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BPP-16-1097Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-295342 Scheduled Inspection Date: January 19, 2018 Inspector. Naranjo, Ismael Owner: ZELINSKI, JOHN Job Address: 33 NE 93 Street Miami Shores, FL 33138 - Project: <NONE> Contractor. GATOR POOLS AND SPA CONSTRUCTION i Permit Number BPP -4-16-1097 Permit Type: Pools/Whirlpools/Hot Tubs Inspection Type: Final Work Classification: New Phone Number (786)515-5716 Parcel Number 1132060130380 Phone: (305)222-2220 IBuiiding Department Comments NEW POOL Inhaetio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until reinspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP-294975. CREATED AS REINSPECTION FOR INSP-257394.01105f2018 NOT READY AS PER MANNY REQUESTED A POOL BARRIER INSTEAD CANCELLED BY LUIS RIVAS 1/12/18 10:00 January 18.2018 For Inspections please call: (305)762-4949 Page23of32 Inspection Worksheet Miami Shores'Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 nspection Number: INSP-278607 Permit Number: BPP -4-16-1097 Inspection Date: July 28, 2017 Inspector: Dacquisto, David Owner: ZELINSKI, JOHN Job Address: 33 NE 93 Street Miami Shores, FL 33138- Project: <NONE> Contractor: GATOR POOLS AND SPA CONSTRUCTION Permit Type: Pools/Whirlpools/Hot Tubs Inspection Type: Survey Final Work Classification: New Phone Number (786)515-5716 Parcel Number 1132060130380 Phone: (305)222-2220 Building Department Comments NEW POOL Infractio Passed Comments INSPECTOR COMMENTS False 1 I (6—) Passed VA, Inspector Comments CREATED AS REINSPECTION FOR INSP-276484. DECK MUST BE LOCATED NOT LESS THAN 10 FT FROM SIDE PLOT LINE. i CUT BACK DECK AND HAVE NEW SURVEY WITH THE SETBACK BETWEEN THE DECK AND SIDE PLOT LINE CLEARLY IDENTIFIED. Failed Correction Needed Re -Inspection Fee i No Additional Inspections can be scheduled re -inspection fee is paid. until July 28, 2017 For Inspections please call: (305)762-4949 Page 1 of 1 ME LAND c, .\j,..J. i24,--i'wa�tm7,.,T • 'i�huEcnnstm .„=, t"' j NW 90h Sl, 1 NW � m �xaaorwi+M! .+i�'4' I I Pitt_ h3 •T^Mtam t'Shd7l'' ""'a' 1 �^'NW 9011,S1,,,.... �[[r7x^N"'E9kh Std SNE OS h51' I i®j .2iscy94ih ili^,l y b 1 *� 8_y , alyA.s_. _ 2n me 4• m 1 --„—.4---iNE 9fi05t y R- NE 93M S4", -�I 1.4r -it, -,-.1.:7,- tS I}�� jf,- of ti 1- tJj. 1 NW 90th St ---. St. 7r d 2l "000I r.��* i_____xI]�tA.r4r.OM170eeyle Proudly Serving ip-7 the Florida Real ME I:AND ' cr Estate Community for Over 20 Years W W W.MELANDSERVICES.COM LOT 12 BLOCK 3 LOT 13 BLOCK 3 H LOT 14 BLOCK 3 F.I.P.1/ " BLOCK CORNER 509.1311V) F.i. P.1 /2 ON.PL X10. oo' 15.00' LOT 9 BLOCK 3 i 'M7 . N 0 5 W L J Uv wZ It 8z DN PL 3 15' ALLEY 75.00'(P)(M).-- c0 6' WOOD FENCE 29.75' 6' 1. POOL I I a, -I I ow M ` M ' MM MMM M}M NM MMMM M� r7, ■■TILE ■ :::iMemu sion 22.1' 6' I lEl 0 In N ^12:00' 22.60' 10.12' 5.5' o0i Fi. F.1/2. O N "1 N il7iI i7ip14.13'O CO tV 50.00' LOT 15 BLOCK 3 0 V <1 PAVERS 18.32' ONE STOR1Y C.B.S. RESIDENE #3311 18.05' N to 6.05' Cr) OI ai CO 16.85' 0 oi N 2.10' ir 0.42' 9.84' a 0 • • • •• • •••• • 1 • •••• ••• • 14'MAINDER " • ..LOT 16.. • ••BECK 3'••' • •' •• •• 0.&f '•••• 0.22' • 0 0 11.85' 25.00'— LOT 16 BLOCK 3 O !n 3' I 1caF.LP. 75.00'(P)(M) 5' CONC. SIDEWALK 0 7.8' 'ASPHALT DRIVEWAY 7.8' O r7 • • • • • •• • ••• • •. • • • • , ••• • • • •a 1 • • • • • • • • • • • u a res Village \c` SUBJECT CO CCMMPLIFNCE W1TN ALL FEDERAL STATE ANL) L'( UN'I ( RULES AND REGULATIONS L 1 �, 1 - is ?arni Shc m r. APPRO : D ZONING ET BLDG DEPT 21, 20' ASPHALT PAVEMENT 75' TOTAL RIGHT -OF -WAY .E. 9 r E'ET Accepted By: RECEIVED Property Address: 33 N.E. 93 Street Miami Shores, FLORIDA 33138 SURVEYOR'S CERTIPICA110N: 1 HERBY' CORRECT REPRESENTATION OF A WITH THE MINIMUM TECHNIC PROFESSIONAL LAND SUR ADMINISTRATIVE CODE PUR SIGNED EFRAINrLOP STATE OF FL FY THAT Tr$l8 BOUNDARY SURVEY IS A TRUE AND ED UNDER MY DIRECTION. THIS COMPLES FORTH BY THE STATE OF FLORIDA BOARD OF THROUGH 8.1-17-062 FLORIDA TUES. FOR THE FIRM P.S.M. No. 6792 NOT VALID WITHOUT AND AUTH IC SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL AND/OR THIS MAP IS VALID WITHOUT THE SIGNATURE AND THE ORIGINAL RAISED SEAL OF A LICENSED SURVEYOR AND MAPPER. Notes: NO NOTES M.E.,Land Surveying, Inc. 10665 SW 190th Street Suite 3110 Miami, FL 33157 Phone: (305) 740-3319 Fax: (305) 669-3190 LB#: 7989 ptc2am7 CIA 1—N Survey #:B-29995 Client File #: Pane 1 of 2 Not valid without all ogees PROPERTY UNE Surveyor's FND FOUND IRON PIPE / PIN AS NOTED ON PLAT LB# UCENSE # - BUSINESS LSI, UCENSE / - SURVEYOR CALC CALCULATED POINT SET SET PIN • CONTROL POINT CONCRETE MONUMENT • ,BENCHMARKS ELEV ELEVATION POINT OF TANGENCY P.C. POINT OF CURVATURE P.R.M. PERMANENT REFERENCE MONUMENT P.C.C. POINT OF COMPOUND CURVATURE P.R.C. POINT OF REVERSE•CURVATURE P.O.B. POINT OF BEGINNING P.O.C. POINT OF COMMENCEMENT P.C.P. PERMANENT CONTROL POINT M FIELD MEASURED P P PLATTED MEASUREMENT D DEED C CALCULATED LM.E. LAKE OR LANDSCAPE MAINT. R.O.E. ROOF OVERHANG EASEMENT Legend ' B.R. BEARING REFERENCE'TEL TELEPHONE FACILITIES �,. A CENTRAL ANGLE OR DELTA U.P. UTIUTY POLE R RADIUS OR RADIAL E.U.B. ELECTRIC UTIUTY BOX RAD. RADIAL TIE SEP. SEPTIC TANK N.R. NON RADIAL D.F. DRAINFIELD TYP. TYPICAL A/C AIR CONDITIONER I.R. IRON ROD s/yw SIDEWALK I.P. IRON PIPE owv DRIVEWAY N*D NAIL t DISK SCR. SCREEN PK NAIL • PARKER-KALON NAIL GAR GARAGE D.H. DRILL HOLE ENCL ENCLOSURE ® WELL N.T.S. NOT TO SCALE STRUCTURE 4,•m-•. r e.♦ CONC. BLOCK WALL —X—X— CHAIN- UNK FENCE OR WIRE FENCE —'/—•//— W000 FENCE- —0--0— IRON FENCE — — — — EASEMENT — - — CENTER UNE %�������� WOOD DECK r; ` • , .• CONCRETE ///////1 ASPHALTP.T. .•!,._•.�!:llZ BRICK / TILE SSS FIRE HYDRANT F.F. FINNISHED FLOOR ® M.H. MANHOLE T.O.B. TOP OF BANK 0.H.L OVERHEAD ONES E.O.W. EDGE OF WATER TX TRANSFORMER E.O.P ,EDGE OF PAVEMENT CAN CABLE TV RISER C.V.G. CONCRETE VALLEY GUTTER yy,M. WATER METER B.S.L BUILDING SETBACK UNE P/E POOL EQUIPMENT S.T.L SURVEY TIE UNE CONC. CONCRETE SLAB CENTER UNE ESMT EASEMENT R/W RIGHT-OF-WAY D.E. DRAINAGE EASEYENTZ' P.U.E. PUBUC UTIUTY EASEMENT MIT. LB.E. LANDSCAPEBUFFEREASEMENTCALE: CANAL MAINTENANCE EASEMENT L.A.E. UNITED ACCESS EASEMENTA.E. ANCHOR EASEMENT ���� L'. WATER K _'se:' 1 �� 'APPROXIMATE EDGE OF -WATER; S _?' COVERED AREA' ,, ' -� '-"� TREE '' �'":Iti•:' ' �^' SpF�°"�O- ;-:.".�. t POWER 'POLE }: 1111 „,: a' CATCH BASIN, �•': ' { C.U.E... COUNTY EASEMENT I.,1 I.E./E.E..• INGRESS / EGRESS EASEMENT U.E. UTILITY EASEMENT Property Address: 33 N.E. 93 Street Miami Shores, F•rORIpA 33138 •Underground General Notes: 1.) The Legal Description used to perform this survey was supplied by others. This survey does not determine or is not to imply ownership 2.) This survey only shows above ground improvements. utilities, footings, or encroachments are not located on this survey map 3.) If there is a septic tank, well, or drain field on this survey, the location of such items was shown to us by others and the information was not verified. 4.) Examination of the abstract of title will have to be made to determine recorded instruments, if any, effect this prop erty.The lands shown herein were not abstracted for easement or other recorded encumbrances not shown on the pl at -> 5.) Wall ties are done to the face of the wall. 6.) Fence ownership is not determined. • 7.) Bearings referenced to line noted B.R 8.) Dimensions shown are platted and measured unless otherwise shown. 9.) No identification found on property comers unless noted. 10.) Not valid unless sealed with the signing surveyors embossed seal. 11.) Boundary survey means a drawing and/or graphic representation of the survey work performed in the field, coul d be drawn at a shown scale and/or not to scale 12.) Elevations if shown are based upon NGVD 1929 unless otherwise noted 13.) This is a BOUNDARY SURVEY unless otherwise noted. 14.) This survey is exclusive for the use of the parties to whom it is certified. The certifications do not extend to any u nnamed parties. 15.) This survey shall not be used for construction/permitting purposes without written consent from the land surveyor who has signed and sealed this survey. • • • • Information!,• • • •• Flood • • • • Community Number: 12065.1 • • • PaMet Fru'mber' el 2066C0302L• • • It • •• • • Su 1: L• • • • • • • • Dat? Of Firm Ir4leatt *09/114009** Fld'k$d Ebbe: X• • • • • • Base"Flood Elevation' • • • lbdd.•• Dafe LIVIeld Vt•66/26/' 017 Dajer of Oomplgtiop• .06/270017 • • • e • Legal Description: 3 Lot 15 and the West 1/2 of Lot 16', of Block 3, of MIAMI SHORES SECTION NO. ONE , according to the plat thereof, as recorded in Plat Book 10, Page 70, of the p,records of Miami -Dade County, FLORIDA •ih ` Printing Instructions: ,� While viewing the survey in any Reader, select the File Drop-down and select "Print". Serea a color printer, if available; or at least one with 8.5" x 14" (Iegitl) paper. Select ALL for Print Range, -and the # of copies you would like to print out. ''°-- • Under the "Page Scaling" pleaskdke sure you have selected "None". Do not check the "Auto -rotate anenter" box. Check the "Choose Paper size b DF" checkbox,ethen click OK to print.' • Certified To: John Zelinski Self its successors and/or assigns as their interest may appear. Please copy below for policy preparation purposes only: This policy does not insure against loss or damage by reason of the following exceptions: Any rights, easements, interests, or claims which may exist by reason of, or reflected by, the following facts shown on the survey prepared by _ EFRAIN LOPEZ dated 06/27/2017 bearing Job # B-29995 : a. NO NOTES _ � M.E. Land Surveying, 10665 SW 190th Street, Suite ME'LA D t 4 �, Phone: (305) j5 , Fax: (305) LB#: Inc: , u�4 3110'Miami, FL 33157 , NTE LAND 740-3319 - -. �- 669-3190 `, , _ ,,- 7989; . Survey #:B-29995 Client File #: Page 2 of 2 Not valid without all pages • Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit NO. BPP -4-16-1097 ■ Per t mi m Permit Type: PoolsANbirlpools/Hot Tubs Work Classification: New Permit Status: APPROVED Issue Oa 7/28/2016 Expiration: 01/24/2017 Parcel Number Applicant 33 NE 93 Street Miami Shores, FL 33138- 1132060130380 Block: Lot: JOHN ZELINSKI Owner Information Address Phone CeII JOHN ZELINSKI 33 NE 93 Street MIAMI SHORES FL 33132- (786)515-5716 33 NE 93 Street MIAMI SHORES FL 33132- Contractor(s) Phone GATOR POOLS AND SPA CONSTRUC (305)222-2220 CeII Phone Valuation: Total Sq Feet: $ 15,000.00 " 400 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type1of Work: Swimming Pool Additional Info: NEW POOL Classification: Residential Occupancy: Bond Return : Scanning: 4 Fees Due Bond Type - Contractors Bond CCF i DBPR Fee DCA Fee Education Surcharge Permit Fee Plan Review Fee (Engineer) Plan Review Fee (Engineer) Plan Review Fee (Engineer) Scanning Fee Technology Fee Total: Amount $500.00 $9.00 $6.75 $6.75 $3.00 $450.00 $80.00 $120.00 $80.00 $12.00 $12.00 $1;279.50 Pay Date Pay Type Invoice # BPP -4-16-59514 07/28/2016 Credit Card 04/22/2016 Credit Card Bond #: 3175 Amt Paid Amt Due $ 1,229.50 $ 50.00 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Fence Final Pool Deck Wall Steel Review Electrical Review Plumbing Review Plumbing Review Planning Review Structural Review Structural Review Structural Review Building Review Building Review Building 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 . • he . rk stated. Authorized Signature: Owner / Applicant / Contractor Building Department Copy e July 28, 2016 Date July 28, 2016 1 lb, (9\41)- 'k " I <0\ \12 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 BUILDING. ❑ ELECTRIC ❑ ROOFING ❑PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS JOB ADDRESS: 33 kr 4213 S Master Permit No. Sub Permit No. 5 Fsc zo f�P ?PK tO9� ❑ REVISION .❑ EXTENSION RENEWAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Folio/Parcel#: it- ;2O(- 0/3-0380 Occupancy Type: f / - Load: Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): J0/1Y1 2-el//?.S I&J Address: 3 y3 City /`,%'GCnn/ S'/10r-ei State: Miami Dade Zip: .33 St Is the Building Historically Designated: Yes NO Tenant/Lessee Name: Em ail: BFE: 'FFE: Phone#: tv Phone#: Zip: %.3 8 CONTRACTOR: Company'Name: Address: 64.1or pori/S Gln/ J� ; 132q$ .c ua 2.00gr City! /%i /111 !' State: /2/ Phone#: Qu jlifier Name: (j%!� t/e/ £2Vr, /cvi State Certification or Registration #: �� 1954?zel Certificate of Competency #: Phone#: ,tZZ-z•- 2ZZ97- Zip: 3314 17' DESIGNER: Architect/Engineer:. Phone#: Address: City: State: Value of Work for this Permit: $ /5/ DOO Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Description of Work: /V tC(% 00 ❑ New ❑ Repair/Replace • Zip: ❑ Demolition Specify color of color thru tile: Submittal Fee $ W Permit Fee $ 4j CCF $ 9.410 CO/CC $ Scanning Fee $ /Zr p O Technology Fee $ 40 G Radon Fee $ 6 , J' DBPR $ 6. 7j Structural,Reviews $/20 -ael i (Revised02/24/2014 Training/Education Fee $ 340 9001 .70-c0 Notary $ P Double Fee $ Bond $ .5-0 a TOTAL FEE NOW DUE 027 5c' 229. se Bonding Company's Name (if applicable) . Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address f 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. OWNER or AGENT The foregoing instrument was cknowledged before me this 'ZZ day of ejtr,20 fro ,by V ` L'u&, k1 , , who is personallyknown to �J O me or who has produced i b?0 J lQ ' I as me or identification and who did take an oath. NOTARY PUBLIC: Signature The foregoing instrumen z- day of was acknowledged before me this Sign: Print: Seal: :•r -. p: OJEDA MY COMMISSION 0 FF 9632S9 EXPIRES: Febuery 22. 2020 Bonded Thru Notary Public Undenv^d i . APPROVED BY (Revised02/24/2014) /15) • , 20 /I, , by who id/ s personally known to omo has produced C- 1-(''67 ZZD--0as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: Plans Examiner Structural Review ARIANY OJEDA MY COMMISSION A FF 963289 EXPIRES: Febn ary 22, 2020 Bonded Thru Notary Public Underrrrite:s:'•is (e.- Zoning Clerk 4/20/2016 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 10 be exernpt from Florida Workers' Compensation law. 01-04-2016 EFFECTIVE DATE: PERSON: FEIN: 02/28/2016 CARMONA 061693428 BUSINESS NAME AND ADDRESS: GATOR POOLS & SPA CONSTRUCTION INC 13295 SW 200 5T MIAMI FL 33177 SCOPES OF BUSINESS OR TRADE: 1- LICENSED POOL CONTRACTOR EXPIRATION DATE: 02/27/2018 MIGUE:L * * :0Po0TA➢r, P 010.14, 440 . 05(,4, ss.. 44 Ntieer et 0 C0'Pa=srmn who erects emit.. Rom Me 54.2(41 by tiff. v ,enninre of ,lets,.. a , IA,• ( Y be... r ce e... L n. P Dep., 440.05113 Fs, e rIIlitLL i t F.P l A 044 fie. .sane n n NR.N.A be o be .p. lY A Me ( be 4 mire. Ii Cl PI r or I. i31, S. A 1 ,t to be x -t of 1,p, no empr Mali bre*( (P rer<eN 'I. [ 1'^- 9 tel 4..0.0 e - MR e 0 h I t ;oche Peri *.mea e. Moe o0* re e. cnen 0404I. 10 *4N: of M I of . ca rlrcNa. T. dap.. _ !M iAaflMer t <en�Il[.rr 4 n e for f.11nre 1 (k aerson named oe tie thaN ra mart M �<eerrem4LL N (bis mi., 4n OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 STATE OF FLORIDA DEPARTMENT OF FINANC1AL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO PE EXEMPT FROM FLORIDA WORKERS' COMPENSATION lAW \ � EFFECTIVE 02/28/2016 EXPIRATION DATE 02/27/2018 PERSON: MIGUEL CARMONA IM G_1786.J PG 08E5010440, 18500, 413-1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE FEIN 061893428 BUSINESS NAME AND ADDRESS: 00(00 2001S a 5PD ASCOT0UclrON IfIC 3205 See 200 ST 0010401, 21 3917) SCOPE OF BUSINESS OR TRADE: r fEr0SEO 400f (7, es.CFO IMPORTANT Pwsuant to Chapter 440.05)14), f 5., an officer of a =poet,. who L elects exemption from this chapter by filing a certificate of election under this Section may 001 recover benefits or compeclentIer1 under MS D chapter. Pursuant to Chapter 440,05021. P.S., Certificates of election to be H exempt... apply only within the scope al the business or trade listed on E the notice of election to be exempt E Pursuant la 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. in 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 01 a certificate. The department shall revoke a certificate at any time far failure of the person named On the CerliliCate t0 meet the requirements of this Section, CUT HERE QUESTIONS? 1850) 413-1609 * Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECT/ON TO 80 EXEMPT REVISED 01-11 INNp.Irl/Ifl1nllirrl,4 lF1.11 I l i rl l'I:111 I.I.I l,4i i I=1 https://mai I.google.com/mai I/u/0/#i nbox/1543452c27cf4de9?proj ector= 1 1/1 GATOR POOLS & SPA CONSTRUCTION, INC. DATE: 7/28/2016 Estate of Florida Miami Dade County Before me this personally appeared MIGUEL A, CAMONA who, being duly sworn, deposes That he or she will be the only person working on the project located at : 33 NE 93 ST MIAMI SHORES 33138 I Sworn to and subscribed before me this 27 day of July, 2016 by Personally know Or produced identification e- (055 9-f J-5 7 2ZD—D Type of identification produced DriVe-Y Lj .€l c CILisE Print, type or stamp name of notary Notice to Owner — Workers' Com p Miami Shores Viiiage 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: 'i 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. 1 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: State of Florida County of Miami -Dade Owner The foregoing was acknowledge before me this By QI3?Ict21 Notary: SEAL: 6 day of ,20 1b. who is personally known to me or has produced as identification. .N•7, 4y u�. EXPIRES: February 22, 2020 ,° P Bonded Thru Notary Public Undernaiters ARUWY OJEDA MY COMMISSION # FF 963289