RC-18-1702:s BUILDING PERMIT APPLICATION ❑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 6,ZOjg FBC 20• OA\ Master Permit No.ir G' G - t$' l7Oa Sub Permit No. ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I4a IiE 103 5t City: Miami Shores Folio/Parcel#: t 13R 06O 131750 Occupancy Type: Load: County: Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): fe.12Wto.roo /p Address: City: MZhit7 SnoVLtz_5 State: Ft- Zip: 33 i35 142- NE 103Ivo 57 Miami Dade Zip: 331 3rp Is the Building Historically Designated: Yes NO BFE: FFE: Phone#: 305.6t0 - 33% Tenant/Lessee Name: Phone#: felts piJasf PU & me. tam Email: CONTRACTOR: Company ,Name: L tfy f(.1(,15?.iiA � .(142'3 LA--C.. Phone#: 5 ? g 8O Address: .4 9 F g City: y1Ftt}V\ I State:. Zip: 33U/ L Qualifier Name: A GalVY1g5 Phone#: 365 Ul 6O ¥0$ 4 State Certification or Registration #: VA( (c 1'0 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this PIrp Termit: $ '� o(9, �%:> Square/Linear Footage of Work: + Type of Work:. ❑ Addition ❑ Alteration ❑ Description of Work: R t(1\ ' A-t o U,u t� OF RA :Wilt � :OL'O • /(.041 v✓.S New // -- Repair/Replace ❑ Demolition 'eCQSS Or• te-OcivvN Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $....)......R r^ TOTAL FEE NOW DUE $ I S. S2 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. ., r "WARNINGTO 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."', :E. w .•, Notice to Applicant: As a condition to the issuance of a building permit with an estimated value'ekceeding i$2500, the applicant must promise in good faith that a copy of the notice of co mencement and construction lien law broch will be delivered to the person whose property is subject to attachment. Al a cert ied copy of the recorded notice of commence y' t must b`e posted at the job site for the first inspection which occurs seve ') days after the building permit is issued. In th • . nce of such posted notice, the 1.. li inspection 1ad�J-� ed . . a r. : ction will be charged. ,� , r r AMA, , r�f .. I ' Signature �f�!�;� Signature Ii'' .. OWNER or A NT t /liA/RACTOR r The fforeg ing instrume t wasacknowledged before me this The foregoing instrument was acknowledged before me this 13 day of v , 20 1' , by L 5 day of N1.0 , 20 __ , by 1 ikO VI-51° CI N'e w2io is personally known to W kS LJr L rfL , who is personally known to me or who has produced as me or who has produced r'Ape-Cv I y as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: -1 . o = °O •� ,���„ " i'iii' A S LrnA HAHH soN Notary Public, State of Florida Commission# FF 987414 My comm. expires May 20.2020 identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: ************************************* ******************************************************************** APPROVED BY Plans Examiner Zoning Structural Review Clerk • -(Revised02/24/2014) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): / l Zi (f1Z w-5 / 0 $� City Miami Shores Village \ County: Miami Dade Zip Code: 2 ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO K.'. ARHI Sheet Attached: YES ❑ NO ❑ (Ccintract Attached: YES/0 UNIT BEING REPLACED DATA NEWUNIT 4E,tits.l1C1'rc.- }1�j/%&'fO4if2Dl(5fb l 1`(4ffe-tol-ta00- MANUFACTURER (M AHU or PKG. UNIT MODEL# COND. UNIT MODEL# 49 KW HEAT /QL4-/ NOM TONS .314 --IVA), AHU CU PKG 1) M.C.A ,5 AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG .4� 3) VOLTS c c a :✓' AHU CU PKG PKG UNIT / / d PKG UNIT / / EER/SEER /4-f. $ YES NO REPLACING DUCTS YECil YES NO REPLACING THERMOSTAT YE NO YES NO NEW 4"CONCRETE SLAB YES YES NO NEW ROOF STAND YES A' YES NO NEW RETURN PLENUM BOX YES Q 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (20 %24 480): ,p24"-f0 (/ 4. Size Disconnecting Means: CObf Contractor's Company Name• 4 • o. �u i;, � � Certificate ers signature) State Certificate or Registr Signature CO (Revised02/24/2014) 1d35'(oZz Certificate of Product Ratings AHRI Certified Reference Number : 10346022 Date : 11-15-2018 AHRI Type : RCU-A-CB Outdoor Unit Brand Name : AMERISTAR Outdoor Unit Model Number (Condenser or Single Package) : M4AC4042D1 Indoor Unit Model Number (Evaporator and/or Air Handler) : M4AH4044A1000AA Region : All Region Note : 1803 The manufacturer of this AMERISTAR product is responsible for the rating of this system combination. Model Status : Active Rated as follows in accordance with the latest edition of ANSI/AHRI 210/240 with Addenda 1 and 2, Performance Rating of Unitary Air -Conditioning & Air -Source Heat Pump Equipment and subject to rating accuracy by AHRI-sponsored, independent, third party testing: Cooling Capacity (A2),7 Single or. High Stage (95F), btuh : 42000. SEER 14.f50 h � � xV ? EER (A2) 7'Single or,,High Stage (95F, "Active" Model Status are those that an AHRI Certification Program Participant is currently producing AND selling or offering for sale; OR new models that are being marketed but are not yet being produced."Production Stopped" Model Status are those that an AHRI Certification Program Participant is no longer producing BUT is still selling or offering for sale. Ratings that are accompanied by WAS indicate an involuntary re -rate. The new published rating is shown along with the previous (i.e. WAS) rating. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www.ahridlrectory.org. TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRI. This Certificate shall only be used for individual, personal and confidential reference purposes. The contents of this Certificate may not, in whole or in part, be reproduced; copied; disseminated; entered into a computer database; or otherwise utilized, in any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The information for the model cited on this certificate can be verified at www.ahridirectory.org, click on "Verify Certificate" link and enter the AHRI Certified Reference Number and the date on which the certificate was issued, which is listed above, and the Certificate No., which is listed at bottom right. AIR-coNDmONING, HEATING, & REFRIGERATION INSTITh E we make life better 131867893674397708 ©2018Air-Conditioning, Heating, and Refrigeration Institute -1CATE NO Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A / COPY OF QUALIFIER'S STATE LICENCES B V—� COPY OF LOCAL BUSINESS TAX RECEIPT C.'✓' COPY OF LIABILITY INSURANCE* D. C D COPY OF WORKERS COMPENSATION INSURANCE* - -- - (Workers Compensation -EXEMPTION. must have NOTICE'TO:OWNER for and,Contractor Affid I 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: MIAMI7SHORES-VIL-LAGE.BLDG,DEPT ,10050_NE'2ND:AVE g:3 MIAMI'SHORES,-FL-33138_ Certificate,must.specify thedescription of-operations,or contractor license.number.1 Lw BUSINESS NAME: I_ In f ^,� 1dvlel Ccb (\ -4 BUSINESS ADDRESS: 49cI L t<�) CITY ft� F/A STATE ZIP 330 /3_ BUSINESS PHONE: (3() ) `lZ 8(� FAX NUMBER ( 6) 00//O CELL PHONE ( ) ,6S CZ )— QUALIFIER'S NAME: . Y 6 d/ 1�' - QUALIFIER'S LIC NUMBER: C a 5 16 c c� 2'752 —5 33 LLB P Proposal Sales Agreement and % Refrigeration Control L. LICENSED g INSURED LIC. CAC 1816470 1640 SW 16 ST. Miami FL. 33145 L. C Ph: 305.968.8087 luis31@live.com PRO R1EDTO if+PQ di-6 r Vt04`PHONEL �A0I�'��STREETE t,t6-yct„ V� JOB NAME V b _"- I g CRY, STATE 8 P DE JOB LOCATION , MASTER PERMIT No. Xi FOLIO No. AIRHORIZED BY: DATE Equipment Schedule QUANTITY BRAND BEER CONDENSING UNIT MODEL AIR HANDLER MODEL PACKAGE MODEL STRIP HEAT Sig TONS 4. AN€SMfL t4Cq) /a d low- 't1g-1 S (it iwd A to ,-, Qn„, . (to J 4. etiageatb .,e' z. 67-2.e,s. „04:26,_ict___ /.2.-e? eryiacy-a-45. cal._ orica5ide„ rayen-,-- Service Warranty: Wilt be Provided free by us for a period of one year from date of certMcate of occupancy or start up date whatever happens first, providing is not more than six months from Installation date, and during regular working days at regural working hours. Weekends, Holidays and maintenance are excluded. RESPONSIBIUTY LG. REFRIG. OTHER N/A RESPONSIBILITY LG. REFRIG. OTHER N/A MANUFACTURER WARRANTY YEARS ON COMPRESSOR DRAIN PIPING DELIVERY YEARS ON EVAPORATOR COIL AIR HANDLER SUPPORTS INSTALLATION Of EQUIPMENT YEARS ON CONDENSER COIL PITCH PANS / ROOF WORK DUCTWORK' YEARS ON PARTS CUTTING OF HOLES FOR PIPES, DUCTS, ETC. GRILLS DOCTWORK NOTES: f tisk ci. DAINTING AND DECORATING PERMITS FEE ,, s +ea¢S Oti �• - ' BATHROOM EXHAUST CONDENSER UNIT PLATFORM CONTROLS NOTES:. t UQ ELECTRICAL WIRING FROM PANEL TO UNIT FREE RETURN - DUCTED RETURN /� p �..� .t ; 41. FRESH AIR INTAKE REFRIGERATION PIPING REMARKS:. it 63 U141-" 0M� ��-"t4.1T dS v - 1 > 44 a tori2!h?V4 A 0.) do to ai i 3%2 " a, �i4 often L�uJ�lae t /14 i a„t" R.A4/14,4 ./12.aca ,442.-- /Mee ropose y to furnish mate Ian r - compie In accord c ce wtih ve specifications, for the sum oft aa � Uft-e_ Dollars $ -130 a , cyo 6n d o C7 -ci c29 ✓ — ,- 30`0 4r I. 't / gryijzi ,„.,-4,-,,cci....037,,,..&.,_ of' 4 brtlek _.,./.), . s cd_ _26,..ye AB material Is guaranteed to be as specified. All work to be completed In a workmanlike LG Refrigeration Control LLC. /! Authoriz ignature J manner according to standard practices. Any alteration or deviation from above speclfica- Moms Involving extra cost wifi be executed only upon written orders, and will become an extra charge over and above the estimate. AB agreemenh contigen upon strikes, accidents or delays Note: this p I may be beyond our control. Owner to carry fire, tornado and other necessary Insurance. tf dOys• by withdrawn us not within Acceptance of Proposal - The above prices, specifications r2z.ii9 L t.1l 3 i I $ and conditions are satisfactory and are hereby accepted. You are authorized _..it !RC,. ei7 to do the work specified. t will made outlined above. Signature Date of Acceptance: Signature ,1 Aca l 1�13d r� LGREF-1 OP ID: MP A R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/15/2018 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 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 Avante Insurance Agency, Inc. 7490 West Flagler Street Miami, FL 33144 Gabriela F. Dominguez CONTACT NAME:Avante Insurance Agency PHONE FAX (A/C. No. ExtU 305-648-7070 ( No): 305-648-7090 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : United States Liability 25895 INSURED L G Refrigeration Control, LLC 4299 E 8th Lane Hialeah, FL 33013 INSURER B : INSURER C : INSURER D : 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 LTR TYPE OF INSURANCE ADDL INSR_Nvn SUBR POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CL1730741 B 12/12/2017 12/12/2018 EACH OCCURRENCE $ 1 ,000,000 PRS RENTED PREMISES ( (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP {Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE 7 POLICY LIMIT APPLIES PRO JFCT PER: LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED AUTOS- COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (PER ACCIDENT) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y /N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A VC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space Is required) Air Conditioning/Refrigeration Installation, Service and Repair. CERTIFICATE HOLDER CANCELLATION 1 Miami Shores Village g Bldg Dept. 10050 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQEDREPRESENTATIVE ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS D R t FESSIONAL REGULATION CONSTRUCT ING BOARD THE CLASS B AIR CONDITI 01 tNG CANT TOR H REIN IStCERTIFIED UNDER THE PROVISIONS�OF W iT i 489, F I ' STATUTES Always verify licenses online at MyFloridaLicense.com Do not alter this document in any form. This is your license. It is unlawful for anyone other than the Licensee to use this document. Florida 006267 LOCa rrnra, 7�; 66379471 - -, RTy '/ ,4 Y 1 f T' k,, 4� BUSINESS NAMEILOCATION4`h d y L G REF�R6ERAT7oNV CONTROL Le 4299 E ilTh; LN / * ` tr trig, I11AEEAHJFI33O13� _;' z 1'" r -°l ip �r r 44' [ I tr ,p r,• y Mr.r 'n3fi l° dui ss rax:= ce p# '-Dade CoL nttate of ,Florida- vTHsISNOT`ABill' DbP10TPAYr-b owNE<i s' 1 G REFRIGERATIO.:CONTRO LLC�;; CAT LLI'SIM GAIIMES • a RECEIPT NO. +0464. 4.RENEWAL '6908652' k,. rt , EXPIRES S'EPTEMB2019° 196 SPbC MECRANICAL CONTRACTOR] PAYMENT, RECEIVED CAC1816470 �v-£ ". , TAX COLLECTOR, �. = 3 r n r$45.00 0 /26/2Q,i$ - ,Worker(s} • 1 .0--3 [, 1CHECK21—�18-0750' of 1 This Local Business Tax Receipt only caMirms payment of theLocal al Business Tax. The Receipts not a lice r pee or certification"of the holdersqualifications,todobusiness. Holder,mustcomply-wah snygoveMeman g rnmental regulatory laves au�equirements which apply to the business."' t 1° •R , t, St!t r t 4 t :1 ,Thtre RECEIPI.NS: above mist be 'splayed ott all coin erc'ai vehicles 1 Bair-DadeGode Sec 6a-776. y* ,, For more information, visj�-www.miamidade.aovkaxeollector. Must be 'splayed 'at, place of business. -qa,..ePu suant'�to,4County Code l<<^r ChaterBAr=Ark 9 &• 10 r�&,; ytrt ��.s y SEC. TYRE OF BUSINESS: w I A JEFF ATWATER CHIEF FINANICAL 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: 4/6/2017 EXPIRATION DATE: 4/6/2019 PERSON: GALMES LUIS M FEIN: 263812818 BUSINESS NAME AND ADDRESS: LG REFRIGERATION CONTROL LLC 4299 EAST 8 LN HIALEAH FL 33013 SCOPE OF BUSINESS OR TRADE: --Heating;Ventilation. Air - Conditioning and Refrigeration Systems Installation, Service and Repair. Shop, Yard & Drivers IMPORTANT: Pursuant to Chapter440.05(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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Proposal and Sales Agreement LICENSED & INSURED LIC. CAC 1816470 <c>Refrigeration 1640 SW 16 ST. Miami FL. 33145 Control L.L.0 Ph: 305.968.8087 luis31@live.com ll tcl(v t iLb 1 L... Qe r2 rn -e- 4-kA s -rzS �� a )(of L ( tvy‘os_ S \t 2 k ti v 73 c k-kiShea a7s 33.4 ,Y, ir Hi ��-„�� ��s bey , �e �C a c 2 b Lot Per_ S'„c,v lL`e \---Q \A.-0 `-e-, -k/p-C 0 C. 14:62ke.4-Ac.ca. ler2e)Lo2_ FIZIV(11- \\\`\�011*1111///% n.•,gam T 1, � T. 9 ti O• •if, . r a`.. -4. o Spa\+.. ,,,, : ,'/'' /// "U. l 1111100 \\\\\\\ ithkyLe 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: State of Florida County of Miami -Dade The foregoing was acknowledge before me this 13 day of U , 20/ By Y s1ct nd Ci 1. )16 e z' who is personally known to me or has produced L as identification. CASSANDRA HARRISON Notary Public. State of Florida Commission# FF 987414 My comm. expires May 20.2020