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PLC-19-1164Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address rl- Issue Date: 08/06/2019 Parcel Number 9830 NE 2 AVE, Miami Shores, FL 33138-2347 1132060132240 Contacts Permit NO.: PLC-05-19-1164 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 02/03/2020 MIAMI SHORES CENTER LLC Owner MIAMI SHORES CENTER LLC Applicant 20171 ST 309, MIAMI BEACH, FL 33141 20171 ST 309, MIAMI BEACH, FL 33141 Mobile:7862368569 ORIT@ELYSEEINC.COM Mobile:7862368569 ORIT@ELYSEEINC.COM Other:3058648885 Other:3058648885 IGE CONSTRUCTION INC Contractor ELIER GONZALEZ 6270 NW 114 ST, HIALEAH, FL 33012 Business: 7864880144 Description: SEPTIC TANK ABANDONMENT Valuation: $ 550.00 Inspection Requests: Total Sq Feet: 75.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 Change of Contractor $110.00 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: $220.30 Payments Date Paid Amt Paid Total Fees $220.30 Credit Card 08/06/2019 $60.30 Credit Card 05/21/2019 $50.00 Check # 8629 12/20/2019 $110.00 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: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulatinAgnsmy lbp an j zoning. Futhermore, I authorize the above named contractor to do the work stated. l Owner /) I Applicant / Contractor / Agent Date December 20, 2019 Page 2 of 2 Miami Shores Village XL"X` 0 E I 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 FBC 20 BUILDING Master Permit No. PLC-05-19-1164 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION 7 EXTENSION 7RENEWAL QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS X CHANGE OF ❑ CANCELLATION 7 SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9830 NE 2ND AVE City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): MIAMI SHORES CENTER LLC Phone#: (305) 864-8885 Address:210 71 ST STREET SUITE 309 City: MIAMI BEACH State: FL Zip: 33141 Tenant/Lessee Name: MIAMI SHORES CENTER OFFICES Phone#:(305) 864-8885 Email: orit@elyseeinc.com CONTRACTOR: Company Name: IGE Construction Inc ne#: (786) 488 0144 Address: City: Hialeah state: FL Zip: 3300,1�8/� 1 Qualifier Name: Elier Gonzalez Phone#: -3C3 ! 6-7 Z! 1 T State Certification or Registration #: CFC 1429669 Certificate of Competency #: DESIGNER: Architect/Engineer: JOSEPH CHAN Phone#: (786) 488-1000 Address:21051 SW 234 STREET City: HOMESTEAD State: FL Zip: 33031 Value of Work for this Permit: $ 550.00 Square/Linear Footage of Work: 75 Type of Work: ❑ Addition F01 Alteration ❑ New ❑ /Re lace Re air p p ❑Demolition Description of work: SEPTIC TANK ABANDONMENT Specify color of color thru the: Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF S DBPR $ CO/CC $ Notary $, Double Fee $ Bond $ TOTAL FEE NOW DUE $ 110. (Revised02/24/2014) Bonding Company's Name (if applicable) NA Bonding Company's Address City State Mortgage Lender's Name (if applicable) NA Mortgage Lenders Address City 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 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 OWNERorA The foregoing instrument was acknowledged before me this \day �of^�!-: 20by who is personally known to _pg.Qr who has produced as identification and who did take an oath. NOTARY PUBLIC: Signature CON ACTOR The foregoing ins /ument was acknowledged before me this day of n'.-Cenol 20 � � by e `firZl�.w4i� is personally known to me or who has produced identification and who did take jiw. NOTARY PU Sign: Print: Seal: as YADIRA S RUQ OMMsslOn # GG 113978 Expires June 12, 2021 Boom T.B dgw YServioes *ssrsss*tssse**•**s*:s*s*k:*ss•*suss+s*t**�s*�*�*s***�*sat**s*** Plans Examiner Structural Review Zoning Clerk (Revised02/24/2014) Miami Shores Village eut�i3 W uo� °= Building Department �LpR>�pA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. PLC-05-19-1164 Owner's Name (Fee Simple Title Holder): Miami Shores Center LLC Owner's Address: 210 71st Street Suite 309, City: Miami Beach State : Florida Phone #:(305) 864-8885 Zip Code:33141 Job Address (Of where work is being done):9830 NE 2nd Ave City: Miami Shores State: —Florida Zip Code:33138 Contractor's Company Name: SOUTHERN SEPTIC AND LIFT STATION C phone ##: (305) 598-8266 Address: 21051 SW 234 Street City: Homestead State: Florida Zip Code:33031 Qualifier's Name : Roberto Rodriguez Lic. Number: Architect/ Engineer of Record Name: Joseph Chan Address: 12000 SW 92nd Street City: Miami State: FL Describe Work: Septic Tank Abandonment for sewer hook up Phone ;-:786 - 488-1000 Zip Code: 33186 I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores -harmless of all leg Iv ent. :R Signature Signature Owner or Agent Cont motor or Architett The foregoing instrument was aknowledged berore me The foregoing instrumen was nowt ged before me this IL day of 04. 20�,by Z kej this % 3 day of Noeel l v— , 20 2,by � . Who is personally known to me or who has produced who is personally known to me or who has produced as indentification. as indentification. Notary Public: -_ _J� Notary Public: Sign: {� Sign: _ n J. Seal: OR1TAgtMOUN "' my (""SSAN ,'t G i 19240 EXP!RES. �tar i4. 2021 Seal: JANET VALLECILLO •r�� ��%, Notary Public State.ot Florida " Commission N FF 991465 My Comm. Expires Bonded through NaWal Notary Assn. i STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Centedic) PROPERTY ADDRESS: 9830 NE 2 Ave Miami, FL 33138 PERMIT #: 13-SC-1 981036 APPLICATION #:AP1427656 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR1248628 LOT: BLOCK: SUBDIVISION: [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 11-3206-013-2240 [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ ] GALLONS / GPD ] GALLONS / GPD ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY [ D [ ] SQUARE FEET R [ ] SQUARE FEET A TYPE SYSTEM: [ ] STANDARD I CONFIGURATION: [ ] TRENCH N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L DE O T H E R CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS U ]DOSES PER 24 HRS #Pumps [ SYSTEM SYSTEM [ ] FILLED [ ] MOUND [ ] BED [ ] ][ABOVE/BELOW] BENCHMARK/REFERENCE POINT ]LABOVE/ BE LOW] BENCHMARK/REFERENCE POINT 'ILL REQUIRED: [ 0.00 ] INCHES EXCAVATION REQUIRED: [ J LNL;nzb Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank fror> ,LgAomtedEFIRY4960 tank shall be filled with clean sand or other suitable material, and completely coveredsaYrAI%,oil Wmea�>ryWpn� iRptgegY A STATi by the health department after it has been pumped, ruptured, and filled with sand ancF66j4MFD SEPTIC TANK CONTRACTOR OR STATE LICENSED PLUMBER, BOTTOM OF TANK OPENED OF RUPTURED, AND TANK FILLED WITH CLEAN SAND OF OTHER SUITABLE MATERIAL. CONTRACTOR MUS CERTIFY COMPLETION OF ABOVE WORK AN SCHEDULE INSPECTION WITH THE SPECIFICATIONS BY: Yliarja Serra TITLE: Engineering Specialist II / APPROVED BY: -IAV�WV, TITLE: Engineering Specialist II Dade CHD Jesus D HernandezAcosta DATE ISSUED: 11/12/2019 EXPIRATION DATE: 02/10/2020 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 v 1.1.4 AP1427656 SE-1 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a'final order'. Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Issue Date: 08/06/2019 Location Address Parcel Number 9830 NE 2 AVE, Miami Shores, FL 33138-2347 1132060132240 Contacts Permit No.: PLC-WI9-1164 Permit Type: Plumbing - Commercial Work Classification: Septic Permit Status: Approved Expiration: 02/03/2020 MIAMI SHORES CENTER LLC Owner MIAMI SHORES CENTER LLC Applicant 20171 ST 309, MIAMI BEACH, FL 33141 20171 ST 309, MIAMI BEACH, FL 33141 Mobile:7862368569 ORIT@ELYSEEINC.COM Mobile:7862368569 ORIT@ELYSEEINC.COM Other:3058648885 Other:3058648885 SOUTHERN SEPTIC AND LIFT STATION Contractor CORP ROBERTO RODRIGUEZ 12040 SW 118 ST, MIAMI, FL 33186 Business: 3055988266 Description: SEPTIC TANK ABANDONMENT Valuation: $ 550.00 Ins ection Requests: 305-762-4949 TotalSq Feet: 75.00 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 Credit Card 08/06/2019 $60.30 Credit Card 05/21/2019 $50.00 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 zoning. Futhermore, I authorize the above named co tractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent Date August 06, 2019 Page 2 of 2 RECEIVED BUILDING PERMIT APPLICATION Miami Shores Village M 21 2019 Building Department BY: 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 (% Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 �? FBC 20 (-� Master Permit No. �(O —q_ (9 - 2 3 ) 8 Sub Permit NoPLE OS-1 (`1 1 q BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL PLUMBING ❑ MECHANICAL-:iOUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9830 NE 2nd Ave City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:1132060132240 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):_ Address:210 Seventy First Streei city: Miami Beach Miami Shores Center LLC Phone#:305-864-8885 State: FL zip: 33141 Tenant/Lessee Name: na Phone#: Email: orit@elyseeinc.com CONTRACTOR: Company Name: '�'`� Sew c Phone#: Address: 2» -' I '� w 2''� ` V— r l City: �OVA -4 S�� \ ^ State: t L zip: 3 -3 Qualifier Name: '-i;� QS'L L"m 61� Z Phone#: State Certification or Registration #: S �o 02 Certificate of Competency #: DESIGNER: Architect/Engineer: Joseph Chan Phone#: 786-488-1000 Address:12000 SW 92 street city. Miami State: FL Zip: 33186 Value of Work for this Permit: $, SSA 'ad Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of work: Septic Tank Abandonment, property is connecting to sewer system (PLC 9-18-23 Specify color of color thru tile: Submittal Fee $ � , CZ) Permit Fee $ Scanning Fee $ Technology Fee $_ Structural Reviews $. Radon Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ / - TOTAL FEE NOW DUE $ (Revised02/24/2014) Bonding Company's Name (if applicable) na Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address na 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 r Signature OWNER or AGE T ONTRAC*OR The foregoing instrument was acknowledged before a this day of G{ 20 by ( K \Jrwho is personally known to me or who has produced as identification and who di a an oath. NOTARY PUBLIC: The foregoing instrume was ackno edged efore me this 9_ day of 20 i ' by ( Z Q)� Irho is personally knowwnn to 12 me or who has produceJj-,,DU �Iv DU VE - L , as identificatiorY9tid who did take an oath. NOTARY PU Sign: C Sign: Print: ` Print: Seal: 4tA'f ORITMIMOUN MY COMMISSION fi GG 162406 14, 2021 Seal: ��"` P�•: ......,� '= 'a:= SINDIA ALVAREZ MY COMMISSION # GG 238273 EXpIM- December EXPIRES: September 3, 2022 Bonded Ttru Notaryy P�bMe Ursdw**.ta '�FOF F4°� Bonded Thru Notary Public Underwriters #######VFW################################################################################## # �/��9 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (Miami Shores Center LLC) PROPERTY ADDRESS: 9830 NE 2 Ave Miami, FL 33136 LOT: NA BLOCK: 17 SUBDIVISION: PERMIT #.13-SC-1936548 APPLICATION #: AP1405861 DATE PAID: FEE PAID: RECEIPT $: DOCUMENT #: PR1210198 PROPERTY It) 11-3206-013-2Z40 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N K I GALLONS / GPD ] GALLONS / GPD ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY [ D [ ] SQUARE FEET R [ ] SQUARE FEET A TYPE SYSTEM: [ ] STANDARD I CONFIGURATION: [ ] TRENCH N F LOCATION OF BENCHMARK: CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ SYSTEM SYSTEM [ ] FILLED [ ] MOUND ] BED [ ] I ELEVATION OF PROPOSED SYSTEM SITE [ ][ E BOTTOM OF DRAINFIELD TO BE [ ][ L D F--- - -- O T H E R / ][ABOVE / BELOW]BENCHMARK/REFERENCE POINT / ][ABOVE/ BELOW] BENCHMARK/REFERENCE POINT .+. n VuU i U; L U_UV ) 11VC:hk;Z3 H:XC:AVAT1UN REQUIRED: [ ] INCHES ave the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of e tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The nk shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected � the health department after it has been pumped and ruptured but before it is filled with sand and covered. SPECIFICATIONS BY: TITLE: APPROVED BY: TITLE: Environmental Specialist II Erick Warera Dade CHD DATE ISSUED: 04/U3/2019 EXPIRATION DATE: 07/02/2019 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 V 1.1.4 AP1405861 SE-1 Re/./OrF DIVISION OF 44>"<e> Environmental Health Florida Health AnO Miami-Dade County eQ� OSTDS/Well Division A� 11805 SW 26th Street • Miami, FL 33175 Inspector RI�iNf Qt/Sr�.% Date i .2-�� Z©t,y Address g 3 �N"t , OSTDS # Comments: Signature LTLc Notice to Owner — Workers' Com Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 ation 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 a contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: /V V `" Owner State of Florida County of Miami -Dade [16C The foregoing was acknowledge before me this I6 day of 20 By AWA V EHE J�f &Zl_ who is personally known to me or has produced as identification. Notary: SEAL: OBIT MIMOUN — ,' MY COMMNISSION # 03162406 EXPIRES: December 14, 2021 _ ©a4ed Thru Namry we,w, i IGE Construction INC CGC 111522734 Certified General Contractor & CFC 1429669 Certified Plumbing Contractor 6270 NW 114 ST Hialeah FL 33012 PH: 305-967-2117 PH: 954-825-7274 Email: ige 1010@aol.com Date: 12/19/2019 State of Florida County of Dade 1 ,. Before me this day personally appeared `who, being duly sworn deposed and says: That he will be the only person working on the project located at 9830 NE 2n' AVE Miami Shores, FL 33138 / PLC-05-19-1164 P umbin ontractor gnature Swore to (or affirmed and subscribed before me day of , 20� By c G ✓ Personally Known YADIRASRUM Or Produced Identification ' C,0"S"#GG113978 ,�, EVIM June 12, 2b21 Type of Identification Produced // af��P rnM*'`"°WY ""°" Print, The or'9ftMftNAme of Notary