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PL-18-50Miami 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 F VB2 019 as FBC 2014 3*tl BUILDING Master Permit No. i19 PERMIT APPLICATION Sub Permit No. [I,—_S d ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING MECHANICAL [-]PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 42-0 N E -1 ( ` — City: Miami Shores County: Miami Dade Zip: 3313b Folio/Parcel#: 1 )32Lf n 01C1o0 Q Is the Building Historically Designated: Yes NO ` Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): C11 I i _Phone#: Address.I D? ( (0`7 T City: �J Tenant/Lessee Name: Email State: EL- Zip: 33 UU-7 CONTRACTOR: Company Name: 7/1 T Z /LAd�G(,�� ;,f�� ,c/ Phone#: �— Address: %mac , :` - GU 3 - City: State: Yrz Zip: -93Ci a Qualifier Name: -47cIs Phone#: 4'riS 6' S'(A State Certification or Registration #: r. C_- / L� `ei g� Certificate of Competency M DESIGNE rchi Engineer: S:)d 8CO L/ y-A+ WbC ' Phone#: aS 4 -SiQd-14I J Address: ifA City: Ud 6A"1r •Statef],-_ Zip: 33c Value of Work for this Permit: $ ocl Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑Repair/Replace El Demolition Description of Work: Specify color of color tnru tne: Submittal Fee $ Permit Fee $ �' c CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ i TOTAL FEE NOW DUE $ i 1 Q— (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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: 1 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. OWNER or AGENT The foregoing instrument was acknowledged before me this day tof n�jf , 20 by ,1 Ki.Q 1, who e y know me or who has produced as identification and who did take an oath. NOTARY PUBLIC: �dkSig n: ram/ Print: IV Bby� Seal: APPROVED BY (Revised02/24/2014) Signature CONTRACTOR The foregoing instrument was acknowledged before me this _ day of .1 20 by w on=no me or who has produced s identification and who did take an oath. NOTARY PUBLIC: Seal: NATASHABOOKE % NATASML MY COMMISSION # GG 154422 MY COMMISSION4422EXPIRES: October 27,2021 'sP�? EXPIRES: Octo21lWtltf! ************* Plans Examiner Structural Review Zoning Clerk Miami Snores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE�OFCONTRACTOR RCHITECT Permit N. RC-6-17-1597 Owner's Name (Fee Simple Title Holder): Property Hounds LLC Owner's Address: 7021 Nw 67 CT City: Parkland Job Address (Of where work is being done):420 NE 91 ST City: Miami Shores Contractor's Company Name: Capote Plumbing Corp Address: 6811 SW 7 ST City: Miami Qualifier's Name: Omar Capote Architect/ Engineer of Record Name: Address: City: Describe Work: Plumbing per plans State : FL Phone #:954-520-2268 Zip Code:33067 State: —Florida Zip Code:33138 State: FL State: Phone #:305-788-1737 Zip Code:33144 Lic. Number: CFC1427737 Phone #: Zip Code: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the iami Shores harmless of all legal involvement. Signature /" /i Owner or Agent The foregoing instrument was aknowledged before me this Z day o ,20 by N ej?Wf5 Who ersonall k o me or who has produced Michael Rares Seal: k1k Signature F _ Contractor or Architect The foregoing instrument was aknowledged before me as indentification. NAI%.W BOOKS MY COMMISSION # GG 154422 'Ny "= EXPIRES: OcMw27.2021 'f,QR„ Bonded Ttru NOWY Pubic UrrdenerMere this 2 day of Feb. 20 by C& -'If o is personally known o me or who has produced Omar Capote as indentification. Notary �,�.�bli Sign: `iI��S1 Seal: NATASHA BOOKE MY COMMISSION # GG 154422 '•'± Pej= EXPIRES: October 27, 2021 ${!„'' Bonded Tteu t't "Pubrk Underwriters �` SHORES L�! 9 L� Erop �`CpRtdA Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit NO. PL-1-18-50 Permit Type: Plumbing - Residential Per I t Work Classification: Addition/Alteration Permit Status: APPROVED Parcel Number Issue Date:1119/2018 1 Expiration: 07/18/2018 Applicant 420 NE 91 Street 1132060190070 Miami Shores, FL 33138- Block: Lot: PROPERTY HOUNDS LLC Information PROPERTY HOUNDS LLC 420 NE 91 Street MIAMI SHORES FL 33138- 7021 NW 67 Court PARKLAND FL 33067- Contractor(s) Phone Cell Phone CAPOTE PLUMBING CORP (305)588-9917 Type of Work: 4 BATHROOMS, KITCHEN, LAUDNRY AND Type of Piping: Additional Info: Bond Return : Classification: Residential Scanning: 3 Fees Due Amount CCF $8.40 DBPR Fee $7.35 DCA Fee $4.90 Education Surcharge $2.80 Permit Fee $490.00 Scanning Fee $9.00 Technology Fee $11.20 Total: $533.65 (954)520-2268 Valuation: $ 14,000.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # PL-1-18-66071 01/19/2018 Check #: 1089 $ 483.65 $ 50.00 01/08/2018 Check#: 1231 $ 50.00 $ 0.00 Avanaoie 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 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. Futhermore, I authorize the above -named contractor to do the work stated. January 19, 2018 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy January 19, 2018 1 DATE (MM/DD/YY) 01/17/18 -4� �® CERTIFICATE OF LIABILITY INSURANCE PRODUCER Florida Bankers Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 6874 SW 8 ST HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305) 266-6493 Fax (305) 262-0679 INSURERS AFFORDING COVERAGE NAIC # INSURER A. UNITED STATES LIABILITY INSURAN INSURED CAPOTE PLUMBING CORP. INSURER B: 6811 SW 7 Street INSURER C: MIAMI, FL 33144 INSURER D: (305) 266-3618 INSURER E: COVERAGES INSURERF: J THE POLICIES OF INSURANCE LISTED 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ _ INSRI ADD'L TYPE OF INSURANCE POLICY NUMBER LTR INSRD _. _ 'POLICY EFFECTIVE POLICY EXPIRATION j DATE (MMIDDIYY)TDATE�MMIDD/VY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE 1,000,000.00] ❑— COMMERCIAL GENERAL LIABILITY ❑❑ CLAIMS MADE W OCCUR ❑ ❑ GENT AGGREGATE LIMIT APPLIES PER 0 POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ ❑ SCHEDULED AUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS El �n GARAGE LIABILITY ❑ ❑ ANY AUTO EXCESS/UMBRELLA LIABILITY ❑ ❑ OCCUR ElCLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under 1 SPECIAL PROVISIONS below OTHER DAMAGE TO RENTED 100,000.00 CL-1795410 02/18/17 02/18/18 PREMISES (Ea occurence) MED EXP (Anyone person) 5,000.00 PERSONAL & ADV INJURY 1,000,000.001 { GENERAL AGGREGATE 1,000,000.001 PRODUCTS - COMP/OP AGG 1,000,000.00I COMBINED SINGLE LIMIT (Ea accident) I BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG _ 1 EACH OCCURRENCE AGGREGATE I ❑ WC STATU- ❑ OTH- TORY LIMITS ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE I E.L. DISEASE - POLICY LIMIT DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS L # CFC1427737 CERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 AVE MIAMI SHORES, FL. 33138 ACORD 25 (2001/08) CIF CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE © ACORD CORPORATION 1988 Miami Shores Village RECE,V ED Building Department fAN082017 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 IL{ QA BUILDING Master Permit No. RC-6-17--1597 PERMIT APPLICATION Sub Permit No. P.I O — !S_0 ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL [PLUMBING MECHANICAL ❑ ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 420 NE 91 ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-3206-019-0070 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Property Hounds LLC Phone#: 954-520-2268 Address: 7021 NW 67 CT City: Parkland State: FL Zip: 33067 Tenant/Lessee Name: Phone#: Email: /� • CONTRACTOR: Company Name: (; n ���� �f Phone#: Address: k'qGI -cce-) f City: dj%tqlwi State: /—C . Zip: Qualifier Name: 0y Ae_ �e�-6®%�� Phone#: State Certification or Registration #: ?/�3 / Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ N000 Square/Linear Footage of Work: Type of Work: ❑ Addition Q Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: Per Plans r '�-:, eckr c c.y e_r� L-k- C-ke r Specify color of color thru tile: Submittal Fee $ 0-0 Permit Fee $ u �. f CCF $ CO/CC $ Scanning Fee $ Radon Fee $ `' 9070 D B P R $ —i • 3r7 Notary $ Technology Fee $ Structural Reviews $ Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) ffs Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Zi 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. j;!Signature Signature 't OWNER or AGENT CONTRACT R The foregoing instrument was acknowledged before me this - 01— day of December 20 17 by Mdia . aare S wh !!!5� me or who has produced identification and who did take an oath. NOTARY Sign The foregoing instrument was acknowledged before me this _ day of December 20 17 by Q i 2PO-ffwho is personally known to me or who has produced �1 !Gen- & as identification and who did take an oath. NOTARY PUBLIC: Sign: A ki" Print: �o ••NAWPrint: :,: MY COMMISSION # GG 154422 ; �?`t` r NATASHA B001� Seal: `*: Seal: s+; MY COMMISSION# AA:� EXPIRES; October27, 2021 - 1522 OF °P8 BOl: ThN NOt uy Public Undeiwrtimra :,r�' oP EXPIRES: October 27, 2021 OF t t` Bonded This Nobly Pualp Undwffi m ####################################]####################################################################### APPROVED BY (—(�—� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) 6 e CONSTRUCTION INDUSTRY LICENSING BOARD �,�� 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 (850) 487-1395 CAPOTE, OMAR CAPOTE PLUMBING CORP 6811 SW 7TH STREET MIAMI FL 33144 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects.to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.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 Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! ;. STATE.OF FLORIDA R DEPARTMENT'OF•BUSINESS AND -� PROFESSIONAL°REGULATION, CFC142737 ISSUED:' 08/10/2016 ':.CERTIFIED PLUMBIN6a✓ONTRACTOR _ -.CAROT,.E,�OMAR`-`- =- CAPOTE PLUMBING CORP IS'CERTIFIED-underthe.provisions-of-Ch.489 FS. �•`"� �� ,ExpeeGCn tlate:;fAUG 31,.2018r Y L1608100001462 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY ,�....._,,•'"' ..—"-r.. _ _ STATE OF FLORIDA_-. -DEPARTMENT.O BUSINESS`.,AND PROFESSIONAL REGULATION --ate may~ CONSTRUCTIOWINDUSTRY LICENSING, BOARD ;'•` �`��`� `T c ' , \ 'The PLUMBING,CONTRACTOR---�.--- •" _ ." K, `,`�` `Ye. ., `x.`,`�� ` :°�1 _ - •Named'below.IS'CERTIFIED :l'Jnder the wislons°of:Cha ter 489,FS. Explration,date: AUGe31, 20i8 CAPOT.E=OMAR--_,-~-_—_,, CAPOTE,PLUMBING CO_-Rto- fi8-11,SV1! 7T,H STREE ..,� _,. MI'AfMI= -•� FN33'144"��+,-� _ --' o ,� 4 S • �.+�� _'�!-�. _may, --�. �- T_ r �, '-6 O. ,y.. Ws � �+. �CFC1427737� °'.- . f--...�`` ..,;; ►.' .�ti w. "� �'�;�. _ °-,.. ``,;1. � � `''�.-„'�` ��.,; ISSUED: 08110/2016 DISPLAY AS REQUIRED BY LAW sEQ # L1608100001462 OO5ty6 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6295927 LBT BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES CAPOTE PLUMBING CORP RENEWAL SEPTEMBER 30, 2018 6811 SW 7 ST 6561790 Must be displayed at place of business MIAMI FL 33144 Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED CAPOTE PLUMBING CORP 196 PLUMBING CONTRACTOR BY TAX COLLECTOR CFC1427737 $45.00 08/09/2017 Worker(s) 1 CREDITCARD-17-053107 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 governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0, above must be displayed on all commercial vehicles - Miami -Dade Code Sec Ba-276. For more information, visit www.mismidade.gov/taxcollector s flips "Al ,,. ,4,L..4SS DRIVER U E C-136-11' fc,.h3-732-0 OMAR CAPOTE REYES 6811 SW 7 ST MIAMI, FL 331" Doe 08-12-1963 SEX 16-01-2012 M0014 x ' vex 3.12-2020 SAFE DRIVtk .., KM �ew.�rwutss e,w�w.r ro � �abYwv Na .wrw br i+.. JIMMY PATRONIS 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: 7/17/2016 EXPIRATION DATE: 7/17/2018 PERSON: CAPOTE OMAR FEIN: 262552341 BUSINESS NAME AND ADDRESS: CAPOTE PLUMBING CORP 6811 SW 7 ST MIAMI FL 33144 SCOPE OF BUSINESS OR TRADE: Licensed Plumbing Contractor Plumbing NOC and Drivers IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from 0ds chapter by fling 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 Bated 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 arty 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-F2-0WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 CAPOTE PLUMBING CORP 6811 SW 7 ST, MIAMI, FL 33144 (786) 788-1737 Date:12/22/2017 State of Florida County of Dade Before me this day personally appeared (oja CCX)ZftC, who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 420 NE X t— CSignature Sworn to ( or affirmed) and subscribed before me this 22- day of MCP, . 2017, By AMC C CCPDn-t-C Personally Known Or Produced Identification ve Type of Identification Produced Lv,P.W , JN;tbh�l Print, Type or Stamp Name of Notary HATA" BLOKE My COMM1WM # GG 154W ;Ipa: EXPIRES: October 27, 2021 Foo n° Bonded Tin Notary PuJ r: Underwft$ Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 k1 4c:L- n %A.- --I-- - -+ A - I'VNVG w vVV"gUi — YYVInC1� vVIf1JJt:I1,d41Vf1 Insurance Exempxion 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 2_ k_ day of _ 20 1 1 . a N as SEAL: •v?"E„ 1., NATA"BOOKE W COMMISSION # GO 154422 =": off EXPIRES: OCiobw 27, 2021 to me or has produced