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PL-17-1510 1S L I /D Miami Shores Village RECE g � IVED Building Department NOv 3 Zo» 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201(A BUILDING Master Permit No. V, C -1 Co- s2Co PERMIT APPLICATION Sub Permit No. [:]BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: 1311?(3I -+ Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: `�C"oonstructiionn Type: )p �. Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): / jK,J'✓►I f W lAs,'V-P Phone#: 30's-225 A M13 S &) / G Address: �� - City: '" 1_I�WI(S ��'1�[�Y State: L Zip: c�l Tenant/Lessee Name: Phone#: i Email: CONTRACTOR:Company Name:_117M (,'O/1S U %D/�, ��C Phone#: Address: /O,;a,! cSLc, –L� City: ti-t1'4��/&11' State: %�f/ Zip: Qualifier Name: /<1 0d-"S �Bm�1S Phone#: State Certification or Registration#: Certificate of Competency'#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 1=�1 .cs Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑.Demolition Description of Work: Chaooc cvn�� r Specify color of color thru tile: Submittal Fee$ 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) I I ;r Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) i 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 I 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..... f 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. gnature Signature WNERorA ENT CONTRACTOR The foregoing instru ent was acknowledged before eelme this The foregoing instrument was acknowledged before methis 21 da of '1Noyt.m� t( ,20 1 by n� day of/ 0 Q ( �" by ( 11�.T� • Vveh S.Pt who is personally known towho i ersonelly knDh to me or who has produced �)eogy UI-e as me or who has produced as t identification and who did take an oath. identification and who did take an oath. NOTARY UB C: NOTARY PUBLIC: Sign: Sign: Print: Ana 1(`1 rint: ���"� MY COMMISSION#GG071524 Seal: ;, YANADY PRI 0 Seal: = M MISSION#FF 214031 ', EXPIRES February 26,2021 a EXPIRES:March 25,2019 fi nF,1y4` Bonded Thru Notary Public Underwriters I ************************************************************************************************************ i I APPROVED BY Plans Examiner Zoning i Structural Review Clerk (Revised02/24/2014) I ♦ ES Di — �T Miami shores Village some - , Building Department 9 p T 10050 N.E.2nd Avenue F�ORNA Miami Shores, Florida 33138 Tel: (305) 795,2204 Fax: (305) 756.8972 Notice�to Owner - Workers' Compensation Insurance Exemption i 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 i 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. Owner !Slate of Florida County of Miami-Dade The foregoing was acknowledge before me this day of O v 20 L � B �0V dS W�X-+ wC�wo s personally known to me or hasproduced as identificati MAHARAI K.GONZALEZ MY COMMISSION*GG 044602 Nota ;,;� P EXPIRES:November 2,2020 o f Fro,.' Bonded Thru Notary Public Underwriters SEAL: ACA Construction Inc. 10725 SW 55`hTerrace, Miami FL 33165. CFC-1427635 305-788-8914 J November 26 2017 State of Florida County of Miami Shore Before me this day personally appeared.//mss �S who,being duly sworn,deposes and says: That he will be the only person working on the project located at: Contractor Signa re b� Sworn to and subscribed before me thisday of A a mbC90 / Personally known or p duced identification No I Exp: Z6 2021 c.(.� Signa re of notary public Seal µ"• KELLY i VILLA 'c MY COMMIS-"' *Gg0715Z4 EXPIRES February 26,2021 d SNORES txc.�rs3s G Miami hores Village logo , nm?" Building Department 0 10050;N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. +' 3X[ Owner's Name (Fee Simple Title Holder): O'M 0 Phone#: .7S':7;0 Owner's Address) I�T City:' b 'mi ..Q State Zip Code: UY 4 r s�Job Address (Of where work is being done): 1AJ City: Miami Shores State:—Florida Zip Code: II Contractor's Company Name: Ift PtL%,btw( 60 Phone#: Address: 7k $2L. IQ City: State: ( Zip Code: �— Qualifier's Name Lic. Number: Architect/ Engineer of Record Name: Phone#: Address: { City: State: Zip Code: "w Describe Work I f hereby cern that the work has been abandoned and/or the contractor/architect Y fY is unable or:unwilling to complete the contract. I hold the Building Official and the Miami ores harmless of all legal involvement. t ignature Signature w r or et Contractor or Architect The foregoing instr' ent was a owled ed before me The foregoing instrument was aknowledged .before me this�ay of N,20 y S � �P this day of ,20 by Who is personally known to me or who has producerI c1 5j OC who is personally known to me or who has produced as indentification. as indentification. Notary P Notary Public: Si Sign: Seal: Seal: .;��pr ry"M",•,,,I MAHARAI K.GONZALEZ MY COMMISSION#GG 044602 o EXPIRES:November 2,2020 •,,e;���oPe Bonded Thru Notary Public underwriters I, a 4 5N°RFS Miami Shores Village Building Department 10050 N.E. 2ND Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ORiNA Change of Contractor/Architect or Engineer 4 A change of contractor, architect or engineer must be done under a permit number. There is a $75.00 charge for a change of contractor. The owner will submit a Change of Contractor Form completed,with notarized signatures. If the signature of the previous contractor cannot be obtained the owner must send a certified letter/return receipt notifying the previous contractor, architect or engineer the reason for the change. The owner must allow 10 business days for the contractor, architect or engineer to respond. A permit application must accompany the change of contractor form, with the information and signature of the new contractor. The new contractor must be registered with the Village or must submit the required documents to register with the Village. 1. Change of Contractor form completed, signed and notarized. 2. Permit application by new contractor. 3. Required fees. 4. Copy of original letter sent via certified mail along with the returned receipt. In addition to the requirements above the architect or engineer of record must authorized the new architect or engineer to reproduce his documents. The authorization must be in writing and must be signed and sealed. � � f if ` r ,.a ..w..'.�...��.xt:.,rF�.+ar•«w-aer'._t!s,+.w.t..r.s,.s.•s,,::fiw le�+— Aj SECTIONE THIS DELIVERY A. Signatur s Complete items 1,2,and 3. O Agent, • Print your name and address on the reverse X 0 Addressee so that we caii return the card to you. g eceived by( rinte ame) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits.x 1. Article Addressed to: D. is delivery address different from item 1? 1n If YES,enter delivery address below: 0 No P/us 4 10 aid GnS 3. Service Type D Priority Mail Express® II I IIIIII IIII III I II II II I IIT I I i I I III I I I III II SII 0 Adult Signature PAestricted Defivery [3Registered Mail Restrictbd 0 Certified Mail®; Delivery firm 9590 9402 2512 6306 0283 20 ❑Certified Mail ReWicted Delivery ❑Retum Receipt for Merchandise 0 Collect on Delivery❑Collect on Delivery Restricted Delivery Signature Co if,.tionT"' insured Mail O Signature Confirmation 2. Article Number(transfer from service label) — Restricted Delivery 7017 219 0 0000. ; 5 218, 0 416 "'o�e�mail Res<rioted Deuvery �. PS Form 3811,July 2015 PSN 7530-02-000-9053 I , USPS TRACKING# First-Class Mail Postage&Fees Paid USPS -10 Permit No.G 9590 9402 2512 6306 0283 20 United Staies I Sender:Please print your name,address,and ZIP+4®in this boze Postal Service WCC S�Ct /(j ie- /00 5,7- a October 17,2017 A Plus Plumbing and Gas 11876 SW 121'Place Davie, FI 33325 Dear Mr.Adrian Vazquez This letter is to notify you that we are changing plumbing contractors on the work being done in my house located at 1135 NE 100 St.Miami Shores,FI.33138. Your services will no longer be needed at the job site mentioned,please and accept this letter as notice of termination of your services. Sincerely, � homas W ns e Homeowner: 1135 NE 100 ST Miami Shores,FI 33138 e 1 E Permit NO. PL-6-17-151°0 `9gORE5 Miami Shores Village Permit Type.Plumbing-Residential 10050 N.E.2nd Avenue NEPen wi Work Classification:Addition/Alteration - Miami Shores,FL 33138-0000 Permit Status:APPROVED Phone: (305)795-2204 FLORIDA Issue Date:8/18/2017 Expiration: 02114/2018 Project Address Parcel Number Applicant 1135 NE 100 Street 1132050340050 THOMAS WENSJOE Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell THOMAS WENSJOE 1135 NE 100 Street MIAMI SHORES FL 33138 Contractor(s) Phone Cell Phone $ 2,000.00 Valuation: A PLUS PLUMBING AND GAS LLC (954)604-5025 __W...... .. . ....� � Total Sq Feet: 0 Type of Work:OFF SET AND RESET 1 TOILET OFF SET Available Inspections: Type of Piping: Flnection Type: Additional Info: ew Plumbing Bond Return Classification:Residential Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1,20 Invoice# REV-6-17-64239 DBPR Fee $3.38 DCA Fee $3.38 08/18/2017 Credit Card $242.96 $0.00 Education Surcharge $0.40 Notary Fee $5.00 Permit Fee $225.00 Scanning Fee $0.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $242.96 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 a foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zo ' ermore, I uthorize the above-named contractor to do the work stated. August 18, 2017 Author' na : / scant / Contractor / Agent Date Building epartOw ent Copy August 18, 2017 1 Miami Shores Village RECEIVED Building Department JUN 07� 1017 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 S FBC 20 ISI /- BUILDING Master Permit No. �C _ ZV PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL \QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP 7 / CONTRACTOR DRAWINGS JOB ADDRESS: 4/JS City: Miami Shores County: Miami Dade zip: 3J7 l3 Folio/Parcel#: �/-3zo5-o-3�i�—D[:S� Is the Building Historically Designated:Yes NO Occupancy Type: Load: „„ Constructiion Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder)l3)�ONi C--4 k0l-. I GN GVCaS Z Phone#: Address: C✓ OU r0 7' City: / S 1102 1 State: i Zip: Tenant/Lessee Name: �� Phone#: Email: / /ffi� CONTRACTOR:Company Name: t!pA-, Phone#: (9b D Address: 11Q-7 So U) 12'' City: !� U 1 L State: -t-/ _ Zip: Qualifier Name: V'4JU C- Phone#: State Certification or Registration#: 2 772, Certificate of Competency#: CA `/1-77 `DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ I X0 Square/Linear Footage of Work: Type of Work: ❑ Addition EKAlteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: nn CTFK� E (.J /'.JITf67-7 Specify color of color thruAl,e:.!, Submittal Fee$ ti �� ` Permit Fee$ � � CCF$ ! CO/CC'$ r Scanning Fee$ Radon Fee$ DBPR$ .. -Notary_$=� Technology Fee$ Training/Education Fed$ Double Fee$ Structural Reviews$ p Bond$ TOTAL FEE NOW DUE$ 2— l (Revised02/24/2014) Bond ing',Companyts'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 tb 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 Signature _ 94V ONA CONTRACTOR The foregoin instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 2 day of l~ k 20 1) by 0 day of 'J-U"67 20 /7 by LAN%2 is personally known two /¢D21. " 11#Zgc t�Z who is personally known to me or who has produced C `- Q W1T-""mss me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY P LIC: NOTARY PUBLIC: Sign: 1, Si v Print: n)��- �wC'` � rint: O Seal: Seal: NOTARY PUBLIC u,. STATE OF FLORIDA :01 ° Notary Public State of Florida CO M0 FF9B8d49 . Sindia Alvarez Expires 3J7/Z000 ********* * �* ofp Expires09f03/2018 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY DEPARTMENT OF=BUSINESS AND PROFESSIONAL REGULATION-- j -----CONSTRUCTION;INDUSTRY,LICENSI NG,BOARD r.; ,. .-CFC14277,72�,.^ ;.•.--'-" LL' -.�..— 's...--.,-. —. ^� �� -..,. '`.,_� \ � `. `.` � .-*'ri .s �- " ._..d-+ar_✓--" ' -+.•.. "�,` ""._„"'.,,,,._.`^`"`�"'\,ne._.._."�..�'�.'ice..�•.� ••.,_-'-<.'�..`� ",*- The,PLUMBIN G'CONTRACTOR Named,below.IS.CERTIF-IED t ''` "�` -- •. ; -�:Under�the provisions-of.Chapter 489-FS--,, Explratlon;date:,:AUG-31;x'20,18 VAZQI'1EZ-ADRIAN•D--� -,,AlpLUS;PLI'�1MBING�ANDG�-'LC: 2145`NE 65TH;,COURT, �—_" FORT„LfA`�UDERDALE�FL�33308 +, t ISSUED:: 018 "--`flISPLAY AS'REOUIRED BY LAW SEQ'#"L'1609010002801 a +*A 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2016 THROUGH' SEPTEMBER 30,2017 j j DBA: Receipt#•182-276076 i A PLUS PLUMBING AND GAS LLC PLUMBING/LWN SPRNKL/CONT CTOR Business Name: Business Type: (PLUMBING) j 'I Owner Name:ADRIAN VAZQUEZ Business Opened:04/01/2016 j Business Location:2145 NE 65 CT State/County/Cert/Reg:CFC1427772 k FT LAUDERDALE Exemption Code: j Business Phone: 954-604-5021; j I Rooms Seats Employees Machines Professionals 1 _ For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 I i 4 � i I THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS i . THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is j non-regulatory in nature:You must meet all County and/or Municipality planning jWHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. I I i Mailing Address: A'PLUS PLUMBING AND GAS LLC Receipt #04B-15-00007874 i 11712 SOUTH ISLAND RD Paid 09/06/2016 27.00 j COOPER CITY, FL 33026 j 2016 - 2017 i r Y j r r , C�® r6/5/2017 TE(MM/DD/YYYY) AC" CERTIFICATE OF LIABILITY INSURANCE 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 CONTACT Certified Ins Sol NAME: Certified Insurance Solutions PHONE N Ext (954)369-1214 q/C No: (954)323-0975 11555 Heron Bay Blvd EMAIL ADDRESS:csr@ciccrm.com Suite 200 INSURER(S)AFFORDING COVERAGE NAIC# Coral Springs FL 33076 INSURERA:Arch Specialty Insurance Co 21199 .INSURED INSURER B: A Plus Plumbing and Gas LLC INSURER C: 11876 SW 12th Pl INSURER D: INSURER E: Davie FL 33325 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1741306059 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 ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSD WVD POLICY NUMBER MM/DD/YYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADEOCCUR DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence $ AGL004672700 4/13/2017 4/13/2016 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X O- POLICY❑ PRO ❑ JLOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE ' OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Plumbing-Appliance- Installation, Service & Repair CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ` Village of Miami Shores THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE K Schwartz, CIC, CRM/ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 4/5/2016 EXPIRATION DATE: 4/5/2018 PERSON: VAZQUEZ ADRIAN D FEIN: 454912053 BUSINESS NAME AND ADDRESS: A PLUS PLUMBING AND GAS LLC 2145 NE 65 COURT FORT LAUDERDALE FL 33308 SCOPES OF BUSINESS OR TRADE: LICENSED PLUMBING CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation ff,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 SCORE'S D� .... ,.,„� Miami shores Village Building Department OR 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner Workers' Compensation Insurance Exemption T 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 1 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. ignature: Her State of Florida f County of Miami-Dade ,. t The foregoing was acknowledge before me this day or U ,20 By l t OMO-S (Aen� A'2P, who is personally known to me or has produced (� ? 83 as dentification. �S� Notary. p°•. MAHARAI K.GONZALEZ SEAL: =�'”"``�'': MY COMMISSION#GG 041101 Nc EXPIRES:November 2.2020 %� oP: Bonded Thru Notary Public U,erWdters 7't' :'� 1 { r t •A PLUS PLUMBING 6 GAS ! t Date: { State of } County of Eco Before me this day personally appeared �rl Q/V �` wg ho bein sworn, deposes and says: i k ` j That he or sheivill be the only person working on the project located at: oosf R Contrac is gnature 1 Sworn to (or` ffirmed) and ubscribed before me this cam—day of , 20�, by Cl �� Personally know OR Produced Identification t- Type of Identification Produced Jamue#m emdford NOTARY PUBUC STATE OF FLORIDA, 174 Pint,Type of AM0re4 W 0 9 ! ' t I