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EL-18-1219 E , Permit NO. EL-5-18-1219 �sµO1s y� Miami Shores Village Pennit Type:Electrical-Residential 10050 N.E.2nd Avenue NE " r ""* rion, `� Wr�rtc Classification:Repair Miami Shores,FL 0000 PPelt t Status:APPROVED Phone: (305)795-22095-2204 � F�OR1Dp' issue nate.519/2018 Expiration: 11/05/2018 Project Address Parcel Number Applicant 1209 NE 98 Street 1132050090230 CARSTEN PETERSEN Miami Shores, FL 33138-2562 Block: Lot: Owner Information Address Phone Cell CARS EN PETERSEN 1209 NE 98 Street (305)807-2221 MIAMI SHORES FL 33138- 1209 NE 98 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 800.00 POWER BY PURKIS INC (305)281-0546 Total Sq Feet: 0 Type of Work:REPAIR EXISTING METER CAN 200 AMPS Available Inspections: Additional Info:REPAIR EXISTING METER CAN 200 AMPS Inspection Type: Classification:Residential Final Scanning:3 � Review Electrical f Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# EL-5-18-67464 DBPR Fee $2.25 05/09/2018 Credit Card $ 114.85 $50.00 DCA Fee $2.00 Education Surcharge $0.20 05/08/2018 Credit Card $50.00 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $9.00 Technology Fee $0.80 Total: $164.85 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 cur nd that all work will be done in compliance with all applicable laws regulating construction and Toning. Futhermore, I authorize the abo a-na e 6 rac r t do the work stated. S i i9 May 09, 2018 Authorized Signature:Owner / Applicant / C ntra'for / Agent Date Building Department Copy May 09,2018 1 r i Inspection Worksheet Miami Shores Village j 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-303512 Permit Number: EL-5-18-1219 Scheduled Inspection Date: June 08, 2018 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: PETERSEN, CARSTEN Work Classification: Repair Job Address:1209 NE 98 Street Miami Shores, FL 33138-2562 Phone Number (305)807-2221 Parcel Number 1132050090230 Project: <NONE> t Contractor: POWER BY PURKIS INC Phone: (305)281-0546 Building Department Comments REPAIR EXISTING METER CAN 200 AMPS W 150 AMP Infractio Passed Comments INSPECTOR COMMENTS False f i t Inspector Comments Passed Failed Lq Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. June 07, 2018 For Inspections please call: (305)762-4949 Page 8 of 26 i k K Miami Shores Village 1 Buildin Department aYoa2os;g p 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 $Y: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 2W 11 BUILDING Master Permit No.��` �, 12.1°1 PERMIT APPLICATION sub Permit No. ` ❑BUILDING IXELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL t r ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP f� CONTRACTOR DRAWINGS JOB ADDRESS: /�� A//✓ / City: Miami Shores County: Miami Dade Zia' Folio/Parcel#: Is the Building Historically Designated:-Yes NO ,Occupancy Type:bWNg t Load: Construction Type: 65 _Flood Zone: Ve) BFE: FFE: OWNER:Name(Fee Simple Titleholder):_ 09A?5 �-5Z" /P S',!5�Phone#: :5e5-907 2Z2l r ' Address: City: /"///q f—/ 911b/Z/5'S' State: Zip: � 313 8 Tenant/Lessee Name: Phone#: Email: q uJrL' Say CONTRACTOR:Company Name: b � Phone#: Address: Z�ZZ {-31 A-6 City:—4State: Zip: Qualifier Name: fLG r. , 2 5 � Phone#: State Certification or Registration#:- '�S e� 54 q . ;. Certificate of Competency#: s DESIGNER:Architect/Engineer: f , - Phone# Address: Q City: State: Zip: Value of Work for this Permit:$ U `+ Square/Linear Footage of Work: Type of Work: ❑ ition ❑ Alteratiqrn Repair/Re lace ❑ Demolitio Descriptiton of Work: 6 2 —�C c S �, ' 1 i.i✓ ZG�' S +✓ k 7 Specify color of color thru tile: Submittal Fee$ SOWid Permit Fee$ l ©`b CCF$ CO/CC$ Scanning Fee$ Radon Fee$a W DBP,R$ CK Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ I 1 14 (Revised02/24/2014) r• . Bonding Company's Name(if applicable) t J ' ,.;Bonding Company's Address City J/ State Zip Mortgage,Lender's Name(if applicable) i�''at it Mortgage Lender's Address t � City )� t. r..j 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 per4isissue;dthabsence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature SignaturOWNER or AGENT TRACTOR I The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this () day(o�f 12f Fly 120 Z& by n�A _day of d LA i' j20 is by T r who is personally known to ,"`1 Ord VV)v who is personally known to me or who has produced as me or who has roduced _IJ fi V`e Y lj�111S� as identification an who did ake an 'th. identifica ' and wh oath. NOT RY PU IC: ! NOTAR PUBLIC: 4 t • Sign: a Sign: Print: ► Print: 01 Yt O Seal: Seal: nn� �^i •, NADY PRIET �2;•••••••,c+% ,.;�pqY`Py r, YANAD PRIEM Ml'COMMISSION#FF 214031 = =_ MY COMMISSION#FF 214031 EXPIRES:March 25,2019 '' t EXPIRES:March 25,2019 %Fp'p f Bonded Thru Notary Public Underwriters :" s�` P * t Pu li Underwriters APPROVED64/ Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application - Miami-Dade County Page 1 of 2 HE PROPE22RTY" OFFI^E 0=2 T AFETRAISER Summary Report Generated On:5/8/2018 Property Information. Folio: 11-3205-009-0230 1209 NE 98 ST Property Address: Miami Shores,FL 33138-2562 ', r Owner CARSTEN PETERSEN 1209 NE 98 ST Mailing Address MIAMI SHORES, FL 33138 USA PA Primary Zone 1400 SGL FAMILY-3001-3250 SQ + 0101 RESIDENTIAL-SINGLE Primary Land Use z a FAMILY: 1 UNIT Beds/Baths/Half 3/2/0 Floors 1 Living Units 1 t s Actual Area Sq.Ft a .. a g Sq.Ft ., Area Living Adjusted Area 3,693 Sq.Ft Lot Size 4,442.5 Sq.Ft Taxable Value Information 1 Year Built 1950 2017 2016 2015 County Assessment Information Exemption Value $50,000 $50,000 $0 Year 2017 2016 2015 Taxable Value 1 $340,546 $332,514 $567,500 Land Value $520,369 $484,315 $440,000 School Board Building Value $207,219 $207,315 $127,500 Exemption Value $25,000 $25,000 $0 XF Value $21,186 $21,484 $0 Taxable Value $365,546 $357,514 $567,500 _.._......_..__........... ...... _.._......-.------- ___............ _ city Market Value $748,774 $713,114 $567,500 Assessed Value $390,546 $382,514 $567,500 Exemption Value $50,000 $50,000 $0 11 1 Taxable Value $340,546 $332,514 $567,500 Benefits Information Regional Benefit Type 2017 2016 2015 Exemption Value $50,000 $50,000 $0 Save'Our Homes AssessmentTaxable Value $340,546 $332,514 $567,500 Cap Reduction $358,228 600 Portability Assessment $330, Sales Information Reduction Previous Sale Price OR Book-Page Qualification Description Homestead Exemption 1 $25,000 $25,000 08/18/2014 $669,000 29286-3368 Qual by exam of deed Second Homestead Exemption $25,000 $25,000 04/01/1985 $140,000 12483-0801 Sales'which are qualified Note:Not all benefits are applicable to all Taxable Values(i.e.County, School Board,City,Regional). Short Legal Description 5 53 42 EARLETON SHORES PB 43-80 LOT 11 &W1/2 LOT 12 BLK 2 &E20FT LOT 10 LOT SIZE 132.500 X 109 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 https://www.miamidade.gov/propertysearch/ 5/8/2018 STATE OF FLORIDA 2.� DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION E ELECTRICAL CONTRACTORS LICENSING BOARD (850)487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 i f 'PURKIS, MICHAEL JOHN POWER BY PURKIS, INC. 12222 SW 131 ST AVE i MIAMI FL 33186-6402 f Congratulations! With this license you become one of the nearly -- �, a�- ---Y - -Z l one million Floridians licensed by the Department of Business and �. i •' "�, "� Professional Regulation. Our professionals and businesses range STATE:OF_FLORIDA,,— t from architects to yacht brokers,from boxers to barbeque ^ t DEPARTMENT•,OF-BUSINESS AND restaurants,and they keep Florida's economy strong. �.b- PROFESSIONAL REGULATION Every day we work to improve the way:we do business in order _EC1'3005447.�' r ISSUED x106/19/2016 , to serve you better. For information about our services,please . _r log onto www.myfloridalicense.com. There you can find more CERTIFIED ELECTRICAL CONTRACTOR I information about our divisions and the regulations that impact "PURKIS,*MICHAEL'JOHN` you,subscribe to department newsletters and learn more about + POWER'BY PURKIS=-INC"T rt+w the Departments initiatives. �' Our mission at the Department is:License Efficiently,Regulate41 ` " <� Fairly.We constantly strive to serve you better so that you can .r ' �^ '''�-•' tet. IS CERTIFIED under the provision"s of.'Ch:489 F&: .� serve your customers. Thank you for doing business in Florida, ,,,. I t ++Expiratwn date:AUG`3i,2018 .�•—; .«. L1806190001638 ' and congratulations on your new license! 1 �, r r w'•cis..,,_.�-.-....c...^.-_••--•--�.,..,..�..�---.,.—..�..-,.--..,-.-.-..rte-•---:..�...G......,....,..--.^' DETACH HERE 1 RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY M.,.'.iy� r -.a -'k --• ♦ `.'�._m„` �.-sa""y„�....�% .-w.,<--.....fr, +4x..:�.. ��a+w:.�+�& .,kw+.�.ayr�•Nw�.iwn_+,�:.r�, -w.�c... -.r.-,. .+....;,�;w-.....-s•• ZZ.pw.•6•°„t°'" ar ;N".+ .r'••'„Yr«.. ,..a: ,, ....STATE OF FLORIDA" ,a.,,...�•rs.»ss� wP�•'*^•�,w,:_ - ^� _ �,.,zei. +'°w`"`.- 'w�,n..''La: '4�.,"'• � r ,• . "k + f--�"�' > =, DEPARTMENT•OF,'BUSINESS SAND PROFESSIONAL REGULATION B " " "" "'"� ``ELECTRICAL CONTRACTORS LICENSING BOARD �` I �' .mow ,.J ' .J.�, ac .xawe.y. .".r. *� ,+�a+i+...: M.,A-"y}.y w.Ya� .,�, $, +•- .%i'4. ° t�" S +^ �..wtr.ti.r- �.�*`._ ""+� °"'y�f♦ '*x.. xb. �'"'s. '*w n. a 16 w �EC'I3005447.,�+` r. �' ., *�"....w-.,�-•_�„ ,.�r. -,,,� ;'�,�"^'.�. __ �-,•, �,''` w.,' �-„�,'. ,.•� `,".•��- '�a-'"+5, ,�,�' � � +:.e'' ��y. The�ELECTRICAL"CONTRACTOR ;;r�� ::�- " �, a; 4,='� '> «` - Named below IS CERTIFIED «- " �.. . ++�"� ' 5 ' •*� �� �r; '� ,c »^Under the,provlsrons ofCFiapfer.489 FS:.� '. '` "��;'w "^ .� s , •,� , •� Explra�ti6n.date rt•AUG +a•',,,..F'�+'�M' -.if-.+rtl y..ew+�"� ., 'lrrr'” r..,,, h� �-� ` �4:, �,..�"'A �+,. �"+n K'4�°N. a�at 4 fKf�a+ w.F"" �„e,.+rw•'•.ar `+`:..say a i� - � .-«,,�"�..,��., '"aa h, h,.�.A,•� k �` -r _,.. n€i1 ..w- - '+..e,.d .cxa.. '•�9' �''�^ i."'1"' -t"".1.�,v°'� +'f��,�� n..''�. "+s,,, '1�.. ,'C1{"n, "• 'y�,`r'. qq '� r+'+u"T^'�+ .. y.aY"^a J. fM,t KA 'a4h .s a'4 "*t ' '4•,p ` t 1 ;s, 4 j+( k �.,•Y'r ...a.'{"� sw'+t-.ay ?"°r'�'4. _ ip �4. � •k; '4„�r�wr "4M1 �,.a �• �� � 4 °• PURKIS, .. `► k, . MICHAEL JOHN: .�••. ••.�:� � �;�.�,, ��C.►. 'a,� �,_, � .�: .., -, POWER BY,4PURKIS;INC:+ •. yy,^^�,� 12222,5%131ST AVEC 7 -. •�MIAMI<.,.�.-�^ _1,FL.33186_=6 �M .aw."s� roF'.,,,+.+� "„s,;*.'an°�",,.�•++r-,fit:. .�'• r ,,,,•,,.w.�, ...i`.-,�� �i..kc� i' ,5:,�y .�y:A:�{ 't 'iS'"�.- i c : ■ ��'1' de'•._ ., '.r err°"` w w!M.,�`�.,,': '�4...��h'!G4. S'4 r"dt � � ,fie„���� .owr� `�y"����ti+er,��g3'�„�„�"1.y�'"�c.,`�"•���+r.4.""� hF3 �`� � � w.�4y. ��� ISSUED: 06/19/2016 DISPLAY AS REQUIRED BY LAW _ SEQ# L160619000,1 38 k 4 Y k, To find out about business and economic opoortunities for Florida veteran business enterprises,as well as Florida's small minority and ,•. ,> 4� women-owned businesses,please contact or visit the Department of Management Service's Office of Supplier Diversity at: hup.11www.dms.mvtlorida com/otlier nrozrams/ofrce of supplier diversity osd E i To find out about State of Florida tools supporting statewide centralized procurement activities which have streamlined interactions /Ytt �r between vendors and state government entities,please contact or visit the Department of Management Services'MyFloridaMarketPlace at: htWs://vendor.myfloridamarketvlace.com 1 . l r AC# 01502551 E { *Note:Backside of License s g s SIGNATURE 1 , (For the protection of our professional license holders,this license contains hidden security features to prevent counterfeiting. Unauthorized reproduction is strictly prohibited and will be prosecuted to the fullest extent of the law) The Department of Business and Professional Regulation(DBPR),issues licenses for many licensed businesses and practitioners in the State of Florida. DBPk is changing the way you interact with state government. Many of DBPR's services are available online at www.MyFloridaLicense.com. We encourage you to utilize these services to make address changes,licensing changes or to renew your license. 1 Name changes require legal documentation verifying the name change,which must be mailed to the DBPR. An original,a certified copy or a duplicate copy of an original or certified copy of a document that shows the legal name change will be accepted,unless the DBPR has a question about the authenticity of the document. .If applicable,the DBPR will send a renewal notice to your last known address or email address of record. If you have not received your renewal notice,please call our Customer Contact Center at 850.487.1395 or online at www.MyF]oridaLicense.com/contactus. Please refer to your profession's governing statutes and Administrative codes for further information regarding renewals. These may be accessed from our website. i . AC# 0150'2051 —L--occil-Business-,Tax-Peceiot Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 3129723 _ T BUSINESS NAME/LOCATION RECEIPT NO EXPIRES POWER BY PURKIS INC RENEWAL SEPTEMBER 30 2018 5901 SW 93 PL 3268638 Must bedi'splayed at plai:I a of business MIAMI,FL 33173 Pursuant to County Code Chapter BA-Art.9& 10 OWNER SEC.TYPE OF BUSINESS PAYM ENT_RECEIVED_ .-POWER BY PURKIS INC'—,--, 196 71 ELECTRICAL—-r BY TA X'COLLECTOR, CONTRACTOR '1715.00 6716U2017­ Worker(si y EC13005447 I CHECK21M-052127 r I or the �This Local Business iftonly con-ffm' payrnent of the Local Business Tax.The Racelpt Is riot a license, Jperrrit,or a6erti holders quali*cations,to 6 business.Holder mw cornply-with anygmwmww- lawiand FirrentSWhiCh'applylothebusiness. The FEMPrNO abo'we nW Ile disoyed on all co'rmwaal vehicles-Miarni-DedaOxIi Sac Ba-276, For more I rdorrrlatron,,visitww.nj"d6dsagM�Wc�l w 2 i AC D CERTIFICATE OF LIABILITY INSURANCE DATE(MMrODrYYYY) 4/2312018 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(les)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 thls certificate does not confer rights to the certificate holder In lieu of such endorsement(&). PRODUCER.Liberty Mutual Insurance CONTACT PO Box 188065 PHONE �- FAx l Fairfield, OH 45018 AIC,No,6tt):.. 800-9b2-7132 _(Alc,Ne):... 800-845_3666 .MAIL - - -. .. ....... ... .... ....... ADDRESS: SUSInessServic Libe Mutual.com INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Ohio Security Insurance Company 24082 INSURED INSURER B: Power By Purkis Inc 12222 SW 131st Ave INSURER C: Miami FL 33186 INSURER 0: ! INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 41469123 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, INSR6111 TYPE OF INSURANCE ADDL.WinR POLICYNUMBER MMIDDmYF M IOQn XP LIMITS A ✓ COMMERCIAL GENERAL uAari-ITY ;BKS56663177 4120/2018 412012019 I EACH OCCURRENCE $1,o00,000 !—••-- CLAIMS-MADE L✓ OCCUR I PREMISE 'Ea 9mwrw!c9). is 300,000 MED EXP(Any areperson) $15,000 PERSONAL&.ADV INJURY $1 000.000 GEN'L AGGREGATE LIMIT APPLIES PER: ( GENERAL AGGREGATE $2,000,000 —1 PRO- ✓ POLICY_�JECT FLOC ;PRODUCTS-COMP/OP AGO $2,000,000 OTHER: i S AUTOMOBILE LIABILITV ;COMBINED SINGLE LIMIT S Ee accident ANY AUTO y BODILY INJURY IPerpers0n) $ I OWNED SCHEDULED L---- AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ t HIRED NON-OWNED r�AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Per acadentl S UMBRELLALIAB OCCUR r EACH OCCURRENCE $ I EXCESS LIAR CLAIMS-MADE AGGREGATE $ � - DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LU1BILtTY YIN __ STATUTE. „___ ER __._..__...— ANYPROPRIETORIPARTNERJEXECUTIVE E,L.EACH ACCIDENT I'S OFFICER(MEMBEREXCLUDED? NIA (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE.$ If es,describe under --- DESCRIPTION OF OPERATIONS below 1 E.L.DISEASE-POLICY LIMIT $ f DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 104,Additional Remarks Schedule,may be attached If mon apace is required) Electrical Contractor Lic#EC13005447 ` CERTIFICATE HOLDER CANCELLATION Miami Shores Village, Building Det SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE Miami h re Avenue 9 p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS- Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE Todd Cornwell ®1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 41663_23 566E3177 18"; N:a^tar C-ti'ir_a-a 1 Ted, C-rowel! i •1 122/20.8 6:43:4; 7V1, (E:;7i I Face 1 tf i I dE Vw"ME , 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' Compensations law. EFFECTIVE DATE: 8/21/2017 EXPIRATION DATE: 8/21/2019 PERSON: PURKIS MICHAEL J FEIN: 650412525 G BUSINESS NAME AND ADDRESS: POWER BY PURKIS, INC. a I 12222 SW 131 AVENUE ' MIAMI FL 33186 SCOPE OF BUSINESS OR TRADE: s Licensed Electrical Contractor f 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 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. .i DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 w . c l� �V 0 � k N Date: r State of Florida Country of US 1 Before me this day personally appeared Michael Purkis who, being duly sworn, deposes and says: That he will b e only person working on the property located at: 1209 NFASirek Mia i S ores FL. 33138 Mic rkis Cont act r t Q�-h Sworn to (or affirmed) and subscribed before me this$day of a t 2018 by M;c I - - PU r " Personally Known / Or Produced identification qi ation Prod a �ryyStamp Notary " .�•'�P•�,1�'-. YANADYPRIETO * -I M4'COMMISSION#FF 214031 i EXPIRES:March 25,2019 8011181 T11.Notary Public Underwriters 1 � 5NoRF�s s� Miami shores Village Building Department 10050 E.2nd Avenue RIDp' Miami Shores; Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 i 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 frorn'this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of WorkersCompensation 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'comperisatidri 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 I0°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 bf Corporations. No more-than three corporate officers per corporation or limited liability company members are 1 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 a`n`d has acknowledge that he or she will not use day labor,part-time employees or subcontractors foryour 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 1 workers'compensation'insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOLT'ACKNO DGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner i State of Florida County of Miami-Dade 2 The foregoing was acknowledge ,,before me this J"lf/day of I9Alle. _,20 /9 . � 11 __ By_CC,LY SAtn Qek se If1 who is personally known to me or has produced 1�,eJ1�Ls� as identification. Notary: h ��r rue COURTNEY ESPINOSA SEAL: ,P "' �'O Commission#GG 121986 wr s` Expires August 8,2021 s F a t t Miami Shcros Village MAY O a 0181 APPROVED BY DATE ZONING DEPT 6-- Existing 150 amp. Main Breaker Nema 311 Enclosure SUBJECT i"O CCNIP ANCE WITH ALL FEUERAL . • .0.00• .. 0000 STATE ANo C(1_jN�.')Y HL,L_S AND REGULATIONS •• ' •�"'• Existing 1-1/2" Rigid Conduit w/#1 wire 0.0:,0 •' 0.00;• - Existing 200 amp. Main Panel,"•• • • 0.00. �•..., 09000* too*. •0,,,, •0000 Existing 200 amp Meter Can •, • �..�;• 0,00:0 • • �i Existing 27 Sch 40 PVC Service Lateral from FPL Transformer 2 Ground Rods-on#6 C Water Pipe lad Loacation: 1209 NE 98 Street. Miami Shores, FL. 33138 -Drawn by: Michael Purkis w/Power by Purkis