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MCC-08-19-1966Permit NO.:MCC-08-19-1966 Miami Shores Village i0050NE2Ave Miami Shores FL 33138 305-795-2204 Permit Type:Mechanical -Commercial Work Classification:Alteration Permit Status:Approved Expiration:03/09/2020IssueDate:09/09/2019 Parcel NumberLocationAddress 11320601325109600NE2NDAVE,Miami Shores,FL 33138 Contacts SUPER COOL INC .DBA SUPER COOL AIR CONDITIONING VICTOR AVILA 1463 BANKS RD.MARGATE,FL 33063 Business;9549781838 ContractorPALAZZOLEONILLC TODDLEONl PO BOX 381703,MIAMI,FL 33238 Owner victor@supercoolinc.com Inspection Requests: 305-762-4949$25,000.00Valuation:Description:SHEET METAL DUCT WORK AND 2 NEW 7.5 TON SPLIT SYSTEM (AS PER PLANS)Total Sq Feet:0.00 Amount Amt PaidFeesDatePaidPayments $810.50$50.00 $15.00 $11.25 $7.50 $5.00 $700.00 $3,00 $18.75 Application Fee -Other CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total Fees Credit Card 08/26/2019 09/09/2019 $50.00 Credit Card $760.50 $0.00AmountDue: Total:$810.50 Building Department Copy In consideration of the issuance to me of this permit,I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village.In accepting this permit I assume responsibility for all work done by either myself,my agent,servants,or employes.I understand that separate permits are required for ELECTRICAI ’LUMBING.MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. all the foregoing information is accurate and that all work will be done in compjliancp nintf.^/Futhgicaofe;I authorize the above named contractor to do the work stated. with all applicable lawsOWNERSAFFIDAVIT;I regulating construction and / Authorized Signature:Owner Applicant /Contractor D^e//Agent September 09,2019 Page 2 of 2 Miami Shores Village Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 ■ BY: FBC 20 Q <_0CBUILDING PERMIT APPLICATION Master Permit No. Sub Permit No. JRENEWAL]EXTENSION□REVISION]ELECTRIC □ROOFING□BUILDING ^[^ECHANICAL PUBLIC WORKS □CHANGE OF □CANCELLATION CONTRAaOR SHOP DRAWINGS JPLUMBING %/X)me .a JOB ADDRESS;rt"jy :3313%Miami Dade Zip:Miami ShoresCity:County: NOFolio/Parcel#:(!-3 -~C>/3 ~Z^/Q Load; Is the Building Historically Designated;Yes Flood Zone:BFE:FFE:Construction Type:Occupancy Type: 3c9Phone#:OWNER:Name (Fee Simple TItleholder): Po (3Address: TM V Gv /v\j Zip:City: Tenant/Lessee Name: State: Phone#: Email: Phone#:CONTRACTOR:Company Name: Address://^3.7in:5:^05 3City:^State: Phone#:Qualifier Name: State Certification or Registration #: DESIGNER:Architect/Engineer: Address: Certificate of Competency #: S' Phone#: Zip:City: Square/Linear Footage of Work: i 1 Repair/Replace ... State: SfOO 0ValueofWorkforthisPermit:$. Type of Work:CH Addition I 1 DemolitionAlteration Description of Work: Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ fl^sr z f co/cc$_ Notary $ Double Fee $_ Bond $ -Perrtiit Fee $ .Radon Fee $ Training/Education Fee $ CCF$_ DBPR $ TOTAL FEE NOW DUE V (Revised02/24/2014) Bonding Company's Name (if applicable} Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender’s 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 s^h posted notice,the inspection will not be/opproved and a reinspection fee will be charged. Signature.Signaujxe OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this AtJl >bydavofdayof.by.20 .20 10 .,who is personally known to who is personally known to me or who has produced 'TL.me or who has produced identification and who did take an oath. as as identification and who did take an oath. NOTARY PUBLIC:NOTARY PUBLIC: 0Sign:,Sign:, Print:Print: NotfflyPuMe^ANDREW VOGEL))MY COMMISSION #FF919683EXPIRES:Novembtr 25.2019 Seal:Seal: Plans Examiner 4:D:D:m ilA »\^^i:i,tt!**************It********* ZoningAPPROVEDBY Structural Review Clerk (Revised02/24/2014) 1 CERTIFIED www.ahridirectory.org ●●●●L ●●●●>●●● Certificate of Product Ratings ●● ●4 »●●● A 4 ●\●44 9 Model Status:Activ'eDate;08-19-2019AHRlCertifiedReferenceNumber:201930666 *●●«4 4 4 4 444444 Brand Name;TRANE ●● Model Number:TTA0904(3,4,W)AA*OOA* ●●● Indoor Unit Model Number:TWE0904(3,W)A*A*”00 ●●●●● ●● ●●●Series Name:ODYSSEY AHRi Type;RCU-A-CB Refrigerant Type;R-410A /c ..^OGHertz:60 \BY;\Sold In?:USA.Canada Al -accordance with the latest edition of AHR!340/360 Performance Rating of Commercial and Industrial Unitary Air-conditioning and Heat Pump Equipment and AHRI 365 and subject to rating accuracy by AHRI-sponsored,independent, Rated as follows in third party testing; Cooling Capacity 95F/Cooiing Capacity 95F at 230v:94000/94000 EER 95F/EER 95F at 230v :11.50/11.50 lEER/tEER at 230v:13.0/13.0 The following data is for reference only and is not certified by AHRI Full Load Indoor Coil Air Quantity (scfm):2625 -■Active''Model Status are those that an AHRI Certification Program Participant is currentJy producing AND selling or offering ^sale;OR●rarxeted but are not yet being produced.“Production Stopped'Model Status are those that an AHR!Certification Program Participant is no longer produang BUT is still bv WAS indicate an involuntarv re-rate.The new published rating is shown along with the previous {i.e.WAS)rating AHR?doeTifo^endorse the productfs)listed on this Certificate and makes no representations,warranties or guarantees as to,and assumes no responsibility for, the product(s)listed on this Certificate.AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s),or theunauthorizedalterationofdatalistedonthisCertificate.Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS ^This Certificate and its contents are proprietary products of AHRI.This Certificate shall only be used for individual,personal and confidential reference purposes.The contents of this Certificate may not,in whole or In part,be reproduced;copied;disseminated;entered into a computer database;or otherwise utilized.In any form or manner or by any means,except for the user’s individual, personal and confidential reference. MBImwi AIR-CONDITIONING,HEATING. &REFRIGERATION INSTITUTECERTIFICATEVERIFICATION^^The information for the model cited on this certificate can be verified at www.ahrldirectory.org.dick on Verify Certificate link and enter the AHRI Certified Reference Number and the date on which the certificate was issued, wnich is listed above,and the Certificate No.,which is listed at bottom right we make life better' 132107137802229203CERTIFICATENO.:\SJ2019Air*Conditloning,Heating,and Refrigeration Institute \^ ●●● t ● ●●●●●● ft ftft ft ft ftft ft ftftft ft ft ft ft ftft ftftftftftft ftft ft ft ft ft ft ft ft ftft ftft ft ft ft ftftft ft ftftft JIMMY PATRONIS CHIEF FINANCIAL 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. EXPIRATION DATE:2/3/2022EFFECTIVEDATE:2/4/2020 EMAIL:VICTOR@SUPERCOOLINC.COMPERSON:VICTOR R AVILA FEIN:050550250 BUSINESS NAME AND ADDRESS: SUPER COOL.INC 1700 BANKS RD.SUITE 100 POMPANO BEACH,FL 33063 SCOPE OF BUSINESS OR TRADE: Heating,Ventilation,Air- Conditioning and Refrigeration Systems Installation,Service and Repair,Shop,Yard &Drivers IMPORTANT:Pursuant to subsection 440.05(14),F.S.,an officer of a corf>oration 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 subsection 440.05(12),F.S.,Certificates of election to be exempt issued under subsection (3)shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to subsection 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)413-1609E01114076 lami Shores illage Building Department 10050 N.E.2nd Avenue Miami Shores,Florida 33138 Tel;(305)795.2204 Fax:(305)756.8972 'm 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 allow's 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 w'ork 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 U'NDERSTAND ITS CONTENTS.A 1(jMlSi2nature: Owner State of Florida County of Miami-Dade Per .20 ZO.day ofTheforegoingwasacknowledgebeforemethis who is personally known to me or has producedBy. as identification. ANDREW VOGEL *laijr »Commission #GG 359037ExpiresNovember25.2023 Bond#tfThniBud9«tNottryS«vle*» Notary: SEAL: c a W-M■'’-i STATE LICENSED #CAC1816581 10/5/2020 Date: State Of Florida County of Broward Before me this day personally appeared Victor Avila who,being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 9600 NE 2^^Ave,Miami Shores,FL 33138 Contractor Signature Sworn to (or affirmed)and subscribed before me this 05 day of October. 2020,by Victor Avila Personally Know Or Produce Identification Type of Identification Produced. Print,Type or StarnpTMame of Notary 1700 Banks Rd.Suite niOO Margate,FL 33063 -PH 954-978-1838 www.supercoolinc.com t *ffa9UhAWMpai Wifl»3 'JL *●, 2019 FLORIDA LIMITED LIABILITY COMPANY ANNUAL REPORT FILED Apr 18,2019 Secretary of State 1456641703CC DOCUMENT#L13000150548 Entity Name:PALAZZO LEONI LLC Current Principal Place of Business: 9600 NE 2 AVE MIAMI.FL 33138 Current Mailing Address: PO BOX 381703 MIAMI,33238 AF FEI Number:46-4350354 Name and Address of Current Registered Agent: LEONI,TODD 9600 NE 2 AVE MIAMI,FL 33138 US Certificate of Status Desired:No The above named entity submits this statement for the puqx>se of changing its registered office or registered agent,or both,in the State of Florida. SIGNATURE: DateElectronicSignatureofRegisteredAgent Authorized Person(s)Detail: MGRM LEONI,TODD 9600 NE2AVE City-State-Zip:MIAMI FL 33238 Title Name Address I hereby certify that the informatior)indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as if made under oalh;that I am a managing member or manager of the limited liabilily company or the receiver or trustee empowered to execute this report as required by Chapter 605,Florida Statutes:and that my name appears above,or on an attachment vhth all other like empowered. 04/18/2019MANAGINGMEMBERSIGNATURE:TODD LEONI Electronic Signature of Signing Authorized Person(s)Detail Date RICK SCOTT.GOVERNOR JONATHAN ZACHEM.SECRETARY Florida STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE CLASS A AIR CONDITIONING CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489,FLORIDA STATUTES AVILA,VICTOR RAUL SUPER COOL AIR CONDITIONING 1463 BANKS ROAD MARGATE IFL33063 LICENSE NUMBER:CAC1816581 EXPIRATION DATE:AUGUST 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. City of Margate,Florida Local Business Tax Receipt901NW66*'^Avenue Margate,FL 33063 (954)979-6213 cnv Of MARGATE logdher Wc Make 11 Ureal 19-00008476SUPFRCOOLAIRCONDITIONING 1463 F3ANKS RD Receipt Nhr;Business Name: Location address: Issue Date /Class: Effective Date: Receipt Fees: Comments: CONTRACTOR MECHANICAL A/C CLASS A October OL 2018 130.00 Expiration Date:September 30,2019 For Home Local Business l ax Receipt:No Cttmmcrcial Vcliiclcs PcTmitled at Residence.No Inventory. Stock of Trade.Sales or Display.Pennitted. No Outside Sales.Service.Display.Stock or Storage vsithoui prior Cit\'Commission Approval. Commercial and all others: 0007245 SUPER COOL AIR CONDITIONING SUPER COOL.INC. 1463-1465 B.ANKS RD MARGATE FL 33063-3941 NOTICE RECEFT MUSTBEIRANSFERRED WhB^BUSteSS B MOVH)OR SOLD. (Rease see bodDm poroon of this cfim) Post This Receipt in a Conspicuous Place Maximum Capacity:N/A BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave.,Rm.A-100,Ft-Lauderdale,FL 33301-1895 -954-831-4000 VALID OCTOBER 1,2018 THROUGH SEPTEMBER 30,2019 DBA: Business Name:SUPER COOL INC Receipt #:183 -1546"^’HEATING/AIRCONDITION CONTRACTRBusinessType;(class CONTR) A AIR CONDITIONING Owner Name:VICTOR r avila Business Location:1463 BANKS RD MARGATE Business Phone:954-978-1838 Business Opened:04/23/2005 State/County/Cert/Reg;CAC18i658i Exemption Code: Rooms Scats Employees Machines Professionals 2 For Vending Business Only Number of Machines:Vending Type; Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS This tax is levied for the privilege of doing business within Broward County and isnon-regulatory in nature.You must meet all County and/or Municipality planningandzoningrequirementsThisBusinessTaxReceiptmustbetransferredwhen the business is sold,business name has changed or you have moved the business location.This receipt does not indicate that the business is legal or thatitisincompliancewithStateorlocallawsandregulations. THIS BECOMES A TAX RECEIPT WHEN VALIDATED Mailing Address: VICTOR R AVILA 1463 BANKS RD MARGATE,FL Receipt #02C-17-00004423 Paid 09/28/2018 27.00 33063 2018 -2019 DATE (MM/DDAnrYY) 8/23/2019ACORDCERTIFICATEOFLIABILITYINSURANCE 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 INSUFIANCE 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 poNcy(les)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 endorsementjs). eOMTAdI NAME;ZUBERO ADMN Zubero Ins Group IncPRODUCER FAXPHONE (AK;.No.Exli: E-MAIL ADDRESS: (866)400-7674 xlOO ,(e$6)6S7-3S7BZuberoInsuranceGroup 100 N State Road 7 Unit 304 Margate (A/C,No): QUOTES zuberoagency.com NAIC 8INSURERIS)AFFORDING COVERAGE FL 33063 INSURER A :AMTRUST NORTH AMERICA INSURED INSURERS Super Cool,Inc.,DBA:Super Cool Air Conditioning INSURER C INSURER D 1700 BANKS ROAD SUITE 100 INSURER E FL 33063Margate INSURER F REVISION NUMBER:CERTIFICATE NUMBER;CL191209652COVERAGES THIS IS TO CERTIFY THATTHE 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. iirotinwii POUCY EFF(MM/DD/YYYYI POUCY EXP IMM/DD/YYYYlINSR UMITSTYPEOFINSURANCEPOUCYNUMBERLTR 1,000,000XCOMMERCIALGENERALUABIUTYEACHOCCURRENCES bAUACSTOWNTED PREMISES (Ea occurrence)100,0005CLAIMS-MADE X OCCURA 5,00012/29/2018 12/29/2019HFF160546701 MED EXP (Any one peraon)S 1,000,000PERSONAL&ADV INJURY 2,000,000GENERALAGGREGATESGEWLAGGREGATELIMITAPPUESPER; PRO JECT 2,000,000XPRODUCTS-COMP/OPAGG $LOCPOUCY N/A$OTHER: COMBINED SINGLE UMU (Ea acddent)N/ASAUTOMOBILEUABIUTY N/ABODILYINJURY(Per p«wi)SANYAUTO ALL OVflJED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS N/ABODILYINJURY(Per accident) PROPERTY DAMAGE (Per aeodentl N/A$HIRED AUTOS N/AS N/AUMBRELLAUABEACHOCCURRENCESOCCUR EXCESSUAB N/AAGGREGATE$CLAIMS-MADE N/A$DEO RETENTION S OTH-PERWORKERSCOMPENSATION AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERAitEMeER EXCLUDED? (Mandatory in NH] If yes.describe underDESCRIPTIONOFOPERATIONS STATUTE ER Y/N N/AE.L.EACH ACCIDENT S N/A N/AE.L.DISEASE ●EA EMPLOYEE S N/AE.L DISEASE -POUCY LIMIT Sbelow DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES (ACOR0101,Additional Remarks Schedule,may be attached If more space is required) Lie#CAC1816581 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 Department 10050 Northeast 2nd Ave Miami Shores,FL AUTHORIZED REPRESENTATIVE33138 Mike Zubero/GLOBAL ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) INS02S (201401) The ACORD name and logo are registered marks of ACORD 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:1/28/2018 EXPIRATION DATE:1/28/2020 PERSON:AVILA VICTOR 050550250FEIN: BUSINESS NAME AND ADDRESS: SUPER COOL.INC SUPER COOL AIR CONDITIONING 1463 BANKS RD POMPANO BEACH FL 33063 SCOPE OF BUSINESS OR TRADE: Healing,Ventilation.Aif- Condilioning and Refngeralion Systems Installation.Service and Repair,Strap,Yard & Drivers 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 beexemptandcerliricatesofelectiontobeexemptshallbesubjecttorevocationif.at any time after the filing of the notice or the issuance of the certificate,thepersonnamedonthenoticeorcertificatenolongermeetstherequirementsofthissectionforissuanceofacertificate.Tfie 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 Supercool Inc. 1700 Bank Rd.Suite 100 Margate,FL 33063 Date:5/16/19 State of Florida County of Dade ^^ho.being duly sworn.Before me this day personally appeared deposes and says: 21 That he or she will be the only person working on the project located at: Contractor Signature Sworn to (or affirmed)and subscribed before me this ^A^ay of by ,2019 Personally Known OR Produced Identification ^ Type of Identification Produced ^ AnmiaRiii NotayPubilo State of Florida My Gommtssion B^lm 07/17^1 —Commiiilon fte.QQ124650— Print,Type or Stamp Name of Notary '*'rsI /'>y:●t *fleh^A lOhof^toe^^ r5fS^T f'TO ir«a yM OoBrii ()d M noaansnoO hores illage Building Department 10050 N.E.2nd Avenue Miami Shores,Florida 33138 Tel:(305)795.2204 Fax:(305)756.8972 lami 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 industr>'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 Slate.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'scompany for day labor,part-time employees or subcontractors. BY SIGNING B£LOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade Ik V5Theforegoingwasacknowledgebeforemethisdayof,20. ir>bo tgbM who is personally known to me or has producedBy. as identification. Notary:ANDREW VOGELmycommission#FF919683EXPIRES;NoN'ember 25.2019SEAL: