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PL-16-121 (2)
Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Issue Permit NO. P"L-1-16-121 Permit Type: Plumbing - Residential Work Classification: Addition/Alteration Permit Status APPROVED te:1/1512016 Expiration: 07/13/2016 Parcel Number Applicant 1201 NE 94 Street Miami Shores, FL 33138- 1132050100010 Block: Lot: BERNARD LEE Owner Information Address Phone Cell BERNARDLEE L 1201 NE 94 Street MIAMI SHORES FL 33138- (954)673-6513 1201 NE 94 Street MIAMI SHORES FL 33138- Contractor(s) Phone PAU PLUMBING CONTRACTOR INC (305)934-2894 Cell Phone Valuation: Total Sq Feet: $ 29,160.00 0 Type of Work: NEW BATHROOM AND KITCHEN FIXTURES A Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $18.00 $15.31 $15.31 $6.00 $1,020.60 $9.00 $24.00 $1,108.22 Pay Date Pay Type Invoice # PL-1-16-58351 01/15/2016 Check #: 202 Amt Paid Amt Due $ 1,108.22 $ 0.00 Available Inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 certi • =t all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction an. • .p.=rmore, I authorize the above -named contractor to do the work stated. January 15, 2016 Authorizener / Applicant / Contractor / Agent Date Building Department Copy January 15, 2016 1 i ' ti ti ctIlift* BUILDING PE MIT APPLICATION BUILDING ❑ ELECTRIC PLUMBING ❑ MECHANICAL JOB ADDRESS: City: Folio/Parcel#: 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 ❑ ROOFING ❑PUBLIC WORKS REC r TN/Tr. DEC 3 0 2015 FBC 2010 Master Permit No. 12-G 5 l 2-9 Sub Permit No. ❑ REVISION ❑ CHANGE OF CONTRACTOR / Of NE 4?liT",5Eer- ❑ EXTENSION ❑ CANCELLATION ❑ RENEWAL ❑ SHOP DRAWINGS Miami Shores County: Miami Dade Zip: 33 /35 1 1 - 3.2 05 - 010 - 00 i 0 Is the Building Historically Designated: Yes NO I" Occupancy Type: JSlad: Construction Type: L 1n 1 Flood Zone: 41D;OWNER: Name (Fee Simple Titleholder): V*T�{.S1�lr I�l�INO Lb��hone#: �7 v v 7 1 Address: l02 0 / A) & ?v sTFe61 City: Nt i A-µ ( 540 it s State: Ft- Zip: ,3 3 r 35 Tenant/Lessee Name: Phone#: Email: BFE: FFE: CONTRACTOR: Company Name: Address: 0/At C©ti.y712oC-7-10 367Ac / .28 0 W(5-47- •5 p tc ToA) g'� 3 -'2 0 City: L 4U /6 Phone#: (8�) el a,3.5a State: FFLIDIZCc)/ Zip: 333-2 C Qualifier Name: OQ46 GPhone#: (96) [.6ii3. State Certification or Registration #: C $ G /5 /$ -7S5 Certificate of Competency #: • DESIGNER: Architect/Engineer: • Phone#: Address: / // City: C7 Value of Work for this Permit: $ 2 1 ?BSquare/linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration State: Zip: I IS 00 5q/FT ❑ New ❑ Repair/Replace Description of Work: (5./4ODEa1/4 ?)A7N qD/l ,3 6pfo00,5 4 /0,9 3/ 05 P P.4i,�Jt_ ❑ Demolition .NE,ui Flea Specify color of color thru tile: Submittal Fee $ -CO Permit Fee $ t i 1 50 CCF $ . '� CO Scanning Fee $ L4 2 Radon Fee $ DBPR $ acl • Technology Fee $ 'a) Training/Education Fee $ \ 3 . CAD Co/CC $ Sp' CO Notary $ ' Q Double Fee $ Structural Reviews $ tab• (od • W Casz.- y • Bond $ ECO. CrO �-D -�-� TOTAL FEE NOW DUE $ a/{-3369 • C 9. 0 (Revised02/24/2014) , Y . 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 • yf 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. inspection will notbe approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this 3 3 day of 5-4— , 20 l S , by Vft-PNA2i L.La'L , who is personally known to me or who has produced �-ar2t' r:"11-- as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: %,/ 94(IS g\ ***************.*******************1i‘1*\***************************************************************** Signature In,the absence of such posted notice, the OR The foregoing instrument wa rcknowledged before me this 34::' day of 17- L ,20 tS ,by (44.5TI'r..�--?who is personally known to me or who has produced �L-' c)24va 2 as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: ' Seal:• APPROVED BY (Revised02/24/2014) Plans Examiner Structural Review Zoning Clerk r r"` \T1 T 1 DEC 3 0 2015 CQnstructic)n Services l_Lc Date:12-28-15 PROPOSAL # 0M15-800031 Proposal for: General Contractor /Remodeling Services at Master bathroom. 1201.NE 94th Street, Miami Shores Florida ATTENTION: Bernard Lee . . . . .. . .. . .. . . •. • .. • •••• • • •• • •••• .... • • • • •• •• •••• • • • • • • • • • • • • • • • • • .. . • ••• .. • Thank You for this Bid Consideration. I look forward to any questions or comments you may have. If I may be of any other help or may be able to make any changes in order to secure this project please contact me at your earliest convenience 1 CQr str+uctic)rt S rvic s LLC WORKMANSHIP We will be responsible for the rectification of such damage, the clean-up involved in the work outlined in this specification, and our employees during the performance of their labor. All work will be done in workmanlike manner by skilled laborers. We will maintain trade workers and direct personnel on site as needed to complete job in a timely manner. on the job at all time to lead all work in progress and be the liaison between sub -contractors and main office. ACCESS The Owner agrees to and will be responsible for access to the jobsite so that we may proceed without delays. LICENSE Om Construction Services LLC license as a General Contractor is CGC#1518755. Subcontractors will produce the licenses necessary to operate. INSURANCE Om Construction Services LLC and/or its subcontractors will furnish suitable insurance certificates covering liability and property damage, workman's compensation coverage and they shall be kept in force during the course of the work. RELEASE OF LIENS Om Construction Services LLC will furnish a release of lien for all materials and labor supplied. • • • • • . • •• • •• . • • • • • • •• •••• • • • • • • • •••• •• •• •••• • • • • PREPARATION OF THE.SURFACES • • • • •••• If surfaces cannot be put into proper condition for finishing by specified methods, Om Construction • • • • • • • • • • • • • • Services LLC will notify owners in writing of any changes or additions that are necessary due to unfores: en . • • conditions or conditions not included. • • • • ••• • • • • 2 C Onsti-uctiort rviccs LLC NOTE CONCEALED CONDITIONS Occasionally, the contractor's construction technique develops an unforeseen condition necessitating additional labor and/or materials. Om Construction Services LLC must either re -negotiate our contract or offer a change order if necessary to cover additional costs to properly correct the condition. PERMIT AND GOVERNMENT FEES The fees are going to be reimbursed to OM Construction Services and its subcontractors after tramitting every related work master and sub permit. EXTRAS AND CHANGES • The need for extra work or changes in the specifications will be the sole responsibility and determination of the owner and will be submitted as a written work order to Om Construction Services. LLC. No extra work will be done or changes made in the work as specified without a written change order from the Owner. • All changes orders will be submitted to the owner and must be approved by the owner, before proceeding. • • • • • • • •• • •• • • • • • • • •• • • • • •••• • • • • • • • • • •••• •• •• • • •••• • • • • •• •• •••• • • • • • • • • • • • • • • • • • • • •• • • • • • • • • • • 3 )I, Cr•nst-ructic n S rvicses LLC Scope of Work Description Totals 1.00 General Requirements: Disposal of the construction debris. $4,400.00 2.00 Demolition: Demolition of existing floor, interior partition walls ,shower enclosures, water fixtures, and light fixtures. Remove glass block walls facing the outside In the Master Bathroom Make opening in external wall to install new fixed 5 ft window with 2 opening top lights as per drawing. Total demolition: $7,500.00 3.00 Build out: Build partition walls an soffit as per design plans. Close glass opening walls with CMU blocks, stucco finish on the outside and drywall on the inside. Finish drywall ready for paint. $19,700.00 4.00 Tile: Installation of 24"x 48" tiles on walls . (inside the shower, water closet and bidet area.) $14,500.00 I Installation of 24"x 48" tiles on floors. $14,078.00 5.00 Plumbing: • •Install new water closet (3) ' • • • • . • Install new shower pan with new faucet system, (3). • • • • • • • •' • Install new lavatory with faucet, (4). """ ' Install new Bathtub, floor mounted (1). • ' • ' • • Install new Bidet, floor mounted(1). ••i••: �•••41 Of "" • • • • 4 Install washing machine temporary, (1). " ..•... Install electrical tank water heater temporary, (1) • • Installation with new sanitary and water pipe. • • • Demolition and capping pipes. •• • •• O• Replacing old cast iron pipes with new pvc in the whole house. • Installation of gas line to the stove from the gas meter. Total Plumbing: $24,160.00 6.00 Electrical: Remove and relocate outlets, lights and switches as per design plans provided by owner. Relocate electrical exterior connection for A/C compressor. Remove and replace electrical panel next to the bathroom up to code. Total Electrical: $14,000.00 • •• • • • • • • • • • • •• • • • • • Ccanstructic>n S rvicAs LLC ITEM DESCRIPTION TOTALS, 7.00 Mechanical: Relocation of A/C units outside and the re-routing of all services currently on exterior wall. Re-routing new A/C ducts in central dropped ceiling with new diffusers as per drawing and exhaust fan. $3,500.00 8.00 Window: As per design provided by customer and attached specs. . Installation Total Window: $3,300.00 • • • • • • •• • • • •• • • • • •. • • • •&•••• •••••• All labor and rough materials are included. Otherwise expressed. •••• • •••• • • • •• • •••••• •••4 • • • •• •M••• •• •••d • • • • • 4 • • • • • a • a •• • • •4 • • Total: $'105,138.00 • • • • • • • • • • • • • • • • • • • • • • • • • Miami Shores Viiiage Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. '� COPY OF QUALIFIER'S STATE LICENCES B. / COPY OF LOCAL BUSINESS TAX RECEIPT C. , COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUSINESS NAME: art 6,0s-teacTiod LLc_ BUSINESS ADDRESS: l a28 50 W T SZ9e # 3 :2 )CITY 1'4uGs STATE ' L ZIP 33 ,9.2S BUSINESS PHONE: ( ) L/02.44ti 3si FAX NUMBER ( ) CELL PHONE ( ) .350 QUALIFIER'S NAME: 6,77E�E� QUALIFIER'S LIC NUMBER: C4-CG L' (g45.5 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 GUTIERREZ, JORGE L OM CONSTRUCTION SERVICES LLC 12850 W STATE ROAD 84 SUITE 3-20 DAVIE FL 33325 Congratulations With this license you become one of the nearly one million Ftoridians 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 the way we do business in order to serve you better. For information about our services, please log onto www.myf►oridaticense.com There you can find more Information 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 (`ably. We constantly strive to serve you better so that you can !servo your customers. Thank you for doing business in Florida, and congratulations on your new license' DETACH HERE RICK SCOTT, GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND ' PROFESSIONAL REGULATION CGC 1518755 -`' ; ISSUED 07/29/2014 .... CERTIFIED GENERACCONTRACTOR ..' GUJTIERREZ. JORGE L ''';, OM CONSTRUCTION SERVICES LLC IS CERTIFIED under the prowleivre of Ch.4110 FS Espealottla+i' AUQ31.241e ., L1aQ'2DI7t1015M KEN LAWSON. SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUNIffER CGC1518755 The GENERAL CONTRACTOR :Named below IS CERTIFIED - Under the provisions of Chapter 489 FS. "7:Expiration date: AUG 31, 2016 r GUTIERREZ, JORGE,L: .� '`0M,CONSTRUCTIONSERVICES LLC 1285O.W STATE ROAD 841UITES-20 ✓,,Q VIE - AFL 33'32'T' ISSUE©: 07r29R0t4 DISPLAY AS REQUIRED BY LAW SEQ * 1.14072000015m • ,. j7 5: RUBIN OWNER, L OM CoNSUCi1ON SERVI,LLC flu ...�t�� THIS) Its IN0T AA BILL AT10 ? NIDADEV r 1. Thi ca Businesslexiieceipt o certificati to tthe'holdea ivernmentil e ulatory law ECEIPT Q above m of N0, PAY/ SEC Tye 196 GEN • ord wRE JIiTANa► PENE1l1 CGC1518755 1 a BUSINESS BUILT NG G IIti iu t % disph+ayeed at p18C c fib�ti lfte !Pura 'ant:t 'Coe ty4txt e) Chapter 8A r Art. 9f&t 1O, PAYMENT RECEIVED) Bit TAX COLLECTOi 3 .00 Q9 5/25/20 4 (REDITC D--14— 940206 confirms payment payment of tilt:local Business Tax. The Piece balificatibris, to do business. Holder.mustscam' alvv�w requirements which apply to the business: : be displayed on'aJI taonte ' ial vehiclisM ea is not a lid any govcitt de Sec 8 Jorge ;Gutierrez From: Sent: To: Subject: MDCTXC@miamidade.gov Tuesday, December 29, 2015 10:24 PM jlghouse@gmail.com MDC Tax Collector - Online -payment confirmation Thank you for using the Miami -Dade Tax Collector Online Payment Service to pay your taxes. Funds will be withdrawn immediately from your account. Your payment will post to your local business tax account, however, it is not final until accepted byyour financial institution. If all required documents are on file, LBT receipts will be mailed in a postcard format and it may take from 7-10 days to receive this receipt. Returned electronic payments will be canceled, discounts may be lost and a service fee of not less than $25 up to a maximum of 5% will be assessed based on the amount of the canceled payment. Your transaction confirmation is as follows: Tax Description: Account Number(s): Payment Timestamp: Amount Paid: Payment Type: Order Number: Processor Reference Number: Account Holder Name: Local Business Taxes 6735410 December 29, 2015 10:24:04 PM $90.00 Credit Card (VISA) 167369 1475792374.80A1 Jorge Luis Gutierrez Keep this E-Mail for your records. This is an automated response - DO NOT reply to this message. i ACOREP CERTIFICATE OF LIABILITY INSURANCE 4.—./ DATE(MMIDDIYYYY) 12/28/2015 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 pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the pollcy, certain policies may require an endorsement A statement on this certificate does not confer rights to the cortificate holder in lieu of such endorsement(s). PRODUCER Knight Insurance Of Broward 1259 S. Pine Island Rd. Plantation FL 33324 CONTACT Barry Sanders (AIC No. Ex1); (954) 382-5244 FAX (MC, No): (954) 382-5263 EMAIL rY@kni ADDRESS: bar htinsuranceof ce.COm g INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A: UNITED SPECIALTY INSURANCE CO INSURED OM Construction Services, LLC 12850 W State Road 84 3-20 Davie FL 33325 INSURER H : INSURER C: INSURERD: 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 CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTRJUSD TYPE OF INSURANCE ADDL SUER MD POUCY NUMBER POUCY EFF (MMIDDIYYYY) POLICY EXP IMMIDD/YYYY) LIMITS A X COMMERCIALGENERAL LIABILITY DCG02453-00 12/21/2015 12/21/2016 EACHCCCURRENCE 5 1,000,000 CLAIMS -MADE X OCCUR AMAGE TO RENTED PREMISES Ea occurrence) 5 100,000 MED EXP (My one person) S 5,000 PERSONAL BADVINJURY 5 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPUES JEa PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMPKF'AGG S 2,000,000 $ AUTOMOBILE UABIUTY _ — SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY ROP RTY DAMAGE $ $ UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORJPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? I I (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N 1 A .. PER OTH- STATUTE ER E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT 5 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule. may be attached N more space Is required) Carpentry - residential remodeling CERTIFICATE HOLDER CANCELLATION Miami Shores Village Building Department 10050 NE 2 Ave. Miami Shores Village, FI. 33138 ACORD25 (2014101) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. 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: 12/4/2015 EXPIRATION DATE: 12/3/2017 PERSON: GUTIERREZ JORGE L FEIN: 203855410 BUSINESS NAME AND ADDRESS: OM CONSTRUCTION SERVICES LLC 12850 WEST STATE ROAD 84 # 3-20 DAVIE FL 33325 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR 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 Construction Services LLC 12850 W STATE ROAD 84 # 3-20 DAVIE, FL 33325 TELF: 786-426-6350 FAX: 954-756-7178 COC 1518755 Date: 12/29/15 State Of Florida County of Broward Before me this personally appeared Jorge Gutierrez who, being duly sworn, deposes and says: That he will be the only person working on the project located at: 1201 NE 94th Street, Miami Shores Florida. Sworn to (or affirmed) and sal%scribed before me this �o day of 0 FLO-- 2015, by --So C (J/ iY-2Q�iZ Personally Know OR produced Identification Type of Identification Produced .. Print, Type or Stamp I : e N ' `� co:%•d/9a p x 3`� s d.. Miami Shores Viiiage 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: State of Florida County of Miami -Dade The foregoing was acknowledge before me this 3 day of r..0rt C By 3rL(2a' 2X) L ,z Notary: SEAL: 20 tS who is personally known to me or has produced ,\\\ as #lrnii0 9,t). a/atl ...... . 000282 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6735410 BUSINESS NAME/LOCATION OM CONSTRUCTION SERVICES LLC DOING BUS IN DADE CO MIAMI FL 33000. OWNER OM CONSTRUCTION SERVICES LLC Worker(s) 1 RECEIPT NO. RENEWAL 7008923 BT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 GENERAL BUILDING CONTRACTOR CGC1518755 PAYMENT RECEIVED BY TAX COLLECTOR $90.00 12/29/2015 CRED ITCARD-16-0 16510 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must csuply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed Drell commercial vehicles - Miami -Dade Code Sec 8a-276. For more information,,visit www.miamidade.gov/taxcollector �. 12C