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DS-17-2658Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Pe M 1 Permit NO. D$-11-17-2658 N. Permit Type: Driveways/Sidewalks/Slabs Work Classification: Aced ition/Alteration Permit Status: APPROVED Issue Date: 2/2/2018 Expiration: 08/01/2018 Parcel Number Applicant 922 NE 91 Terrace Miami Shores, FL 1132060000030 Block: Lot: BBJJB LLC Owner Information Address Phone Cell BBJJB LLC 922 NE 91 Terrace MIAMI SHORES FL 33138- (954)558-3959 922 NE 91 Terrace MIAMI SHORES FL 33138- Contractor(s) Phone AG & GENERAL CONSTRUCTION INC (954)203-9219 Cell Phone Valuation: $ 4,800.00 Total Sq Feet: 1000 Approved: In Review Comments: Date Approved:: In Review Date Denied: Type of Work: REMOVE EXISTING DRIVEWAY , MAKE N Bond Return : Scanning: 3 Additional Info: REMOVE EXISTING DRIVEWAY , MA Classification: Residential Fees Due Bond Type - Contractors Bond CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $500.00 $3.00 $2.00 $2.00 $1.00 $125.00 $9.00 $4.00 $646.00 Pay Date Invoice # 11/07/2017 02/02/2018 Bond #: 3631 Pay Type DS-11-17-65592 Credit Card Credit Card Amt Paid Amt Due $ 50.00 $ 596.00 $ 596.00 $ 0.00 Available Inspections: Inspection Type: Final Foundation Review Building Review Building Review Building Review Building Review Planning Review Planning Review Planning 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 amed contractor to do the work stated. Authorized Signature: Owner %Applicant / Contractor / Agent February 02, 2018 Date Building Department Copy February 02, 2018 1 U BUILDING PERMIT APPLICATION 0BUILDING ❑ ELECTRIC 0 ROOFING 0 REVISION ❑PLUMBING 0 MECHANICAL 0PUBLIC WORKS 0 CHANGE OF CONTRACTOR JOB ADDRESS: �1 ZZ /v R/ T rt City: Miami Shores Folio/Parcel#: // 3 20(e, 0.000 3 0 Occupancy Type: Load: County: Miami Dade Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 RECEIVED JAN 2 5 1018 FBC ioiu Master Permit No. Sub Permit No. Q 5 / — 2 6, 5T 0 EXTENSION 0 RENEWAL 0 CANCELLATION ❑ SHOP DRAWINGS Zip: 3 s/ aye Is the Building Historically Designated: Yes NO X Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): F 1 o [Re( h vse5twne t/N-1 pr•e- LLC•Phone#:'7SY — 2 LS — Ls-, 7-9- Address: 922 NF cti -jGtr City: ,,LL; aWti 9 n State: r+g Zip: 73 3/3if Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: A-/, aytd 6e a/ Address: f 9(0% /SW Li& lair" City: �f // / State:/rn�rct�- Qualifier Name: e,"Ct (O /t-cotlk Phone#:' 95'1 2-0392/ 1 Phone#: Zip: • 97/ Z03 9 Z-0 333/?' State Certification or Registration #: _ ( 6G ! S Z YS 9S Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: /y Value of Work for this Permit: $ ( goo Square/Linear Footage of Work: / 00 0 SA Type of Work: ❑ Addition 21 Alteration n New ❑ Repair/Replace ❑ Demolition Description of Work: 12)e+tn • . cjri oe.v..) a yuc�� u� Specify color .of rolorrthrutile: Submittal Fee $ Fee$ i` CCF $ Scanning Fee $ Radon Fee $ Technology Fee $ . Training/Education Fee $ Structural Reviews $ g' ..., •. i.. �..� 44.1,. DBPR $ CO/CC $ Notary'( Double Fee $ • Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) Boriding Company's Name (if applicable) Bonding Comp`any's Address City ' State Zip 4 � 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 reinspection fee will be charged. OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this Sday of 20 kg , by `"a`% day of ,r_AA'elai c� , 20 a , by N V 1 COO epe.,(wlo is personally known to -«'-4,4-Od74 , who is personally known to ,eer end' (6 A itare.),." • as me or who has produced -Pt • tta r; e. identification and who did take an oath. NOTARY PUBLIC: as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ********************************* ***************************** APPROVED BY Plans Examiner Structural Review gar NIXIAMOREIRA MY COMMISSION # GG 139651 EXPIRES: October 27,2021 *********** Zoning Clerk (Revised02/24/2014) Company Letter Head Date: //1 V/?p iy State of /70 4 ( ell County of ��A,o-r-d Before me this day personally appeared picaico AL-oSta- who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at 922. NE at 1-yv - j-& sI— 33/ 3�3i Sworn to or (affirmed) and subscribed before me this 2y day of -141 , 2014-by �t a.1-b /oo VY I IS MOftEIRA MY COMMISSION # GG 139651 ,z7 EXPIRES: October 27, 2021 %teggi)0 Bonded Thru Notary Public underwriters Personally known jC Or Produced Identification Type of Identification Produced 4/4//e4 / ii414 41,4e-IZA Print, Type or Stamp of Notary ‘elp 40`,„. .)-k) /BUILDING PERMIT APPLICATION NJ BUILDING ❑ ELECTRIC ❑PLUMBING ❑ MECHANICAL Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 Master Permit No. ;TVED NOV 2017 FBC20 r` fir'?-375 Sub Permit NoDS ) �% — Ztj�B ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION SHOP CONTRACTOR I DRAWINGS JOB ADDRESS: q9.09. 1 £ , C1 / 7'e r r4L e City: Miami Shores Folio/Parcel#: r/3 di. 00,oQ30 County: Miami Dade Zip: 3,1 /OS) Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): (%oew b er ..TA/ ✓ T Medi* dry Phone#: Address: �� N , (. 9 / re rr4L State: ivy d Zip: City:1'31)41h; Tenant/Lessee Name: Email: CONTRACTOppR-�: Co jii` y Na Address: )''( S,W, /j/ Terr6s- City: ,k) . 1 G ve/P'r c14.,/ e q State: /� / D T ,�c% Qualifier Name: R iCr4 r. t7 rciekliac Phone#: 6vY St( 81 2 . hone#: ��i�.235y 434/5 Phone#: Zip: 3 3, State Certification or Registration #: c GC ''I 4G 5 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address:? State: Value of Work for this Permit: $ Type of Work: ❑ Addition ❑ 'Alteratio Description of Work: Re Mot/ ew Zip: r Footage of Work: / &i'O 6./T ❑ Repair/Replace ❑ Demolition MAX& Nti.i QJve 441 Specify color of color thru tile: Submittal Fee $ 41 Permit Fee $ Scanning Fee $ ) Radon Fee $ CCF $ DBPR $ CO/CC $ s„ Notary $. - Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) } Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 0 'f Mortgage Lender's Name (if applicable) Mortgage Lender's Address City cState 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 a promise in good faith that a copy of the notice of commencement and construction lien law brochure will be deliver- f whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be po for the first inspection which occurs seven (7) days after the building permit is issued. 'In the absence, of suc/ inspection will not be approved and a reinspection fee will be charged. °' '`' ' t'' I , Y Signature OWNER or AGENT The foregoing instrument was acknowledged before me this cQ� G day of G/Y7 e.L_ , 20 / , by ‘,./OAN 52fA(M AC h , who is personally known to F. r . yi �! me or who has produced Identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ******** /Yi aC/;7 NIXIA MOREIRA -NAY COMMISSION #FF066232 (407) 398-0153 FloridallotaryServicy.com APPROVED BY Signature .licant must o the person at the job site osted notice, the / CONTRA TaR The foregoing instrument was acknowledged before me this 60 day of O(i/ he2_ , 20 / 9 , by TCG.7oL.,r1,/.}., who is personally known to pme or who has produced as identification and who did take an oath. at yw' + 1 NOTARY PUBLIC xF' Sign: Print: Seal: ******************* Plans Examiner NIXIA MOREIRA MY COMMISSION #FF066232 aFckt• EXPIRES October 27, 2017 iRP 14,9ice*****IRS444141IWr*SR **** /V/X/tl ! XID ev-7,t.� ..PY PLC•, **********it'u)(( Zoning (Revised02/24/2014) Structural Review Clerk Property Search Application - Miami -Dade County Page 1 of 1 Summary Report Property Information Folio: 11-3206-000-0030 Property Address: 922 NE 91 TER Miami Shores, FL 33138-3220 Owner POOMPAKA KOMOLVASRI Mailing Address 922 NE 91 TERR MIAMI SHORES, FL 33138-3220 PA Primary Zone 0900 SGL FAMILY - 1901-2100 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 3/2/1 Floors 1 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 2,226 Sq.Ft Lot Size 12,375 Sq.Ft Year Built 1940 Assessment Information Year 2017 2016 2015 Land Value $334,051 $271,978 $185,402 Building Value $153,749 $153,749 $153,749 XF Value $24,657 $24,835 $16,418 Market Value $512,457 $450,562 $355,569 Assessed Value $244,677 $239,645 $237,980 Benefits Information Benefit Type 2017 2016 2015 Save Our Homes Cap Assessment Reduction $267,780 $210,917 $117,589 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description 6 53 42 .284 AC E75FT OF W169FT OF S165FT OF S1/2 OF SE1/4 OF NE1/4 OF SE1/4 LOT SIZE 75.000 X 165 OR 17759-1371 0297 5 Generated On : 11/7/2017 Taxable Value Information 2017 2016 2015 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $194,677 $189,645 $187,980 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $219,677 $214,645 $212,980 City Exemption Value $50,000 $50,000 $50,000 Taxable Value $194,677 $189,645 $187,980 Regional Exemption Value I $50,000 $50,000 $50,000 Taxable Value 1 $194,677 $189,645 $187,980. Sales Information Previous Price OR Book - Qualification Description Sale Page 07/22/2016 $430,000 30183- Unable to process sale due to deed 0265 errors 02/01/1997 $0 17759- Sales which are disqualified as a result 1371 of examination of the deed 05/01/1991 $120,000 15052- Sales which are qualified 2769 05/01/1986 $95,000 12911 Sales which are qualified 4034 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 and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp Version: http://www.miamidade.gov/propertysearch/ 11/7/2017 4 CFN: 20170583286 BOOK 30720 PAGE 3381 DATE:10/17/2017 01:56:00 PM HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY This Instrument Prepared By: J. Beauregard Parker, Esq. Record and Return to: J. BEAUREGARD PARKER, PA 1900 NW CORPORATE BLVD. SUITE 301-W BOCA RATON, FL 33431 Parcel Id No.: 11-3206-000-0030 CORRECTIVE WARRANTY DEED This corrective deed is given to correct an error in the legal description of that certain deed dated September 22, 2016 and recorded December 14, 2016 in Official Records Book 30345, Page 4522, Public Records of Miami -Dade County, Florida. 4 THIS INDENTURE, made this 2 > day of September 2017, between GMNCB "LLC", a Florida limited liability company and BBPJJB, LLC, a Florida limited liability company, GRANTOR* whose address is 2871 Somerset Dr., Apt #200, Lauderdale Lakes, FL 33311, andsFLOCABER, INVEST ONE'LLC, a-Florida:limited liability company, GRANTEE(s)* whose address is 2871 Somerset Dr., Apt #200, Lauderdale Lakes, FL 33311; (*Wherever used herein the terms "Grantor" and "Grantee" shall include all the parties to this instrument and heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations.) WITNESSETH, That said Grantor, for and' in consideration of the sum of TEN AND 00/100 ($10.00) DOLLARS and other good and valuable consideration, to said Grantor in hand paid by said Grantee, the receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, releases, conveys and confirms unto the Grantee and Grantee's heirs, successors and assigns forever the following described land located in the County of MIAMI-DADE, State of Florida, to -wit: The East 75 Ft of the West 169 Feet of the South 165 Feet of the South'/Z of the SE'/a of the NE % of the SE 1/4, of Section 6, Township 53 South Range 42, East Lying, Being and Situate in Miami -Dade County, Florida SUBJECT TO all restrictions, reservations and easements of record, if any; zoning restrictions and prohibitions imposed by governmental authority, and taxes for the year 2016 not yet due and payable. 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 SAID GRANTOR does hereby covenant with the said Grantee that the Grantor is lawfully seized of said land in fee simple; that the Grantor has good right and lawful authority to sell and convey said land, and hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever. CFN: 20170583286 BOOK 30720 PAGE 3382 Corrective Warranty Deed (cont. page 2) IN WJTNESS WHEREOF, Grantor has hereunto set Grantor's hand and seal this day and year first above written. Signed, sealed and delivered in the presence of: Witnesses as to both: Hess Signature Printed Name: Witness Sign Printed Name: 1 STATE OF FLORIDA . ) COUNTY OF PALM BEACH ) GMNCB "LLC", a Florida limited liability company a,T�HN STALIVIACH, Authorized Representative BBPJJB, LLC, a Florida limited liability company N STALMACH, Authorized Representative The foregoing instrument was sworn to, subscribed and acknowledged before me this 2y day of r ! , 2017, by JOHN STALMACH, as Authorized Representative of GMNCB "LLC" and Authorized Representative of BBPJJB, LLC who [ ] is personally known to me or who has [ ] produced as identificatio "'1;'P''''JAMES BEAUREGARo PARKER ': Public - State of Florida Noty Expires Jan 16, 2016 My Comm.0 Commission t# FF 063996 gnature CFN: 20170583285 BOOK 30720 PAGE 3379 DATE:10/17/2017 01:56:00 PM HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY This Instrument Prepared By: J. Beauregard Parker, Esq. Record and Return to: J. BEAUREGARD PARKER, PA 1900 NW CORPORATE BLVD. SUITE 301-W BOCA RATON, FL 33431 Agent File No.: 16-1212 Parcel Id No.: 11-3206-000-0030 CORRECTIVE WARRANTY DEED This corrective deed is given to correct an error in the legal description of that certain deed dated July 22, 2016 and recorded August 8, 2016 in Official Records Book 30183, Page 0265, Public Records of Miami -Dade County, Florida. THIS INDENTURE, made this / day of September 2017, between iPOO11PAKA� IKOMOLVASRI,t a single woman, GRANTOR* whose address is 4973--.LEEWARD LANE, FT tLAUDERDALE; FL 33312, and GMNCB "LLC", a Florida limited liability company and BBPJJB; LLC, a Florida limited liability company, GRANTEE(s)* whose address is 2871 Somerset Dr., Apt #200, Lauderdale Lakes, FL 33311; (*Wherever used herein the terms "Grantor" and "Grantee" shall include all the parties to this instrument and heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations.) WITNESSETH, That said Grantor, for and in consideration of the sum of TEN AND 00/100 ($10.00) DOLLARS and other good and valuable consideration, to said Grantor in hand paid by said Grantee, the receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, releases, conveys and confirms unto the Grantee and Grantee's heirs, successors and assigns forever the following described land located in the County of MIAMI-DADE, State of Florida, to -wit: The East 75 Ft of the West 169 Feet of the South 165 Feet of the South'/2 of the SE '/ of the NE '/ of the SE 1/4, of .Section 6, Township 53 South Range 42, East Lying, Being and Situate in Miami -Dade County, Florida SUBJECT TO all restrictions, reservations and easements of record, if any; zoning restrictions and prohibitions imposed by governmental authority, and taxes for the year 2016 not yet due and payable. 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 SAID GRANTOR does hereby covenant with the said Grantee that the Grantor is lawfully seized of said land in fee simple; that the Grantor has good right and lawful authority to sell and convey said land, and hereby fully warrants the title to said land and will defend the same against the lawful claims of all persons whomsoever. CFN: 20170583285 BOOK 30720 PAGE 3380 Corrective Warranty Deed (cont. page 2) IN WITNESS WHEREOF, Grantor has hereunto set Grantor's hand and seal this day and year first above written. Signed, sealed and deliver:. • in the presence of: itne s Signature Printed Name: kii Witness .Signal Printed Name:, STATE OF FLORIDA ) COUNTY OF MIAMI-DADE•) The foregoing/instrument day of �,�•�. known to me or produced -POOMPAKA KOMOLVASR y was sworn to, subscribed and acknowledged before me , 2017, by POOMPAKA KOMOLVASRI who [ ] ;1- • ; /.- c r. (y as _i fje lion. 1 Pu JAMES BEAUREGARG PARKER d•'" ",,,` tart' Public - Stale of Florida No Jan 16,2019 My Comm. Expires FF 16,'20 N•. � si Commission 0 083996 otary Signature this .2ei is personally 2017 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT 190CUMENT# L15000139170 Entity Name! FLOCABER INVEST ONE C �---- may-- - Current Principal Place of Business: 2871 SOMERSET DRIVE APT 200 LAUDERDALE LAKES, FL 33311 Current Mailing Address: 2871 SOMERSET DRIVE APT 200 LAUDERDALE LAKES, FL. 33311 US FEI Number: 35-2540616 Name and Address of Current Registered Agent: BREIT, RICHARD H 8551 WEST SUNRISE BLVD. STE. 300 PLANTATION, FL 33322 US FILED Mar 07, 2017 Secretary of State CC3655896494 Certificate of Status Desired: No 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: RICHARD H. BREIT 03/07/2017 Electronic Signature of Registered Agent Authorized Person(s) Detail : Title Name Address City -State -Zip: MANAGER BERLIOZ, JEAN-JACQUES 23 ROUTE DE FOUR VAULX-MILIEU 38090 Title AUTHORIZED REPRESENTATIVE Name CTACMACH,JOHN Address 2871 SOMERSET DRIVE APT 200 City -State -Zip: LAUDERDALE LAKES FL 33311 Title MANAGER Name BERLIOZ, NICOLAS Address 2871 SOMERSET DRIVE APT 200 City -State -Zip: LAUDERDALE LAKES FL 33311 Date 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: JEAN-JACQUES BERLIOZ MANAGER 03/07/20.17 Electronic Signature of Signing Authorized Person(s) Detail Date Florida Department of State DIVISION OF CORPORATIONS DPIMOPI of Sorg ok a� \r f� �J 00000002300.0.......w► of ritti Slum of Florida writsite Department of State / Division of Corporations / Search Records / Detail By Document Number / Detail by Entity Name Florida Limited Liability Company GMNCB "LLC" Filing Information Document Number L12000068085 FEI/EIN Number 36-4733654 Date Filed 05/21/2012 Effective Date 05/21/2012 State FL Status ACTIVE Principal Address 10552 S FEDERAL HWY. PORT ST. LUCIE, FL 34952 Changed: 11/13/2015 Mailing Address 10552 S FEDERAL HWY. PORT ST. LUCIE, FL 34952 Changed: 11/13/2015 SRegiste l Agent Name &Address, BERLIOZ, JEAN-JACQUES 10552 S FEDERAL HWY. PORT ST. LUCIE, FL 34952 Address Changed: 11/13/2015 Authorized Person(s) Detail Name & Address Title MGRM BERLIOZ, JEAN-JACQUES 10552 S FEDERAL HWY. PORT ST. LUCIE, FL 34952 Title Authorized Member CSTALMACH,;JOHN , 10552 S FEDERAL HWY. PORT ST. LUCIE, FL 34952 Annual Reports Report Year Filed Date 2015 01/21/2015 2016 01/12/2016 2016 10/21/2016 Document Images 10/21/2016 -- AMENDED ANNUAL REPORT 01/12/2016 -- ANNUAL REPORT 11/13/2015 -- AMENDED ANNUAL REPORT 01/21/2015 — ANNUAL REPORT 02/05/2014 -- ANNUAL REPORT 02/16/2013 -- ANNUAL REPORT 05/21/2012 -- Florida Limited Liability View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format Florida Department of State, Division of Corporations Miami Shores Village Building Department 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 The foregoing was acknowledgeQ�before me this By Hi e010i C VLI( 62. Dam Notary: SEAL: Leah Rene Notary Public State of Florida I `f day of 14t V i b , 2011 who is personally known to me or has produced as identification. 40, „oo My Commission Expires 5/25119 Commission No. FF 234172