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RC-17-1755 (2)VMiami Shores Village //�� p� ���.� Budding Department "1`�2 \ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ��yy,, W(�� O�� Tel: (305) 795-2204 Fax: (305) 756-8972 bINSPECTION LINE PHONE NUMBER: (305) 762-4949 Q\ BUILDING APPLICATION ❑ ELECTRIC ❑ ROOFING PLUMBING ❑ MECHANICAL PUBLIC WORKS JOB ADDRESS: St -014 /\P Ci 9r f ((5e Master Permit No. Sub Permit No. RECEIVED JUL 0 7 017 FBC 201w i ss- ❑ REVISION ❑ EXTENSION ❑ CHANGE OF CONTRACTOR ❑ CANCELLATION City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is She Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: ❑RENEWAL ❑ SHOP DRAWINGS NO FFE: OWNER: Name (Fee Simple Titleholder): G ) /\ v6S1r Vn f Phone#: '7 1 9 2 1-3 y 0 'l99 Address: l 6' e t L City: ¶ P 'CI ' c '." Zip: Tenant/Lessee Name: Phone#: Email: State: \ 6 C CONTRACTOR: Company Name: G49/V4102-S-"l� CDs 7.,€'Phone#: Address: 71 ,3945„ /v _j 3 i9 /c City!'�r Name: / ��� State: ff s^ Qualifier Name: //9 � G/ 12/ Zip: p3_S ( - Q Phone#: 1 C�t/a'�M-711 1•7 State Certification or Registration #: c�G,/2. J3Za 2- Certificate of Competency #:G&- I G City: ✓""`�' '6 State: Zip: 0 quare/Linear Footage of Work: DESIGNER: Architect/Engineer: 4.10444 , uA'K, Address: Value of Work for this Per Type`of Work: ❑ Additio • Phone#: on ❑ New +❑ Repair/Replace ,❑ Demolition Description of Work: U (2.-A0 I I 4 • vq /c . �,t, . -"W f / AL -a • v -t A ?:1iii lo; s r n *1!.9-.. La u4.1`I r'i Specify color of color thru,tille: :it to �:? • Submittal Fee $ Permit Fee,$ 7 s... • r NAA_'" I Ri t� �° ' � L 1C�1 A -"it J! SDr, /t .,<�>2 t CCF $ CO/CC $ 50 Scanning Fee •$ � , ,\ ,`-,'\i Radon Fee $ DBPR $ Notary $ 5 '\ \ •.. , '•, ��, \ , \ t )_ Technology Fee $� AN `-%Training/Education Fee $ Double Fee $ Bond $ . J00 ' '� � 50 TOTAL FEE NOW'DUEV $x" I .-R � t (o of • S -C2 - Structural Reviews $ (Revised02/24/2014) 1 f i 17 i Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 1.S fa , Mortgage Lender's Name (if applicable) T �r 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 The foregoing instrument was acknowledged before me this f� day of y , 20 (� , by [ 7' j ,1' p j / ;/ , who is personally known to me or who has produced identification and w NOTARY PU Si d take an oath. Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of who is personally known to ,20 1/ ,by t s „� as me or who has produced .identificatio d who did take an oath. NOTARY PUBNC: • nt Seal: *************************** ****** APPROVED BY • (Revised02/24/2014) as Sign Print: Seal: .t ,;N -' W.H.J NNII 1 ' ` _ ^'COMMISSION 0 GO 00639.1 tx�EXPIRES: 10, 2021 ThPi1 Nns **************************** ** ********************** Plans Examiner Structural Review /7 Zoning Clerk Property Search Application - Miami -Dade County OFFICE OF THE PRO:.ERTY AItP Summary Report Property Information Folio: 11-3206-005-0390 Property Address: 800 NE 91 TER Miami Shores, FL 33138-3218 Owner BANCROFT INVESTMENTS LLC Mailing Address 7950 NE BAYSHORE CT UNIT 1201 MIAMI, FL 33138 USA PA Primary Zone 0900 SGL FAMILY - 1901-2100 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds/ Baths / Half 3 /2 /0 Floors 1 Living Units 1 Actual Area 1,777 Sq.Ft Living Area 1,182 Sq.Ft Adjusted Area 1,479 Sq.Ft Lot Size 7,233.8 Sq.Ft Year Built 1954 Assessment Information Year 2017 2016 2015 Land Value $195,196 $159,366 $108,561 Building Value $102,938 $102,938 $102,938 XF Value $0 $0 $0 Market Value $298,134 $262,304 $211,499 Assessed Value $298,134 $126,261 $125,384 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction $50,000 $136,043 $86,115 Homestead Exemption $75,384 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description GOLDEN GATE PARK ADDN PB 6-130 LOT 13 BLK 3 LOT SIZE 51.670 X 140 OR 21306-0679 062003 6 COC 25109-4979 11 2006 5 Page 1 of 1 Generated On : 7/6/2017 Taxable Value Information ! Previous 2017 2016 2015 County Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 School Board Exemption Value $0 $25,000 $25,000 Taxable Value $298,134 $101,261 $100,384 City Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 Regional Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 Sales Information Previous PriceSale OR Book- Page Qualification Description 07/20/2016 $289,000 30195- 1084 Qual by exam of deed 06/30/2016 $255,000 30186-Qual 3040 by exam of deed 03/16/2012 $100 28068- 4253 Corrective, tax or QCD; min consideration 11/01/2006 $0 25109- 4979 Sales which are disqualified as a result of examination of the deed 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://www.miamidade.gov/propertysearcW 7/6/2017 Detail by Entity Name Florida Department of State Department of State / Division of Corporations / Search Records / Detail By Document Number / Page 1 of 1 DIVISION OF UORPOFAnCNS Detail by Entity Name Rejected Filing BANCROFT INVESTMENTS LLC Filing Information Document Number W16000047587 Filed Date 07/06/2016 Expire at Usual Time Y Penalty Fee 00.00 Associated Document Number Document Type Filed By EDMUND PHILLIPS 7951 BAYSHORE CT #910 MIAMI, FL 33138 Document Images No images are available for this filing. Florins Daeart^-ent of State, F 00 0 htt//search.sunbiz.or /In ui /Cor orationSearch/SearchResultDetail?in ui t e=Enti 7/6/2017 P� g q n' P q rY YP — ty... POC ID --> 200519202722 1 DATE: DOCUMENT ID DESCRIPTION FILING EXPED PENALTY CERT COPY 07/12/2005 200519202722 ARTICLES OF ORGANIZATION/DOM. 125.00 .00 .00 .00 .00 LLC (LCA) 111111111111111111111111111111111111111111111111111111111111 Receipt This is not a bill. Please do not remit payment. EDMUND G PHILLIPS 2967 C KNOLL RIDGE DR DAYTON, OH 45449 STATE OF OHIO CERTI.FICATE Ohio Secretary of State, J. Kenneth Blackwell 1555208 It is hereby certified that the Secretary of State of Ohio has custody of the business records for BANCROFT INVESTMENTS, LLC and, that said business records show the filing and recording of: Document(s) ARTICLES OF ORGANIZATION/DOM. LLC United States of America State of Ohio Office of the Secretary of State Document No(s): 200519202722 Witness my hand and the seal of the Secretary of State at Columbus, Ohio this 8th day of July, A.D. 2005. Ohio Secretary of State Page 1 1 Doc ID --> 200519202722 { ( Prescribed by J. Kenneth Blackwell Ohio Secretary of State C_cntral Ohio: (614) 466-3910 'tog Frcc: 1.877 -SOS -FILE (1.877-767-3453) www.slale.oh.usisos e-mail: busserv@sos.state.oh.us ORGANIZATION / REGISTRATION OF LIMITED LIABILITY COMPANY (Domestic or Foreign) Filing Fee $125.00 THE UNDERSIGNED DESIRING TO FILE A: (CHECK ONLY ONE (1) BOX) Expedite this Form: fe.h.•ho..1 Mali Form to one of the Following: gree PO Box 1390 Columbus, OH 43216 ***Rebukes an aeddianl beef $1M" O� PO Box 670 C�43216 JUN 0 8 2005 J.ELL SECRETARY OF STATE (1)❑✓ Artides of Organization for Domestic Limited Liability Company (115 -LCA) ORC 1705 (2) Q4pptication for Registration of Foreign Limited LiabAity Company (106 -LFA) ORC 1705 (Dere of Formation) (Stale) Complete the general information M this section for Ms box checked above. Name Bancroft Investments, LLC ❑ Cheek here N additional provisions are atbeMd If box (1) is checked. name must Include one of lbefoiowlne endings: ironed 110015 cahi0any, limited, Ltd, LIA., LLC. L.LC. Complete the information in this section If box (1) is checked Effective Date (Optional) Date specified can be no nun than 90 days akar data of Ranµ if a dab 1 speNRad. the date martin a ate an or atter the data of sing. (ikldl1YYy) This limited liability company shall exist for (Optimise Purpose Genal) (Period otexistence) The address to which interested persons may direct requests for copies of any operating agreement and any bylaws of this limited liability company is (Optlonall (Name) (Sheet) NOTE: P.O. Box Addresses ata NOT acceptable. (C (Slate) (Zip Code) 533 Peps 1 of 3 Lasr Revised: May 2002 Page 2 Roc ID -->' 200519202722 Compiere the Information In this section if box (1) is checked Cont. ORIGINAL APPOINTMENT OF AGENT The undersigned authorized member, manager or representative of Bancroft Investments, LLC (name of limited 5gbgty company) hereby appoint the foliowing to be statutory agent upon whom any process, notice or demand required or permitted by statute to be served upon the limited liability company may be served. The name and address of the agent is: Edmund Phillips (Name of Agent) 224 Northwood Ave., Apt # 1 (Segel) NOTE: P.O. Box Addresses awe NOTacceptabio Dayton (Cly) Must be authenticated by an authorized representative Ohio (State) `4'414 7 'L1' !�/^�-'�}IJ���j Au i Represen Date 45405 (Zip Coda) Authorized Representative ACCEPTANCE OF APPOINTMENT The undersigned, named herein as the statutory agent for Bancroft Investments. LLC (name of limited nabaty company) hereby acknowledges and acceptsa ap ' pt of agent for said limited liability Company. 4 .Y, f Date (Agent's signature) 533 PLEASE SIGN PAGE (3) AND SUBMIT COMPLETED DOCUMENT Pepe 2 of 3 Last Revised: May 2002 Page 3 Doc ID --> 200519202722 { Complete the Infamatlon In this section If box (2) Is checked. ) The address to which interested persons may direct requests for copies of any operating agreement and any bylaws of this limited liability company Is (Name) (Sheet) NOTE: F.O. Bos Addresses err NOT acceptable. (city) (State) (Zip Code) The name under which the foreign limited liability company desires to transact business in Ohio is The limited liability company hereby appoints the following as its agent upon whom process against the limited liability company may be served in the state of Ohio. The name and complete address of the agent is (Name) (Street) NOTE: P.O. Eos Addresses ere NOT acceptable. (CO) Ohio (State) (Zip Code) The limited liability company irrevocably consents to service of process on the agent listed above as long as the authority of the agent continues. and to service of process upon the OHIO SECRETARY OF STATE if: a. the agent cannot be found, or b. the limited liability company fails to designate another agent when required to do so. or c. the limited liability company's registration to do business in Ohio expires or is canceled. REQUIRED Must be authenticated (signed) by an authorized representative (See Instructions) epresentat Anghara Phillips r 4 . c0 as Date (Print Name) 224 Northwood Ave., Apt41 Dayton, OH 45405 Authorized Representative 'Date (Print Name) 533 Page 3 03 Last Revised: May 2002 Page 4 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more 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\ / A cJ .„rt p&,' State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of ,20 who is personally known to me or has produced C:OWrr;?210 !u(.:('Util3il? .� 1 1'1 •;:qtiE't1!JtiV aeM:: "e'er,"' •,^;*:w..• =ate.„ w. ,,..,11,1 C (©F IUD vAl i ?t- 7 7 76' 2( &O nt p l} LI -C- I A61S 7/3 )-(12 ,D CHAMBERS CONSTRUCTION INC Date: State of T UJ. -PA County of N Before me this day personally appeared Ac'LL t•3 L=! p21 who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 506 jet 1 A.N► I SS -{4O(-0/14—) 33(3 Contractor's Signature Sworn to (or affirmed) and subscribed before me —co day of J U LL1 . 20 t-), by Ate, g--trtN) Personally know OR Produced Identification Type of Identification Produced .----1) ' fv9c dost' i Notary Public. State of Florida Sindie Alvarez "fi. My Commission FF 156750 �1 pyo Expires 09/03/2018 rint, Type or Stamp Name of Notary Property r ajSApplication - Miami-Dade Co unty OFFICE F THEPROPERTYAPPRAISER Page 1 of 5 RECEIVED JUL 072017 Detailed Report Property Information Folio: 11-3206-005-0390 Property Address: 800 NE 91 TER Miami Shores, FL 33138-3218 Owner BANCROFT INVESTMENTS LLC Mailing Address 7950 NE BAYSHORE CT UNIT 1201 MIAMI, FL 33138 USA PA Primary Zone 0900 SGL FAMILY - 1901-2100 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 3/2 / 0 Floors 1 Living Units 1 Actual Area 1,777 Sq.Ft Living Area 1,182 Sq.Ft Adjusted Area 1,479 Sq.Ft Lot Size 7,233.8 Sq.Ft Year Built 1954 Assessment Information Year 2017 2016 2015 Land Value $195,196 $159,366 $108,561 Building Value $102,938 $102,938 $102,938 XF Value $0 $0 $0 Market Value $298,134 $262,304 $211,499 Assessed Value $298,134 $126,261 $125,384 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction $50,000 $136,043 $86,115 Homestead Exemption $75,384 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Generated On : 7/3/2017 Taxable Value Information 2017 2016 2015 County Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 School Board Exemption Value $0 $25,000 $25,000 Taxable Value $298,134 $101,261 $100,384 City Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 Regional Exemption Value $0 $50,000 $50,000 Taxable Value $298,134 $76,261 $75,384 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://www.miamidade.gov/propertysearch/ 7/3/2017 Property Search Application - Miami -Dade County Page 2 of 5 OFFICE OF THE PROPERTY APPRAISER Generated On : 7/3/2017 1 Property Information Folio:'11-3206-005-0390 Property Address: 800 NE 91 TER Roll Year 2017 Land, Building and Extra -Feature Details Land Information Land Use Muni Zone PA Zone Unit Type Units Calc Value GENERAL R-15.5, R-16.5 0900 Front Ft. 51.67 $195,196 Building Information Building Number Sub Area Year Built - Actual Sq.Ft. Living Sq.Ft. Adj Sq.Ft. Calc Value { 1 1 1954 1,777 1,182 1,479 $102,938 Extra Features Description Year Built Units Calc Value 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://www.miamidade.gov/pronertysearch/ 7/3/2017 Property Search Application - Miami -Dade County Page 3 of 5 OFFICE OF THE PROPERTY APPRAISER n 7320,7 Property Information Folio: 11-3206-005-0390 Property Address: 800 NE 91 TER Roll Year 2016 Land, Building and Extra -Feature Details Land Information Land Use Muni Zone PA Zone Unit Type Units Calc Value GENERAL R-15.5, R-16.5 0900 Front Ft. 51.67 $159,366 Building Information , Building Number Sub Area Year Built Actual Sq.Ft. Living Sq.Ft. Adj Sq.Ft. Calc Value 1 1 1954 1,777 1,182 1,479 $102,938 Extra Features Description Year Built Units Calc Value 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.govfrnfo/disclaimer.asp Version: httn://www.miamidade.gov/pronertysearch/ 7/3/2017 Property Search Application Miami -Dade County Page 4 of 5 OFFICE OF THE PROPERTY APPRAISER Property Information Folio: 11-3206-005-0390 Property Address: 800 NE 91 TER Miami Shores, FL 33138-3218 Generated On': 7/3/2017 Roll Year 2015 Land, Building and Extra -Feature Details Land Information Land Use Muni Zone PA Zone Unit Type Units Calc Value GENERAL ` R-15.5, R-16.5 0900 Front Ft. 51:67 $108,561 Building Information . I Building Number Sub Area Year Built , Actual Sq.Ft. Living Sq.Ft. Adj Sq.Ft. Calc Value 1 1 1954 1,777 1,182 . 1,479 $102,938 Extra Features Description Year Built Units Calc Value 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/iinfo/disclaimer.asp Version: 1 http://www.miamidade.gov/propertysearch/ 7/3/2017 Property Search Application - Miami -Dade County Page5of5 OFFICE OF THE PROPERTY APPRAISER Generated On : 7/3/2017 Property Information Folio: 11-3206-005-0390 Property Address: 800 NE 91 TER Full Legal Description Previous Sale' GOLDEN GATE PARK ADDN PB 6-130 OR Book -Page LOT 13 BLK 3 07/20/2016 LOT SIZE 51.670 X 140• 30195-1084 OR 21306-0679 062003 6 06/30/2016 COC 25109-4979 11 2006 5 30186-3040 Sales Information Previous Sale' Price OR Book -Page Qualification Description 07/20/2016 $289,000 30195-1084 Qual by exam of deed 06/30/2016 $255,000 30186-3040 Qual by exam of deed . 03/16/2012 $100 28068-4253 Corrective, tax or QCD; min consideration 11/01/2006 $0 25109-4979 Sales which are disqualified as a result of examination of the deed 06/01/2003 $20,000 21306-0679 Other disqualified 06/01/1988 $75,000 13704-1750 Sales which are qualified 09/01/1987 $70,000 13429-0573 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: httn://www.miamidade.gov/pronertvsearch/ 7/3/2017 002279 Local Business Tax Receipt • Miami—Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY 4919818 BUSINESS NAME/LOCATION CHAMBERS CONSTRUCTION INC 21395 NW 33 AVE MIAMI GARDENS FL 33056 • OWNER CHAMBERS CONSTRUCTION INC Worker(s) 1 004149 RECEIPT NO. RENEWAL 5136072 EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SUB—GENERAL BLDG CONTRACTOR CBC1250382 PAYMENT RECEIVED 'r BY TAX COLLECTOR $45.00 08/18/2016 CREDITCARD-16-047981 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. bolder must comply with any governmental or nongovernmental regulatory laws and requiremehts which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles — Miami—Dade Code Sec 8a-275. For more information, visit www.miamidade.novhaxcellector Local Business Tax Receip Miami—Dade County, State of Florida —THIS IS NOT A BILL —DO NOT PAY 6951538 BUSINESS NAME/LOCATION CHAMBERS CONSTRUCTION INC 21395 NW 33 AVE MIAMI GARDENS FL 33056 OWNER CHAMBERS CONSTRUCTION INC Worker(s) 1 RECEIPT NO. RENEWAL 7227200 EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 SEC. TYPE OF BUSINESS PAYMENT RECEIVED 196 SPECIALTY BUILDING CONTRACTOR BY TAX COLLECTOR CCC1326780• $45.00 08/18/2016 1� CREDITCARD-16-047981 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit. or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which.apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles — Miami—Dade Code Sec 8a-276. For more information, visit www,miamidade.novhaxcollector �Tt „STAA TEE OF FLORIDAf.�.,... , ;DEPARTM F1BUSINESS AND` ,,� : kPROF • 1 1 A �. ,GULATION -- CBG1C125�0382 ISSt�ED 8/1`0/2016 - . ...,4CERTIFIED B IL0ING,CC)NT CTO r,a. CLP RKEALL{A"DRI,i"" � ' , - , -CHAMBERS COiAN,.STR JCTUO I INE IS C'E Unhe 'ro dons„of Ch:469 FS L16081000012354, "itplraF+`dateyAtJG 31�2b18r•'�-- ^- ► "'1 f • •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 CONSTRUCTION INDUSTRY EXEMPTION LAW EFFECTIVE DATE: 2/29/2016 This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.: PERSON: CLRRKE EXPIRATION DATE: 2/28/2018 ALLAN FEIN: 043632745 A BUSINESS NAME AND ADDRESS: CHAMBERS CONSTRUCTION INC . I 21395 NW 33 AVENUE MIAMI GARDENS FL 33056 SCOPES OF BUSINESS OR TRADE: LICENSED BUILDING LICENSED ROOFING CONTRACTOR CONTRACTOR Pu; suant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by riling a certificate of election under this section 1.1 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, Y 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 4 {i, QUESTIONS? (850)413-1609 DFS F2 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 ACI R!]'� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/06/2017 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 have ADDITIONAL INSURED provisions or 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 Annette Willis Insurance 4759 N.W. 183rd St. Miami, FL 33055 Phone (305) 625-8131 INSURED CHAMBERS CONSTRUCTION INC 21395 NW 33 Ave Miami Fax (305) 625-3694 CONTACT NAME: Daniel Willis, PHONE 305 625-8131 Fax (A/C, No, Ext)• ( ) (A/c, No): (305) 625 3694 E-MAILSS: awil@bellsouth.net INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : international Companmy of Hanover Se FL 33056 INSURER B : INSURER C : INSURER D : COVERAGES CERTIFICATE NUMBER: INSURER E : INSURER F : REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. , INSR LTR TYPE OF INSURANCE ADDLSUBR INSR Y WVD POLICY NUMBER 1G06A0143919-00 POLICY EFF (MM/DD/YYYY)JMM/DD/YYYY) 03/24/2017 POLICY EXP 03/24/2018 LIMITS EACH OCCURRENCE $ 1,000,000.00 A vel COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrenc)_ $ 100,000.00 $ 5,000.00 MED EXP (Any one person) ❑ PERSONAL &ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO- RO JECT LOC JECT ❑ OTHER GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 AUTOMOBILE LIABILITY ❑ !ANY AUTO i OWNED ❑ SCHEDULED ❑ AUTOS ONLY AUTOS El ❑ AUTOS ONLY ❑ED AUTOS NON-OWNEDNLY I.J ❑ COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑j EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ Cl DED ❑ RETENTION$ $ WORKERS COMPENSATION AND AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE N / A ni PER ❑ STATUTE ❑ OTH- E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 1 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CONTRACTOR'S LICENSE #CBC1250382 CANCELLATION VILLAGE OF MIAMI SHORES Building Department 10050 NE 2 Ave Miami Shores Village,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 (2016/03) QF © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD