EL-16-3225pertaining thereto an
accepting this permi
required for ELECTR
OWNERS AFFIDA
construction an
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Parcel Number
Issue €Date: 3/2;
Permit NO. EL-1`1-16-3225
Permit Type: Electrical - Residential
Work Classification: Addition!Alteration
Permit Stat s APPROVED
2017
Expiration: 09/19/2017
Applicant
135 NE 98 Street
Miami Shores, FL 33138-
1132060132310
Block: Lot:
FLORIDA MINORITY COMMUNIT
Owner Information
Address
Phone
Cell
FLORIDA MINORITY COMMUNITY
7210 N MANHATTAN Avenue
TAMPA FL 33614-
(813)598-6361
7210 N MANHATTAN Avenue
TAMPA FL 33614-
Contractor(s)
PULSAR ELECTRIC INC
Phone
(954)394-5827
Cell Phone
Valuation:
Total Sq Feet:
$ 3,000.00
1200
Type of Work: RENOVATION ELECTRICAL REPAIR
Additional Info: RENOVATION ELECTRICAL REPAIR
Classification: Residential
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee - Additions/Alterations
Scanning Fee
Technology Fee
Total:
Amount
$1.80
$3.38
$3.38
$0.60
$225.00
$3.00
$2.40
$239.56
Pay Date Pay Type
Invoice # EL-11-16-62186
11/28/2016 Credit Card
03/23/2017 Credit Card
Amt Paid Amt Due
$ 50.00 $ 189.56
$ 189.56 $ 0.00
Available Inspections:
Inspection Type:
Final
Meter Box
Alteration
Relocation
Fire Alarm
Service Change
Review Electrical
W. W.
Underground
In consideration of the issuanoe to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
�nformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
IlBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
in strict
assum
AL, PLI
Building l► epa
ing information is accurate and that all work will be done in compliance with all applicable laws regulating
above -named contractor to do the work stated.
March 23, 2017
Applicant / Con ractor__ — girn
ment Copy
Date
March 23, 2017
1
r
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
BUILDING
PERMIT APPLICATION
BUILDING ELECTRIC ❑ ROOFING
❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS
JOBADDRESS: ) 3S V . 91(14
City: Miami Shores
County:
Master Permit No.
FBC 20
Rc U - as
Sub Permit No. ft_ 1 6327S
❑ REVISION ❑ EXTENSION ❑RENEWAL
'RiAf- �
❑ CHANGE OF4,,s„ ❑ CANCELLATION ❑ SHOP
CONTRACTOR ° DRAWINGS
Miami Dade
Zip:
Folio/Parcel#: Is the Building Historically Designated: Yes
Occupancy Type: Load:
OWNER: Name (Fee Simple Titleholder):
Address: 7 /O
City: kt.4,4
Construction Type:
State: T/U// h Zip:
Flood Zone: BFE:
Phone#:
N0
FFE:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: PULSAR ELECTRIC �.1 C/
Address:
- 1591 Si 1\i`r Y)
City: F�DR I t State: FL
Qualifies Name: JA 1,9 IX04
State Certification or Registration #: EC V3o� 13�
DESIGNER: Architect/Engineer:
Address:
Value of W_orKfo�}tfiis'Permit: $ '9p O ,Square/Linear Footage of WorkT 0-0(
Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Replace
Description of Work i K- ,fry dt2i
v4, (�,:,► Le a- h�-�--�
Phone#: Q►j r3I4-- °j $21
Zip: .3.596,3
Phone#:
Certificate of Competency #:
Phone#:
City: State: Zip:
emolition
Specify color of color thru tile:
Submittal Fee $ Permit Fee $ 2 ieseo CCF $ , l • 3 ° CO/CC $
22
Scanning Fee $ Radon Fee $ c7 . S8 DBPR $ 't; 1 • +Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $ [ 'S" q . 'sCe
(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 applo ei and a reinspection fee will be charged.
rA /;
Signature
C / OWNER or AGENT
The foregoing instrument was •acknowledged before me this
dray of NOWvV 10(J1/ , 20 I (.p , by
�1000/± Y\V'.QOl , who is personally known to
me or who has produced 1 A/c,6\Aa`) Ck/10k-Z as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: V,Vl.S1/1ii
Seal:
*******************
APPROVED BY
ss.0 ,,,,,,,, VERUS
-?°�t's1 Notary Public -State of Florida
• - ., Commission • FF 197696
.- °'c' My Comm. Expires Feb 9,,2019
•E q :�`s. Bonded through Nato* filmy
imyyAssn.
Sign:
Print:
Seal:
Signature
CONTRACTOR
The foregoing instrument was acknowledged before me this
l3� day of p1.4�r1,(y� ?.20—/� .- , by
m � (>/— /�Qh1^who is personally known to
me or who has produced—f d t"7v141,k 14Art.rv;n—as
identification and who did take an oath.
NOTARY PUBLIC:
. - -—
• PP,; VERUSHKA ORTEGA
+° '` , Notary Public - State of Florida
Commission FF 197898
1 ire � My Comm. Expires Feb 9, 2019
OF F� ,, .N..
************** **0414**Seeded throughtiationakNotariy�grlx
Plans Examiner Zoning
Structural Review
Clerk
(Revised02/24/2014)
ti }s
NLami Shores iilage
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 requestizxg 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 a9i nowiedge before me this �- day of
By Ai Raft
SEAL:
20 17 .
who is personally known to me or has produced
dentification.
,, e�!l:�!/, ,; John Joseph
��� A. Commission # GG023014
4 4.�� Expires: August 21, 202
,,,,a ;;,,,,, Bonded thru Aaron Notary
Pulsar Electric
Pulsar Electric, Inc
1352 Silverado
North Lauderdale, FL 33068
March 22, 2017
Donald Dixon
Pulsar Electric Inc
To: Miami Shores Village building Department
Before me this day personally appeared Donald Dixon who being duly sworn,
deposes and says that he will be the only person working o the projec
located at 135 NE 98th st Miami shores. f wi 1 t I X DVEC / 300 6/3
,4
Sworn to (or affirmed) and subscribed before me this March 22, 2017.
Smcer- d 1
f��,,,
John J • eph! otary
Personally Known to me
Driver license Produced to verify
John ,Joseph
Commission # GGu23O14
5�c ?►_ Expires: August 21, 2041
Bonded thru Aaron Notary
ee.Itvereellepi ezfem� TrE ape.
aa,,,�,,;,,.,. P:, �r,l; l;!lY, �,.; ,::.,,'.., ., ,.:..�d+,i,.,r.r., .r'•v. .. •..I. 7?t9r!.W,''.flti. i1 n?ilf!,SP!Tfl.i 1
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1396
2601 BIAIR STONE ROAD
TALLAHASSEE FL 32399-0783
DIXON, DONALD
PULSAR ELECTRIC, INC.
1352 SILVERADQ
NORTH LAUDERDALE FL 33068
Congratulations? With this license you become one of the nearly
one million Floridians licensed by the Department of Business and
Professional Regulation, Our professionals and businesses range
from architects to yacht brokers, from boxers to barbeque
restaurants, and they keep Florida's economy strong,
Every day we work to improve theway we do business in order
to serve you better. For information about our services, please
tog onto www myfioridalicense.corri. 'There you can.flnd more
inormation about our divisions and the regulations that impact
you, subscribe to department newsletters and learn more about
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,
and congratulations on your new license)
SLICK SCOTT, GOVERNOR
EC'13006136'
n
STATE OF FLORIDA
DEPARTNIENT7OF,J3USINESS'AND
PROFESI_ t° fxG:ULATION
EC.13006136 ;;, V, ''='T9104/2016
CERTIFIED EL1 cO,N > OR
,.P LSAR ELEO u
• ES' CER?IFIU'urider tnc prom131ion9 pf Ch..489 FS.
Exairdtion.dara.". .' LiModo0oaMe
DETACH HERE
KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION -
ELECTRICAL CONTRACTORS LICENSING. BOARD
The ELECTRICALCONTRACTOR •
Named beiaw.ISCCERTIFIED
Uhler the provisions-df Chapter 489 FS.
Expiration date: AUG 31, 7.018.
•
DL3(ON;1DONALD
PULSAR ELECTRIC: I1\t : :
.1711,COSTAL ! 1
ISSUED: 09/0 2016
DISPLAY AS REQUIRED BY LAW
5F4 # L 1609040o03038
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
s Andrew-5 Ave . Rat A-100. Ft Lauderdale. FL 33301-160 - 954-831-400
VALID OCTOBER 1, 2016 THROUGH SEPTEMBER 30,2017
.2 DBA: Receipt ic gittzigitelidonAnis
Bte usiness ems: • 7
8111416114 typ ! ctitT ELECTS1 CAL
Business Opened:1% /13/1989
StatemountyiCeitiRelpetn 10051t6
Exemption Codir
OWIler NEMO: ,
Business Location: •.*-o-11..;_‘
Business Phone: -
Roams Siam E:roayses
Fur VerrOire Bustrieus Or*/
Runithee CO" Missitinns.
Tar AortsArg
Trans* igas -#43s- [
e
Vorethtp Ty's=
Penalty Ptlor nen Car Gott Ural Pad
? 7-;! D . JJO 21,79
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY [NYDER PLACE OF ERISINESS
THISEEMIlilES A TAX ftECSFT
WHEW VALIDATED
ilimatag Aaldanis:
.7y72.-;
1
Thiete7_161oviffil f tiseprWeegeintsioing-beetness mkt*BiConlyand,
nee-reguiatery it -news Yee. nustrnsetell Ceureyand(orVisielsoiestoiessiv-
arro =ging ARPtitorrtaalts. Thla anitiessTas iiscalrilmust isaneitgens, SW
the bananas is -. -baseless ii pas tranipal aryieu l'avgi moms* ills
business lopetion. Mee niesipt eteesleittelissisitisillsitsliteessim limikwittn
it* airaratiliariso ,athStabraelacarlavastatrogikinni;
intsegrt teas-16-03.0a22811
Vaittalf/UMME 2";71i
PO •..4. t-It1144r44,100 Y{wa.l"!{f;Fi Pr-RM. rt." L.42 ',at: W-K.4QV
VALID OCTOBER 1,10t6
Su ; insee N Put.SAR RLE RTC INC
Owner Namet isxxos
I4uslnees Cocatker 1.352 5TT,V
UDIA
Business/a Phone: "7a3,-ee84
Mechem •
ALARMs
(CSRT
89.'
6E36.
oidaaalarnt%
ii#wrtib r .stactdrws
Per Yandfrg eu a Ord'
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ilia e'.
"
roillPtud
9:00
0; 00
0.00
w9ir
2.
' 0.00
t0.00_ ! 0
OAS RE IPT MUST BE POSTED CONSP1 UOLUSLY Pi YOUR PLACE OP afieptiesS
THAVBECOMEREei TAX IRMEW" Thls tsoc fs levied for WMear of doing business N�dtin 9Fntwr tDoUoty tux! le
rron. e9i �suily lh nadtcl.xYou must meet M LoucRy Midbi MtnY ty {fiwnN
KVALIDATED errd=art"regt t0.,1111$ °Oen*** Toot Recifot nutbe
tie buainae is Sold, bus%int *nee has EIOVed-or you lta
busGaeas location. This reelpt does'notk4tatikliwtthe b010000'
kis In complIefice vim Stetetr looellsweene u40111tweL
DIXON
ST
333t3
It140114't #042.26:06e0024!
n ate,3.0Istt:0a6. %2e.70
A� D CERTIFICATE OF LIABILITY INSURANCE
DATE lo/zo s
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(ies) must be endorsed. If SUBROGATION IS WAIVED, Subject to
the terms and conditions of thepolicy, 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
Stirling Insurance Services, Inc.
1700 North Dixie Highway
Suite 109
Boca Raton FL 33432
CONTACT Adele snadiker
PHONS Ext}, (561) 338-3030 Fi3c
(361) 338-3Ob5
,pvc,_No):
ADDREsi;del@ stirlingfinancial.cola
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA:Capitol Specialty Insurance .
10328
INSURED
Pulsar Electric, Inc
1352 Silverado
North Lauderdale FL 33068 �INSURER_F:
INSURER B
IP4 UREIC:
INSURER D :
INSURER E: _
IFICATE NUMBER:CL16111016
•
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
N R
TYPE OF INSURANCE
ADDL
IN:ir)
SOSII
WW
POLICY NUMBER
POLICY EFF
ikiwor YYY)
POLICY EXP
(MMJPPIYYYY)
UNITS
A
X
COMMERCWL GENERAL UABIUTY
_
C302624042-01
2/17/2016
2/17/2017
EACH OCCURRENCE
$ 1,000,000
CLAIMS MADE X OCCUR
DAMAGE TO aENT1=D
Peami5Es ma occurrence)
9 100, ODO
MED EXP (Any one person)
$ 5,000
PERSONAL &ADVINJURY
$ 1,000,000
GEN'L
X
AGGREGATE
POLICY
OTHFR;_
�•
LIMIT APPLIES
PRO-
JECT
PER;
LOC
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OP ACC
i 2,000,000
S
AUTOMOBILE
---
_
UABIUTY
AUTOS
NON -OWNED
AUTOS
COMBIN6LSS7N(,LE-LAW
(Ea acciderj
$
BODILY INJURY (Per person)
S
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accltlentj,
$
$
UMBRELLALIAe.
EXCESSIJAa
—
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DED
RETENT ON $
$
WORKERS COMPENSATION
AND EMPLOYERS' UABIUTY
ANY PROPRIETOR/PARTNER/EXEG(1nvE
OFFICER/arEMBER EXCLUDED?
(Mandatory In NH)
11 yyees, describe under
DESCRIPTION OF OPERATIONS below
Y! N
N!A
_
PGA
ER"
E.L EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE • POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (ACORD 101. Additional Remarks Schedule. may be attached It mare apace la required)
Electra.ciaa
(305)756-8972
Miami Shores Village
9ui1ding Department
10050 NE 2nd Avenue
Miami Shores, FL 33138
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Nicole Rarttdeeri/
ACORD 26 (2014/01)
INCA7R,1n,Am
Igo 1988-2014 ACORD CORPORATION. Alt rights reserved.
The ACORD name and Togo are registered marks of ACORD
JEFF ATWA'T
CHIEF FINANCIAL OFFICER
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVIceeS
DIVISION OF WORKERS' COMPENSATION
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORTDA WOR1(!i � COMP
CONSTRUCTION INDUSTRY EXE M ENSATI4N LAW • •
This certifies that the Indfuldual listed below oas elected to be exe N
EFFECTIVE DATE; 41181ZO1g rapt from Florida Workers' Compensation taw,
PERSON: DIXQN EXPIRATION DATE: 41171244E
FEIN; 650707353 aONALD
BUSINESS NAME AND AADRESS:
PULSAR ELECTRIC INC
13E2 SILV,ERADO
NORTH L AUDERDALE FL. moos
SCOPES OF BUSINESS OR TRADE:
UcENSED ELECTRICAL
cONT RACTOR
Pursuant to Chapter .+4.as f14), F S., on WOW of a
not n' ¢r p or cnm enaAt' COrPeration who 001e a>�
ettr eeeraaa er!rase! brog +on UPder onager. 1'ursilant tG 0_06 frort, t11a erti ca by flier a t oreMcflanf under lY 7te�lele
0 n to be s Dt avtaA !M nretlo, pf olseHan M be Per �4Q_4d j1sl, F,9. Certificate* of erection
ssreRcate no 1 ilea to wnaeaeeb fi ao a Imlnat Puteuant to Cl a * 440.12503). F.O. Notice a scion bo w e Y and artirl y1e y
p �0� meets then reQ l ' ny Om* altar MI *Ma of !ranee Or lrat Issuance of the aert
rarned ran the n to meet 111s aer Ofatf
kimono) ofa a errft Pt and rxdifi�`ati! of
CFI Ants of IRS atg�fey, dope/torrid 4t1a1l rooks a r�tMcata at person named a n the rroRks Or
-OWG23Z CI TIF:C4kTE O� gLECilrN TO aC PxEMP7' 1� l:1/tSED 07-12 ^Y thee for haute of or e
QUESTIONS? oii.1sla.1f309
si
BROVVARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 -- 954-831-4000
VALID OCTOBER 1,2016 THROUGH SEPTEMBER 30, 2017
DBA:
Name: PT LSAR ELF:CTR; C
Owner Name: DONT LD DIXON
BusinessLocation: 1.352 SILVERADO
NORTH LAU RDALE
Business Phone: 7 3 3 - s r 84
Rooms
tt Transfer Fee
THIS BECOMES A TAX
WHEN VALIDATED
Address:
ITN
Receipt #:i
Business Type: (CRT
Business Opened:11 / 13 / 198 9
State/Coumy/CertfReg: FC13 0 0613 6
Exemption Code:
Employees
3
For Vending g 8u i ies� Oi
NSF Fee Pewit),..s f a
TBEPOSTED C
YOUR PLACE OF B
This tax
r10n-rat) a
and
Office Depot 11/28/2016 12:53:40 PM PAGE 1/001 Fax Server
JEFF ATWATEER
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: 4/22/2016 EXPIRATION DATE: 4/22/2018
PERSON: DIXON DONALD
FEIN: 650709353
BUSINESS NAME AND ADDRESS:
PULSAR ELECTRIC INC
1352 SILVERADO
NORTH LAUDERDALE FL 33068
SCOPES OF BUSINESS OR TRADE:
LICENSED ELECTRICAL
CONTRACTOR
Pursuant to Chapter 440.05(14), F.S., an offloor of u corporation who elects exemption from this, chapter by filing a certificate of election under thin section
may not recover benefits or compensation under this chapter. Pursuant to Chapter 440,05(12), F.S„ Certificates of election 10 bo bxompt,,. apply only
within the scopo of the business or trade listed on the notice or election to bo exempt. Pursuant to Chapter 440,0S(13), F,S., Noticee of election to bo
exempt and certificates of election to be exempt shall be subject to revocation if, at any time atter the filing of the notice or the icsuanco of the cortificato,
the person named on the notice or certificate no longer moots tha roquiromonts of this aoction 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