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DEMO-19-1496Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit 'No : D1=N110-06-19-1496 Permit Type: Demolition Work Classiiiration Residential: Permit Status: Approm issueDate:07/16/2019'F Expiration: 01/13/2020 Location Address Parcel Number 967 NE 91ST TER, Miami Shores, FL 33138 1132060030030 Contacts R Description: DEMOLISH SMALL 10' AWNING ABOVE FRONT Valuation: $ 200.0Requests: 0 Inspection ection 762 4lR DOOR. PATCH STUCCO. NO STRUCTURAL WORK Total Sq Feet: 0.00 Fees COMMUNITY DEVELOPMENT FUND I REO Owner ELITON CONSTRUCTION CORP Contractor $50.00 LLC JOSE MENDEZ CCF 967 NE 91 1385 CORAL WAY SUITE 203, MIAMIF, FL 33145 $3.75 DCA Fee Business: 3053333953 Education Surcharge R Description: DEMOLISH SMALL 10' AWNING ABOVE FRONT Valuation: $ 200.0Requests: 0 Inspection ection 762 4lR DOOR. PATCH STUCCO. NO STRUCTURAL WORK Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 Building Demoloition Fee $50.00 CCF $0.60 DBPR Fee $3.75 DCA Fee $2.50 Education Surcharge $0.20 Scanning Fee $9.00 Technology Fee $6.25 Total: $122.30 Payments Date Paid Amt Paid Total Fees $122.30 Credit Card 06/28/2019 $50.00 Cash 07/16/2019 $72.30 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 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 corgt; Actor to do the work stated. Authorized Signature: Owner / Applicant / Contractor ! 4ent Date July 16, 2019 Page 2 of 2 BUILDING X\�\ Miami Shores Village RECEIVED Ju 2 8 zo�9 Building Department BY: 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 Tt+ INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 201 Master Permit NoIPWO - W - 96 PERMIT APPLICATION BUILDING ❑ ELECTRIC ❑ ROOFING Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL [_]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: N V-- 1 I k T -e -f City: Miami Shores County: Miami Dade Zip: 33 13 9 Folio/Parcel#: 3 2-0G oo0 > - 40 30 Is the Building Historically Designated: Yes \/_L NO Occupancy Type: Load: Construction Type: B`U Ck Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):( OmmUylitV �\jgA0 tiyl� TUvt8'1 14\)5 Phone#: 3(�' (o��O -O� „'�. Address: ZO}s o'CJCxr 3R0kCA(\ 6\16. 5"r.Q . too City: '4&A AO 1p)kc& �A State: (I Zip: 90 2 �-g Tenant/Lessee Name: \31k Phone#: Email: CONTRACTOR: Company Name: ! ll hOn Con GO ,fP Phone#: Address: 13F-5 (--,) q y sr�1 #Zoe City: / State: �L Zip: Qualifier Name: _ )OSS A.. ��/1 //G� Phone#: ,30S .3� 3 3q�3 State Certification or Registration #: e-86 /7_ 6 ZO_SD Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 2P/O Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New 11Repair/Replace Demolition Description of Work: 11.evv�i �lsi - � 'V\m A\ooV TI i'On-� � _ o,`�CN� R Specify color of color thru tile: ' i '• s Submittal Fee $ ' Permit Fee $ CCF $ -...,. - VCO/CC $�.. Scanning Fee $ Radon Fee $ DBPR $ Notary $/ Technology Fee $ Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ ouble Fee Bond $ TOTAL FEE NOW DUE $ 2- ' 30 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 s Application4s 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 anAa reinspection fee will be charged. OWNER or AGENT The foregoing instrument was acknowledged before me this Q(tO day of f��Q� ,20 10 by -fn)�t who is personally known to me or who has produced identification and who did take an oath. NOTARY U LI Sign: The foregoing instrument was ackno tTdged before me this )�O day of �p ,/� v Y) -P-20 G by SOSV, _A. I�IQ,1 I l.� who'is personally known to as me or who has produced as identification and who did take an oath. NOTARY PUBL : Sign: Print: Print: Seal: „pY N`B,, SH EYLA i Seal: I_ � �,; State of Florida -Notary Public • Commission # GG 146739 j =•". My Commission Expires i November 11, 2019 **s*****sss*ssssss*ssssssss s*sssssssssssssssssssss*ss**sssssssssssssssss*s**ss***ssssss*sssssssssss*sssss*s I�% L APPROVED BY � Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ;r ;State of Florida -Notary Public �• •_ Commission # GG 146739 My Commission Expires ` '••a i� �� November 11, 2019 **s*****sss*ssssss*ssssssss s*sssssssssssssssssssss*ss**sssssssssssssssss*s**ss***ssssss*sssssssssss*sssss*s I�% L APPROVED BY � Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application - Miami -Dade County Page 1 of 2 OFFICE OF THE PROPER TY APPRAISER Summary Report Property Information Folio: 11-3206-003-0030 Property Address: 967 NE 91 TER Miami Shores, FL 33138-3219 Owner COMMUNITY DEVELOPMENT FUND I REO LLC Mailing Address 2015 MANHATTAN BEACH BLVD STE 200 REDONDO BEACH, CA 90278 USA PA Primary Zone 0900 SGL FAMILY - 1901-2100 SQ Primary Land Use 0101 RESIDENTIAL -SINGLE FAMILY: 1 UNIT Beds / Baths / Half 2/2/0 Floors 1 Living Units 1 Actual Area 2,461 Sq.Ft Living Area 1,880 Sq.Ft Adjusted Area 2,015 Sq.Ft Lot Size 11,188.41 Sq.Ft Year Built Multiple (See Building Info.) Assessment Information Year 2019 2018 2017 Land Value $301,771 $301,771 $301,771 Building Value $154,268 $155,437 $156,606 XF Value $22,472 $22,518 $22,564 Market Value $478,511 $479,726 $480,941 Assessed Value $478,511 $293,241 $287,210 Benefits Information Benefit Type 2019 2018 2017 Save Our Homes Cap Assessment Reduction $50,OOOF $186,485 $193,731 Homestead Exemption $237,210 $25,000 $25,000 Second Homestead Exemption $25,000 $25,000 $25,000 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description PL OF BISCAYNE RIDGE PB 39-41 LOT 3 & E22.06FT OF LOT 4 LESS N7.5FT BLK 1 LOT SIZE 75.090 X 149 OR 20742-1215 09 2002 1 Generated On : 6/28/2019 Taxable Value Information Previous 2019 2018 2017 County Exemption Value $0 $50,OOOF $50,000 Taxable Value 1 $478,511 $243,241 $237,210 School Board Exemption Value $0 $25,000 $25,000 Taxable Value $478,511 $268,241 $262,210 City Exemption Value $0 $50,000 $50,000 Taxable Value $478,511 $243,241 $237,210 Regional Exemption Value $0 $50,000 $50,000 Taxable Value $478,511 $243,241 $237,210 Sales Information Previous OR Book - Price Description Sale PageQualification 07/25/2018 $100 31080-1337 Corrective, tax or QCD; min consideration Corrective, tax or QCD; min 06/21/2018 $100 31038-2967 consideration Corrective, tax or QCD; min 06/15/2018 $100 31039-4815 consideration Federal, state or local government 06/04/2018 $426,100 31003-4771 agency 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 Countv assumes no liability, see full disclaimer and User Aareement at httr)://www.miamidade.aov/info/disclaimer.asD https://www8.miamidade.gov/Apps/PA/propertysearch/ 6/28/2019 Detail by Entity Name Page 1 of 2 Flonda Department of Slate DIVISION OF CORPORATIONS Department of State / Division or Corporations / Search Records / Detail By Document Number / Detail by Entity Name Foreign Limited Liability Company COMMUNITY DEVELOPMENT FUND 1 REO, LLC Filing Information Document Number M16000001852 FEI/EIN Number 81-0777971 Date Filed 03/03/2016 State DE Status ACTIVE Principal Address 2015 MANHATTAN BEACH BOULEVARD SUITE 100 REDONDO BEACH, CA 90278 Changed: 04/12/2017 Mailing Address 2015 MANHATTAN BEACH BOULEVARD SUITE 100 REDONDO BEACH, CA 90278 Changed: 04/12/2017 Registered Agent Name & Address COGENCY GLOBAL INC. 115 NORTH CALHOUN STREET SUITE 4 TALLAHASSEE, FL 32301 Authorized Person(s) Detail Name & Address Title Manager Wedgewood, LLC 2015 MANHATTAN BEACH BOULEVARD STE 100 REDONDO BEACH, CA 90278 Title Manager HMC Assets, LLC http://search. sunbiz. org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 6/28/2019 Detail by Entity Name 2015 MANHATTAN BEACH BOULEVARD STE 200 REDONDO BEACH, CA 90278 Annual Reports Report Year Filed Date 2017 04/12/2017 2018 03/13/2018 2019 04/29/2019 Document Images Page 2 of 2 04i29/2019 -- ANNUAL REPORT I View image in PDF format 03i13/2018 -- ANNUAL. REPORT View image in PC7F format 04!12/2Q.7 _ANNUr1L ftEP01tT, View image in PDF Formal 03!0312016 -- Foreign Limited View image in PDF format .onda Oepa:. nient . St—, r Co, p—t.on> http://search. sunbiz.org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 6/28/2019 TRUST AGREEMENT for the Community Development Fund I Trust among Community Development Fund I, LLC, a Delaware limited liability company as Depositor Wells Fargo Bank, N.A., as Paying Agent and Wilmington Savings Fund Society, FSB d/b/a Christiana Trust, as Certificate Trustee and Delaware Trustee Dated as of January 6, 2016 TRUST AGREEMENT FOR THE COMMUNITY DEVELOPMENT FUND I TRUST THIS TRUST AGREEMENT (the "Trust Agreement"), dated as of January 6, 2016 among Community Development Fund 1, LLC, a Delaware limited liability company, as Depositor (the "Depositor '), Wihnington Savings Fund Society, FSB, d/b/a Christiana Trust ("Christiana Trust" and in its capacities as certificate trustee and Delaware trustee, the "Certificate Trustee" and "Delaware Trustee", respectively) and Wells Fargo Bank, N.A., a national banking association, as paying agent (not in its individual capacity but solely as paying agent, in such capacity, the "Pgying Agent'). WITNESSETH: It is the intention of the parties hereto that this Trust Agreement provide for (a) the conveyance of Transferred Assets to the Trust and (b) the issuance of one or more Trust Certificates evidencing the beneficial ownership of the Trust. The terms and provisions of this Trust Agreement will govern the Trust and the Trust Certificates. The Depositor shall cause Transferred Assets, described more fully in the related Asset Transfer Notice, to be delivered to the Custodian on behalf of the Trust, and the Depositor will receive the Trust Certificates issued under this Trust Agreement from the Certificate Trustee evidencing the entire beneficial ownership interest in the Trust. In consideration of the mutual agreements and covenants herein contained, the parties hereto hereby agree for the benefit of each of them and the Holders of the Trust Certificates as follows: ARTICLE I DEFINITIONS SECTION 1.1 Capitalized Terms. For all purposes of this Trust Agreement, the following terms shall have the meanings set forth below: "Administrators" shall mean the Persons designated on Schedule 1 attached hereto, who shall serve as the Administrators for the Trust created hereunder, solely in each such Person's capacity as Administrator of the Trust and not in such Person's individual capacity, or such Administrator's successor in interest in such capacity, or any successor appointed as herein provided. Schedule l may be amended or modified at any time by the Majority Certificateholders, who shall forward a copy of the amended or modified Schedule 1 to the Trustees and the Paying Agent; provided that neither of the Trustees nor the Paying Agent may be named an Administrator without its express written consent. "Affiliate" shall mean, with respect to a specified Person, any other Person who (a) directly or indirectly controls, is controlled by, or is under common control with, such Signature Page to Trust Agreement for Coninumity Development Fund l Trust 5: to establish and maintain the collection accounts pursuant to Section 5(b) of the Master Repurchase Agreement (the "Collection Accounts"); 6. in the event of a liquidation and dissolution of the Trust, to make a liquidating distribution in respect of the Certificates; 7. to own, hold, service, sell, assign, transfer, pledge, finance, borrow against, grant security interests in, encumber or otherwise exercise ownership interests with respect to the property described in Section 2.3(a)(4); 8. to make certain covenants to the Buyer pursuant to the Master Repurchase Agreement; 9. to pledge, assign and hypothecate to the Buyer and to grant to the Buyer a first priority security interest in (A) the Mortgage Loan Assets, (B) the Collection Accounts, all amounts deposited therein, any investments held therein, and all income, revenues, issues, products, revisions, substitutions, replacements, profits, rents and all cash and non-cash proceeds of the foregoing; and 10. to negotiate, authorize, execute, deliver, assume the obligations under, and perform, any agreement, instrument or document relating to the activities set forth in clauses (1) through (9) above, and to engage in any other acts and activities and to execute any powers permitted to statutory trusts under the Statutory Trust Act that are incidental, advantageous or necessary to the foregoing. 11. to issue the Trust Certificates pursuant to this Trust Agreement; and 12. to engage, on behalf of the Trust, in those activities, including entering into, executing, delivering, and performing its obligations under this Trust Agreement and such other agreements, documents and other writings that are necessary, suitable or convenient to accomplish the foregoing or are incidental thereto or connected therewith- (b) herewith (b) and the Administrators shall have power and authority, and each is hereby authorized and empowered, in the name and on behalf of the Trust, to do or cause to be done all acts and things determined by the Administrators to be necessary, appropriate, or convenient in exercising the authority and power, express or implied, otherwise granted to the Trustees or the Administrators, as the case may be, under this Trust Agreement, and to perform all acts in furtherance thereof, including without limitation the following: 1. to enter into, execute, deliver and perform its obligations under the Basic Documents to which the Trust is a party; 2. to enter into, execute, deliver and perform its obligations under the Facility Documents, any amendments thereto and any related agreements to which the Trust is a party; 0 3. to sell or dispose of the Trust Estate in whole or in part and to acquire and manage Assets in the Trust Estate through foreclosure or otherwise, in each case at the direction of the Owners; and 4. to engage in those activities, including entering into, executing, delivering, and performing its obligations under, agreements, documents and other writings that are necessary, suitable or convenient to accomplish the foregoing or are incidental thereto or connected therewith, unless otherwise directed in writing by the Holders. The Trust is hereby authorized to engage in the foregoing activities. The Trust shall not engage in any activity other than in connection with the foregoing or other than as required or authorized by the terms of this Trust Agreement or the Basic Documents. SECTION 2.4 Appointment of Trustees, Authority. The Depositor hereby appoints Wilmington Savings Fund Society, FSB, d/b/a Christiana Trust, as Delaware Trustee and as Certificate Trustee of the Trust effective as of the Closing Date for the Trust, to have all the rights, powers, authority, authorization and duties set forth herein. SECTION 2.5 Transfer of Transferred Assets to Trust Estate. On the related Transfer Date, the Depositor shall cause the assignment, transfer, conveyance and setting over of the Transferred Assets to the Trust. Except as may otherwise be directed by Depositor, such transfer of Transferred Assets will be effected by delivery of the asset files relating to the Transferred Assets to the Trust or the Trust's designee which may be the Custodian on behalf of the Trust. The Depositor shall pay organizational expenses of the Trust as they may arise or shall, upon the request of a Trustee, promptly reimburse such Trustee in its individual capacity for any such expenses paid by such Trustee in its individual capacity. At least two (2) Business Days (or such lesser time as is acceptable to the Trustees) prior to the related Transfer Date, the Depositor shall deliver an Asset Transfer Notice to the Trustees and the Paying Agent identifying the Assets to be transferred to the Trust on the related Transfer Date, and such other information as may be required for the proper administration of the Trust by the Trustees. In connection with the issuance of the Trust Certificate, on or after the initial Transfer Date, the Depositor shall sell, assign, transfer, convey and deliver or cause to be sold, assigned, transferred, conveyed and delivered to the Trust all of the Depositor's right, title and interest in, to and under the Transferred Assets under an. Assignment and Assumption Agreement. Except as to the representations and warranties in the Master Repurchase Agreement, such transfer and conveyance is made without recourse to the Depositor. The parties hereto intend that the, sale, assignment, transfer, conveyance and delivery- of the Transferred Assets shall make the Transferred Assets part' of the Trust Estate. As of the Transfer Date, or such later date as the foregoing sale, assignment, transfer, conveyance and delivery is completed, and thereafter, the Custodian shall hold the Transferred Assets in trust for the Trust and shall act only in accordance with the terms of the Custodial Agreement. SECTION 2.6 Declaration of Trust; Creation of Trust; Pledge of Trust Certificates; Release Notice. (a) The Certificate Trustee hereby declares that it will hold (directly or through the custodian or the Trust's designee) the Trust Estate for the Trust in trust upon and 10 IN WITNESS OF, the parties Hereto have caused this Trust Agreement to be duly executed by their respective officers hereunto duly authorized, as of the day and year first above written. COMMUNITY DEVELOPMENT FUND I, LLC, a Delaware limited liability company, as Depositor By: Falcon Ventures, LLC a Delaware limited lAility comps as a Manager By v Gregory L. qieistr, Manager Signature Page to Trust Agreement for Community Development Fund I Trust SCHEDULEI LIST OF ADMINISTRATORS 1. Wedgewood, a California corporation; and 2. HMC Assets, LLC, a California limited liability company COMMUNITY DEVELOPMENT FUND I TRUST 2015 Manhattan Beach Boulevard Suite #100 Redondo Beach, CA 90278 Phone: 310-640-3070 Facsimile: 310-640-3090 To Whom It May Concern, This letter is to name Jose Marichal as our local representative and authorize him to sign on our behalf for the following property: 967 NE 91 TER Miami Shores, FL. If you should have any questions or concerns please contact me at 310-640-3070. 7Sincl re Y, Gregory L Geiser President RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY FI 'da pr STATE OF FLORIDA DEPARTMENT OF BUSINESSA -PROFESSIONAL REGULATION CONSTRUCT IC; SANG BOARD THE BUILDIN ,- C. ` =R'aE, OR.. REI & I-SCERU t THE VNDER PROVIS : OF°CI T_ER 89.-,F RID'A'�STATUTES EF,,Eµ J' :ANx j �P� ELI E . CONST l�C- F10. N CO.I P 9 3 ,441 O�RALi, A UITE 2 3= 'C*► MFAM1 ;:F ,33=145 LIENSEN. MBE i9kBC;26 0 EXP IRATIOIr1iEEICJG.UST 31, 2020 Always verify licenses online at MyFloridaLice nse.com ♦ Do not alter this document in any form. This is your license. It is unlawful for anyone other than the licensee to use this document. a�* ��Wu Local Business Tax Receipt Miami—Dade County,' State of Florida -THIS IS NOT A BILL -DO NOT PAY 7248789 BUSINESS NAME/LOCATION ELITON CONSTRUCTION CORP 1385 CORAL WAY STE 203 MIAMI FL 33145 OWNER EUTON CONSTRUCTION CORP C/O JOSE ANTONIO MENDEZ RECEIPT NO. • RENEWAL 7535321 LBT EXPIRES SEPTEMBER 30, 2019 Must be displayed at place of business Pursuant to County Code Chapter SA - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SUB -GENERAL BLDG CONTRACTOR PAYMENT RECEIVED CBC1262050 BY TAX COLLECTOR Worker(s) 1 -:).00 07/24/2018 CHECK21-18-073418 This Local Business Tax Receipt only confirm gAment of the Local Business Tax. The Receipt isnot a license, permit or a eertiflcatien of the holder: s ue�if'icahons, to do business. Holder must comply with any governmental er nongovemmemal regulatory lays and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles - Miami -Dade Code Sec ga-276. For more Information, visit Www miamideds oov/laxc lii *WNW., 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: 5/11/2018 PERSON: JOSE A MENDEZ JR FEIN: 821127920 BUSINESS NAME AND ADDRESS: ELITON CONSTRUCTION CORP 1385 CORAL WAY SUITE 203 MIAMI, FL 33145 SCOPE OF BUSINESS OR TRADE: Licensed Building Contractor Contractor -Project Manager, Conatnxxion Executive, Construction Manager or Construction Superintendent EXPIRATION DATE: 5/10/2020 EMAIL: JOSEAMENDEZ@BELLSOUTH.NET 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 shag 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 lime for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609 Elliton Construction Corp 1385 Coral Way Ste 203 Miami, FL 33145 Lic. CBC1262050 Date: State of Florida County of Miami -Dade Before me this day personally appeared Jose A. Mendez who, duly sworn, deposes and says: That he will be the only person working on the project located at 967 NE 91 TER Miami Shores, FL Sworn to (or affirmed) and subscribed before me this 10 day of d � f��- 2019. Personally known Or produced identification Type of identification produced SHEYLA WINTER State of Florida -Notary Public Commission # GG 146739 o.r My Commission Expires November 11, 2019 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' Comaensation 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 -rime 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 -rime employees or subcontractors for your project. The contractor has provided an affidavit staring 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 BELO YO CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: k' ner State of Florida County of Miami -Dade The foregoing was acknowledge before me this a- day of , 20 By e & who is personally known to me or has produced as identification. Notary: _° ,A State of Florida -Notary Pcbli SEAL: = Commission 8 GG 146739 r �.` My Commission Expires or F` November 11, 2019 Miami shores Village' Building Department CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. ✓ COPY OF QUALIFIER'S STATE LICENCES 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 B. ✓ COPY OF LOCAL BUSINESS TAX RECEIPT C. OPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ........................................................................................... BUSINESS NAME: BUSINESS ADDRESS: BUSINESS PHONE: ( CELL PHONE ( QUALIFIER'S LIC NUMBER: CITY_ FAX NUMBER (� QUALIFIER'S NAME: STATE ZIP RECIVED JU 2 8 2A19 FLAT ROOF PfrCHED TRE ROOF 967 NE 91 TER SFR RESIDENCE NE 91 TER ILLEGAL AWNING TO BE REMOVED, WHOLES TO BE PATCHED UP WITH CEMENT AND STUCCO :.J.*: Y• 0000 00.00 •0•••• • I • • w••• 0000•• • 0000 • •• • 0000•• • •• 0000• • •• • 0000• •• • 0000•• • • • • •••6•• 0000•• 0699 ...... ...�.. ...... • � � � Y • • •��• • � ! � � • • • • • Y � 1 f • • • O � � � •