 NE 101 ST MIAMI, FL 33138 USA PA Primary Zone 1100 SGL FAMILY - 2301-2500 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 2/2 / 0 Floors 1 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 1,731 Sq.Ft Lot Size 8,775 Sq.Ft Year Built 1948 Assessment Information Year 2017 2016 2015 Land Value $315,734 $294,255 $267,765 Building Value $86,204 $86,204 $86,204 XF Value $0 $0 $0 Market Value $401,938 $380,459 $353,969 Assessed Value $241,730 $236,759 $235,114 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction $160,208 $143,700 $118,855 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values ('.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 8 REV PB 43-67 LOT 3 BLK 177 LOT SIZE 75.000 X 117 Generated On : 11/16/2017 Taxable Value Information Previous Sale 2017 2016 2015 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $191,730 $186,759 $185,114 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $216,730 $211,759 $210,114 City Exemption Value $50,000 $50,000 $50,000 Taxable Value $191,730 $186,759 $185,114 Regional Exemption Value $50,000 $50,000 $50,000 Taxable Value $191,730 $186,759 $185,114 Sales Information Previous Sale Price OR Book -Page Qualification Description 05/14/2012 $300,000 28125-0155 Qual by exam of deed 04/24/2009 $100 26847-2106 Affiliated parties 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: L MILIANI CONSTRUCTION November, 14th of 2017 State of Florida County of Miami -Dade Before me this day personally appeared Adolfo Miliani who, being duly, sworn deposes and says: That He will be the only person working on the project located 1114 NE 101th St, Miami Shores FL, 33138. Contractor Signature Sworn to and subscribe before me this 14 day of November 2017 by Personally know OR Produce Identification t•. n RAQUEL HARRIS Commission it GG 086!:.,7 Expires July 24,2021 lorded TAN bey Fib :a f. 2051 NW 112 AVE SJITE 114 MIAMI. FLORIDA 3.3172 PH. 305-424-4414 305 542 9075 Print, Type or Sta p 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 NiNe The oing was acknowledg• before me this f %1 day of B �f1S H 4L4 who is personally known to me or has produced as identification. 3 Notary: SEAL: c05`"ue(/ NANCY GOLDRING MY COMMISSION # GG 059069 EXPIRES: February 15, 2021 '"OF Fig- Bonded Thru Budget Notary Services STATE OF FLORIDA A DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MILIANI, ADOLFO RAMON MILIANI CONSTRUCTION CORP. 11012 NW 73RD ST DORAL FL 33178 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 learn 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! RICK SCOTT, GOVERNOR ilF40 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CGC1524033 ISSUED: 06/14/2016 CERTIFIED GENERAL CONTRACTOR MILIANI, ADOLFO RAMON MILIANI CONSTRUCTION CORP. IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31 2018 L1606140001296 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CGC1524033 The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 MILIANI, ADOLFO RAMON MILIANI CONSTRUCTION CORP. 2051 NW 112TH AVENUE STE 114 MIAMI FL 33172 ISSUED: 06/14/2016 _ DISPLAY AS REQUIRED BY LAW SEQ # L1606140001296 Local Busi ness Tax 1ecei pt M ia,m i-Dad:e County, State of ROT ida -THIS IS NOTA BILL •DO NOT PAY 7204974 BUSINESS NA M E/LOCA TION MILIANI CONSTRUCTION CORP 2051 NW 112 AVE 114 SWEETWAMER, FL 33172 OWNER MILIANI CONSTRUCTION CORP C/O ADOLFO MILIANI PRES Worker(s) 1 RECEIPT NO RENEWAL 7487984 EX MASS- SEPTEMBER 'I•RESSEPTEMBER 30, 2018 Must be displayed at place of business Pursuant to County Code Chapter BA - Art. 9 & 10 SEC. TYPE Of BUSINESS 196 GENERAL BUILDING CONTRACTOR CGC1524033 PAYM ENT RECEIVED BY TAX COLLECTOR 45,00 07/06/2017 C R E D I TCA R D-17-04 3 874 ThisIt ral Busine53Tax.Receipt.only.con^.mspat/robotof,theLA:Ja sinestT X RiePaceiptisnot alicense, pearl t, ora certi "cation of the holders qual i "cations, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The I43r8PT NO, above rrusf be displayed o1 all comrercial vehicles - Miami -Dade Code Sec 8a-278 H t For more information, visit www.mianidade Cpllecta ACO Ue THI�TIFICATE 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. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/17/2017 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 ADVANTAGE INSURANCE OF AMERICA 4520 NW 7th St Miami, FL 33126 CONTACT NAME: (aG No.EXq: (305) 649-5566 FAX 305) 649-5559 E Mk (A/C, No): AooREss:j ackiebatista_749@hotmail .coon INSURER(S) AFFORDING COVERAGE NAIC, INSURER A : UNITED SPECIALTY INSURED MILIANI CONSTRUCTION CORP 2051 NW 112 AVE STE 114 MIAMI, FL 33172 INSURER B . INSURER C INSURER D : INSURER E : INSURER F : CERTIFICATE NUMBER' REVISION NUMBER: L,vvcrwGES 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. NSR LTR TYPE OF INSURANCE AODL INSR SUBR mm POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM(DD/YYYY) LIMITS GENERAL — X LIABILITY COMMERCIAL GENERAL LIABILITY SII1004B210944 04/29/17 04/29/18 EACH OCCURRENCE $ 1,000,000 DAMAGE O REN I PREMISES (Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 5, 000 CLAIMS -MADE OCCUR PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2, 000, 000 PRODUCTS - COMP/OP AGG $ 2 , 0 0 0 , 0 0 0 GEN'L AGGREGATE TO POLICY LIMIT APPLIES PRO- JECT PER: LOC $ AUTOMOBILE — — `— — LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS +I 1 SCHEDULED AUTOS NON -OWNED AUTOS CU BINEDtSINGLE LIMIT(Ea $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ — UMBRELLA LIAR EXCESS LIAB — OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE I OFFICER/MEMBER EXCLUDED? I (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required) ***Residential and commercial remodeling additions and alterations General Contractor** CERTIFICATE HOLDER CANCELLA Miami Shores Village Blgd dept 10050 NE 2nd Ave Miami Shores FL 33138. SHOULD A1OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPI TION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDAN E WITH THE POLICY PROVISIONS. AUTHORIZED E,PRESE TATIVE LI (� 1 /©1988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010/05) 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: 3/3/2016 EXPIRATION DATE: 3/3/2018 PERSON: MILIANI ADOLFO R FEIN: 811350620 BUSINESS NAME AND ADDRESS: MILIANI CONSTRUCTION CORP. 2051 NW 112TH AVENUE SUITE 114 MIAMI FL 33172 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover 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