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EL-20-155Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 v UQ r t -1) Issue Date: 02/25/2020 Location Address Parcel Number 1460 NE 103RD ST, Miami Shores, FL 33138 1132050310060 Contacts Permit NO.: EL-01-20-155 Permit Type: Electrical - Residential Work Classification: Repair Permit Status: Approved Expiration: 07/21/2020 MONICA SAVITS Owner PARDIME ELECTRIC INC Contractor 1460 103 OLEY JACKSON SMITH Mobile: 3059799053 sales@outdoorkitchenservice.com 2629 SW 31 CT, MIAMI, FL 33133 Description: DOCK ELECTRIC REPAIR Valuation: $ 900.00 Inspection Requests: 305-762-4949 Total Sq Feet: 124.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Building Department Copy Payments Date Paid Amt Paid Total Fees $110.30 Check # 1005 02/25/2020 $110.30 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. DAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws *uction and z g. Futhermore, I authorize the above named contractor to do the work stated. Owner / Applicant / Contractor / Agent \ Date February 25, 2020 Page 2 of 2 Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address issue Date: 02/25/2020 Parcel Number 1460 NE 103RD ST, Miami Shores, FL 33138 1132050310060 Contacts Permit NO.: EL-01-20-155 Permit Type: Electrical - Residential Work Classification: Repair Permit Status: Approved Expiration: 07/21/2020 MONICA SAVITS Owner 1460103 Mobile: 3059799053 sales@outdoorkitchenservice.com PARDIME ELECTRIC INC Contractor OLEY JACKSON SMITH 2629 SW 31 CT, MIAMI, FL 33133 Description: DOCK ELECTRIC REPAIR Valuation: $ 900.00 Inspection Requests: 305-762-4949 TotalSq Feet: 124.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Payments Date Paid Amt Paid Total Fees $110.30 Check # 1005 02/25/2020 $110.30 Amount Due: $0.00 Applicant Copy For Inspections, Call (305) 762-4949 or Log on at hops://bidg.miamishoresvillage.com/cap/. Requests must be received by 3pm for following day inspections. NOTICE: In addition to the requirements of this permit, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OTHER additional restrictions applicable to this property that may be found in the GOVERNMENTAL ENTITIES SUCH AS WATER MANAGEMENT DISTRICTS, public records of this county. STATE AGENCIES, OR FEDERAL AGENCIES. February 25, 2020 Page 1 of 2 Proof of Coverage Page 1 of 1 WC Home(http://www.myforidado.com/Division/WCO Search Our Data (http://dwcdataportal.fldfs.com) CFO Home (http://www.myfloddado.com) Business Activities Detail Page This database was last updated Tuesday, February 25, 202012:09 AM. Return to Exemption Detail Page I Business Activities on Exemption for OLEY J SMITH Conduit Construction For Cables or Wires & Drivers Electric Light or Power Line Construction & Drivers Electrical Wiring Within Buildings and Drivers Licensed Electrical Contractor Return to Search Page If you have accessed the database listed herein and are in need of additional help with requests for information or data, please submit a written request, specifying all criteria necessary to provide you with the required information and format, and submit it to the following e-mail address: WC_Exempbon@myfIoridacfo.com (maiko:WC_Exemption@myfloddacfo.com?subjecta Data Request). We will acknowledge receipt of your data request within one business day. ® 2020 (hftp:/twww.myfloridado.conVsitepages/required/oopydght.aspx) Florida Department of Financial Services (http:/hvww.myfIoddacfo.com) Privacy (http://www.myfloridacfo.com/sitepageslmquired/p6vacy.aspx) Accessibility(http://www.myfloddacfo.com/sitepagestrequired/accessibility.aspx) https://proofofcoverage. fldfs. com/BusinessActivitiesDetail?EffectDate=712612018%2012:... 2/25/2020 Proof of Coverage Page 1 of 2 WC Home(http:/ANww.myfloddado.com/Division/WCn Search Our Data (http://dwcdataportal.fldfs.com) CFO Home (http:/twww.myflohdacfo.com) Exemption Detail Page This database was last updated Tuesday, February 25, 202012:09 AM. Return to Previous Page Exemption Details Name Title Effective Date 'Termination Date Exemption Type "Business Activities Employer Name Click Here to Yew Activities Listed on Exemption (BuslnessAcbvidesDetall.8spx? PARDIME ELECTRIC OLEY EflectDate=7262018 12:00:00 INC J Jul 262018 Jul 252020 Construction AM&EnpID=814089001&PersonName=OLEV (EmployerDetail.espx? SMITH JSMITH EmpID-814089001) &PersonID-073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=6242015 12:00:00 INC J CE Jun 24 2015 Jun 23 2017 Construction AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH JSMITH EmpID=814089001) &Person ID-073255750&RejectType=CO) Click Here to 1Am Activities Listed on Exemption (BusinessActivitiesDetaiLespx? PARDIME ELECTRIC OLEY 9201312:00:00 INC J PR Apr 192013 Apr 192015 ConstructionEffectDate=411 AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH J SMITH EmpID=814089001) &Personl D=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessAcdvidesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=2)152011 12:00:00 INC J PR Feb 152011 Feb 142013 Construction AM&EmpID=814089001&PersonName=OLEY(EmployerDetail.aspx? SMITH JSMITH EnplD=814089001) BPemonlD=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivftiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=21182009 12:00:00 INC J PR Feb 18 2009 Feb 15 2011 Construction AM&EmpID=8140890018PersonName=OLEY (EmployerDetail.aspx? SMITH J SMITH EmpID-814089001) &Personl D-073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=223200712:00:00 INC J PR Feb 232007 Feb 182009 Construction AM&EmpID=814089001&PersonName-OLEY (EmployerDetail.aspx? SMITH JSMITH EmpID=814089001) &Personl D=073255750&RejectType=CO) Click Here to Vim Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=3/1 /2005 12:00:00 INC J PR Mar 12005 Feb 232007 Construction AM&EmpID=814089001&PersonName=0LEY (EmployerDetail.aspx? SMITH JSMITH EmpID=814089001) ..__..___ &PersonID=073255750&RejectType=CO) _...__r......... _...... __.... _ ............... .............. .... _,,,....... ..... _.... ................ _..... _...... _........ Click Has to View Activities Listed on Exemption (BuslnessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=127200312:00:00 INC J PR Jan 272003 Dec 312003 Construction AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH J SMITH EmpID=814089001) &Personl D=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate-1272001 12:00:00 INC J PR Jan 27 2001 Jan 27 2003 Construction AM&EmpID-814089001&PersonName=0LEY (EmployerDetail.aspx? SMITH JSMITH EmpID=814089001) BPersonID=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivltiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=128/1999 12:00:00 INC J PR Jan 281999 Jan 272001 Construction AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH J SMITH EmpID=814089001) &Personl D=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessAcbvitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=4/9/ 1994 12:00:00 INC J PR Apr 91994 Jan 281999 Construction AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH JSMITH EmpID=814089001) &PersonID=073255750&RejectType=CO) Click Here to View Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDate=8f7/1992 12:00:00 INC J PR Aug 7 1992 Aug 7 1994 Construction AM&EmpID=814089001&PersonName=OLEY (EmployerDetail.aspx? SMITH JSMITH EmpID-814089001) &Personl D=073255750&RejectType=CO) https://proofofcoverage.fldfs.com/ExemptionDetail?pr_person_id=073255750 2/25/2020 Proof of Coverage Page 2 of 2 Click Here to View Activities Listed on Exemption (BusinessActivitiesDetail.aspx? PARDIME ELECTRIC OLEY EffectDete=577/1991 12:00:00 INC J PR May 7 1991 Nov 17 1991 Construction AM&EmpID=814089001&PemonName=OLEY (EmployerDetail.aspx?, SMI7H J SMITH EmpID=814089001) &PersonlD=073255750&RejectType=CO) 'Termination may be through the revocation of the exemption, or expiration of the exemption. ..The exemption only applies to the business activities listed on the exemption. Return to Search Page I If you have accessed the database listed herein and are in need of additional help with requests for information or data, please submit a written request, specifying all criteria necessary to provide you with the required information and format, and submt it to the following e-mail address: WC_ExemptionQmyfkddacfo.com(mailto:WC_Exemption@nry8oddado.wm?subject= Data Request). We will acknowledge receipt of your data request within one business day. ® 2020 (http://wnwv.myfloddado.comlsitepages/required/copyright.aspx) Florida Department of Financial Services (http:/twww.myfloddacfo.com) Privacy (http://www.myfloddacfo.wm/sitepages/required/privacy.aspx) Accessibility(http://vnvw.myforidacfo.win/5itepages/required/accessibility.aspx) https://proofofcoverage.fldfs.com/ExemptionDetail?pr_person_id=073255750 2/25/2020 4 l 2p_ZD k\ , Ar\ BUILDING Miami Shores Village ENTERED Building Department JAN 2 20 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 041 PERMIT APPLICATION BUILDING LECTRIC ❑ ROOFING FBC 201—+ Master Permit No.O�_ t I �-d `L �p "�V( 5 Sub Permit No. EL.- 01 W— I SS ❑ REVISION ❑ EXTENSION ❑ RENEWAL PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP �f �/ , S•4 CONTRACTOR DRAWINGS JOB ADDRESS:/ / � 0 �y � /a3 / City: Miami Shores County: Miami Dade Zip:.3313 2 Folio/Parcel#: I �2��- 0 3l - M(o 0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: -Flood Zone: BFE: FFE: Email: Phone#: `?g (. g �% �✓�S 6 f� rr� el_ ff'e"Ly ►�:� A press:` � v�-'� u •- �� City. �'�'� State: Qualifier Name: tf,' State Certification or Registration I r 9v DESIGNER: Architect/Engineer: (1 Address: Value of Work for this Permit: $ Type of Work: ❑ Ad Description of Work: .,L,e ❑ 'Alteration i/A s-Q-- C.� rZiip: Phone#: / 7 !� Certificate of Competency #: —ram Phone#: City: State: /A ..`Zip/: Square/Line r� Footage of Work: \d I\ Newt� L�q Kepair/Kepiace I_I uemonuon Specify co o color thru tile: ass ��s�t,t,;;:�,::......•� ;,: Submittal Fee $ wit Fee $ CCF $ i ' S tr ' :CD/,,CC Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ \� Double Fee $ Structural Reviews $ \ Bond $ TOTAL FUE $ 1 1 0 ' 30 (Revised02/24/2014) *1 NO Bonding Company's Name (if Bonding Company's Address City Mortgage Lender's Name (if Mortgage Lender's Address City I State 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 f. 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 c the notice of commencement and construction lien law brochure will be delivered to the person whose property is subjec o ac ent. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection w is urs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be r ed nd a reinspection fee will be charged. Signatu 7P K-,�s I OWNER or AGENT \__�?NTRACTOR The foregoing instrument was acknowledged beforemethis The foregoing instru ent was acknowledged before me this darat, `--day-Of 2p__ bY'_ A whoi6 personally known to r� �� who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: / Print: p��L Wh AE �Uy Print: Seal: ,,. Seal: JOSEMIGUELDELACRUZ • JOSE MIL CRla MY GdMM16310N 00 07UZ MY COMMI3810P1 # (i 077576 ' t : EXPIRE EXPIRES: Mgy 12, 2021 (J jyy�� 3: May 12, Y021 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSONESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES SWTH, OLEY JACKSON PARDIME ELECTRIC, INC. 24625 SW 127 AVENUE HOMESTEAD FL 33032 LICENSE NUMBER: EC13008012 EXPIRATION DATE: AUGUST 31, 2020 Always verify licenses online at MyFloridalicense.com � Do not alter this document in any form. ti e ,' This is your license. It is unlawful for anyone other than the licensee to use this document. o r. ,r, Local Business Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT A BILL —DO NOT PAY 1208347 BUSINESS NAME/LOCATION PARDIME ELECTRIC INC 24625 SW 127TH AVE MIAMI, FL 33032 OWNER PARDIME ELECTRIC INC Worker(s) RECEIPT NO. RENEWAL 1208347 SEC. TYPE OF BUSINESS 196 ELECTRICAL CONTRACTOR EC13008012 LBT EXPIRES SEPTEMBER 30, 2020 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR 82.60 10/10/2019 0225-20-000161 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 holders qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must be displayed on all commercial vehicles — Miami —Dade Code Sec ga—M. M® For more information, visit www.miamidade.govhaxcollector NOTICE OF ELECTION TO BE EXEMPT If this application contains incomplete or inaccurate information, it may cause a delay in the issuance of your exemption. An officer electing an exemption under Chapter 440, Florida Statutes, is not entitled to benefits under this chapter. Section 1: APPLICANT INFORMATION First & Last Name: OLEY J SMITH State Driver's License Number: State ID Number: State: FL S530650470200 Date of Birth: 1/20/1947 Social Security Number (last four digits): 0877 Email Address: FALK_RITA@YAHOO.COM Section 2: CONSTRUCTION INDUSTRY APPLICANT ($50 FEE REQUIRED) Officer of a Corporation Section 3: This section should be completed with information specific to your corporation or to the limited liability company in which you are a member. The name of the corporation or limited liability company listed on this application MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations. Name of Corporation or LLC: PARDIME ELECTRIC, INC. FEIN: 267780877 Business Name (DBA): PARDIME ELECTRIC, INC Phone: 3054768080 Applicant's Address of Record: 24625 SW 127 AVE. City: HOMESTEAD State: FL Zip 33032 County: MIAMI-DADE Scope 1: 00009 Licensed Electrical Scope 2: 05190 Electrical Wiring Scope 3: 06325 Conduit Scope 4: 07538 Electric Light or Contractor Within Buildings and Driv Construction 0 For Power Line Cables or Wires ❑ Construction & Section 4: The corporation of which you are an officer or limited liability company of which you are a member must be registered and in ACTIVE status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must be listed as an officer of the Corporation with the Florida Division of Corporations. List the document number on file with the Florida Division of Corporations. G90236 Section 5: Pursuant to Chapter 489, F.S. (contractor licensing law), list certified or registered licenses related to the scope of business or trade listed in Section 3 held by the applicant, or the certified or registered license numbers held by the qualifier for the corporation or limited liability company listed on this application. The business name listed on the license MUST match the name of the corporation or limited liability company as registered with the Florida Division of Corporations and on this Notice of Election to be Exempt. EC13008012 EC13008012 Section 6: If you have submitted an electronic payment for this application, the transaction confirmation number is listed in the following space: Confirmation Number: 2THJRQTZ53 Application Number: E00843435 Section 7: N/A Are you affiliated with any corporation or limited liability company other than the corporation or limited liability company to which this application applies? Section 8: CONSTRUCTION INDUSTRY AND NON -CONSTRUCTION INDUSTRY LLC MEMBERS ONLY To be eligible for a construction industry exemption or a non -construction limited liability company exemption, an applicant must have the required ownership of the corporation or limited liability company. I am a shareholder owning at least ten percent(10%) of stock of the corporation listed on this application. Section 9: I certify that any employees of the corporation or members of the limited liability company listed in Section 3 are covered by workers' compensation insurance. Please identify the workers' compensation insurance carrier that covers any non-exempt employees. Carrier Name: My business does not have any non-exempt employees; or, my business is not required to obtain workers' compensation. Section 10: FRAUD NOTICE A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, insurance company or any other person, files a Notice of Election to be Exempt containing any false or misleading information is guilty of a felony of the third degree. B. Attestation of applicant — By providing my name below, I attest that I have read, understand and acknowledge the foregoing notice. C. Acknowledge that this Notice of Election to be Exempt does not exceed limits for corporate officers, including any affiliated corporations as provided in Section 440.02, Florida Statutes. First Name: OLEY Last Name: SMITH Note: The Division has 30 days to review your application to determine if it meets the eligibility requirements for the issuance of an exemption. The Division will either issue a Certificate of Election to be Exempt or notify you that your application is incomplete. The Division reviews and processes exemption applications in the order they are received. Exemption information is reflected on the Proof of Coverage database the day following the issuance of the exemption. Visit the Division's website at http://www.myfoddacfo.com/division/wc to print your certificate. WC Mobile App WC Home Search Our Data CFO Home Exemption Detail Page This database was last updated Wednesday, August 07, 201912:10 AM. Return to Previous Page Lxemption Det_ails_�_�.___A �__ ___ _•____. hnrreTitle Ertcctiv_ Dc:c 'T3r Anatlon Dch ' Exc-iptio! Type **H_.,, ss Activlh. s E-nplcyer Name Click Here to View pARDIME OLEY J SMITH Jul 26 2018 Jul 25 2020 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View PAR DIME OLEY J SMITH CE Jun 24 2015 Jun 23 2017 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Apr 19 2013 Apr 19 2015 Conshuction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Feb 15 2011 Feb 14 2013 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Feb 18 2009 Feb 15 2011 Construction Activities Listed on ELECTRIC INC Exemption Clldx Here to View pgRDIME OLEY J SMITH PR Feb 23 2007 Feb 18 2009 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Mar 12005 Feb 23 2007 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Jan 27 2003 Dec 312003 Construction Activities Listed on ELECTRIC INC Exemption Crick Here to View pARDIME OLEY J SMITH PR Jan 27 2001 Jan 27 2003 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Jan 28 1999 Jan 27 2001 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pgRDIME OLEY J SMITH PR Apr 91994 Jan 28 1999 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR Aug 71992 Aug 7 1994 Construction Activities Listed on ELECTRIC INC Exemption Click Here to View pARDIME OLEY J SMITH PR May 71991 Nov 17 1991 Construction Activities Usted on ELECTRIC INC Exemption R *Tr•rmin-:t•on may be through the mvecation of tha exemption, or ctrp ration of the excmption. I —The exemption only applics to the business act.vities listed on the exemption. 6 Return to Search Page 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 4b20_20. By, IN TS who is personally known to me or has produced as identification. Notary: LIZETTE LLORET SEAL: � 1PRY PVB �i State of Florida -Notary Public Commission # GG 116087 My Commission Expires rt" June 22, 2021 COMPANY LETTER HEAD Date: 2/14/20 State of Florida County of Miami -Dade Before me this day personally appeared Oley J. Smith who, being duly sworn, deposes and says: That he will be the only person working on the project at: Contract nature P N, 6�, t Q�� _ ZS Sworn to and subscribed before me this,14' day of February 2020. Produced Identification Type of Identification Produced T�74� t4SQ= Print, Type or Stamp Name of Notary SINDIA ALVAREZ «: MY COMMISSION # GG 238273 EXPIRES: September 3, 2022 Bonded ThN Notary PuWb Uflde�vnllers