RC-18-16 (2) Miami Shores Village
JAN 2018
Building Department BY:
\ 10050 N.E.2nd Avenue, Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
�J FBC 20Q
BUILDING Master Permit No.AC -1— 1� �b
PERMIT APPLICATION Sub Permit No. `
QBUILDING Q ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: 10666 NE 10 COURT (�
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO X O
Occupancy Type: SFR Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder):F-1 PERFORMANCE LLC JOHN BOWES hone#:786-302-8768 (�
Address:
530 N SHORE DR
City: MIAMI BEACH State: FL Zip: 33141
Tenant/Lessee Name: NA Phone#:
Email: JBOWES.F1@GMAIL.COM
CONTRACTOR:Company Name: COMPLETE SECURITY SERVICE, LLC Phone#: 954-714-8833
Address: 2601 NW 55 COURT
City: FORT LAUDERDALE State: FL Zip: 33309
Qualifier Name: BRADLEY CROW Phone#: 954-714-8833
State Certification or Registration#: CGC1522153 Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$Afy7GM 3s 003 Square/Linear Footage of Work: 2.500 '
Type of Work: ❑ Addition ❑■ Alteration ❑ New FE-1 Repair/Replace ❑ Demolition
Description of work: REPLACE KITCHEN CABINETS (SAME LAYOUT), RENOVATE MASTER BATH
(REPLACE TUB, SINK, VANITY, SHOWER STALL), NEW FLOORING THROUGHOUT HOME,
PAINT EXTERIOR AND INTERIOR.
'Sped
fy color of color thru tile: �Tt�
Submittal Fee$ 2 - r���Permit Fee$ `` • (70 CCF$ ' vv CO/CC$ 5 0 • C�
Scanning Fee$ 2• Radon Fee$ U•�J DBPR$ Notary$
.Technology Fee$ 00 Training/Education Fee$ �• Q Double Fee$
Structural Reviews$ `• W Bond$ vr00 G�
,. TOTAL FEE NOW DUE$ i If 2O3 -;7--5
(Revised02/24/2014)
/ --�()3 . 2.5
Bonding Company's Name(if applicable)
Bonding Company's Address _
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE;RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of com ncement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issue . n the absence of suc o ed notice, the
inspection will not be approved and a reinspection fee will be charged.
Signatur Signature
OWNER or AGENT CONTRACTOR
The)foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
/ day of ��/e,1',fjgb?iY 20 1 by I / day of ► ��C,,ettrnbe 20'� by
C)hA) &We-5 who is personally known to - / ,qa l�1 t��f who is personally known to
me or who has produced as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
st��
Sign: Sign:
�Q
Print: � ��L�e=AJ Print: hlele"Id L- S;nmf
Seal: �µr►� Seal: 4F�.-4`4b KATHLEEN L SIMONS
,0,••.;% KATHLEEN L SIMON3 MY COMMISSION►FF 106173
* * MY COMMISSION>t FF 106173
EXPIRES:March 27,2018 ,y o� EXPIRES:March 27,2018
co, Al BondedThru Naar ervlces °�ar�a�� BondedThNBudgetNotaryServices
*r*r**#*****s***• �****r*** * * * �*�********r*rs******************•*r***a***s*s*•r******s*********
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
Property Search Application- Miami-Dade County Page 1 of 2
OFFICEOF THE PROPERTY APPRAISER
Summary Report
Generated On: 1/3/2018
Property Informations „
Folio: 11-2232-028-0910
Property Address: 10666 NE.10 CT '' �
Miami Shores,FL 33138-2102 '• ` " !�+>
WELLS FARGO BANK N A . ' •Es
Owner C/O WELL FARO HOME - *• ,', i, 't
MORTGAGEti j
3476 STATEVIEW BLVD � k
Mailing Address , s, p
FORT MILL,SC 29715 USA � .�- « ,, � �{ �. „_,-..•. � � ,: � ,,}
PA Primary Zone 1000 SGL FAMILY-2101-2300 SQ
0101 RESIDENTIAL-SINGLE r.
Primary Land Use ��
FAMILY: 1 UNIT
Beds/Baths/Half 4/2/1
Floors 1
I.
Living Units 1 .mk.!rs §'hot T►;,1
Actual Area 2,956 Sq.Ft
Living Area 2,450 Sq.Ft Taxable Value Information
Adjusted Area 2,646 Sq.Ft 2017 2016 2015
Lot Size 12,996 Sq.Ft County
Year Built 1986 Exemption Value 1 $50,500 $50,500 $50,500
' Taxable Value 1 $202,007 $196,814 $195,095
Assessment Information
School Board
Year 2017 2016 2015 Exemption Value $25,500 $25,5001 $25,500
Land Value $318,693 $237,188 $188,652 Taxable Value $227,007 $221,814 $220,095
Building Value $305,613 $309,979 $314,345 City
XF Value $24,789 $25,123 $18,110 Exemption Value $50,500 $50,500 $50,500
Market Value $649,095 $572,290 $521,107 Taxable Value $202,007 $196,814 $195,095
Assessed Value $252,507 $247,314 $245,595 Regional
Exemption Value $50,500 $50,500 $50,500
Benefits Information
Taxable Value $202,007 $196,814 $195,095
Benefit Type 2017 2016 2015
Save Our Homes Assessment Sales Information
Cap Reduction $396,588 $324,976 $275,512
Previous OR Book-
Homestead Exemption $25,000 $25,000 $25,000 Sale Price Page Qualification Description
Second Exemption $25,000 $25,000 $25,000 Federal,state or local government
Homestead p 08/03/2017 $400,100 30645-2542 agency t
Widow Exemption $500 $500 $500 02/01/1988 $152,500 13577-0580 Sales which are qualified
Note:Not all benefits are applicable to all Taxable Values(i.e.County,
School Board,City, Regional).
Short Legal Description
MIAMI SHORES ESTATES PB 47-58
LOT 1 BLK 6
LOT SIZE 86.640 X 150
OR 13577-580 0288 1
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
http://www.miamidade.gov/propertysearch/ 1/3/2018
CFN X20170767184'1]100K30795 PAGE 6,._
DATE:12/18/2017 09:44:32 AM
O240.00-
I, K:-SURTAX
2;430.00
HARVEY RUVIN,:CLERK OF COURT,MIA-DADE CTY
PREPARED BY:
Jarrod Turner,Esq.
On behalf of
Betters Law Firm PLLC
800 Town and Country Blvd.#300
Houston,TX 77024
RETURN TO:
F-1 Performance LLC
10666 NE 10th Ct
Miami Shores,FL 33138
File Number:WF-FL-17549484-NTR
APN/PIN: 11-2232-028-0910
SPECIAL WARRANTY DEED
This Special Warranty Deed made between WELLS FARGO BANK,N.A.,whose address is
8480 Stagecoach Circle,Frederick,MD 21701,Grantor,and F-1 Performance LI:C?whose address is
530 N Shore Dr,Miami Beach,FL 33141,Grantee:
(Whenever used herein the terms Grantor and Grantee include all the parties to this instrument and the heirs,
legal representatives,and assigns of individuals,and the successors and assigns of corporations,trusts and
trustees)
Witnesseth,that said Grantor,for and in consideration of the sum of$540,000.00,and other good
and valuable considerations to said Grantor in hand paid by said Grantee,the receipt and sufficiency whereof
is hereby acknowledged,has Granted,bargained,and sold to the said Grantee,and Grantee's successors,heirs
and assigns forever,the following described land,situate,lying and being in Miami-Dade County,Florida,
to-wit:
LOT 1,IN BLOCK 6,OF MIAIVH SHORES ESTATES,ACCORDING TO THE PLAT THEREOF,
RECORDED IN PLAT BOOK 47,AT PAGE 58,OF THE PUBLIC RECORDS OF DADE
COUNTY,FLORIDA.
SUBJECT TO:
1.Taxes and assessments for the current calendar year and all subsequent years;
2.Zoning ordinances,restrictions,prohibitions and other requirements imposed by governmental
authority;
3.Conditions,restrictions,reservations,limitations and easements of record,if any,but this reference
shall not operate to reimpose same;
TOGETHER with all the tenements,hereditaments and appurtenances thereto belonging or in
anywise appertaining TO HAVE AND TO HOLD,the same in fee simple forever.
And the Grantor hereby covenants with said Grantee that the grantor is lawfully seized of said land
220-FL-V3 0484574306B
}
y � r
CFN:20170707184 BOOK 30795 PAGE 4447
in fee simple; that the Grantor has good right and lawful authority to sell and convey said land; that the
Grantor hereby specially warrants that title to the land is free from all encumbrances made by Grantor,and
will defend the same against the lawful claims of all persons claiming by,through or under Grantor, but
against none other.
IN WITNESS WHEREOF,GRANTOR has signed these presents on
WELLS FARGO BANK,N.A.
By: I Z !J
Name:
Its: We President loan Documentation
d
SIGNED IN THE PRESENCE OF THE FOLLOWING WITNESSES:
Witness:
t
I
Name:
i ��
Witness: / .*-
Name: X�"Are.
State of Iowa
County Dallas
On this /5T day of ,A.D.,2 efore me,a Notary Public in
and for said county,personally appeared !L/L/L�7C- CO to me personally
!mown,who being by me duly sworn(or affirmed)did say that that p on is pz—� (title)
of saids h Fargo Bank, .A.,b authority of its board of(directors or trustees)and the said(officer's
name) I14�i.1t-9�( acknowledged the execution of said instrument to be the
voluntary act and deed of said(c rporation or association)by it voluntarily executed.
CHINA LEM
Commission Number 766656
(Signature) My Commisslon Expires
V February 10,2020
Notary Public
220-FL-V3 0484574306B
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2017 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT FILED
DOCUMENT#L13000110578 . Jan 23, 2017
Entity Name:(F_-TPERFORMANCE CLC- Secretary of State
�
Current Principal Place of Business: CC6112825478
530 NORTH SHORE DRIVE
MIAMI BEACH, FL 33141
Current Mailing Address:
530 NORTH SHORE DRIVE
MIAMI BEACH, FL 33141
FEI Number: 46-3879536 Certificate of Status Desired: ,.Yes
Name and Address of Current Registered Agent:
BOWES,JOHN E
530 NORTH SHORE DRIVE
MIAMI BEACH,FL 33141 US
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The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida.
SIGNATURE:
Electronic Signature of Registered Agent Date
Authorized Person(s) Detail
Title MGRM Title MGRM I
Name [BOWES,JOHN E— Name GOMEZ-BOWES,LUISA
Address 530 NORTH SHORE DRIVE Address 530 NORTH SHORE DRIVE
City-State-Zip: MIAMI BEACH FL 33141 City-State-Zip: MIAMI BEACH FL 33141
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I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under
oath;that I am a managing member or manager of the limited liability company or the receiver or trustee empowered to execute this report as required by Chapter 605,Florida Statutes;and
that my name appears above,or on an attachment with all other like empowered.
SIGNATURE:JOHN BOWES MEMBER MANAGER 01/23/2017
Electronic Signature of Signing Authorized Person(s)Detail Date
I
Permit No. RC-1-18-16
Miami Shores Village M t Permit Type:Residential Construction
10050 N.E.2nd Avenue NE r��� ' Work Classi I fibation:'Alteration
Miami Shores,FL 33138-0000 IV Permtt Status:APPROVED
Phone: (305)795-2204
issue oatel:2121/2018 Expiration: 08/20/2018
Project Address Parcel Number Applicant
10666 NE 10 Court 1122320280910
Miami Shores, FL 33138- Block: Lot: F-1 PERFORMANCE LLC
Owner Information Address Phone Cell
F-1 PERFORMANCE LLC 530 N SHORE Drive (786)302-8768
MIAMI BEACH FL 33141-
530
3141-530 N SHORE Drive
MIAMI BEACH FL 33141-
Contractor(s) Phone Cell Phone Valuation: $ �5,000.00
COMPLETE SECURITY SERVICE LLC (954)714-8833
Total Scl Feet: 2500
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Approved:In Review Available Inspections:
Comments:
Inspection Type:
Date Approved:: In Review Final PE Certification
Date Denied: Window Door Attachment
Type of Construction:REPLACE KITCHEN CABINETS Occupancy: Framing
Stories: Exterior: Insulation
Front Setback: Rear Setback: Drywall Screw
Left Setback: Right Setback: Window and Door Buck
Bedrooms: Bathrooms: Fill Cells Columns
Plans Submitted: Certificate Status: Review Electrical
Certificate Date: Additional Info:REPLACE KITCHEN CABINETS Review Electrical
Review Electrical
lBond Return Classification:Residential Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural
Bond Type-Owners Bond $500.00 Review Structural
CCF $21.00 Invoice# RC-1-18-66033 Review Planning
CO/CC Fee $50.00 02/21/2018 Credit Card $ 1,703.25 $200.00 Review Building
DBPR Fee $15.75 01/03/2018 Check#: 1059 $200.00 $0.00 Review Building
DCA Fee $10.50 Bond#:3664 Review Mechanical
Education Surcharge $7.00
Permit Fee $1,050.00
Plan Review Fee(Engineer) $80.00
Plan Review Fee(Engineer) $120.00
Sca6ng Fee $21.00
Technology Fee $28.00
Total: $1,903.25
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 do the work stated.
February 21, 2018
Authori"d ignatdre:Owner / Applicant Contractor / Agent Date
Building Department Copy
February 21, 2018
��R9
SNG 193Z Miami
shores Village
"" Building Department
10050 N.E.2nd Avenue
fitORYpA 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 i£
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:
)M(
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this }day of Q1 20$.
By \phy) d and b W'C's who is personally known to me or has produced
live- t c.,VIS 4—' as identification.
0.PY pti•
Notary: ..•••. c; YANADYPRIEiO
s+: + MY COMMISSION#FF 214031
EXPIRES:March 25,2019
SEAL: ':Fp„°`` Bonded Thru Notary Pub!ic Underwriters
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ICK COTT GOVERNOR KEN LAWSON',SECRETARY
STATE OF FLORIDA
_DEPARTMENT OF,BUSINESS AND PROFESSIONAL REGULATION
-""CONSTRUCTION,INDUSTRY LICENSING,BOARD' ' c
,��.CGC1522153 :. _ - --••. _ -- «y�,.a: --- ;p.
--:,The GENERAL'CONTRACTOR
Named below IS CERTIFIED ~
,Under the-provisions of-Chapter 489'FS..
-,Expiratioh,date:-AUG 31`,2018-
CROW,--BRADLEY
018 CROW,=BRADLEY
COMPLETE SECURITY ERV CE LC
F 2601 NW 55 COURT k FORT-LAUDL
ERDAE*--•FL 33309 _ w
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c t r••►- •tom,."i';.. ..,..wt �, ,.;t �k" ,� ��a y,. 4,- ..
ISSUED. 66125120 ` DISPLAY AS'REOUIRED BY LAW" —" _ `SEQ# L1608250002136`
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BRO NAR 0-MIN - - - - ._ iEIP _-.-----
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
r VALID OCTOBER 1,2017 THROUGH SEPTEMBER 30,2018
ti
DBA: COMPLETE SECURITY SERVICE LLC Receipt#:E 8 CTRICAL/ALARMS/CONT TOR
1EC-254778
Business Name: . Business Type: (CERT ALARM SYSTEM CON II)
Owner Name:CROW, BRADLEY Business Opened:04/05/2013,
Business Location:2601 NW 55 CT State/County/Cert/Reg:EG13000244
FT LAUDERDALE Exemption Code:
Business Phone: 954=714-8833
Rooms ' Seats Employees Machines Professionals
If 5
For Vending Business Only
Number of Machines: Vending Type:
Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid
27.00 i' 0.00 0.00 2.70 0.00 0.00 29.70
i f
i.
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non-regulatory in nature. You must meet all County and/or Municipality planning
WHEN 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.
Mailing Address:
COMPLETE SECURITY SERVICE LLC Receipt #05A-17-00000166
2601 NW 55 CT Paid 10/06/2017 29.70
FT LAUDERDALE, FL 33309 1
i
2017 - 2018
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.eco CERTIFICATE OF LIABILITY INSURANCE DATE`M
olrozrmis-
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,EMEND 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.
I IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
It 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 NAME: Amanda Chase
Rick Gibbs,PA Insurance Agency PHONE . (954)581-7740 c No: (954)584-9875
1000 S.State Road 7 ADDRESS:
INSUFIER(SI AFFORDING COVERAGE NAIC#
Plantation FL 33317 INSURERA: Scottsdale Ins Cc
INKED INSURERS:
COMPLETE SECURITY SERVICE,LLC INSURERC:
2656 NE 35th Court INSURERO:
INSURER E [
FTLAUDERDALE FL 33308 INSURr;RF: (t
COVERAGES CERTIFICATE NUMBER: CL1710607848 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 t
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 PAIDCLAIMS.
LTR TYPE OF INSURANCE INSD1=0 I POLICY NUMBER MIDD LIMITS F
X COMMERCIAL GEHERALLIABILITY EACHOCCURRENCE $ 1,000,000
a AIMSMADE 1—x-1 OCCUR PREMISES Ee occurrence $
100,000 r
MED EXP Ary one person) $ 5,000 1
A CPSA17185 10A512017 10!0512018 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY❑JJECT El LOC PRODUCTS-COMPICIPAGG $•2,000,000
OTHER $
AUTOMOBILE LIABILITY ore Iden $ h
ANY AUTO BODILY INJURY(Per person) $ i
OWNED SCHEDULED BODILY INJURY(Per accWant)- $
AUTOS ONLY AUTDS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Por weirent
HOCCUR EACH OCCURRENCE S
4EE)(CESS;L�IAB CLAIIJSMADE AGCREGATE ENTION$ 3
WORKERS COMPENSATION
rATUrrF OT
AND EMPLOYM'LIABILITY Y I N
ANY PROPRIETORJPARTNERrJ(ECUTIVE NIA EL EACH ACC DENT... $ ...
OFFICERIN NISER EXCLUDED?
(MandatatyinNH) EL DISEASE-EA EMPLOYEE $
If yes.describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY U MT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VB-OCLES(ACORD 101,Additional Remarks Schedule,maybe attached V more space is required)
License Number'CGC1522153
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I
THE EXPIRATION DATE THEREOF,NOTICE WLL BE DELIVER I IN
Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVialONS,
10050 NE 2nd Avenue
AUTHORIZED REPRESS RATIVE
Miami Shores FL 33138 �~
®1988-2015 ACORD CORPORATION. All rights reserved.
ACORD`25(2018/03) The ACO RD name and logo are registered marks of ACOR D I
,
JIMMY PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
*' CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation,law.
EFFECTIVE DATE: 5/25/2016 EXPIRATION DATE: 5/25/2018
PERSON: CROW BRADLEY
FEIN: 320345774
BUSINESS NAME AND ADDRESS:
COMPLETE SECURITY SERVICE LLC
2856 NE 35TH COURT ,
FORT FL 33308
LAUDERDALE
SCOPE OF BUSINESS OR TRADE:
licensed General Contractor Burglar and Fire Alarm
Installation or Repair&Drivers
I
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IMPORTANT:Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter'by filing a certificate of election under
this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply r
only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be
exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the
person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a
certificate at any time for failure of the person named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609
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