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PL-18-1626 (2)Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address Permit Permit NO. PL-6-18-1626 Permit Type: Plumbing - Residential Work Classification: Pool - Private Permit Status: APPROVED Issue Date: 7/25/2018 Expiration: 01/21/2019 Parcel Number Applicant 150 NE 107 Street Miami Shores, FL 33161-7032 1121360070200 Block: Lot: PATRICK & SARAH SULLIVAN Owner Information Address Phone Cell PATRICK & SARAH SULLIVAN 150 NE 107 Street MIAMI SHORES FL 33161-7032 Contractor(s) RESIDENTIAL POOLS INC Phone (954)430-0845 CeII Phone Valuation: Total Sq Feet: $ 1,000.00 0 Type of Work: EQUIPMENT SWIMMING POOL PLUMBING IN Type of Piping: Additional Info: EQUIPMENT SWIMMING POOL PLUMBING IN Bond Return : Classification: Residential Scanning: 1 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $0.60 $3.38 $2.25 $0.20 $225.00 $3.00 $0.80 $235.23 Pay Date Pay Type Amt Paid Amt Due Invoice # PL-6-18-67921 06/13/2018 Credit Card $ 50.00 $ 185.23 07/25/2018 Check #: 3522 $ 185.23 $ 0.00 Available Inspections: Inspection Type: Main Drain Final Rough Review Plumbing 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 AFFIDAVI 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 rlin . Futhe, I authorize the above -named contractor to do the work stated. July 25, 2018 Autjied Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy July 25, 2018 1 BUILDING PERMIT APPLICATION UILDING ❑ ELECTRIC PLUMBING ❑ MECHANICAL JOB ADDRESS: // f City: Miami Shores 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 V ED JUN 13 2018 /2,-d4 pFBC 20 Master Permit No. V PP b' %- \6'Z Sub Permit No. ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS County: Miami Dade //—.z/3d-0d7-- OZaO Zip: 33 /'/ Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: NO FFE: OWNER: Name (Fee Simple Titleholder): S /%h /} ) SUh-L/ tif 19 /V Phone#: Address: z' J-D /t/ City: / - //}Yi-, / s h1172t State: Zip: 3 3 / 6"/ Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: ie-E. S', rt/ T7A9/ Address: — U S 4/ &O / D/ Phone#: q571 y3 DO $ City: P m biv e—S State: L Zip: 3 3 2 5 Qualifier Name: �l o iz6� V ,q- N e G' /9 c1— Phone#: 7ZYy7Z� State Certification or Registration `#: G P' / yf el 7c� Certificate of Competency #: \/ DESIGNER: Architect/Engineer: "GEC % A/617 Phone#: Address: l h% `77 h /" w y j. A N E 4- S City: /V 6 ) State: Value of Work for this Permit: $ Type of Work: ❑ Addition ❑ Alteration Description of Work: Square/Linear Footage of Work: 171--New 6 r /// l,Z 2 / -7--b .ram/ • ❑ Repair/Replace C2 zip: 33 / 7g n Demolition Specify color of color thru tile: Submittal Fee $ 2Ob f et i d Permit Fee $ �j3 O • CA CCF $ CO/CC $ Scanning Fee $ Radon Fee $ • 6 DBPR $ • Li L✓' Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ G0 • Q Bond $ 9313' (Revised02/24/2014) TOTAL FEE NOW DUE $ � 3 • 3G ,/o�3,35- 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 approved and a reinspection fee will be charged. Signature The foregoing instrument was a rv-. g day of Signature CONTRACTOR The foregoing instrument was acknowledged before me this -- 644 day of Ai � ��"e , 20 P, , by L�UL\ �, �.a v4, who is personally known to J d Y 1 Q. \'CkAAQ , who is personally known to me or who has produced identification and who d' NOTARY PUBLIC: Sign: Print: Seal: d before me this , 20 _NC, by res..rt.a4 fakeanoat ;J Yp IrC2f/pUi`IM E Z1 •lt,��;;' My Comm. Expi.esJuno2Flodda Commission f FF901 � 219 as me or who has produced as identification and who did take an oat rry—Lt ****************************** APPROVED BY (Revised02/24/2014) NOTARY PUBLIC: Sign: Print: Seal: **************************************************************************** .,Jy?1.1 Plans Examiner Structural Review Zoning Clerk Property Search Application - Miami -Dade County Summary Report Property Information Folio: 11-2136-007-0200 Property Address: 150 NE 107 ST Miami Shores, FL 33161-7032 Owner SARAH C SULLIVAN Mailing Address 150 NE 107 ST MIAMI SHORES, FL 33161 USA PA Primary Zone 1000 SGL FAMILY - 2101-2300 SQ Primary Land Use 0101 RESIDENTIAL - SINGLE FAMILY : 1 UNIT Beds / Baths / Half 3/2/0 Floors 1 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 1,802 Sq.Ft Lot Size 9,300 Sq.Ft Year Built 1938 Assessment Information Year 2018 2017 2016 Land Value $232,690 $232,690 $199,874 Building Value $125,419 $125,419 $125,419 XF Value $1,597 $1,608 $1,620 Market Value $359,706 $359,717 $326,913 Assessed Value $227,228 $222,555 $217,978 Benefits Information Benefit Type 2018 2017 2016 Save Our Homes Cap Assessment Reduction $132,478 $137,162 $108,935 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (..e. County, School Board, City, Regional). Short Legal Description DUNNINGS MIAMI SHORES EXT NO 3 PB 42-33 LOT 4 BLK 208 LOT SIZE 75.000 X 124 OR 21264-2902 0403 1 Generated On : 6/13/2018 Taxable Value Information 2018€ 2017 2016 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $177,228 $172,555 $167,978 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $202,228 $197,555 $192,978 City Exemption Value $50,000 $50,000 $50,000 Taxable Value $177,228 $172,555 $167,978 Regional Exemption Value $50,000 $50,000 $50,000 Taxable Value $177,228 $172,555 $167,978 Sales Information Previous Sale Price OR Book- Page Qualification Description 06/25/2015 $100 29731 0121 Corrective, tax or QCD; min consideration 04/01/2003 $262,000 21264 2902 Sales which are qualified 04/01/1999 $135,000 18579 1304 Sales which are qualified 02/01/1995 $0 16716- 3257 Sales which are disqualified as a result of examination of the deed The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp Version: Miami Shores Viiiage 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 �� /✓ / • is/are the fee simple owner(s) of the following "described property: situated and being in Miami Shores Village, Florida: Address: /5-1 ,cif / a % c Whereas, the undersigned owner(s) desire to utilize said Lot(s) as a single building site, and the undersigned owner(s) do(es) hereby declare and agree as follows: 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. 01. 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,1/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 successorin 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 concerning 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 accordance of said Village then in effect. OWNER SIGN & PRINT OWNER SIGN & PRINT I Hereby Certify that on this day personally appeared before me faXA .su 1 r J P) and has produced ID # C3422/ 513� 4 t. 24 0 as identification and he/she acknowledge that he/she executed: the foregoing, freely and voluntarily, for purposes there in expressed. SWORN TO AND SUBSCRIBED before me on this 12 day of I I-) ti 20 I S ,z4ti'"Y, ;,GLORIAE.VANEGAS tir_ MY COMMISSION # FF 926723 EXPIRES: NWembar 19; 2019 Bonded Thru Notary PubfittelMtr " (Revised 05/2209 UBLIC STATE OF FLORIDA STATE OF (FLORIDA) COUNTY OF (DADE) The undersigned Affiant, Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 SURVEY AFFIDAVIT , does hereby attest that The attached survey, performed by (Name of surveyor's company) /So NE /o fr` /t vi �S�n s / / 33/62 For address: Performed on il2Z// 0) (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence of any such structures may affect final inspections as applicable to this or other permits. Further, Affiant s eth naught. Propewner SightPit ~... SWORN TO AND SUBSCRIBED before me this ci day of Affiant is personally known to me, ,><' produced FL, i) I_1 as identification. /;111-a-14- C Property Owner Print Name YERRY P Nary Mk. ��p Casa Epos C�. RAZA Raids o, Notary Revised (6/25/12)Revised on 5/22/2009/ Revised on 6/12/09 Miami Shores Viiiage 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 (We) acknowledge that a new swimming pool, spa or hot tub 'II b constructed or installed at /''� A' ? _ —, A� % is/`8 ,-/NItami Shores, FL, and hereby affirm that one of the following methods will be used to meet the requirements of Chapter 515, Florida Statues andthe 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 f all non dwelling walls. Florida Building Code, R4101.17.1 Any combination of protection which incorporates dwellingwalls with openings directs into the Y 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. 54ft 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 presumed to be unsafe: I understand that not having one of the above installed will constitute a violation of Chapter 515, F.S ., an d will be considered as committing a misdemeanor of the second degree, punish as provided in Section 775.082 or Section 736 083 F.S . This form must be signed by the ownet and the prime contractor. CONTRACTOf S SIGNATURE AND DATE a>l' tAili'(r2z e/c i CONTi iCTOR'S NAME (i EASE>PRINT) NATURE /AND DATE 7/1 /e YERRY PERAZA OWNER'S NAME (PLEA` ) Ndntl : �xteo , 21,2019 TA' PUBLIC Miami Shores Vi:iage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795 2204 Fax: (.305) 756.8972 SWIMMING POOL OWNER'S CERTIFICATION Date T/1-1lt Miami Shores Village Building & Zoning .Department Attention: Building Official I certify that 1 am the legal owner of the property described as Sv L c. U, n/ , located at /T°/4Je- / p7 /14-22/'%9,e S /7; 33 i b/ In accordance with Section 33-12(f), Code of Metropolitan Dade County, :! 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 inspec ion and use of the pool. Legal Owner Note: This certification is to be submitted with a swimming pool permit application ii Ut IHUH HtKt RICK SCOTT, GOVERNOR KEN LAWSON, SECRETAF. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER CPC1456978 The RESIDENTIAL POOL/SPA CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 VANEGAS, JORGE I RESIDENTIAL POOLS INC 20841 JOHNSON STREET #101 PEMBROKE PINES FL 33029 ISSUED: 07/04/2016 DISPLAY AS REQUIRED BY LAW RICK SCOTT, GOVERNOR CGC1521259 Uc IML.ri ntrct SEQ # L1607040002016 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION. CONSTRUCTION INDUSTRY LICENSING BOARD The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 VANEGAS, JORGE I RESIDENTIAL CONSTRUCTION 20841 JOHNSON STREET #101 PEMBROKE PINES FL 33029 ISSUED 07/04/2016 DISPLAY AS REQUIRED BY LAW SEQ # L1607040001915 BUStNESB` t"'RE�C EIP1' r_. 11 S. Andrews Ave,;' Rm. A-100, Ft.= Lauderdale,; FL 33301=1895-= 954-531-4000. VALIDOCTOBER 1,2017 . THROUGH SEPTEMBER 30,2018 • t a DBA:',RESIDENTIAL—POOLS INC Business Name• Owner Name: JORGE" 1 vANEQAS Business Location: 20841 JOHNSON ST 101 PEMBROKE PINES Business Phone. 954-430-6845 Rooms Number of iMaetlnes:;. ".. ' Receipt #: OOL?ii NE CONTRACTOR (P<)L & Business-Type:SPA CONTRACTOR) Business Opened:a7/1o/a0.07 State7CountyiCert/Reg:CPC 1456978 Exemption Code: For vending 8uslnsss Patty . Ven • nB Tyl Profeesionats Tax Amount Tranafbr Fee ; NSF Fee , Penalty - r Prior: Years ; CoICiion Cast Total Paid 27.. 00 •0.00 , ..Y'. 0. 00, 0.00' 0: 00 ,:; 0.00 *; ._- r 27` 00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY' IN YOUR PLACE OF BUSINESS THIS BECOMES ATAX RECEIPT WHEN VAUDATED Mailing Address: .RESIDENTIAL POOLS INC 20841 JOHNSON ST 101 PEMBROKE PINES, FL 029 This tax is levied for the privilege of doing business within Broward County and is non -regulatory in. nature. Yon must meet all County andtor Municipality planning and zoning; requirements. This Business Tax Receipt: must be transferred when. the business is sold, business" name has changed ,or you havemoved the business location. This receipt does not indicate that the business is legal or that it is incompliance with State or local laws and regulations. Receipt #OSc-16-00006360 Paid 08/15/2'017 .27.00 ACORO1 CERTIFICATE OF LIABILITY INSURANCE ‘, ...►--- DATE(MM/DD/YYYY) 06/13/2018 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 INDEPENDENT INSURANCE AGENCY 5834 SW 80 ST S MIAMI FL 33143 CONTACT NAME: PHONE Extl: 305-978-2853 (A/C No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: NAUTILUS INSURANCE INSURED RESIDENTIAL POOLS IND DBA RESIDENTIAL CONTRACTOR 20841 JOHNSON ST STE 101 PEMBROKE PINES FL 33029 INSURER 8 : INSURER INSURER D : INSURER E : INSURERF: COVERAGES CERTIFICATE 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 POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY X NN915721 03/26/2018 03/26/2019 EACH OCCURRENCE $ 1000000 CLAIMS -MADE �/ /� OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100000 MED EXP (Any one person) $ 5000 PERSONAL&ADVINJURY $ 1000000 GEN'L AGGREGATE LIMIT APPLIES JECOT PER: LOC GENERAL AGGREGATE $ 2000000 PRODUCTS - COMP/OP AGG $ 2000000 $ 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 O OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N/A PER STATUTE OTH- 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 if more space is required) STATE GENERAL CONTRACTOR CGC 1521259 STATE POOL CONTRACTOR CPC 1456978 SERVICE, CONSTRUCTION, REPAIR, RENOVATION CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 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. AUTHORIZED REPRESENTATIVE JOSE CORREA ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • JIMMY OATRONIS CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERSCOMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM. FLORIDA WORKERS' COMPENSATION LAW* * cousTRuoTtosikoutrrRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE:. 10/15/2017 EXPIRATION DATE: 10/15/2019 PERSON: VANEGAS JORGE FEIN: 650666110 BUSINESS NAME AND ADDRESS: RESIDENTIAL POOLS INC IRESIDENTIALCONSTRUCTION 20841 JOHNSON ST SUITE 101 , FEMBROKiilikES .FL. -33029 ,scopipp‘ausiNERR OR TRADE: Licensed Contractsir Licensed Pool Cont 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 secfion may not recover benefits or cornpensedon 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 shrill be subject to revocation If, at any time after the Ming of the notice or the issuance of the catlike* 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* failure tithe Orson named on the certificate to meet the requirements of this section: DFS-F2-DINC-25.2 CERTIFICATE OF ELECTION TO BE T VISED 08-1 3 • QUESTIONS? (850)4134609 Residentiai Poo dt .: r+osid4 rit ell cc>rttru+cticlori RESIDENTIAL POOLS, INC. 20841 Johnson St # 101 Pembroke Pines, FI 33029 Phone: 954 - 430 0845 Date: une 2018 State : Florida County : Dade AMINIMINeir c7b7e1/.0 C/91— Before me this day personally appeared °-arah-SaHtvan who, being duly sworn, deposes and say: That he will be the only person working on the project located at : 150 ne 107 st, Miami S s, FI 33161 Contr,"ctor Signature Sworn to (or affirmed ) and subscribed before me this ( day of June , 2018 By Personally know Or produced Identification Type of identification Produced _f_i_j\Cf2P)e eo s .mpNameofNotary 1 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 worker's' 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. i Signature: State of Florida County ofMismi-Dt4e 040VS:-„0 The foregoing was acknowledge before me this w,2 3 day of ' v L.ti , 20 1' By 5 AV R h {• S u L L) J F1'I fL Notary: SEAL: who is personally known to me or has produced as identification. GLORIA E. VANEGAS MY COMMISSION i FF 926723 EXPIRES: November 12, 2019 ?ji; , 0.. Bonded Thru Notary Pubfic Underwriters