Loading...
MC-16-1926 Pefmit No. MC-7-164926 Miami Shores Village Permit Type:Mechanical-Residential 10050 N.E.2nd Avenue NE Per iWork Classification:Addition/Alteration Miami Shores,FL 33138-0000 Permit Status:APPROVED y E— ' Phone: (305)795-2204 �'coR1oA issue Date:711812016 Expiration: 01/14/2017 Project Address Parcel Number Applicant p 1420 NE 103 Street 1132050310030 MARC AND ANNE LITZENBERG Miami Shores, FL Block: Lot: Owner Information Address Phone Cell MARC AND ANNE LITZENBERG 1420 NE 103 Street MIAMI SHORES FL 33138- 1420 NE 103 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 40,000.00 RUIZ CONSTRUCTION INCORPORATI (305)688-9770 Total Sq Feet: 0 Tons: Available Inspections: Additional Info:NEW MECHANICAL 10 TONS,EXHAUST FAN Inspection Type: Classification:Residential Final Approved:In Review Rough Duct, Comments: Date Approved: : In Review Review Mechanical Date Denied: Type of Work: Underground Scanning: 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $24.00 Invoice# MC-7-16-60554 DBPR Fee $21.00 DCA Fee $21.00 07/12/2016 Credit Card $50.00 $1,459.00 Education Surcharge $8.00 07/18/2016 Credit Card $ 1,459.00 $0.00 Permit Fee $1,400.00 Scanning Fee $3.00 Technology Fee $32.00 Total: $1,509.00 t . S 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_Al work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the ab�jamed con(act th �ork stated. July 18, 2016 Authorized Signature:Owner / Applicant / Col racr / Age t Date Building Department Copy July 18,2016 1 Miami Shores Village I IeIRECRIVFU)a l g �- BU' ilding Department J 1`2 2016 V' 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 20 (� �— BUILDING Master Permit No. F-c-3- I PERMIT APPLICATION Sub Permit No. 90 16— lg2G ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL ❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP aCONTRACTOR DRAWINGS JOB ADDRESS: 1 �, .(? to 3 S T- City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple TitleholderPhone Address: w City: ¢ State: Zip: 3 ` Tenant/Lessee Name: Phone#: Email: vi z Con S-rru C+J,o;l _ G CONTRACTOR:Company Name: C-?—L"J> i"j(-phone#: ap Address: /'b,c =7 A J j)In/ )20T T / 2 City: IV.T/ I c e h State: f-- / Zip: 0 Qualifier Name: j� 'ZJ i 7 �Q r4l C, Phone#: State Certification or Registration#: C L 13 1 7 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 'J _-(or.60)7 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ nA_lteration � New ❑ Repair/Replace E] Demolition Description of Work: VV/ Al"CInadi ca t Specify color,of color.thru,tile..; Submittal Fee �( � y C $ $ U� Permit Fee$ �O D CCF$ �"T � w� CO/CC$ Scanning Fee$ • vV Radon Fee$ DDB��PR$ W Notary$ Y� Technology Fee'$ ' 0Z) Training/Education Fee$ W Double Fee$ Structural Reviews$ 0 Bond$ TOTAL FEE NOW DUE$ I, ��• yV (Revised02/24/2014) 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 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-rem -ta ee will be charged. Signature Signa reJy r %� OWNL-1 CONTRACTQR� ` The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this,, 9 Z day of ���- �N4 by 'D—I- day of _1__3 , 20 \I.P by tvL ben w �personown to ,I l7 v who! :ers:on:all:y�know'to me or who has produced as me or who as produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: 0 S0.cv , Sign/: 2a V Print: Print: ^M. NiEA-1 RAOu.:: OUCH .'4, .? ?i218j Seal: ::+ �a2161 Seal: ; 2019 MYCi ' �. ..nderwrihn EXPIRES:Octcne! td,2019orwled Thr Notary Pu*Underreitera ************************************\*** ******************************************************************** APPROVED BY `� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CCC1329241., •The ROOFING CONTRACTOR Named below 1S CERTIFIED °` ,. Under the provisions of Chapter 489 FS. - . Expiration.date;:AUG 31,2016.., x yx B' RUIZ,JORGE, .�* • ` `; ,"* ; ❑ "RUIZ CONSTRUCTION INCORPORATED- 3827 NW 125 STREET �. y"- `APA t_OCKA r"' Ft_33054 N l .,�• �.:a.— .'"� 1:r,.Y+yy+a'+�n' ".,'• y .;�•t•'j"� �,�.':+W `�\ � ny� ~,S`� -�Y t. _. ISSUED: 061D4/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406040001574 ......_.. CONSTRUCTIO IRD`USTRYL'iCtW5I1VGi3VAKU ----- 4 t° - _ a 'CAC1817314 „ The CLASS B AIReCONDITIONING CONTRACTOR^ * ;.�. Named below IS CERTIFIED: - _ 4 , r Under`the`provisionsof Chapter 489 FS.-- y Expiration-date:'AUG 31;2016w .ems' .r �" ns. f �'^�- 'P's'W ; 7 �'xR. •' s. ' RUIZ;JORGE--, «�'""-"".� yc +: ( 'RUIZ CONSTRUCTION'INCORPORATED 4 �,3827,NW.,125°STREET « 'ra s*3 � _ t� � �4,'. 'ISN;.OPA LOCKA ,—- FL'33054 ISSUED: 06/04/2014 DISPLAY AS REQUIRED BY LAW SEC1# L1406040001481 ......_......_ _............... .. ....._..-.... _ RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY _. _. STATE OF FLORIDA DEPARTMENT OF.BUSINESS AND PROFESSIONAL REGULATION r _ CONSTRUCTION INDUSTRY LICENSING BOARD ' J The BUILDING CONTRACTOR" Named below IS CERTIFIED_ +, u!6� 'Under the provisions of-Chapter 489 FS. Expiration date: AUG 31;'2016 b".RUIZ JORGE Q1.6;38217 NWN 25 STREET (3RPORATEDOPA LOCKA ,FL3054 -y ISSUED: 06/04/2014 DISPLAY AS REQUIRED BY LAW SEa# L1406040001537 RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION skir -CONSTRUCTIOWINDUSTRY LICENSING BOARD CCC1330316 The ROOFING CONTRACTOR` Named below IS:CERTIFIED w., Nkb Under the provisions of Chapter 489 FS Expiration date:'AUG 31^2016 »} RUIZ,JORGE- RCI ORGE ` RCI ROOFINGINCORP0 .7ED 3827 NVi1.1253TREET ,; OPA LOCKA 1FL 33054 ISSUED: 06/04/2014 DISPLAY AS REQUIRED BY LAW SEC!# L1406040001575 004.Ix • '_may""- •__ `r,,u,....,,._ � .,....,t,e, "Y•'4.:-.,, -,N.f`:..�x. ...._,. • ._W. .r. ,....._. r _ { ;Local Business_ Tax°Recti t Miami—Dade County,: Stag 'o# Ffori a ,, '�'• -TIitS-IS'NOTA.BILL -DO NOT PAY- q 7080021' t BUSINESS�NAMElL.t�CAT1011�- itECE1PT N0 EXPIRES , RUIZ CONSTRUCTION INCORPORATED" "RENEWAL SEPTEMBER 30,-2016s 3827 NW 125,ST t 7367999,,- „Must be displayed at place of business i'OPA LOCKA FL 33054, Pursuant to County Code ' _Chapte 8A Alt!9&.10 V OWNER r SEC TYPE OF BUSINESS PAYMENT RECEIVED. RUIZ CONSTRUCTION INCORPORATED' ^196 SPEC MECHANICAL CONTRACTOR ,BY TAE COLLECTOR Wwker(s) ji ° CAC1817314 $45.00 07J29/2015 FPPU02-15-017464_ 1 ThisCacai Business Tait Receipt only.confirms paymeZfthe Wcal Business Tax.The Becoipiisnotalioense, permit ora certificationoi the holder'squalificatfons,todobvshtess.Holder most earn*with any governmental E -or nongovemmemaf regulatory laws and requirements which apply to the business, The-RECEIPT NO.above must be displayed on all commercial vehicles-Mi$mf-Anda Coda Sec 8a-276.` - t Formers information,visit mmmidede aovRaxcollector.:;.__,r ',;. ., 004238 .� ... ..e.. �. tee... .-.. ,,.-. ..« ..,..,� .y. ��. .:.... .. --• ' Loca[Sus ness Tax Receipts Miami=Dade,County;• State' of Florida. f -THIS,IS,n-NOTA BILL" DO NOT PAY, L . 5713706 ^, F BySINESS-NAMEILOCATION_,.r RECEIPT NO.- EXPIRES: s - " UlzCoiastRUCtioial'Nc, RENEWAL' SEPTEMBER 30;2016 3827•NW 125 S7 " '698 01 f " Must be dsplayed at place of business ;'OPA LOCKA FL Pursuant t6 County Code. ce Chapter SA-Art.9&10-- i OWNER; .z a" 4 `" FSEC.TYPE OF BUSINESS+ �. ' I RUIZ CONSTRUCTION INC k 196 SPECIALTY BUILDING CONTRACTOR PAYMENT PECEIVEO CCC1329241 ,'BY TAX COLLECTOR Workers) t r $45.00 07/29/2015 FPPU02-'15-017464 S This Local Business Tax Receipt only coinfirms payment ni the ketal Business Tax.The Receipt is nota license, : i y permit,or a certification of the holdor`aquelifications,to do business.Haidermustcomply with any governmental' { or anngoveremarrtal regulatory lawe and requirements which apply to the business.;The RECEIPT NO.above must be displayed on all commercial vehicles-Miami-Bode Code Sac8a-276. :a For more lntarmetion,visitwww.miamidadsga0/taxcolleofor 003879 r t Ito`cal-Business-Tax Receipt ` ;`Miami-Dade 'County, ` State, of Floridan -,THIS';IS'.NOTA SILL„DONOTPAY,,, IT] i^6430383 L B BUSINESS NAM &OCATION RECe1PT NO. i. •1 RUIZEEXPIRESCONSTRUCTION`INCORPORATED"-, RENEWAL: SEPTEMBER 30, 2016' 3827 NW 125 ST 6698725 Must be displayed a"t place of business �OPALOCKAFL33054-• ", Pursuant'to,CountyCone.:" i t - - - Chapter SA-Art:-9-&10 OWNER-x SEC.TYPE OF BUSINESS,. RUIZ CONSTRUCTION INCORPORATED r , .196 GENERAL BUILDING CONTRACTOR PAYMENT RECEIVED CBC059296 BY TAX COLLECTOR / W irker(s) l - $45,00 07/29/2015 1 FPPU02 45-017464Y due' f 9 t fib 'it t` r' ThisCoeal Business Tax Receipt only confirms paymemof TI. oca.l Business Tax.The Receipt is not a license, ' -t permit or a certification of the holdefaqualificanons,to do business.Holder must comply with any governmental C dor nongovernmental regulatory laws and requirements which apply tothe business.* `Thee RECEIPT N0.above must be displa id on all commercial vehicles-Miami-Oade Cede Sao 8a-276., 7 For more information,visit www:mmmidede:aovhaxcolfectoi i i i AC R® CERTIFICATE OF LIABILITY INSURANCE DATE/M"I 01°"Y'"' 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 po Icy les must be endorsed. ,su sect 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 Harvin PGI of West Central Florida,LLC PHONE AX A/c No Ext): 941-479-7215 (A/C,No): 941-845-4722 515 9th St E.,Ste 211 ADDRESS: amandah.pgi@gmail.com INSURER(S)AFFORDING COVERAGE NAIC# Bradenton FL 34208 INSURER A: Endurance Amerian Specialty 41718 INSURED INSURER B: Wesco Insurance Company 25011 Ruiz Construction Inc.(RCI Group Inc) INSURER C: Commerce&Industry Insurance Company 19410 14028 NW 82nd Ave INSURER D: INSURER E: Miami Lakes FL 33016 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD MWD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE FX OCCUR PREMISES(­TOERENTED a occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A CBC20000850900 10/28/2015 10/28/2016 PERSONAL&ADV INJURY $ 1,000,000 t GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑X JECOT- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL ONED B AUTOS X AUTOSULED WpP1417743 00 10/28/2015 10/28/2016 BODILY INJURY(Per accident) $ X HIREDAUTOS X NON-OWNED $ AUTOS (Per accident) $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,000 C VTIDED EXCESS LIAB CLAIMS-MADE BE026059553 10/28/2015 10/28/2016 AGGREGATE $ 2,000,00 I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 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) CAC1817413 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 Aw►,a.�t.o(.a HatrV�vv @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE" _ F/15/2016 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(les) 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 CONTA TMICHAEL C GEE MICHAEL GEE INC PHONE 941 907-0914 F .(941)907-0916 7353 International Place #301 h-MAIL BTRON VERIZON.NET Sarasota, FL 34240 INSURER(S) AFFORDING COVERAGE NAZCA FWCJUA INSURED RUIZ CONSTRUCTION INC INSURER B: 14028 NW 82ND AVE INSURER C: MIAMI LAKES, FL 33016 INSURER D: 1 (305) 557-3118 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONDITIONSOF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. LTR TYPE OF INSURANCE g P LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE 1:1 OCCUR PREMISES(Ea $ MED EXP(Anyoneperson) $ PERSONAL&ADV INJURY. $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ ROTHER' $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANYAUTO BODILY INJURY(Perperson) $ 1 'AL'LOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED RT A $ HIREDAUTOS AUTOS (Per accident) $ U_.DEUMBRELLA LIAB OCCUR w EACH OCCURRENCE $ D1 IRETENTIONS S EXCESS LIAB CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION ][ PERTITF TH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBER EXCLUDED? Y N/A (Mandatory In NH) 613434562 4/23/1 /23/17 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 110001000 4 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) License#CAC1817413 CANCELLATIONCERTIFICATE HOLDER s. Miami Shores Village Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2 Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. f Miami Shores FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD t VIE JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 6/23/2015 EXPIRATION DATE: 6/22/2017 PERSON: RUIZ- JORGE FEIN: 264036190 BUSINESS NAME AND ADDRESS: RUIZ CONSTRUCTION INCORPORATED RCIGROUP 3827 NW 125 ST OPA LOCKA FL 33054 SCOPES OF BUSINESS OR TRADE: t LICENSED BUILDING LICENSED ROOFING HEATING,VENTILATION, CONTRACTOR CONTRACTOR AIR-COND 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609