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PL-19-971Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 1191 NE 103RD ST, Miami Shores, FL 33138 rentactc Permit NO.: PL-05-19-971 PGt- Permit Type: Plumbing - Residential Work Classification: Addition/Alteration Permit Status: Approved issue Date:12/27/2019 ( Expiration: 06/24/2020 Parcel Number 1122320310050 COBIA LLC Owner EDWARD ROJAS PLUMBING CORP Contractor 8045 NW 155 ST, MIAMI LAKES, FL 33016 EDWARDO ROJAS Mobile: 7869994855 880 NE 111 ST, BISCAYNE PARK, FL 33161 Business: 3059446788 EDDIE.ROJAS@HOTMAIL.COM Home: 7864439846 Description: REPLACE TOILET, SINK, FAUCET, VANITY,SHOWER Valuation: $ 2,750.00 Inspection Requests: PAN LINES,SHOWER VALUE AND PLUMBING FIXTURES IN 305-762-4949 MASTER AND GUEST BATHROOMS Total Sq Feet: 1,800.00 REPLACED WITH PL-8-18-2245 Fees Amount Application Fee - Other $50.00 CCF $1.80 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.60 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $111.90 Building Department Copy Payments Date Paid Amt Paid Total Fees $111.90 Credit Card 12/27/2019 $111.90 Amount Due: $0.00 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 zon/g. F ermore, I authorize the above named contractor to do the work stated. Authorized Siqnatur wner /' Applicant / Contractor / Agent Date December 27, 2019 Page 2 of 2 _ Miami Shores Village RECF-BVEDMAY 02 `019 Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 047 Tel: (305) 795-2204 Fax: (305) 756-8972 �� INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20 P n BUILDING Master Permit No. I�-c- C) S I PERMIT APPLICATION Sub Permit No. Q 1 - OS - 1 q ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [—]RENEWAL ®PLUMBING ❑MECHANICAL ❑PUBLICWORKS JOB ADDRESS: 1191 NE 103 ST ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: 11-2232-031-0050 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): COBIA LLC Phone#: Address: 8045 NW 155 ST Citv: MIAMI LAKES Tenant/Lessee Name: Email: State: FL Zip: 33016 Phone#: CONTRACTOR: Company Name: EDWARD ROJAS PLUMBING Phone#: Address: 880 NE 111TH ST City: BISCAYNE PARK State: FL Zip: 33161 Qualifier Name: EDWARD ROJAS Phone#: State Certification or Registration #: CFC049431 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 2 _4C_:0 ' 03 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ® Repair/Replace ❑ Demolition Description of Work: REPLACE TOILET, SINK, FAUCET, VANITY, SHOWER PAN LINER,SHOWER VALVE AND` PLUMBING FIXTURES IN MASTER AND GUEST BATHROOM. REPLACE KITCHEN SINK. -t—C) 11a lA� LRA 1 � PL-,, O — I f — 22�5 Specify color of color thru the: Submittal Fee S Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $_ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ I I •� O (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 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. 0 Signature Signature OWNER or AGE CONTRACTOR The foregoing instr ment was acknowledged beforemethis The foregoing instrument was acknowledged before me this day of (VICI�i 20 -1 by 3� day of -R Q L 120 1 `1") . by AAAMD&I r-Y-Z , who is personally known to kot-JA -C o:fh� who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: ew QI Seal ********* 'L as me or who has produced identification and who did take an oath. NOTARY PU ��rDIA/AUMMIr_ i■ t' .1AW Seal: Notary Putplic Stela of Fbride Camila Arrerre dondo My Commission GG 262408 Expires 00/26/2022 APPROVED BY � 7 /�� Plans Examiner o�yr Pu'- •., GRECIA M. BERMUDEZ :. Notary Public State of Florida •'P; Commission N GG 305273 My Comm. Expires Mar 3, 2023 * * *,e *,dsi�dR� #�ir;Rt1I'ii�lAi �Rk?IiY*'�39 Structural Review as Zoning Clerk (Revised02/24/2014) k Notice to Owner — Workers' Corn Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 nsation Insurance Exemation 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. t Signature: All caner State of Florida County of Miami -Dade The foregoing was acknowledge before me this � day of , 20_ft_ 14 bhAL: who is personally known to me or has produced 6cation. =F-Vpires b of c do C ?��2? Edward Rojas Plumbing 880 NE 111 St Biscayne Park, FI 33161 LLC 049431 Date: State of R d Vl CMG County of Before me this day personally appeared F wctyd to\G&S who being duly sworn, deposes and says: That he or she will be the only person working on the roject located at: Sworn to)( or affirmed) and subscribed before me this day of n 7 20J�_, by Oct-rAtd g�� OR Produced Identification Type of Identification Produced ANA LUISA PARRILLA s fit, Notary Public - State of Florida . ; � ; • , Commission # GG 090452 r • My Comm. Expires Apr 21, 2021 Bonded through National Notary Assn. OAO Print, Type or Stamp Name of Notary Miami 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 AUG 2 018 _- FBC 20 BUILDING Master Permit No. WZIA —Z03s PERMIT APPLICATION Sub Permit No. 4— zz4S ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL >ePLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: IN oc 103 P-0 S� City: Miami Shores County: Miami Dade zip: 33�3�3 Folio/Parcel#: 4/- 27_ 722Q 71,-- QO Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): LgpG7- A LRa /( 0(71A LLZ-- Phone#: Address: 9 5 j)w 15 :fB �-r City: hlAr11 State: FL_ Zip: 330((Q Tenant/Lessee Name: Phon Email: CONTRACTOR: Company Name: x ADA Al M 61 N 6 60/?_ Phone#:.305- Zr S _ Address: l� �J �� s-w 1"2 f L City: State: L Zip: 33 / Qualifier Name: U ne#: State Certification or Registration #: C F-C le/ 2 9/ FZ Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ © Square/Linear Footage of Work:gb Type of Work: ❑ Addition ❑ Alteration ❑ New � Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Sd Permit Fee $ d 20 - ` CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE $ 214,03 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 charge Signature _ O NER or AGENT The <foorpgoing instrument was acknowledged before me this C day of 20 g by 1kA �9 Z who is personally known to me or who has produced�`�\��V1ls identification and who did take an oath. d. 14N6lei/11(/ a 18I 'r- Signature a W, CONTRACTOR The foregoing instrument was acknowledged before me this o� 7 day of �l�k-I 120 by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: NOTARY PUB Sign: (7Sign: Print: 1..� W\ ko ' ^(YP� �1�( �_ Print: ;,��•Y?, d Camt]a ArredoncPo Seal: ;io r;=rorr,nisior #'ri 163102 Seal: SEP 2h, 2018 OF 5ONTFD T H R U 1 ST F LO R DA N OTARY, LLC ****************************************************************** APPROVED BY O/ �� Plans Examiner Structural Review k Notary Public - State of Florida Commission # FF 992406 My Comm. Expires Sep 6, 2020 Bonded through National Notary Assn. as Zoning Clerk (Revised02/24/2014) Notice to Owner — Workers' Com Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Flori795 3138 2238 Tel: (305) Fax: (305) 756.8972 nsation Insurance Exem 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: er State of Florida County of Miami -Dade (� I The foregoing was acknowledge before me this -1 day of,,Fk►�(i �(1� , 20 It By &)o 1, Lw�Z who is personally known to me or has produced -�•:._..,...as.identif acs n. GRECIA M BERMUDEZ Notary: `_ MY C MMISSION # FF205487 " EXPIRES March 03. 2019 SEAL: 140•'1391i-0'61 FlontlaNnEa•ySevK2u.rr AOR PLUMBING CORP 24/7 Plumbing & Drain Cleaning Service ADR PLUMBING CORP 17313 SW 142nd PL Miami, FL 33177 Phone: (305) 215-9749 STATE LIC # CFC 1429182 Date: 9 Ia I I g State of County of Before me this day personally appeared L.4 � �k � 1 ��r who, being duly sworn, deposes and says: I, Angel Miguel Jr. will be the only person working on the project located at: N6- 103 5 T, 41'AMi S#d �S, rL �;3/ 3 Contractor Signature t Sworn to (or affirmed)and subscribed before me this 17 day of 201?' , by P1C-- Personally know, OR Produced Identification Type of Identification Produced Print, Type or Stamp Name of Notary ,, WILMARIEROSA °� ...k MY COMMISSION #GG061908 iEXPIRES: MAR 13, 2021 01°P1� Bonded through 1st State Insurance A+* "� CERTIFICATE OF LIABILITY INSURANCE DATE 018 07/16/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARTA ALONSO NAME: PHONE , (305)266-6493 ac No): (305)262-0679 Florida Bankers Insurance -NAIL mart♦@floridabankersinsurance.com ADDRESS,Miami, 6874 SW 8 ST INSURERS AFFORDING COVERAGE NAIC k FL 33144 INSURER A: TORUS NATIONAL INSURANCE COMPANY Phone (305) 266-6493 Fax (305) 262-0679 INSURED INSURER B : INSURER C : ADR PLUMBING CORP. INSURER D : 17313 SW 142 PI Miami FL 33177 INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD UBR POLICY NUMBER POLICY EFF MM DD POLICY EXP MM D LIMITS A COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE OCCUR ❑ Y N PCA5043-PC25228 12/30/2017 12/30/2018 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000.00 MED EXP (Any one person) $ 5,000.00 ❑ PERSONAL 6 ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: �/❑ POLICY ❑ PRO- ❑ JECT LOC ❑ OTHER GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS ❑HIRED AUTOS NON -OWNED ❑ AUTOS ❑ ❑ OMBINED SINGLE LIMIT Ea ac ident BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DIED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑ STATUTE ❑ OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED ON THIS POLICY CERTIFICATE HOLDER CANCELLATION Miami Shores Village BLDG DEPT 10050 NE 2nd AVE, Miami Shores, FL 33138 ACORD 25 (2014/01) OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �I 0 RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY db'pr h STATE OF FLORIDA DEPARTMENT OF BUSINES�A 40zRROFESSIONAL REGULATION CONSTRU THE PLUMBI PROVIS G BOARD C�TOR H,ER�1 r1S CERT,IFIEE) UNDER THE _ "V PTER:489,=F ORiDA SI"ATUTES EXPIRATION D-.- E•'AU,GUST 31, 2020 Always verify licenses online at MyFloridaLicense.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. 1 005602 Local Business Tax Receipt --- Ntiarrr'r=Dade County, State of Florida THIS IS NOT ABILL - DO NOT PAY 7178829 &USINESS NAME/LOCATION . AlkliUMBING CORP 17313 SW 142 PL MIAMI FL 33177 -1EXPIRES` -- RENEWAL SEPTEMBER 30, 2018 7459033 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED ADR PLUMBING CORP 196 PLUMBING CONTRACTOR C/O ANGEL MIGUEL JR CFC1429182 BY tax COLLECTOR Worker(s) 1 $75.00 07/25/2017—,,_ .�- . CREDITCARD-17-050025` 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 holder's qualifications, to do business. Holder must comply. with any governmental or nongovernmental regulatory laws and requirementswhich apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec Se 276. For more information, visit www miamidade go A§MQllector 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: 11/29/2017 PERSON: MIGUEL FEIN: 472181415 BUSINESS NAME AND ADDRESS: ADR PLUMBING CORP 17313 SW 142ND PL MIAMI FL SCOPE OF BUSINESS OR TRADE: Licensed Plumbing Contractor 33177 EXPIRATION DATE: 11/29/2019 ANGEL JR 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 shall 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 time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609