DEMO-19-529Location Address
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date:
Parcel Number
243 NE 103RD ST, Miami Shores, FL 33138 1121360130410
Contacts
Permit NO.: DEMO -03-19-529
Permit TYPE: Demolition
Work Classification: Residential
Permit Status: Approved
Expiration: 09/09/2019
Inspection Requests:
Description: DEMO KITCHEN AND BOTH BATHROOMS Valuation: $ 1,500.00
Total Sq Feet: 550.00
Fees
BELLKRIS GROUP LLC Owner
243 NE 103 ST, MIAMI SHORES, FL 33138
Home: 7865396774
ALL STATE CONSTRUCTION GROUP CORP Contractor
RICHARD A RUBI
7420 SW 38 ST, MIAMI, FL 33155
Business: 7865479527
$50.00
Building Demoloition Fee
$250.00
Inspection Requests:
Description: DEMO KITCHEN AND BOTH BATHROOMS Valuation: $ 1,500.00
Total Sq Feet: 550.00
Fees
Amount
Application Fee - Other
$50.00
Building Demoloition Fee
$250.00
CCF
$1.20
DBPR Fee
$4.50
DCA Fee
$3.00
Education Surcharge
$0.40
Notary Fee
$5.00
Scanning Fee
$9.00
Technology Fee
$7.50
Total:
$330.60
Payments
Date Paid Amt Paid
Total Fees
$330.60
Credit Card
03/26/2019 $280.60
Credit Card
03/11/2019 $50.00
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 r uired for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWN R IDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regu t' struction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
Aut d gnature: Owner / Applicant / Contractor / Agent bate
March 26, 2019 Page 2 of 2
Ile Miami Shores Village RECEIVED
Xa1 Building Department MAR 11 2919
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 /�
�• Tel: (305) 795-2204 Fax: (305) 7S6-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2017:" c�7
BUILDING Master Permit No. �Jm� �9
PERMIT APPLICATION Sub Permit No.
!
UILDING F—]ELECTRIC E] ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL
F --]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS [:]CHANGE OF ❑ CANCELLATION ❑ SHOP
City: M (✓( KAj State:
Tenant/Lessee Name: Phone#:
Email: ��gL-L,l.() SS r=` �rR F�(crJ• C c��1
CONTRACTOR: Company Name: rt '2F-& -f- C'Mj%l2U('r1uJ L:((Uy Phone#:
:?313 -7
Address: ��(ZU S(nj 3y�❑
City: l A jk&k __ State: F, Zip:
Qualifier Name: IA41111w �Pug k Phone#: f%YV - 979
State Certification or Registration #: CA C 1c; z'4-1 3 Certificate of Competency #:
DESIGNER: Architect/Engineer:
one#:
Address: City: State: Zip:
Value of Work for this Permit: $ �J 'Square/Linear Footage of Work: s "ii
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Demolition
Description of Work: 2eMu K-lT -L-W It o k 1n -)3 A--t-h4
;4..i�•L�:
Sp&ify.color of.color thru tile:
'h
Submittal!Fee $ ',Q:^�t+ '", Permit�Fee $ 300 CCF $�0 CO/CC $ _
r,
Scanning Fee $ Radon Fee $ 3 DBPR $ . So Notary $
Technology Fee $ -7 • S Training/Education Fee $ `IZ-: o Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(Revised02/24/2014)
CONTRACTOR
DRAWINGS
JOB ADDRESS: �F.
b3"n S C -
City: Miami Shores
County:
Miami Dade
Zip: 3313c
Folio/Parcel#:
Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
Construction Type:
Flood Zone:
BFE: FFE:
OWNER: Name (Fee Simple Titleholder): 6A,
, L'L�
Phone#: -79C4 S-37 C- i % t%
Address: Ul() NE 30�ro
g- Ur jf- 0&(23
City: M (✓( KAj State:
Tenant/Lessee Name: Phone#:
Email: ��gL-L,l.() SS r=` �rR F�(crJ• C c��1
CONTRACTOR: Company Name: rt '2F-& -f- C'Mj%l2U('r1uJ L:((Uy Phone#:
:?313 -7
Address: ��(ZU S(nj 3y�❑
City: l A jk&k __ State: F, Zip:
Qualifier Name: IA41111w �Pug k Phone#: f%YV - 979
State Certification or Registration #: CA C 1c; z'4-1 3 Certificate of Competency #:
DESIGNER: Architect/Engineer:
one#:
Address: City: State: Zip:
Value of Work for this Permit: $ �J 'Square/Linear Footage of Work: s "ii
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Demolition
Description of Work: 2eMu K-lT -L-W It o k 1n -)3 A--t-h4
;4..i�•L�:
Sp&ify.color of.color thru tile:
'h
Submittal!Fee $ ',Q:^�t+ '", Permit�Fee $ 300 CCF $�0 CO/CC $ _
r,
Scanning Fee $ Radon Fee $ 3 DBPR $ . So Notary $
Technology Fee $ -7 • S Training/Education Fee $ `IZ-: o Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(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: 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.
9
Signature ��
Signature
OWNER or AGENT CONTRACTOR
The foregoing instrument J
was acknowledged before methis
day of Q"0Y \ 20 `�I . by
t--tC C, -MV 2eI I;�wf5^1' o is personally known to
me or who has produced H 1 ( CQ.t'15 as
identification and who did take an oath.
NOTARY
`.tPpV PUg' MAHARAI K. GONZALEZ
Sig a°:
MY COMMISSION # GG 044602
s. r
Print: %;F'o'dF o' Bonded ThruNotaryPublirUnderNriters
The foregoing instrument was acknowledged before me this
da of /QAC 20 � `3 by
V- I br► I ho is personally known to Ll�
me or who has produced ARIVCQS QC6G t/S'c as
identification and who did take an oath.
NOTARY PUBLIC:
Print:
Seal: Seal: � �IN
411
�a w�
' /NV%
APPROVED BY v� Plans Examiner
Structural Review
(Revised02/24/2014)
Notary Public State of Floritle
Lizeth Eneida Hemandez
My Commission GG 188904
Expires o3103/2022
**
Zoning
Clerk
(( OMB Approval No. 2502-0265
�
44 ' �� o W� A. Settlement Statement (HUD -1))
h oil DMFS
Previous editions are obsolete 1 ge I of I 02NA DAPIZY&YSIC-8, no. 3 763-5555 -Lamer Ow.mied HUD -1
I. QFRA 2. DRHS 3. 0Conv, Unins,
6. File Number
7. Loan Number
8, Mortgage Insurance Case Number
4. QVA 5. onv. Ins,
1812483
03 a cr line 1400
C. NOTE; This rm is funis a to
"(
glue you a statement o al actusettlement costs. Amounts paid to an y the sett ement agent ares own,
Items marked .o, c.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals,
D. NAME OF BORROWER:
BELLKFJS U KOUT; L '
ADDRESS OF BORROWER:.
E. NAME OF SELLER:
'7851 SW 105thAvenue'-MIAMI,FL'33173
SECRETARY OF 115 -USING & URBAN DEVELOPMENT
105..
40 Marietta St. Atlanta, GA 30303
ADDRESS OF SELLER:
r<. NAME OF LENDER: .
BET -TER.. HOLDINGS, LLC
ADDRESS OFLENDER:
3282 W 53 STREET, SOCA RATON,1rL 33496
G. PROPERTY
243 NE 103 ST
Z
LOCATION,
MIAMI SHORES, FL 33138
$
PINNACLESERVICES
PH# (30E5) 4121181ENT
1069.I N.' UNDSERVICES_ .. .
LL DR , St7ITE 106, 3317b
PLACE 0U,:SE'1'TLEYfbl NTi
10691N.-IONDALL•DR.,.SUITE, 106, MIAMI, FL 33176
SETTLEMENT
465,49
Previous editions are obsolete 1 ge I of I 02NA DAPIZY&YSIC-8, no. 3 763-5555 -Lamer Ow.mied HUD -1
ct sales price 416,000.00
. Con "tot. sales price416,000.00
101 a onal r' 'rty
402,Personal proppm
03 a cr line 1400
13,267.0
1
105..
5:
Adjustments for. Items paid by seller iu ndvanee
Adjustments for items paid by seller in advance
10 Clt es
406 Qjy1town taxcs to
107, Cun t to
Co to
08. Assessments
465,49-
408 Assessments 2/1 /2 I9 0110 1
465,49
1'
:.
to
411,
112, to
412, o
120. Gross Amount Ane from borrower
429,732.49
420. Gross Amount Due To Seller
416,465.49
0:. Mmt :te a%$ ilf its � w r.• ,.., ,�,. - _ ����``-'"; . ^�,���
1�,,, ll...r7� i= t�>=;�'�,:;,r;»z•'.�, ' ? .� : �'�'`°,- -t'
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�'
, - _
�
201. DevoW of earnest
0
7
501, Fxccg deposit see lnstruc ons
202. PrIrtcl al amount ofnew ton 4
22 0 .00
502 Settlement ch r s to seller 1i 400
24
203. Existingto s taken sub'eetto
503. Existingtaken sub ectto
-204.504.
Pa offof first mattvale los '
205,
O5, P oli of second mortgage loan
a
250 0
507
250.00
2
508,
209:599.
209a '•
509s
20
09b
a �.. _ ' e ms=s' s c'?�=;�• 0 77 '.'` -
aFi" ::x_3s?�..:.'?Y'
LAI 9 r 0 „ tltli h
'�`R�._-' =- c..:.s.`�t.,�. 3 C : �: .n;,�"'two- q.
5.10. C'fVtown taxes t0
-
0, City -/ own: taxes O
211, County taxes /I o /15/2 19
1.155.26
511. Count e • 111/2019 -.2/15/2019
1,155.2
212 to-
•512. Assessme
213, to
513 to
l0 04 1
4 o
514.to
15. to
I
216, to
1 o
217
517,:.; • o
218
to'
219. to
519.. to
,lbtal AmMants Paid
k .o'r In RehAlf of b6rrower
-
325,405.26
• Total Redactions in' .'
Amount Doo Seller
36,410.43
*'QQa'iy'°'`s
301. Gros amount ue. onf' orrower (line 32,49
601. oss amount ue to se dr' tie
'-
,49
302; Less amounts.pAid byffor.borrower line 2201
325 405.26
602. Less reductions in"amoiint due seller fline 52
303. Cash 5D WPM [nTo . Borrower
104,327.23
b03. Cash' �Tol ElFrom .' Seller
_M6,410.43
380,055.46
Previous editions are obsolete 1 ge I of I 02NA DAPIZY&YSIC-8, no. 3 763-5555 -Lamer Ow.mied HUD -1
U.S. DF,PARTMFNT OF HOUSING AND URBAN DEVELOPMEtTT
SETTLEMENT STATEMENT PAGE
Page 2 of 3 1812483
�.
24
to 702i 12 480.00
s ,)n Pdid at SQUIemont
—960.00
y7' -
�� � � itr o - .
0
,Y•, .._ _-'^�_.._.::A.Tc,-��??':i.�j:_.. a �_ti �. i���.�,r:7-�:.::� _ �....-lC-�e_:�p.•..S.e�
a = o'an•.��.= -=�'t:�:�.� '�_.�o -.nom—-_,.�.m..:�.�,;: �,�+-.� �—�-�-A
1 LLC' $ rn
807. Your creditor char a ints for the specific
interest rate chosen $ • from GFE #2
Your ad'usted ori in tion c
ftom GFE #A
to
Mom GFE #3
'PE•#3
A06, Tax -gery to
om
om 3
nd
o.c. E9660.00 Buwi
_R09_ Loan Drip, Rt" to Seth
Hill
995,001
3,220.00
. S!`:.. w
Dom-.. : _
,t a.'.^. k� 1 ",.. r � 'ciay'-;`
Gf1i dE iV� •:,^cam-'1i._?C_- ..G::�
-5..:, z �n�•`y t_�_:• lt.
. MZi'v4'. i ss" �=mak _--':-.': T•.ci R '.'-1 w �s�'..e. _ u/�•"=^' Se �lcc._
— -- -
301, Dai} Interest char os from
o FE
2 i
om
Im,r .
. t W INEURAT CH from GFE # 11)
o -c. si s7zsa By.,)
0.to
� e o"os te� � t = .,.e
era•~j'::..,�,,w ��=- ;���= �:•-���::-:� s<x-::,�r�,,;� R ,. - — _
1001, Initial deposit r- r cs
from GFE #9) '
1002, Homeowner's
montb--S.
Mortgages
Gnus a c
10126. m
ber month $
1008.nth-
$
11009, ro ate
'- �_,P:,=.. �a�>. ?a.m„''c�;`,•:ri5�•�r'.. _.«w;:,s•., >• .,�i'rS,cs+,.:f. rF-, rte. __
1101, Title ccs d len is .title insurance 1,340.00
3 850.00
1103, Ownet C_pmmon5&=Jth
Land iffile int. Co. .(from 5)
2,175.00
49000
3K.0' 00 imE225:OD)+HndxALTAB,i-25.00•
”
416.00 O.O 1 Ends 13179.1.20.00;
1107. Agent's portion o the toW titt insurance
r 1 s6 5
1108, 1 nde i '1a ortion o
' e insur ce r• itm. 9 5
1 109, to
:11 t
1112. #o
113. to
1
1201. Government recading car 5
from GFE #7).u
1202
1203. ra er t es
0
2
-
1205,
0
S 0
12
$35.00
f -
_ ,ii;� - ._,'Zf.� �F'�T•< _et r; •.iy�_
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1301. R equirnrl garyineg that yon nnti
om G s 6)
slinp. far13021
to
130
eo.C.stn.is
130
2
I11
3
11
16
1308...
130
t
13,267.00
24,9b0,0U
Page 2 of 3 1812483
HUD -1 Settlement Statement Signature Page
Certification
I have carefully reviewed the HUD -1 Settlement Statement and to the best of
my knowledge and belief, it is a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction. I further certify that I
have received a copy of the HUD -1 Settlement Statement,
gLLLKRIS GROUP, LLC, a Florida SECREATARY OF HOUSING & URBAN
limited liab'' p DEVELOPMENT
B
Ilector o, anager orrower ,.,attorney in Fact Seiler
Itrysti,a os-Meriavr-, ! Borrower Seller
er
,Al
11 ttffrb
sVV
CRA L. BLANCO
�`�•�= NotaryPublic- StateofFlorlda
s COrnrillssiOn R GG 094385
MY Comm, ExFrres May 21, 2021
ficrtledthruu t "i0")KOWYAssn,
The HUD -1 Settlement Statement which .I have prepared is a true and accurate
account of this transaction. I have caused or will cause the funds to be disbursed in
accordance with this statement.
sP 1' TE ERVICES, LLC dba PINNACLE TITLE SERVICES
02/15/19
..ZLulemenc AgentDate
WARNING: It is a crime to knowingly make false statements to the United
States on this or any other similar form. Penalties upon conviction can include a fine
and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010.
F81
11211�83 Loan #: Mortgage Ins. Case #:
Lender's Closing Instructions
THIS LOAN MUST CLOSE WHEN SCHEDULED (AS DATED) OR CONTACT SETH HUBERMAN,
ESQ, FOR FURTHER INSTRUCTIONS
PLEASE FORWARD CLOSED LOAN PACKAGE TO:
SETH HUBERMAN
SETH HUBERMAN, P A
5439 NW 42 -AVENUE, SUITE 100
BOCA RATON, FL 33496
lfrrat closed, Pletwe return the wire promptly,
To:
Cim
Closing Date: frbmary 12,2012
Phone:
Disbursement Date: Fe 2,2Q19
Re:
Bell kris Groun LLC
243 SW 10311 StrrqJ
Payment Plan Type: Monthly
Interest Ratc i' a 1y 12%:$322,000
Title Co:
Sopiya's Title Services LLC
19691 N .Kendall Drive
Miami FL 33176
Leader: Bet -Tel Holdings. LLC
BORROWER MUST EXECUTE ALL DOCUMENTS AS THEIR NAME APPEARS, THE FINAL HUD -SETTLEMENT STATEMENT WILL
REQUIRE FINAL APPROVAL PR10R TO CLOSING,
Title Contpany &g trite and certify the Morlgage/Dees and Nates with u "fhg" aiguirwre—,so slumps please,
TITLC INSTRUCTIONS
A. As closing agent, you are authorized to disburse the net proceeds'delivered to you only when you are in position to comply with the
foilovring:
LENDER TITLE POLICY IS ISSUED.
B. TAXES: must indicate all taxes for the current year and subsequent years are not yet due and payable,
C. PROVIDE ENDORSEMENTS BELOW (IF APPLICABLE):
1) 8.1ENIRONML^'NTALPROTECTION LIEN
2) 5.1 PUD (IF APPLICABLE)
3) 4.1 CONDO (IF APPLICABLE)
4) ANY OTIiF.R STAT SPECIFIC REQUIREMENT OR ENDORSEMFNTTO CLEAR TITLE
D, All conditions, restrictive covenants, building lines, and violated easements must be reflected along with affirmative coverage against
monetary loss of forfeiture of Property.
E. INSURE OUR SECURITY INSTRUMENTS AS A VALID FIRST LIEN FOR THE AMOUNT OF THE PROPERTY DESCRIBED
THEREIN, NAMED THE INSURl3D/MORTGAEE AS FOLLOWS:
BET -TER HOLDINGS, LLC, AND OR ITS SUCCESSORS AND OR ASSIGNS AS THEIR INTEREST MAX APPEAR
THE FOLLOWING CONDITIONS MUST BE SATISFIED OR LOAN CANNOT CLOSE:
1, Clear Title: Pay all lions'attached to the subject property,
2, Tax liens for town, county and school as well as water and sewer rents are to be paid.
3. Delinquent taxes are to be paid.
4. Please make sure that the loss payeo clause on the evidence of hazard insurance reflects as: Bet -Ter Holdings, LLC, 3828 NW 5V
Street, BoLaRaton, FL 33496.
Article IV
The name and address of person(s) authorized to manage LLC
Title: MGR
HECTOR B BELLO
7851 SW 105TH AVENUE
MIAMI, FL. 33173 US
Title: MGR
KRYSTINA M BELLO
7851 SW 105TH AVENUE
MIAMI, FL. 33173 US
Article V
The effective date for this Limited Liability Company shall be:
01/28/2018
Signature of member or an authorized representative
Electronic Signature: HECTOR BRIAN BELLO
L18000029300
FILED 8:00 AM
February 01, 2018
Sec. Of State
cmwood
I am the member or authorized representative submitting these Articles of Or anization and affirm that the
facts stated herein are true. I am aware that false information submitted in a document to the Department
of State constitutes a third degree felony as provided for in s.817.155, F.S. I understand the requirement to
file an annual report between January 1 st and May 1 st in the calendar year following formation of the LLC
and every year thereafter to maintain "active" status.
Electronic Articles of Organization
For
Florida Limited Liability Company
Article I
The name of the Limited Liability Company is:
BELLKRIS GROUP LLC
Article II
L18000029300
FILED 8:00 AM
February 01, 2018
Sec. Of State
cmwood
The street address of the principal office of the Limited Liability Company is:
7851 SW 105TH AVENUE
MIAMI, FL. US 33173
The mailing address of the Limited Liability Company is:
7851 SW 105TH AVENUE
MIAMI, FL. US 33173
Article III
The name and Florida street address of the registered agent is:
HECTOR B BELLO
7851 SW 105TH AVENUE
MIAMI, FL. 33173
Having been named as registered agent and to accept service of process for the above stated limited
liability company at the place designated in this certificate, I hereby accept the appointment as registered
agent and agree to act in this capacity. I further agree to comply with the provisions of all statutes
relating to the proper and complete performance of my duties, and I am familiar with and accept the
obligations of my position as registered agent.
Registered Agent Signature: HECTOR BRIAN BELLO
All State Construction Group LLC
210 NW 871h Avenue
L214
Miami, FL 33155
Date: 2/25/2019
State of Florida
County of Miami Shores Village
Before me this day personally appeared F1 c-HAP-�> who, being dully sworn,
deposes and says:
That he will be the only person working on the project located at:
243 NE 1031d Street
Miami Shores, FL 33138
Contractor Signature
Sworn to (or affirmed) and subscribed before me this � 4 day of rUOdr . 20_1q
By L -2,tY-,
Personally Known
OR Produced Identification V-\ 06 -lam \ - of 2 - co 9 -o
Type of Identification Produced _1D V � V X-%-
410
'�" Notary Public State of Florida
. Lizeth Eneida Hernandez
I Y EExAirf* 03/03/2022 188804
+
Print, Type or Stamp Names of Notary
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
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.
Sign ur .
5
er
State of Florida
County of Miami -Dade (�� � /�
The foregoing was acknowledge before me this � day of O I 1/LJ 120 19
By VQSn
&q I 0 who is personally known to me or has produced
Jv as identification.
Notary:
SEAL: FF�
y"a MAHARAI K. GONZALEZ
MY COMMISSION # GG 044602
EXPIRES: November 2,2020
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MAR 11 2019
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Miami -Dade Official Records - Print Document
CFN 20190159817BOOK 31362 PAGE 2196
DATE:03/12/2019 04:04;57 PM
DEED DOC 2,496.00
HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY
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