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BPP-17-1545Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Pei Permit NO. BPP-6-1 ?-1545 Permit Type: Pools/WhirlpoolslHot Tubs IIIt Work CIa. ssitication: New PermitStatus: APPROVED Issue Date: 7/12/201 7 Expiration: 01/08/2018 Parcel Number Applicant 925 NE 95 Street Miami Shores, FL 33138- 1132060143100 Block: Lot: JUDITH H LEFFERDINK Owner Information Address Phone Cell JUDITH H LEFFERDINK 925 NE 95 Street MIAMI SHORES FL 33138- (847)975-8540 925 NE 95 Street MIAMI SHORES FL 33138- Contractor(s) Phone JENNI POOL DIAMOND BRITE & TILE (305)986-0824 Cell Phone Valuation: $ 49,600.00 Total Sq Feet: 480 Approved: In Review Comments: Date Approved: : In Review Date Denied: Type of Work: Swimming Pool Additional Info: NEW POOL IN BACKYARD Classification: Residential Occupancy: Private Bond Return : Scanning: 3 Fees Due Bond Type - Contractors Bond CCF CO/CC Fee DBPR Fee DCA Fee Education Surcharge Permit Fee Plan Review Fee (Engineer) Scanning Fee Technology Fee Total: Amount $500.00 $30.00 $50.00 $22.32 $22.32 $10.00 $1,488.00 $80.00 $9.00 $40.00 $2,251.64 Pay Date Pay Type Invoice # BPP-6-17-64276 07/12/2017 Credit Card Bond #: 3449 Amt Paid Amt Due $ 2,251.64 $ 0.00 Available Inspections: Inspection Type: Fence Final Pool Deck Wall Steel Review Electrical Review Planning Review Building Review Plumbing Review Structural 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 t — f• oing info tion is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermo I . the above n contractor to do the work stated. Authorized Signature: -Own Applicant / Contractor / Agent July 12, 2017 Date Building Department Copy July 12, 2017 1 AYieIZCI 6/Qrn, 3o'09--81'{3 2v)\'' 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 JUN n a 7017 FBC 201L1 BUILDING Master Permit No. EPP P -15L PERMIT APPLICATION Sub Permit No. E UILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: q 2 S N E C3 57-- City: Miami Shores County: Miami Dade Zip: 33 /O Folio/Parcel#: / / 0 ZQl6 0/1/ 3 / 00 Is the/Building Historically Designated: Yes NO Occupancy Type:3F/2 Load: �C^onstruction Type;«L - /o ( Flood Zone: BFE: FFE: J C OWNER: Name (Fee Simple Titleholder): d' /'7 Ze FFero/ in k Phone#: Address: '25- ,U C1116--- 5 / City: /G/%%'L€ S%o7Ps State: Set c'75; g6-0 Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: 'Tent); r)/ Po/ J/1/4,/rI %/anone#: J06-.9g,6.O 29 Address: Z 9/ S CO City: State: Qualifier Name: ! /V/`/GZJ Zip: 03 / 2.14 /n�/y� �Phone#: 0 • F0(�'06 State Certification or Registration'#. ('� /4 7 27 / Z- Certificate of Competency #: DESIGNER: Architect/Engineer: U iCV �/ 1 'Q/%C-e/ , % Phone#: -3°6' -30S 5631 Address: /0"7 7 /,V . a 694 /A) City: /"1 �C%% State: �%p'' Zip:33/��. Value of Work for this Permit: $ 4/ �/� • 0C) Square/Linear Footage of Work: y0 a .562F/ Type of Work: ❑ Addition ❑ AlteratPIO f New ❑Reepaaiir/Replace El Demolition Description of Work: �% QU _.) 0 1 i V) Ba c.� ya r > Specify color of color thru tile: Submittal Fee $ Permit Fee $ ‘1 't' • Scanning Fee $ ') - 60 Radon Fee $ 2'2 • 32- Technology Fee $ `I-0 • Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ CCF $ 30- OC) CO/CC $ SC-3 • DBPR $ 2- 2' Notary $ (0' Double Fee $ - 0 Bond $ 0 ' C)�• TOTAL FEE NOW DUE $ I . t04-1 2, 2S 1 c 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 • .sence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature The foregoing instrument was acknowledged before me this , by who is personallyvbuwr►to 1.10 Signature 11.��// ��� 7+ OR The foregoing instrument was acknowledged before me this y of , 20 1 , by 4e0who is personally known to me or who has produced as me or who has produced as identificatio u d w o did take an oath. NOTARY Print: Seal: ,*A Notary Public - State of Florida o • . 0,Commission # FF 245271 So I._II1*P� ,, My Comm. Expires Jun 29, 2019 °,, ,, Bonded through National Notary Assn. APPROVED BY (Revised02/24/2014) * * ** * *********** e5 ************* identification and who did take an oath. NOTARY PU Sig Pri Se • a Plans Examiner OBERTO SANCHEZ = Notary Public - State of Florida Cormission # FF 245271 MyComm. Expires Jun 29, 2019 ,'Fi ;o ', Bon iedar Ig iFailaato6y*Assn -411 Structural Review co r)l zing Clerk Miami -Dade Official Records - Print Document Page 1 of 2 Prepared by: Gary Silberman, Esq. Gary Silberman, P.A. 2665 S. liayshore Drive, 1725 Coconut Grove, FL 33133 305-285-0377 File Number: 17-144 Return to: The Herskowitz Law Firm 9100 South Dadeland Blvd., Suite 908 Miami, FL 33156 CFN: 20170259809 BOOK 30525 PAGE 4993 DATE:05/08/2017 04:29:25 PM DEED DOC 4,830.00 HARVEY RUVIN, CLERK OF COURT, MIA-DADE lSpncs Above This l.ine For Recording Data? Warranty Deed This Warranty Deed made this day of May, 2017 between 925 NE 95, LL.C, a Florida limited liability company whose post office address is 600 N.E. 53rd Street, Miami Shores, FL 33137., grantor, and Judith H. Lefferdink, a single woman, whose post office address is 925 N.E. 95th Street, Miami Shores, FL 33138, grantee: (Whenever used herein the terms "grantor" and "grantee' include all the parties to this instrument and the heirs, legal representatives, and assigns of individuals, and the successors and assigns of corporations, trusts and trustees) Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10.00) and other good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged, has granted, bargained, and sold to the said grantee, and grantee's heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: Lot 19 and the East 29 feet of Lot 18, Brock 76, Miami Shores Section No. 3, according to the map or plat thereof, as recorded in Plat Book 10, Page(s) 37, of the Public Records of Miami -Dade County, Florida. Parcel Identification Number: 11-3206-014-3100 Subject to taxes for 2017 and subsequent years; covenants, conditions, restrictions, easements, reservations and limitations of record, finny. Together with all the tenements, hereditament, and appurtenances thereto belonging or in anywise appertaining. To Have and to Hold, the same in fee simple forever. And the grantor hereby covenants with 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; that the grantor hereby fully warrants the tide to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2016. DoubteTtrnex https://www2.miami-dadeclerk. com/officialrecords/PrintDocument.aspx?QS=YaoUfOzxry... 6/30/2017 Miami -Dade Official Records - Print Document Page 2 of 2 CFN: 20170259809 BOOK 30525 PAGE 4994 In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written. Signed, sealed and ess Name: State of Florida County of Miami -Dade to our presence: 925 NE 95, L.€;&?; a l lorida limited liability company Ign�to;.Villanueva, Manager (Corporate Seal) The foregoing instrument was acknowledged before me this day of May, 2017 by Ignacio Villanueva, Manager of 925 NE 95, LLC, a Florida limited liability company, on behalf of the limited liability company. He U is personally known to me or Li has produced his driver's license as identification. 1' r,... [Notary Seal] EMMACtat z Way Me Caudsliart102311at Itort4s Wows hem* S. MI taaaaa. ftaslsr801.4 . Notary Public Printed Name: My Commission Expires: ri'arrant y then- Page 2 Doub l me. https://www2.miami-dadeclerk.com/officialrecords/PrintDocument.aspx?QS=YaoUfOzxry... 6/3 0/2017 IVI iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 DIMING POOL OWNER'S CERTIFICATION Date //501V/7 Miami Shores Village Building & Zoning Department Attention: Building Official I certify that I am the legal owner of the property described as J%t2 , located at 6725-iE q -s% ktpcm:c 9-('S ( ' In accordance with Section 33-12(f), Code of Metropolitan Dade County, I certify that I understand and agree that the swimming pool to be constructed at the above address cannot be used or filled with water until separate permit has been obtained for an approved safety barrier, and such barrier erected, inspected and approved. I further understand that this certification, however, does not eliminate the need for obtaining a permit and erecting and approved barrier prior to final inspection and use of the pool. Legal Owner )�l��G Note: This certification is to be submitted with a swimming pool permit application in duplicate. Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 NOTICE OF REQUIREMENTS RESIDENTIAL SWIMMING POOL, SPA AND HOT TUB SAFETY ACT I e) ackr}o ledge that a new swimming pool, spa or hot tub will be constructed or installed at Miami Shores, FL, and hereby affirm that one of the following methods will be used to meet the requirements of Chapter 515, Florida Statues and the Florida Building Code R4101.17. Please initial the method(s) to be used: // The pool will be equipped with an approved safety pool cover that complies with ASTM F1346-91. (Submit Manufacturer's Specifications). A continuous, one-piece (child) barrier meeting the requirements of Florida Building Code R4101.17.1.15 will protect the pool perimeter. The plans shall show the fence location and method of attachment, including one end that shall not be removable without the aid of tools. (Submit Manufacturer's Specifications). A combination of non -dwelling walls and fences (screen enclosure, child fence, masonry fence walls, chain link or wood fence, etc.) will protect the pool perimeter. The plans must specify the type and location of all non dwelling walls. Florida Building Code, R4101.17.1 Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter and all windows and doors will be equipped with exit alarms complying with Florida Building Code, R4101.17.1.9 (Submit Manufacturer's Specifications). Any combination of protection which incorporates dwelling walls with openings directly into the pool perimeter and all doors will be equipped with a self -latching device with positive mechanical latching/locking installed a min. 54" above the threshold. If this option is selected, submit plans showing all types and location of all perimeter protection. The plans must also show the location and type of all openings, and the hardware type for each location. (Submit Manufacturer's Specifications). In accordance with the Code, the pool may not be filled with water without compliance with the Private Swimming Pool Safety Requirements, and upon expiration of the permit, the pool shall be resumed to be u • .fe. I understand that not having one of the above installed will constitute a lation .f Cha 15, F.S ., an d . considered as committing a misdemeanor of the second nish ' . s pro ' . 75.082 or Section 775.083 F.S . This form must be signed nd t in Section ri contr y,.NATURE DATE 8f/i or. O'TRA• • ',p n' .// NOTE'''' •LIC OF E (PLEASE PRINT) URE AND DATE e aI Address: Whereas, the undersigned owner(s) Tc_ts i UL\ LE QI C !) I1 k desire to utilize said Lot(s) as a single building site, and the undersi ndd owner(s) do(es) hereby declare and agree as follows: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RESTRICTIVE COVENANT PROTECTIVE POOL ENCLOSURE KNOW ALL MEN BY THESE PRESENTS; WHEREAS, the undersigned Jtt d I /1i L f 7P j / fl is/are the fee simple owner(s) of the following described property situated anc being i,AMiami Shores Village, Florida: (t21'►'�.t Ss �3f? a25-k) That the property will not be used in violation of any ordinances of Miami Shores Village or Miami -Dade County now in effect or hereinafter enacted. II. That the purpose of the covenant is to induce Miami Shores Village to issue a permit for a pool where the required enclosure is not on the subject property where the pool is located. III. That if any of our adjoining neighbors remove any portion of their fence or wall, or if our/my property shall fail to meet code requirements for pool barriers, we, as owners will immediately installs a protective enclosure to meet code requirements and will obtain a permit for such fence. IV. That, I/we, as owner(s) hold Miami Shores Village harmless for any negligence or injury that results from not having the enclosure. V. If enclosure belongs to said property, I agree to maintain & or replace said enclosure in the event that is damaged or removed by any case. NOW, THEREOF, for good and valuable consideration, the undersigned do(es) hereby declare that he/she will not convey or cause to be conveyed the title to the above property without requiring the successor in title to abide by all terms and conditions set forth herein. FURTHER, the undersigned declare(s) that this covenant is intended and shall constitute a restrictive covenant conceming the use, enjoyment and title to the above property and shall constitute a covenant running with the land and shall be binding upon the undersigned, his/her successors and assigns and may only be released by Miami Shores Village, or its successors, in accordan of said Village then in effect. OWNER SIGN & PRINT U.C1411 /QPP'PrCi 1\ri WNER SIG & PRINT I Hereby Certify that on this day personally appeared before me <.1 1.?0 and has produced ID # as identification and he/she acknowledge that he/she executed the foregoing, freely and voluntarily, for purposes there in expressed. SWORN TO AND SUB, C,IBIDkefn, re„Ineeonks,, !.-ay .jam E , 20 1 7 a,,vv.,•, ROBERTO SANCHEZ ‘`IPRv PLB �i r","„`'S Notary Public - State of Florida '• ; �� : •i Commission # FF 245271 ,-:,,. ��7 MyComm. Expires Jun 29, 2019 ' OTA"Y P B ' STATE OF FLORIDA (Revised 05/22 °; ; ;°Q'` Bonded through National Notary Assn. LocalBusiness Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 5338009 BUSINESS NAME/LOCATION .RECEIPT NO. JENNI POOL DIAMOND BRITE & TILE COPING SERVIRENEINAL 11777 SW 18 5T 3 5575478 MIAMI FL 33175 ILBTI EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS JENNI POOL SERV & MAINTENANCE INC 196 SPECIALTY BUILDING CONTRACTOR 04BS00144 Worker(s) 1 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 09/21/2016 CREDITCARD-16-055580 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 holders qualifications, to do business. Holder must comply with any govemmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visit yvww.miamidadegov/taxcoHector - STATE,O.F�FLORIpA��....v.� , ,.. DEPARTMENT ©FN.BUSINESS AND"4 ,sue PROFSStONAL:EGU TION` CPC1458712 s ; ►tSSt71=D 40/PM016 CERT GOMMEWVIZ OIjSP.A GONTR BL"ANGO HUNIBEtT'Or0 j' JENNI^POOL-DIAMOND R E.8 TILE'.0 IS,CERI"IFIED n 'er th e p isionsof-Ch 489,,,FS Expiration date. AU6 31 2018'P ` " - "L1610020000814 AC# 01665252 ACORN® `� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DO/YYYY) 05/26/2017 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 MDLP INSURANCE GROUP 10631 N. KENDALL DR #220 Miami FL 33176 CONTACT NAME: Jamie A. Mondaca PHN(A/C, N , . (305) 553-3761 FAX No): (305) 553-2241 E-MAIL enn mdl insurance.COm ADDRESS: I y@ P INSURER(S) AFFORDING COVERAGE NAIC Of INSURER A: NAUTILUS INSURANCE COMPANY INSURED JENNI POOL SERVICE & MAINTENANCE, INC DBA: JENNI POOL DIAMOND BRITE & TILE COPING SERVICI 2891 SW 139TH CT MIAMI FL 33175 INSURER B : INSURERC: INSURER D : INSURER E : INSURERF: 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 INSD SUBR WVD POUCY NUMBER POLICY EFF (MM/DD/YYYY) POUCY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL UABIUTY MYBPM-Y 03/26/2017 03/26/2018 EACH OCCURRENCE $ 500,000 CLAIMS -MADE X OCCUR GERENTED PRREM SESO(Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: JECT LOC PRODUCTS - COMP/OP AGG $ 500,000 BI/PD DEDUCTIBLE $ 500 AUTOMOBILE _ LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAR EXCESS LAB 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 NIA PER OTH- STATUTE ER EL. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) SWIMMING POOL CONSTRUCTION AND SERVICING CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 NE 2 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 POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4/2 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: 4/21/2017 EXPIRATION DATE: 4/21/2019 PERSON: BLANCO HUMBERTO SR FEIN: 651144461 BUSINESS NAME AND ADDRESS: JENNI POOL SERVICE & MAINTENANCE INC. JENNI POOL DIAMOND BRITE & TILE COPING SERVICE 2891 SW 139 CT MIAMI FL 33175 SCOPE OF BUSINESS OR TRADE: Concrete or Cement Work - Floors, Driveways, Yards, or Sidewalks and Drivers Swimming Pool Construction- Ceramic Tile, Indoor Stone, Not Iron or Steel -& Drivers Marble, or Mosaic Work IMPORTANT: 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 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 IVI iami 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. State of Florida County of Miami -Dade The foregoing was acknowledge before me this day of U�% , 2017. By /t. /trff ilAwho is personally known to me or has produced No SEAL: as identification. •.""""�., ROBERTO SANCHEZ �! Notary Public - State of Florida •= Commission # FF 245271 P My Comm. Expires Jun 29, 2019 k ,,,r. �s, Bonded through National Notary Assn. 7 JENNI POOL INC (305) 986-0824 Fax (305)480-8278 DATE: STATE OF: e!l%r'c 7 COUNTY OF: 6Q de, Before me this day personally appeared iIe/k 66(ice who, being duly sworn Deposes and says: That he or she will be the only person working on the project located at: ga--- /VG 9s sT }-Zole1 `pc ‘3 3 i31 . C S By li:t...•.:' : •s= RENE DIOVANY ILLA MARTINEZ :J :.1 MY COMMISSION # GG 034114 Ili EXPIRES: September 27, 2020 'F •►. Bonded Tin Notary Public Undenviiter8 n�a• and subscribe me this Z 7 day of �, . 20 Personally know Or Produced Identification Type of Identification Produced i`.., RENE DIOVANY ILIA MARTINEZ ,., : ? MY COMMISSION # GG 034114 _; L. • 1 EXPIRES: September 27, 2020 z,:eoF :;', &Mod Thru Notary Public Underwriters Print, Type or Stamp Name of Notary