owners workers comp agreementC
FM
�oatp/
1 Y 1 iaml Shores village
Building Department
1 V-1j0 N E. 2nd A vsnua
UAym�6nor" FW4& 33138
T&I-D (3M) 7s6 2204
Fax: (305) 756 $912
Notice to Owner Workers" � �. _. �r � .y-�t-ar4 •� a��. .. �,t - �, •+r — .� +.� r��.-r •rti�� �� +ter � .�� �. l �# .��.. •-. �f- . - -- •7.�4�ti yam• # -�
_ i ��-•-' Compensation
+ 5 �
Florida Ls% t,irrs Vlrarkca' cnrn�ta�ion insua3mil raNenge unAff C� 440 of FkWWLA umuw& fu
8110•vs corrpcoratc ofli%;tr% in the cr+nctrurliun mdu�sry to sxrmpt thcmxl:c� fr�� tt�u rr�,�m►r�n�d fix airy aonstWWAc.+tu
ohtainin,& a bu*llding perma, Pumumt to the F 1{xida Dr'mFion of ih txketa' ["anVcmaiu^ t:"a I acb
An employer in the cotm, trv%:iinn �nda%tr� vitho rk-;i6 c cxx or mcrcr W -Wm vs k4vuAwO
employcts, including the owner. mast «htun Kuxi�tr�' c:}mprauilk�a cu%rr&jr, C ur}+►x�ur 0���M
or mrmbcrS Of a I IM%tW liability company (LiX) to the cwrrsMxttdA :nduW} axa) Rion Ma ae
exempt if:
I - The vfi`icer oKns at leam to percera of the srcxk oft* tNqxxauXft of ai #+r Mv of
an LLC, ostatcrncnt ancming t.x the minimum tO percrrn; av►nrnhip.
2. The officer is ii-swd as an officer of the corpumwn in the rtctxOds of the f hx�
Depmunent ol'State. D'I%isk-Mof ('orpcuaiwns; and
3. The ct:vptlfiation is rcgisttrcd and tiucd as kmx with the FkvNNW4 Dtp&rwww .yt
State. Lei► im"ati v1 CvrporaWns..
No nwrc than thrrc corporate o#Ti"rs per corporation uW II'Mited 14bilit%ti mm�} msant�ers err
alloucd to bc excrnpt. Construction exemptiots art valid for s period of t►w }-cars cx vnut a
►•oluntary re►vcu�n is filed ur the tr�emptio� is rc�v��d b} � �i�ision.
iM # 41019
P"Veld M
Your contractor i4 s rcqucsiing a per, t-, i t under tfiis %►arl►crs' eampenu, cion exemption vW has vkw%te3&+c that he <x she v.tli n►* +nc
day lobar, part-timic rmpltay cts or sut+coptrutats fcw )-cwr Pru cct. Thr contm-tor his pro+idcd in affidava suttaig tac .v skw rn'U
k the only prrsun allv%vcd to wvrk on )out prvjcct. In tte= Cinumscar►M. Miami Shores t illagpc docs txx rNuve vCqif v of
,v+orkcrs' wmpensation tnsurance cor-4cragr from the ��atractar's compan� (cx d3y Isborb Pan -unit mplo)cles cc "k%-XvtrjkUaM
BNP SIGNjING KLLUVI' N`0V ACKNOWLEDGE THAT YOU K-kVE RJLAOD TW5 NOTICE ll%j.%wI] ITS
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