Contractor Registration Form
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS’ REGISTRATION
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. _______COPY OF QUALIFIER’S STATE LICENCES
B. _______ COPY OF LOCAL BUSINESS TAX RECEIPT
C. _______COPY 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
C 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: ________________________________CITY________________ STATE_______ ZIP__________
BUSINESS PHONE: (_______) ___________________ FAX NUMBER (______) ___________________
CELL PHONE (______) _________________ QUALIFIER’S NAME: _________________________________
QUALIFIER’S LIC NUMBER: _________________________________________________________________________
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.
Signature: __________________________________
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this _______ day of _________________ , 20_____.
By__________________________________________ who is personally known to me or has produced
_____________________________________ as identification.
Notary:____________________________________
SEAL:
COMPANY LETTER HEAD
Date:
State of __________________
County of _________________
Before me this day personally appeared _______________________ who, being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
____________________________________________________
______________________________
Contractor Signature
Sworn to (or affirmed) and subscribed before me this ____ day of ________________. 20___,
by _______________________
Personally know_____________
OR Produced Identification_____________
Type of Identification Produced _____________
________________________________________
Print, Type or Stamp Name of Notary