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PL-19-250Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address �;D Ifu1jLL Issue Date: 02/14/2019 Parcel Number 59 NE 101ST ST, Miami Shores, FL 33138 1132060131540 Contacts Permit NO.: PL-02-19-250 Permit Type: Plumbic - Residential Work Classification: Septic Permit Status.* Approved Expiration: 08/13/2019 CHARLES KILLINGSWORTH Owner 59 NE 101 ST, MIAMI SHORES, FL 33138 ALFONSO SEPTIC CONTRACTOR INC Contractor JOSE BOLANOS 1391 W 36 ST, HIALEAH, FL 33012 Business: 7862514099 Inspection Requests: Description: INSTALL NEW 900 GALLONS SEPTIC TANK & 200 Valuation: $ 4,800.00 Ins ction Re SQFT OF DRAIN FIELD TO REPLACE PERM IT#PL 18-1495 49 TotalSq Feet: 0.00 11 Fees Amount 50% Renewal Fee $84.00 Notary Fee $5.00 Total: $89.00 Payments Date Paid Amt Paid Total Fees $89.00 Cash 02/05/2019 $50.00 Credit Card 02/14/2019 $39.00 Amount Due: $0.00 Building Department Copy 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 tha all the oing information is accurate and that all work will be done in compliance with all applicable laws regulating con4truction and zoning. Yitherm e, I authorize the above named contractor to do the work stated. Authorized February 14, 2019 nt /' Contractor / Agent Date Page 2 of 2 r Miami Shores Village CV'ivF'D Building Department FE 05 2919 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 �� INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 � � BUILDING Master Permit NofuO,z—!cf-2,13�) PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL [:]PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP rr CONTRACTOR DRAWINGS JOB ADDRESS: � � W 6_1 10(Sf City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is theBuildingHistorically Designated: Yes NO 01, Occupancy Type: Load: Construction Type: R-e0'1►- Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder)ICI-V ft R t¢-S OIRI Phone#: 2C6 -,7 `� - OVD7� Address: S g- N L • iDI -ST City: He A, K4 S P& rte S State: Alk-- Zip: Tenant/Lessee Name: Email: Phone#: CONTRACTOR: Company Name: p (CyIUSb �C e- t'�P& �6 LC&I Phone#: %F66251-40011 Address: '/c�Ci� Wa-ST �� Sr /f City: �t/State: L��i�- Zip: _`g 3 drZ Qualifier Name: 90 �1a r^ _k:) Phone#: ?gG- ZS 4-�10 ZQ State Certification or Registration #: �,d�� 27 Certificate of Competency #:SA .0 DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Zip: Value of Work for this Permit: $ � CSC/ Square/Linear Footage of Work: .CW Type of Work: ❑ Addition ❑ Alteration ❑ New 14 Repair/Replace ❑ Demolition Description of Work: l r(%� j ,►Z �( Kl C)E,`�i I S� �Tlc V h �-� !�! 1��J�'�l �� r it Specify color of color thru tile: Submittal Fee $ 50. Permit Fee CCF Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ ! LJV (Revised02/24/2014) 1% 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: 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 on 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 Signature OWNER or AGENT CO TRACTOR The foregoing instrument was acknowledged before me this day of re 6 /C. (k t- 20 , by e-� II,1 �iCW4,1w ho is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Seal: ;�i JOSE BOLANDS MY COMMISSION 8 GO 231457 =? Ps EXPIRES: October 8, 2022 ....... 'r ElftW 7Ixu Natery Pubk IJnduw Mn as Th foregoing instrument1was acknowledged before me this day of j`EL'Q� �`? 20 1 by who is personally known to me or who has produced as identification and who did take an oath. NOTARY P' BLIC: Sign: Print: c� NCI P�l1P�� Seal: APPROVED BY (S / [ Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) 2/4/2019 Property Search Application - Miami -Dade County A, OFFICE OF THE PROPERVY APPRAISER Summary Report Property Information Folio: 11-3206-013-1540 Property Address: 59 NE 101 ST Miami Shores, FL 33138-2318 Owner CHARLES G KILLINGSWORTH Mailing Address 59 NE 101 ST MIAMI, FL 33138 USA PA Primary Zone 1000 SGL FAMILY - 2101-2300 SQ Primary Land Use 0101 RESIDENTIAL -SINGLE FAMILY: 1 UNIT Beds / Baths / Half 2/1/0 Floors 1 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 2,101 Sq.Ft Lot Size 11,500 Sq.Ft Year Built 1929 Assessment Information Year 2018 2017 2016 Land Value $287,615 $287,615 $287,615 Building Value $119,766 $119,883 $119,999 XF Value $41,506 $42,016 $42,525 Market Value $448,887 $449,514 $450,139 Assessed Value $317,242 $310,717 $304,327 Benefits Information Benefit Type 2018 2017 2016 Save Our Homes Assessment Cap Reduction $131,645 $138,797 $145,812 Homestead Exemption $25,000 $25,000 $25,000 Second Homestead Exemption $25,0001 $25,0001 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES SEC 1 AMD PB 10-70 LOTS 19 & 20 BILK 11 LOT SIZE 100.000 X 115 OR 15704-2069 1092 1 PROB:04-1790-CP-03 Generated On : 2/4/2019 Taxable Value Information 2018 2017 2016 County Exemption Value $50,000 $50,000 $50,000 Taxable Value $267,242 $260,717 $254,327 School Board Exemption Value $25,000 $25,000 $25,000 Taxable Value $292,242 $285,717 $279,327 City Exemption Value $50,000ES%E $50,000 Taxable Value $267,242 $254,327 Regional Exemption Value $50,000 $50,000 $50,000 Taxable Value $267,242 $260,717 $254,327 Sales Information Previous OR Price Book- Qualification Description Sale Page 01/18/2011 $337,000 27586 Qual by exam of deed 4947 01/18/2011 $100 27586 Corrective, tax or QCD; min consideration 4945 10/01/1992 $120,400 15704- Sales which are qualified 2069 12/01/1991 $0 00000- Sales which are disqualified as a result of 00000 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 sHO1s °�t Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795 2204 ��ORtDp` Permit No. PL-5-18-1495 Permit Type: Plumbing - Residential Per ' Work Classification Septic Permit Sratus: APPROVED Issue Date: 616/2018 1 Expiration: 12/03/2018 Project Address Parcel Number Applicant 59 NE 101 Street 1132060131540 Miami Shores, FL 33138- Block: Lot: CHARLES KILLINGSWORTH Owner Information Address Phone Cell CHARLES KILLINGSWORTH 59 NE 101 Street MIAMI SHORES FL 33138- 59 NE 101 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone ALFONSO SEPTIC CONTRACTOR INC (786)251-4099 Type of Work: INSTALL NEW 900 GALLONS SEPTIC TANK Type of Piping: Additional Info: INSTALL NEW 900 GALLONS SEPTIC TANK Bond Return : Classification: Residential Scanning: 1 Fees Due Amount Bond Type - Contractors Bond $500.00 CCF $3.00 DBPR Fee $4.50 DCA Fee $3.00 Education Surcharge $1.00 Notary Fee $5.00 Permit Fee $300.00 Scanning Fee $3.00 Technology Fee $4.00 Total: $823.50 Valuation: _ $ 4,800.00 Total Scl Feet: 200 Pay Date Pay Type Amt Paid Amt Due Invoice # PL-5-18-67764 05/31/2018 Credit Card $ 50.00 $ 773.50 06/06/2018 Credit Card $ 773.50 $ 0.00 Bond #: 3790 Available Inspections: Inspection Type: HRS Approval Final 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 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. _5uthermore, I authorize the above -named contractor to do the work stated. June 06, 2018 Signafbre:Owner / Applicant / Contractor / Agent ilding D artment Copy 1 Miami Shores Village l9\ Ste. Building Department �i- 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING Master Permit No I WAYI18 FBC 2011 �' L ` ? L 1% Ms PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING (-� REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP DRAWINGS CONTRACTOR JOB ADDRESS: � (I Q � 10I . City Miami Shores County Miami Dade Zip: f Folio/Parcel#: I &! -2 Xo D 12 (S(l (7 Is the Building Historically Designated: Yes NO Occu anc T e: Load: Construction Type: PiuNbFlood Zone: 8FE: FFE: P Y Yp OWNER: Name (Fee Simple Titleholder): J Address: 1 N r City: M (L 61% State: F`— Tenant/Lessee Name: Email rv`ci► l 6 Ca✓vt Phone#: ,. _ _I_ _ . CONTRACTOR: Company Name:�QLQ naE^� �'�&'�Phone#: 'Q�M _ Address: i1 3 "! , (.U� S t �C� 7 14,61.0-C JJ- r'ji �� _Zip: City: �C;Q �l- State: �_-! �' I'f' N FLO qua i ier ame. - - - - State Certification or Registration #: S Q (2 % 6, Certificate of Competency #: t l l � S7G DESIGNER: Architect/Engineer: Phone#: Address: f, City: State: Zip: Value of Work for this Permit: $ '7 SDDO Square/Linear Footage of Work: 9 W Type of Work: ElAddition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 1 (U (A-1� 1'a �.Q (.� �� ' ��0� SQ C C T UDC P1L-11 c-2 2 Specify color of color thru tile: Submittal Fee $ i Permit Fee $ :300CCF $ DBPR $ Scanning Fee $ Technology Fee Structural Reviews $ (Revised02/24/2014) Radon Fee $ Training/Education Fee $ CO/Cc $ Notary $ Double Fee $ Bond $ 1vv `O TOTAL FEE NOW DUE $y ::� --1 'S' S� 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 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 &IN� OWNER or AGENT The foregoing instrument was acknowledged before me this t,,,\ day of tA- ° ck'� 20 by C-bvy i who is personally known to me or who has produced identification and wh NOTARY PUBLIC: t Sign: (40 use Print: Seal: as MARIE JOSEE TAPIA MY COMMISSION #FF146953 EXPIRES July 31, 2018 Y-'-14.- NTRACTOR TXe"foregoing instrument was acknowledged before me this 3� day of_\\\ka 20 19,) by 'e 01 alk0S who is personally known to e or who has produced as identificati n a wh did take a ath. NOTARY P BLIC: Sign: Print: Seal: PRIEZ .- MY COMMISSION # FF 214031 'a EXPIRES: March 25, 2019 F';i1;k1-",Rended l hru NotaiY Public Underwriters ************************************************************* APPROVED BY Plans Examiner ************ Zoning Structural Review (Revised02/24/2014) Clerk M STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT SYSTEM CONSTRUCTION PERMIT AND DISPOSAL CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Charles Gkillingsworth PROPERTY ADDRESS: 59 NE 101 St Miami. FL 33138 PERMIT # : 13-SC-1847764 APPLICATION # : AP 1344926 LOT: 19 20 BLOCK: 11 SUBDIVISION: Miami Shores Section 1 PROPERTY ID #: 11-3206-013-1540 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1117530 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD NEW SEPTIC TANK TO INSTALL CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps D [ 200 ] SQUARE FEET R [ 0 ] SQUARE FEET A TYPE SYSTEM: [s] I CONFIGURATION: [ ] N NEW D.F BED CONFIGUR SYSTEM STANDARD TRENCH [ ] FILLED [x] BED SYSTEM [ ] MOUND [ ] F LOCATION OF BENCHMARK: FFE 12.83' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 23.801 INCHES FT ][ ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 65.801 INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 54.00] INCHES O T H E R 1.- Install a 900 gal. septic tank with an approved filter 2.- Install 200 sf. of drainfield in ... BED...... configuration. 3.- Install 12" of slightly limited soil at the bottom of the drainfield. 4.- Invert elevation and Bottom of drainfield to be no less than 7.85' & 7.35' NGVD respectively. 5.- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or trench. 6.- Existing slightly limited soil at the botton of the drainfield to remain. Any spoil material within 24" vertically that has visible signs of effluent shall be removed as part of the repair. (Comments Continued on Page 2.) SPECIFICATIONS BY: Jose Bolanos APPROVED BY: DATE ISSUED DH 4016, 08/09 Incorporated: TITLE: Registered Septic Tank Contractor TITLE: Engineering SpecD I Dade Frank ras Florida -Dade County 05/17/2018 S T.D.S. P E: 08/15/2018 (Obsoletes all previous editions which may not be e 64E-6.003, FAC Page 1 of v 1.1.4 AP134492 ti CHD DOCUMENT #: PR1117530 The system is sized for 2 bedrooms with a maximum occupancy of 4 persons (2 per bedroom), for a total estimated flow of 300 gpd. The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s. 64E-6.013(3)(0, FAC. Required drainfield area based on rule 64E-6.015(6)(c)2. Install a new drainfield to achieve Drainfield size requirement. NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a 'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. ' LOT- 6 LOT-5 O BLOCK -11 BLOCK -11 O 11 20.W 0"CL GARAGE 0 N 250' 20-W sr 30.1U• S LOT -18 N BLOCK -11 i 7_ ONE STORY 0.66 -- c RES. # 1g820 w c - LOT -19 0.67 Ga �� 64.85' LOT-3 BLOCK -11 90.14-19•' A i 0.30CL 10.82 �— X P 3'so, T1 O - r' --- _-T BR�GK_- - &10.65 7. LOT - 20 BLOCK -11 I of .. F.F.E =12.8T 2.W $o 28.15' 10.85 X BL DCK 11 co z -/j w �- J Q cc G) u J z 4 L .�_ 20'C z z p - O Lij [.0 o w z E-- z fk sr t z W w c� < o N o m m Q U) U) BEIM1�so= J M• 11 II ��t•!tA MaME MINE •�� r��l mm - • • • • • • • • • • • •• •• • • • •• •• ••• • • • ••• • • STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR CONSTRUCTION PERMIT Permit Application Number ---------------------------PART II - SITEPLAN--------------------------- Scale: Eacb,block represents 10 feet and 1 inch = 40 feet. MINE Notes: E"JI, UIds S! J-(1 12(b) 3t�� Site Plan submitted by: Plan Appr Not Appfbvely" ' • Date County Health Department ALL CHANGES MUST BE APPROVM*BY•THE (:(DQ .TY HVPLTH DEPARTMENT DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 2 of 4 (Stock Number: 5744-002-4015-6) "• ' • • • ••' • ' • •• •• • • • •• •• ••• • • • ••• • • Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Uwner — 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this _2:7 day of I L2 ti p , 20LT11_. By �'�.� Tkl (l l Ki!� SCI,t� aM who is personally known to me or has produced Notary: tta',' Y,0202 as identification. DOSE BOLA — MY COMMISSION 0 FF 15M EXPIRES: October 8, 2o18 Bonded TAN Notary Pobrc lhMEtM'I'ftm Alfonso Septic Contractor, INC. 1391 West 36 Street Hialeah, FL 33012 Alfonsoseptic@gmail.com Date: May 312018 State of Florida County of �j g�i Dade Before me this day personally appeared Jose Bolanos who, being duty sworn, Deposes and says: That he or she will be the only person working on the project located at: 59 NE 101 ST S Miami Shores FLA. Contractor ignature Sworn to (or affirmed) and subscribed before me this S� day of Q&A .20� bY s O�AriD \ Personally Know OR Produced Identification Y Type of Identification Produced i r""my +C�Qi1SK of Notary :o YANADY PRIETO .., MY COMMISSION # FF 214031 _. zz EXPIRES: March 25, 2019 ';QV : oo F;°.�'PWary Thru ery PuElic UndenvrAers