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PL-16-2473 Permit No. PL-9-'16-2473 sKurtFs L�� Miami Shores Village Permit Type.-Plumbing-Residential mt • 10050 N.E.2nd Avenue NE � er ' WaGlassfication: AdditionlAlteration Miami Shores,FL 33138-0000 Permit Status:APPROVED Phone: (305)795-2204 CORIDA Issue Date:9122/2016 Expiration: 03121/2017 Project Address Parcel Number Applicant 475 NE 91 Street 1132060140142 AVANT PLACE , LLC Miami Shores, FL 33138-3150 Block: Lot: Owner Information Address Phone Cell AVANT PLACE, LLC 7845 W 2 Court (786)566-2454 HIALEAH FL 33014- 7845 W 2 Court HIALEAH FL 33014- Contractor(s) Phone Cell Phone CONWELL&ASSOCIATES CONSULT 305 962-5673 Valuation: $ 6,000.00 ( ) (305)926 5673 .., �..�. .._,. Total Sq Feet: 1800 Type of Work: Available Inspections: Type of Piping:BATHROOM, KITCHEN,LAUNDRY,REMODEL Inspection Type: Additional Info:BATHROOM,KITCHEN,LAUNDRY,REMODEL Top Out Bond Return: Final Classification:Residential Scanning: 1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.60 DBPR Fee Invoice# PL-9-16-61248 $3.38 09/22/2016 Check#: 1358 $ 199.36 $50.00 DCA Fee $3.38 Education Surcharge $1.20 09/07/2016 Credit Card $50.00 $0.00 Notary Fee $5.00 Permit Fees $225.00 Scanning Fee $3.00 Technology-Fee $4.80 Total: $249.36 r� cam.. r• CD 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 DAVIT: I ce at all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating constructi6n:and zoni . F erm , I a horize the above-named contractor to do the work stated. September 22, 2016 Author ze ignature: ner / Applicant / Contractor / Agent Date Building Department Copy September 22,2016 1 Miami Shores Villagez . ^ -- _ a� . _.,._._..._._ _.._�.. _c. tf Bui-lding_ -Departrne— — nt SEP 07 2016 e2gib l-p". It ,jam;1 ;t tic: i _ - -- - -- -- - �- --- 10050 N.E.2nd Avenue,Miami Shores,Florida 333138 - r11 __ — --Tel:-(305)795-2204 Fax:(305)-756-8972-•- •- — -----�` INSPECTION LINE PHONE NUMBER:(30S)762-4949 f 9i Sb,)1�: -hti;v ztisbn3.ygc�tic?P�". FBC1'�20 Irt9 i 5GT3Si.Fv 01- BUILDING___ ___ _._.,..____.,Mast&Permit No.- PERMIT APPLICATION Sub Permit No.PL I(0 Zy71 . ?6r0 natT,.Ipil nt '+? 'I"l'•{wi irrtt vti'.!'-;) i b!;-wjvi n. cs?ti0i i irvui1 bor, *11,ltla")dt on '1y iir"tnEIq "') -U'-1 1 Tf;i:lt�li V. WJ t• ,1kj,jA u; .BUILDING 11i` ELECTRIGI�l `,1gr0iROOFINGq e�r' PINEl REVISION` bfit- j'Q,,EXTENSIONPzi rtMRENEWAL• 7rt'r1"110-1 %»AFjj(1 J;Ai :tirt!:ti '11m ,r:i.li io' t;d 'JeA1 1 ,f'fbi!(q i!: tat] ci Rd) �3Elf,ir1`l;?!iU t t Jfi?.)S�ttU; Cj? !f! f;rJi7?LI 1:" EitJ 7`t"� ?�'i r n+*s?Eic"t�914 -)itA�T ?PTi alfa.?93!108,23DAV gL,11 ❑■ PLUMBING [:] MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP !I� riSirr �r lrilam(,, ni aFoh _lf) 'I,. t J:t�„'tu iL,i. hE , SrT1 , + CONTRACTOR,'nos tirs� 5(�TJiJ12zi t?�ry rlif it . e:vf i 7E�RAWINGS.niwo D JOB ADDRESS: �� °/ g r?iigt•i tCitv:n ° °I nn-Miami Shores-s-% _m#" 11►c--z-piss County:a"N:10 n1Miami Dade:4 CI IAV •C'4Zi6:;i1r-3"://;-,? , 1p avl 7" iFolio/Parcel#:'sV 31 VT1r43Q 1S1Q CI InV n'r ;;T1A:1AjFtKi"Buildift His"torricalli e`signated:;Yessl Alf NO jf T V Q3h "Occu anc T,""a:'4A�4:ZILoid:A.r4f?,TTTA Const�uctionT`66..j-.1 i$ Y Flooci'Zone:l8iz{C; .BEE+:3 1 13''-FFE�!A B r,. P. Y.Yp yp __ ,�.,�-----i!,... "14 30.r A 3111 O"' Y `51 11'01,1 1:11i OWNER:Name(Fee Simple Titleholder): e'U L_� C- Phone#: �� Z 'Adlldress:��i r.( t }Si!' "Z,4 to2 :ta t>t+l.,+ ,t . .4 G� *s 1l3 3 .a t>t?t�.t 3i ro15,1�E�a? O?� :i1u':''�Q�� f7t n7i!Gfit +'}G1"C�'31t.' �,i 1' .' +�;�'> yr+z+,,.. ]• rl l"fij V! C, .ti t1c' J.1112,1r) t1^q . t95�+t fl4*'+ �c! 3 ttlfl 9ti1S �h+jy7)A Y!.}•" "'W1 •r(n: ., "clt;tsti'!t7 City - = State: Tenant/Les'see';Name:'?10 161 0yircr:c� i:nitstci++i cis ^,:fi�0 ��r.r, �t n�v=Phon e#: Email: CONWELLBE;AS�OCIATES CONSULTING COMPANY 305-926=5673 CONTRACTOR:Company Name:. . - -_ Phone#. L- CE'AA^ Address• 11771-SW•137-P ,tllf:'fs`ti v".4.' I vr::i lt+ +l.l ';EJt -V . City: MIAMI State: FL Zip 33186 7 'lf jAl_.v' 9 '.1!'Y'ti Cti.1'tf'i `./'J! ll iJ fU J!'VLI!tJb D[:'•r 4i t - t I. Qualifier Name-KENNETH F116dl WELL Phone# 305-926k5673 '''' Stat Certification or Registration#: CFC1428047,� 41Azl! (Certificate of Competency# --.•: ;s cl` .",t io. +!.v 1.4-10Z v or IY — _... �.� .. �t f tJv?'3 i'.IFn3sl'_iL} %I c)r DESIGNER:Architect/Engineer: -.. Ptthone# 1 C•' _ _.-_. _._. fir.-J�I1J!J;Lt I-re! 11tY'. ;fJ Virf tri .._.. .._.� 7. ; E 9!'.J..i� tN..bli�t•!dJ u r, Address: City: - State: Zip: et) U •1,.. •.'h!.,f r' '1'W Uf.0 1.�-fr-1 t;!,_, t;riy%,; }hW 11 s;4?'�f.' ,Eg. 1',lfiA t7J�.aJe 1-r71 L:. Value of Work for this Permit: Square/Linear Footage of Work: l� " - J Ulf Ink -i Type of Work: ❑ Addition ❑ ❑ p / p ❑E `649` yp ❑ Alteration New +• �Re air lie lace Demolition � /�CSD./►� , //C f �.; �� L.`�7�1/������>�� Si' �i'�<t' Description of Work: ;L ,,��rr �,6et _ .i.le:C' �illf r � _:1m RL✓� � t�, t ,. K.4qui.% y;AJtd 1 4 ti t.i 1fs�. �.- ..�1 � �.xt. tY`�...lZ Specify color ofcoloritfiru�>ilye:r �'i.` 1f+' �;t� c " ,� rf�r� t,te Submittal.Fee$ {.. .. r., et-.:. Peimit.Fee'$ . .,° CCF$*w.`_x X60..*,,,aft,CO/CC$: ..iJ * Y falai,. Scanning Fee$ OA Radon Fee$ '3;- '-:;10 DBPR$ ��J t Notary$ �J 'tCti"i71 _ `'_ t_,Ml+iR"Ie2 J'V'!"� 4A Technology Fee$ -T ��~ -"_'-_Treining/Education Fee$ 1 !r -� Double Fee$' - Structural Reviews$ Bond$ �l�sti:. �A•nlv�si !ct•lE:3a��±c �• TOTAL FEE NOW DUE$ 1L-(-:( 7 � (Revised02/24/2014) Bonding Company's Name(if applicable) f- Bonding Company's Address I 1 `J FEIFE t;b,itA znind2 trPlii..f, brc*.-4 M Q?vol City State Zip Mortgage Lender's Narfie(if applicable) V'0-0 (ZOE) H 3'0.1 01'T:Q,;2WI Mortgage Lencler,Adldress!I City v%vA t;jvv.i^.Sta,te;P4-im Zip r-) #11(,.11 I 01-- 31jqq iA .44 TiMUIq Application'is hereby'riiade-td-obtain a permit to do the work and installations as indicated. I certify that no work or installation has p 't6-rbeet the)stS6d4ridi-_of all IhWs7r6kUIit6 commenced!prior�:to-the issuance"of'atpOrMit and that'.'all'work'Will be pdrfdrm6d, Lj L I _ I- - g construction in this Ljiulhscliction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... 4 , I UHe Ll V!U! J'JAA-ij ? iF1 0 OJ D I je,t I q OWNER'S`AiFlidAV[T: I certify that all the foreg'oQn"gi'nG' n is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. AOt "WARNING-TO-OWNER:--YOU R_FAI LU RENTO_RECORD!*.NOT-ICE-OF-COM M ENCEM ENT_MAY RESULT IN-,YOUR PAYING13WICE4011'IMPROVEMENTS TO-YOUR PROPERTY.-IF-YOU,),INTEND TO.OBTAIN FINANCING,_CONSULTuWITH YOUR LENDER,OR AN ATTORNEY BEFOREAECORDING YOUR NOTICE OF COMMENCEMENT." r-q-n Z.1911-'InFo PA1Ar'!O 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 td'a't-tachment. Also,a certified copy of the recorded notice of commencement must be posted at the job's i e for the first inspection which occurs;seven (L) days after the building permit is issued In the absence of such,-postedenoticer-the ' -_i�lll_-_ approved- .1. _ fee ---.- - - __-_ — __ ___ .- inspiigofi not b� pi6vid and a reinspection fee will be charged !4 9Are _ . __'Sig'n_a_t_u 31A! Sigri�mfrc� —----- OWNER-6-r AGENT -'CONTRXCTOR'------ 11NA A IM e- Thfore-goi instrument was`acknowledged h&6rd-ffe-this The foregoing initrbri4fif-was a7ckA6wIedgid.bif6re­ffiithis -day ;'20 by--- 29 ----d--f,AUGUS-T--,-----.--- ay o J 20 by -0,-p il A rloljtij;"�",-- "-tic) 1113.)qJ_-J?_ 75 td___KENNETHTX0NWEL ersonall-'k known to who is personally known who i�� me or W ho as identification-'and whb-clid t'ake an oath. identification and WK-6-did t5lCe an 6&K.-- Nol la 9..Jlsv N-OTARYM-US11 _vp-2.NOTARY PUBLIC---- Will r--1 IDDr! nNtb1bA ., F- - hnW!o%jJ 00MX Sign Sign :+.'0V1 10 r.Wfqh�MS1.1 0Z Pri SeaSOA* -Jones Us rr7 & % b 1.0 VZ RZ *,'FWMMISSI0N I•FIT001 EXPIRES; 14 2019 XN ORI DA APPROVEDBYPlans Examiner Zoning a lrji IQ 3 Structural Review Clerk iuu WUO��'l JAW., (RevisZ02/24/2014) -w-A, STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32309-0783 CONWELL, KENNETH FITZGERALD CONWELL&ASSOCIATES CONSULTING COMPANY 11771 SW 137 PLACE 1 MIAMI FL 33186 Congratulations! With this license you become one of the nearly 'r one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE:OF FLORIDA,.._.. from architects to yacht brokers,from boxers to barbeque s dDEPARIIIT�F BUSINESS AND restaurants,and they keep Florida's economy strong. -PROF 1' :`x�LRR' ULATION _ Every day we work to improve the way we do business in order `s " CFC142804717/1;7/201`6 k l to q u serve you better. For information about our services, please log d nto www.myfloridalicense.com. There you can find more CERTIFIED 7D information about our divisions and the regulations that impact ,CONWELL,pKI you,subscribe to department newsletters and learn more about CONWELL"8e CO' a the Department's initiatives. . Our mission at the Department is: License Efficiently, Regulate Fairly.We constantly strive to serve you better so that you can ^ serve your customers. Thank you for doing business in Florida, I$ CERTNfiiro urtde"�the provisions of cn ass FS" and congratulations on your new license! Eiplrati ndate,AUG3f 2018 __;; ,,L16071700013d8 .. s ^if ° DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OlFFLORIDA ION DEPARTMENT OF BUSIkt$AND PRO FESSIONAL�REGULAT ;' _ W0U.9TRY LIGENSINGrBOARD GONSTRUGTION I CFG1428047�, "° ^ .k 8 The PLUMBING CONTRACTOR R Named-below IS CERtIFIED _ . 3� ' U;nder the rovislons*W Cha` terA89 FS.ry t� p w r :0:viratlon date v y{ h ` .,j con�wE>`L, xENNETw Fa. j. �c s r CON-' A SO IA ' ' ULTIIMIJ G CO PONY >s ti F M ISSUED: 07/17/2016 nISPI AY AR RF=f11 IIRFr) RV JAW cGn� i �cnoa�nnna�.•oy Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOT ABILL—DO NOT PAY LBTJ 6242952 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES CONWELL&ASSOCIATES RENEWAL SEPTEMBER 30, 2016 CONSULTING COMPANY 6766001 PL Must be displayed at place of business 11771 SW 137 Pursuant to County Code MIAMI, FL 33186 Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED CONWELL&ASSOC CONSULTING 196 PLUMBING BY TAX COLLECTOR CO CONTRACTOR 75.00 09/13/2015 Workers) 1 CFC1428047 CREDITCARD-15-045695 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is nota license, permit,or a certification of the holder's qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec ffa-276. Mela�MtDADE For more information,visit.Www.minmidademov/taxcollactor AC R® �� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/17/2016 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 ALL CITY INSURANCE INC-ACI CONTACT CARMEN R DRIG E 275 FONTAINEBLEAU BLVD. PHONE 305 463-9431 FAX . 305 436-6797 SUITE 190 'L CRODRIGUEZ LLCITYINS.COM MIAMI FL 33172 IN URE AFFORDING COVERAGE NAIL# IN AMID-CONTINENT CASUALTY CO 23418 INSURED CONWELL&ASSOCIATES CONSULTING COMPANY 11771 SW 137 PLACE I INSURER 0: MIAMI FL 33186 SURER E: - I INSURER F, COVERAGES CERTIFICATE NUMBER:02 REVISION NUMBER:01 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS .LMA GENERAL LIABILITY 04GL930787 06/04/201506/04/2016 EACH OCCURRENCE 1,000,000 A X COMMERCIAL GENERAL LIABILITY 04GL953919 6/04/2016 6/04/2017 DAMAGE TO RENTEDnco $ 100,000 CLAIMS-MADE �OCCUR MEDEXP Any oneperson) $EXCLUDED PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY 04GL930787 6/04/2015 6/04/2016 COMBINED SINGLE LIMIT 1,000,000 A ANY AUTO 04GL953919 6/04/2016 6/04/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSAUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY AITR ANY PROPRIETOR/PARTNERIEXECUTIVENIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If ,describe=PERATIONS below E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks SdreduK N mors space Is required) CGC1515386,CCC1328946,CFC1428047,CMC1250012,CUC1224991 CERTIFICATE HOLDER CANCELLATION A1003027 MIAMI SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CONTRACTOR LICENSING / ACCORDANCE WITH THE POLICY PROVISIONS. SECTION 10050 NE 2 AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES VILLAGE FL 33138- � � 6" ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 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: 6/8/2016 EXPIRATION DATE: 6/8/2018 PERSON: CONWELL KENNETH F FEIN: 383763521 BUSINESS NAME AND ADDRESS: CONWELL&ASSOCIATES CONSUTLING COMPANY 11771 SW 137 PL MIAMI FL 33186 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL LICENSED PLUMBING LICENSED ROOFING HEATING,VENTILATION, CONTRACTOR CONTRACTOR CONTRACTOR AIR-COND Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by tiling 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 �ACC GENERAL CONTRACTORS 173 11 MIN IT§1157, a CONWELL & ASSOCIATES CONSULTING COMPANY DATE: If-a !-lf Before me this day personally appeared Kenneth F.Conwell who,being duly authorzied and says: That he or she will be the only person working on the project located at: t Sworn to(or affirmed)and subscribed before me this (Sign ature) (Date) $4,- cOMW'eAW (Print name) 6� Coils�,,,��� OP 'G (C 3G:ate s 2401 STAT�F FtD......................... COUNTY OF fttfdll266E Thg'foregoin instrume t was acknowledged before me this d y of 4 20 `� by It 6% COA%MOC on behalf of �4rhi who is personally known to me or[ has duced as identification. Notary Signature: Type or Print Name: e AA �'�.�. Zettie Jones ' ?►_ C01WMISSION O FF21MI i` '0."'```�•• 14,2019 WWW'AARONN i0 ARY.COM 11771 SW 137 PLACE Miami, FL 33186 Tel:305-926-5673 Fax:,305-385-7827 Email:info@caconsultingc.com 5gOR>Es Li ..,. ,.,,.M Miami Shores Village - —o�a Building Department f �+LDRIDA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to ' obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers'compensation coverage. Corporate officers` or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade c �p The foregoing was acknowledge before me this day of c7 20 ( `-- By Tum• 4 I2 �-i who is personally known to me or has produced �� �i0@In@Ific . Not SEAL: ' Oti&��' '�'2 ••, zVAar'::