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EL-19-1740Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address mmu Issue Zate: Parcel Number 9315 N MIAMI AVE, Miami Shores, FL 33150 1132060130360 Contacts Permit No.: EL.-07-19-1740 Permit Type: Electrical • Residential Work classification: Alteration Pemzitrswtus Approved Expiration: 02/04/2020 MAXWELL MILLER Owner SECURE TECHNOLOGIES INTEGRATORS Contractor 9315 N MIAMI AVE INC. SYED KAZIM 17690 S DIXIE HIGHWAY UNIT B, MIAMI, FL 33157 Business: 7865739081 Description: CHANGE AC OUTLETS, REMOVING OLD WIRES AS Valuation: $ 2,500.00 Inspection Requests: NEEDED. r 762-4949 TotalSq Feet: 13.75 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 Payments Date Paid Amt Paid Total Fees $111.90 Check # 8652 07/29/2019 $50.00 Credit Card 08/08/2019 $61.90 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: 1 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulatinMconstruction and zoning. Futhermore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date August 08, 2019 Page 2 of 2 Miami Shores Village cEiv� Building Department �u 2 220119 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 , INSPECTION LINE PHONE NUMBER: (305) 762-4949 BY. `lam BUILDING PERMIT APPLICATION ❑BUILDING "ELECTRIC ❑ ROOFING � FBC 20 It Master Permit No. - I— U—� q^ 1b-13 Sub Permit No.T--,— (S:� - q " 1� REVISION EXTENSION DRENEWAL PLUMBING MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS: j/L.. 4A— WIN Folio/Parcel#: i 1 �� P , 1 3y3� Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): Ah-j p&J P 1 t kA CM A SCI ICI h 1.01 M"hone#: ) •3� 1 _ C1 D � � 51 L4 CC - Address: (� .�> X S Q, M 1 U yUM 6V'L City: _%l� G State: Zip: �3 ►�1 Tenant/Lessee Name: T / Phone#: Email: may -We my-w1>Ilt�t/ CONTRACTOR: Company Name: ECG '�Z�f'✓DC �7J � iE 31 Phone#: Address: l 7l0 d L City: "/ / State: Zip: Qualifier Name: J V L-3? L Phone#: 7-26 State Certification or Registration #: c (f / 300 i3 S/ Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: Address: City: State: o-o Value of Work for this Permit: $ -;2S-b O Square/Linear Footage of Work: 2S Type of Work: ❑ Addition —Alttelration ❑ New R[ Repair/Replace ❑ Demolition Description of Work: ( ,1aly' /T-c 1)c tt—rc' Ur i &-a tol&'er Specify color of color thru tile: Submittal Fee $ 0 Permit Fee $ Scanning Fee $ _ Technology Fee $ Structural Reviews $ Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ 4T 0 (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. Signature I \ 1 Signature OWNER or AGENT CONTR CTOR The foregoing instrument was acknowledged before me this 10 day of 20 19 by who is personally known to me or who has produced �-" Mg6Q-6S 1-T 3oV-o as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: l OVU o•r,;,,, FLORA MAD .� e Seal: ;io its State of Florida Notary Publi Commission # GG 38399 My Commission Expires October 13, 2020 APPROVED The foregoing i ment was acknowledged before me this I (7 day of S' 1 V 20 19 by 'S`Lkorq 2- who is personally known to me or who has produced 17 L K250 G J- SO- 4 tj 3 identification and who did take an oath. NOTARY PUBLIC: Sign: 7 Print: Seal: 10 Vu 11"PM P„ :° °State of Florida -Notary Public •= Commission # GG 38399 My Commission Expires October 13, 2020 l� CT411, V Plans Examiner Zoning (Revised02/24/2014) Structural Review Clerk M Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (30.5) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:. A. t/ COPY OF QUALIFIER'S STATE LICENCES B.y1 COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. _� COPY OF WORKERS COMPENSATIONINSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATEOFCOMPETENCY: 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 ofoperations or contractor license number. ■■a aaaaaaaaaaaaaaaaaaaaaa�a�aaaaaaaaa a aaaaaara•a■aaaaraaaaa�aaaaaaaaaaaaaaaaaa a aaaaaaaaaa■ BUSINESS NAME: 9t-Ga %tc— BUSINESS ADDRESS:17L q 6 9• 0r K le- ANY CITY � STATE P ZIP 3 BUSINESS PHONE: CZ?6 �— 7 3 ':�i O 2 t FAX NUMBER (7 1 S—7-7;, `3 6 CELL PHONE ( )- -3 19 QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: f�G 0 0 7-3 57 MCX SCUM GOVERNOR JONATHAN ZA00A SECRETARY STATE OF FLORlDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREINIS CERTIFIED UNDER THE PROXASIONS OF CHAPTER 489, FLORIDA STATUTES KA -1M, SYED K SECURE TECHNOLOGIES INTEGRATORS INC. 17690 SOUTH DIXIE HIGI=1WA`! UNIT B MIAMI FL 33157 LICENSE NUMBER: EC13007351 EXPIRATION DATE-, AUGUST 31, 2020 ,ems ys verity iScenscs c nri .nt.. NtyFloridaLicense..rnm n -a Do not alter this document in any form. QThis is your license. It is unlawful for anyone other than the licensee to use this document Local Business Tax Receipt Miami —Dade County, State of Florida THIS IS NOT A SILL-00 NOT PAY 6394282 BUSINESS NAOA1Elt.00AMCM SECURE TECHNOLOGIES INTEGRATORS INC 17M S DIXiE HWY B PALMETTO BAY, FL 33167 OWNER SECURE TECHNOLOGIES INTEGR INC Wotws) 7 TW61acal LBT APT 1140- EXPIRES R84BNAL SEPTEMBER 30, 2019 6MI939 Must be d spbMW at place of business Pursuant to County Code Chapter SA — Art. S & 10 SEC. TYPE Of BUSINESS PAYUgUT RECEPJW 196 SPEC ELECTRICAL BY TAX COLLMTOR CONTRACTOR 45.00 07117/2018 EC13CM727 CREDITCARD-18-064865 �._—..r.—war—t.1flmtaimet.gj3aG=TWLTba11=6 tISrotaitasase. gnrauGwuwuuw......w..... tiW3aadr�pb��Ytodrobasisess. esuosgwat I Cede see samVE Sbal1>CBPT0. Rabosa meat ba dezed ao emnmeroiai vehicles— liWed-Oads A OR130 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/10/2019 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 have ADDITIONAL INSURED provisions or 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 NAME: Verbert Anderson ON PNNo,E . (305) 253-7555 A/c No): (786) 536-7924 J.V. INSURANCE AGENCY ADORess: jvantwun@bellsouth.net 10755 SW 104th Street INSURERS AFFORDING COVERAGE NAIC p INSURERA: CENTURY INSURANCE GROUP Miami FL 33176 INSURED INSURERB: ASCENDANT INSURANCE INSURERC: SECURE TECHNOLOGIES INTEGRATORS INC INSURER D : 16290 Aladdin Blvd. INSURER E : INSURER F : Miami FL 33187- 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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 ADDL SUER POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 3,000,000 CLAIMS -MADE � OCCUR _7RENTED IMAGE TO ccuence PREM SES Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 3,000.000 A Y Y USA 4180018 07/10/2019 07/10/2020 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000.000 POLICY ❑ PRO- JECT ❑ LOC PRODUCTS -COMP/OPAGG $ 3,000.000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE L MIT Ea accident $ BODILY INJURY (Per person) $ 100,000 X ANY AUTO B OWNED SCAUTOS HEDULED AUT OS ONLY Y CA-47766-0 07/18/2018 07/18/2019 BODILY INJURY (Per accident) $ 300,000 PROPERTY DAMAGE Per accident $ 100,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTIVE - PER OTH- STATUTE ER E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? F N/A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is been named as additional insured with respect to General Liability Secure technologies Integrators Inc. EC #13007351 30 days written notice of cancellation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores Village Building Dept. AUTHORIZED REPRESENTATIVE 10050 NE 2nd Ave. Miami FL 33138 J� _� - •., @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD — J 0 A►�COR� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIMNYYY) 06/17/2019 THIS CERTIFICATE IS ISSUED AS A MATTEROFINFORMATION 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 have ADDITIONAL INSURED provisions or be endorsed. It 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 enddrsement(s). PRODUCER PAYCHEX INSURANCE AGENCY 150 Sawgrass Drive Rochester, NY 14620 CONTACT CNAME __................ ..... .._.___..._� PHONE FAx (IA/C, No): _ _.�._... EMAIL _ ADDRESS INSURER(S)AFFORDING __-_COVERAGE _ NAIG YS iNSURERA: NorGUARD Insurance Company 31470 INSURED Secure Technologies INTEGRATORS INC INSURER B: _.....__ �_....___. INSURER C INsuRI RP: 17690 S DIXIE HIGHWAY INSURERE: _.__._........_.__ _......._._...... Miami, FL 33157 INSURER F : rn;icoer_cc i^t~RTIFIrarF 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. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. IN8R3 L5U8R'----LLPOLICY EFF rPCILICX P f LIMITS LTR I TYPE OF INSURANCE lPOLICY NUMBER MMIDOM MMIODlYY I COMMERCIAL GENERAL LI481UTY EACiH OCCURRENCE S O CLAIMS -MADE OCCUR •Uit1MAGmmES'�REi+tTED PREMISES Fa oo urrence $ 0 MED EkP (Any one pe son) S 0 PERSONAL_& A_DV INJURY $ 0 k I�GEN'L AGGREGATELIMIT JECT APPLIES PECR: POLICY l PRO- U LO GENERAL AGGREGATE S 0 PRODUCTS - COMPI6P AGG $ 0_ _ 1 I OTHER: ( AUTOMOBILE LIABILITY I COM8�3N�EeDSINGLEiiPAIT k$ BODILY INJURY (Perperson)is ANY AUTO BDDILYINJURY (PeraxdenS) S OWNED SCHEDULED AUTOS ONLY AUTOS I HIRED i NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE 4Per accident S $ {i{ jt I 'UMBRELLA LIAR i OCC,UR ERCIH OCCURRENCE $ AGGRE-GA E _ I $ f EXCESS UAB CLAIMS,MADc DED I I RETENTION'S S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y ! N kANYPROFFICEPRIE OREXCLUDRIEXECUTiVE r� ,(Mandatory In NH) �J fl yes- describe under DESCRIPTION OF OPERATIONS below I N(A I i SEWC919783 I 09I17i201S ( 09/17/2O1J IS JATLITE I I ERH- _ EL. EACH ACCIDENT $ 1,_0001000 E.L. DISEASE- EA EMPLOYEES. $ 1 0O O0() i E.L. DISEASE:- PD€.ICY LIMIT, S 1,000,000 l I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACOPO 101, Additional Remarks Schedule, may be attached if more space is required) Employees: Full Time: 4; Part Time: 0 Governing Class Description: BURGLAR ALARM INSTALL,/REPAIR & DRVS Miami Shores Village Bldg Dept 10050 NE 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 01988-2016 ACORD CORPORATION. AN rights reserved. ACORD 25 (201610) The ACORD name and logo are registered marks of ACORD SECURE TECHNOLOGIES 4integrators Date: June 17,2019 State of Florida County of Miami -Dade Before me this day personally appeared id 1 lti{ who, being duly sworn, deposes and says: That he or she will be the at: ci�3f5 N ure person working on the project located Sworn to (or affirmed) and subscribed before me this 11 dayof uv\�,_ 20_ by I! AZIivl Personally know OR Produced Identification Type of Identification Produced 1�rc� MC1cl �a l Print, Type or St MADRIGAL is State of Fiorida-(Votary Public + Commission # GG 38399 My Commission Expires October 13, 2020 Secure Technologies Integrators Inc. 17690 Dixie Highway US # :B Miarni, Florida 33157 T 786-573-9081 F 786-573-9084 syed@isecureu247.corn w-vvw•,isecure 47.com 1C # 13U07351' jEL _Gl-lei -1�4e 11 ' LOGIES �.... SECURE TECHNO 1 nteg rators- Inc Date: June 17,2019 State of Florida County of Miami -Dade Before me this day personally appeared �� KGB( Al who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: Gf 3 f S N J�-t 0.t�•( �Yr'. ra or ignature Sworn to (or affirmed) and subscribed before me this 1 day of V t"e. 20 1 9. by Personally know OR Produced Identification Type of Identification Produced Print, Type or St 1 MADRIGAL �IY �III ;State of Florida -Notary Pub - Commission # GG 38399 My Commission Expires October 13, 2020 Secure Technologies Integrators Inc. 17690 Dixie Highway US # B Miami, Florida 33157 T 786-573-9081 F 786-573-9084 syed@isecureu247.com www.isecureu247.com EC # 1300735 T 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: I . 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: ��jv ��'11�t 0,( O er State of Florida County of Miami -Dade The foregoing was acknowledge before me this Z day of n U q 20 / 9 By M CtXWf, f'Y who is personally known to me or has produced b L M` koo-55 j _ 810- � Z2--b as identification. Notary- OW ��1pY VV i� FLORA MADRIGAL SEAL: ;_°B`�s State of Florida -Notary Pub Commission # GG 38399 My Commission Expires October 13, 2020