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CC-08-22-2098Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: CC-08-22-2098 Permit Type: Building (Commercial) Work Classification: Alteration Permit Status: Approved Issue Date: 09/29/20221 Expiration: 03/29/2023 Location Address Parcel Number 1700 NE 105TH ST 302, Miami Shores, FL 33138 1122300500400 Contacts ALFONSO GIL Owner ALFONSO DAVID GIL Applicant 1700 NE 105 ST 302, MIAMI SHORES, FL 33138 1700 NE 105 ST 302 AV10910@GMAIL.COM Home: 7866637751 avi0910@gmail.com ALLSTATE CONSTRUCTION GROUP CORP Contractor RICHARD A RUBI 7420 SW 38 ST, MIAMI, FL 33155 Business: 7865479527 Description: REMOVE EXISTING CERAMIC TILE FLOOR AND Valuation: $ 8,500.00 Inspection Requests: c MEMBRANE INSULATION THROUGH ALL UNIT INSTALLATION ON NEW ITALIAN TILE WITH SOUND PROOF 305-762-4949 Total Sq Feet: 878.00 I ees Amount Application Fee - Other $50.00 CCF $5.40 DBPR Fee $3.83 DCA Fee $2.55 Education Surcharge $2.70 Permit Fee $205.00 Scanning Fee $9.00 Technology Fee $25.50 Total: $303.98 Payments Date Paid Amt Paid Total Fees $303.98 Credit Card 08/18/2022 $50.00 Credit Card 09/29/2022 $253.98 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOLwork. OWNERS AF AVIT: I cert that al he foregoing information is accurate and that all work will be done in compliance with all applicable laws regulatin nstru ion and z ' g. Futl r authorize the above named contractor to do the work stated. 0'qi /7ld /7.7 2-2 Authorized Applicant / Contractor / Agent Date September 29, 2022 Page 2 of 2 Miami Shores Village ENTERED Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC ❑ ROOFING AUG 18 NZ? BY:r_�-V FBC 2020 - 7-�" Master Permit No. CC— 09- 22 , 20`1$ Sub Permit No ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF [:]CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOBADDRESS: ✓N1 3c0Z City: Miami Shores l ,County: Miami Dade Zip: Folio/Parcel#: I I "ZZ 7U—�c�� C) �/ "400 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Zone: BFE: FIFE: OWNER: Name (Fee Simple Titleholder): �_��,AA /^Flo1od p( `( l L Phone#: L'� 96) Address: I,C)D N E ( b Sty S I p n lt-}A 3u2 1 City: A CA VIM S � l7 ✓� S State: 'P to 21 b A Zip: Tenant/Lessee Name: N Phone#: 4' Email: � q I g CQ_ ). /'1``/}iaA' / Jfia.l WnS�YIJL la r CONTRACTOR: Company Name: �H'�..L p Address: /� 20 _C �� City: I a State: L Zip: �� Qualifier Name: I (-LYI�t� r l l u z6) 1�3r3) Phonei . State Certification or Registration #: -3 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ D / � '- � S Square/Linear Footage of Work: $�l I Type of Work: ❑ Addition ❑ Alteration ❑ New Repaii'rf/Replace ❑ DemoIItl Description of Work: I? �vvwy 4 l2lC I C I l 11L /.�/7VlM i C I �l 1001, R/1A� )� 44 °'D 6, h &w t tlA_,f 04�3 t i 14 1.0 J 1901) Rd PM f of Specify color of color thru tile: Submittal Fee $ 51) •Of> Permit Fee $ 2-0f7 •Ca CCF $ `J • Lit) CO/CC $ Scanning Fee $ q . oo Radon Fee $ Z • 5S DBPR $ •83 Notary $ Technology Fee $ 7G Sb Training/Education Fee $ Z -7y Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ a:5 r (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City Mortgage Lender's Name (if applicable) Mortgbge 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 reinjpection fee will be charged. TO The foregoing instrumentwasacknowledged before me this / , day of l� 201i— . by YLT oN3 J (011(�— who is personally known to me or who has produced ee ryl ll(f" as identification and who did take an oath. NOTARY PUBLIC: Print: Seal: MY COMMISSION # GG 960, EXPIRES: March 6, 2024 Signature CONTRACTOR The foregoing instrument was acknowledged before me this r7� day of 9 .20 'ate by Q I,6 i, who is personally known to me or who has produced � � C P h S q as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: nll� M., oridaSeal: 49VA&V *.**********rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr APPROVED BY �-C 05�1 23 � Lt - Plans Examiner Zoning (Revisedo2/24/2014) Structural Review Clerk •ff THE Sfioms CONDOMINIUM ENTERED AUG 18 2^ZZ BY:�-- 1700 NORTHEAST 105* STREET • MIAMI SHORES, FLORIDA 33138 • PHONE (306) 893-6741 FAX (305(891-0590 • E-MAIL-the hor CGWO@att.-t WORK REQUEST APPLICATION Owner's Name C iti '� �-1�� Unit 32Z I hereby request approval from the Board of Directors for the following modification or alteration to my unit that will be performed by a licensed contractor. Electrical work Plumbing work Carpet Installation ** Windows Tile installation X Other work Description of work k1? p lace m,' A"(yL Y)ems" ',� �N O ✓1 of v IY- s5" W 66Y) Before you decide to upgrade your unit (other than paint or carpet) you must obtain permission from the Board of Directors and/or Miami Shores Village. A copy of plans, specifications and permits, and a description of the licensed work to be performed must be submitted for consideration and approval by the Miami Shores Village Building Department. Contact Miami Shores Village BD directly (305-795-2204). It is the owner's responsibility to ensure that the contractor removes all excess construction material or building debris. It cannot be placed in the dumpsters. ** Window frames must be gray in color to look like aluminum. Windows must be Two (2) panels over Two (2) panels. Glass must be clear color. I, as the unit owner acknowledge responsibility for any damage to the building or personal injuries that may occur during this project. The Shores Condominium Inc. its officers and employees are in no way responsible for damage or theft to my apartment or my belongings. (A $200.00 deposit is required and will be refunded if no damage to the property is reported) I nders nd a d a ee to the statements made above. 7�u U% Z7•?.DZZ- Unit owners sign a Date Approved by Date Page 1 of I EN }E12EA s z 1 ?+U? r 10 STARTING POINT OF INSTALLATION N Miami Sho s Village E Zoning De t. Building D p[. Subject to ompliance and Courtrules and BATH CLOSET ® I-- L II II 11 11 I BEDR OM STO AGE --II II 11 II II I1 I II I .: i - --1 I I _ I II I I I I I I -- l I I I I I I I I L -T- _- 11 1 1 1 1 1 I__ -� l I I I 1 1 KITC H IN I I I I 1 1 I I 1 1 1 1 I 11101 I i 101f ING I- Ii II 11 li 11 �i II II I � I, rtme t i i I � � I AbsorbaSound ' For Use Under • Laminate • Hardwood ,titt • Ceramic Tile Mint • LVT (5mm or thicker) ** Installation Methods • Floating • Glue Down • Thinset DeltaollC 25 g � CA I .W ., bN ml'miYq�'��I =N, 631.=53 ENTERT'-` ) SEP 19 2C ' BY, — ®SUPERIOR SOUND REDUCTION Provides outstanding acoustical performance to cushion the floor, absorb sound, and help make laminate floors sound more like real wood. COMPRESSION RESISTANT Superior compression characteristics to adequately support click -together mechanisms, tongue and groove, and anti -fracture characteristics under tile applications. ® MADE FROM 100% RECYCLED RUBBER MATERIALS i INSTALLATION METHODS TECHNICAL DATA FLOATING FLOORS 1. Roll out underfayment and butt seams together 2. Tape seams with moisture barrier seam tape 3. Click & lock floating floors over the top according to manufacturer DOUBLE GLUED DOWN FLOORS 1. Roll out underlayment with the vapor barrier side up and butt seams together 2. Adhere to subfloor using recommended flooring manufacturer's adhesive and recommended trowel size and install methods 3. Roll over the undedayment with a 75 or 100 pound roller 4. Adhere flooring over the top using manufacturer's recommended adhesive and trowel sae THINSET INSTALLATION 1. Prepare subfloor according to TCNA and file manufacturer instructions 2. Roll out and adhere Absorbasound to the subfloor using a high quality Urethane adhesive. Use 1/8" x 1/8" x 3/16"V-notched trowel. 3. Make sure the edges are tightly butted together, both side by side & end by end. Use a 50-100 Ib roller to fully bond the Absorbasound to subfloor. 4. After 8 hours or when adhesive is fully cured install tile/ stone flooring using a latex modified thin set. Install Tile according to manufacturer's instructions. "ENSURETO READ THE COMPLETE INSTALLATION INSTRUCTIONS BEFORE INSTALLATION ADVANTAGES • Pre -Consumer recycled rubber • Residential & Commercial applications • Great Sound Deadening • Code Compliant • Mold & mildew resistant • Lays flat, easy to install • LEED benefits • Warranted for the Lifetime of the Floor LIMITATIONS AbsorbaSound is not suitable for use as undedayment for: • Carpet • Sheet -vinyl • VCT Installations over concrete in high moisture areas (vapor emission rate above 3 Ibs/ 1000 sq f / 24 hrs) will require additional protection such as a concrete sealant or polyethylene vapor barrier. APPROVED SUBSTRATES • Completely Cured Concrete • Cement Backer Units • Interior Plywood • OSB (Approved for use over property prepared OSB) 'All wood and concrete subfloors must be flat within 1/8" over a 6' span, or 3/16" over a 10' span. All areas must be checked prior to installation. PACKAGING 2mm - 66 Lbs. - 4'40' = 200 s/f roil size 3mm-100Lbs. - 4'x50' = 200 s/f roll size 5mm - 84 Lbs. - 4'x25' =100 s/f roll size 1 Omm -167 Lbs. - 4'x25' =100 s/f roll size FLAMMABILITY: Tested as a rubber floor according to OS EN ISO 9239-1: 2002 PERFORMANCE AND COMFORT: The recycled rubber crumb provides excellent stability and durability for the IRe of approved flooring choices. The cushioning underlay provides anti - fatigue properties for best overall active comfort; transforming cold, hard, and unfriendly floors into softer and warmer flooring environments. SOUND PROPERTIES IMPACT SOUND TRANSMISSION The method is designed to measure the impact sound transmission performance of a floor - ceiling assembly in a controlled laboratory environment. Thickness OC Flooring Sub -floor 2mm 50 Laminate 6" concrete - no ceiling 2mm 60 Laminate 6" concrete - with ceiling 3mm 56 11.92mm Hardwood 2 x 10 w/1" gypsum concrete 5mm 55 11.92mm Hardwood 6" concrete - no ceiling 5mm 50 7mm Ceramic Tile 6"concrete -no Gaging 5mm 62 7mm Ceramic Tile 6"concrete -with ceiling 5mm 56 11.92mm Hardwood 8"concrete -no caging 5mm 52 7mm Ceramic Tile 8"concrete -no ceding 5mm 64 7mm Ceramic Tile 8"concrete -with ceiling 6mm 57 11.92mm Hardwood 2 x 10 w/1" gypsum concrete lomm 50 7mm Ceramic Tile 6"concrete -no ceding 12mm 58 11.92mm Hardwood 2 x 10 w/1" gypsum concrete SOUND TRANSMISSION LOSS The sound -insulating property of a partition element is expressed in terms of the sound transmission loss. Thickness STC Flooring Subfioor 2mm 55 laminate 6" concrete - no ceiling 2mm 54 Laminate 6" concrete - with ceding 3mm 56 11.92mm Hardwood 2 x 10 w/1" gypsum concrete 5mm 50 7mm Ceramic Tile 6"concrete -no ceding 5mm 63 7mm Ceramic Tile 6"concrete -with ceiling 5mm 53 7mm Ceramic Tile 8"concrete -no ceiling Smm 63 7mm Ceramic Tile 8"concrete -with ceiling 6mm 60 11.92mm Hardwood 2 x 10 w/1" gypsum concrete tOmm 53 7mm Ceramic Tile 6"concrete -no ceiling 12mm 60 11.92mm Hardwood 2 z 10 w/1" gypsum concrete DELTA TEST Tests the impact insulation difference between a bare concrete subfloor with no flooring materials and the same concrete subfloor with flooring and underlayment. Thickness SC Flooring Subfioor 5mm 25 11.92mm Hardwood 6"concrete -no ceiling 5mm 20 7mm Ceramic Tile 6"concrete -no ceiling 1 omm 20 7mm Ceramic Tile 6" concrete - no ceding REV 0518 Membranes Mapeguard "I 2 Premium Crack -Isolation and Sound -Reduction Sheet Membran Mapeguard 2is a next -generation, flexible, thin, 40-mil, lightweight, load -bearing, 'c- reinforced'peel-and-stick' crack -isolation membrane. After application, ceramic file or stone can be installed immediately with any polymer -modified cement -based mo(tar. Glue -down wood flooring can also be installed with any MAPEI urethane adhesive. Mapeguard 2 helps to prevent existing or future in -plane floor cracks (with movement up to 3/8' wide) from transmitting througdhceramic tile or natural stone. It also reduces the transmission of impact soun ots bjects, etc.) and airborne wh sound (voice, TV, etc.) through floors e nd car stone or wood - floor coverings. Copy rum ound-Reductfon and Crack -Isolation Sheet Membrane Mapesonic 2 is a patent -pending, next -generation, flexible, 76-mil thin, lightweight, load -bearing, fabric -reinforced "peel -and -stick" sound -reduction and crack -isolation membrane. Application of Mapesonic2can be immediately followed by installation of flooring: ceramic tile or stone with a recommended MAPEI polymer -modified, cement - based mortar; luxury vinyl tile or luxury vinyl plank with an appropriate MAPEI flooring adhesive; or glue -down wood flooring with any MAPEI urethane or hybrid -polymer -based wood adhesive. Mapesonic 2reduces transmission of impact sound (such as footsteps and dropped objects) and airborne sound (such as voice and TV) through floors when installed under ceramic tile, stone, vinyl and wood floor coverings. It also helps to prevent existing or future in -plane floor cracks (with movement up to 3/8' wide) from transmitting through grout, ceramic file and natural -stone assemblies. Mapesonic" RM Premium, Sound -Reduction Rubber Membrane Mapesonic Wis a high-performance, acoustic underlayment designed to reduce ambient and impact sound transmissions in installations or ceramic and porcelain life, natural stone, wood flooring, luxury vinyl life (LVT), luxury vinyl plank (LVP), sheet vinyl and carpel tile. Mapesonic RM is ideal for applications in apartments, condominiums, college dormitories, classrooms and office buildings. Y,• �8�10 S� sEP 1 202z BY: '%IMF /) -to y ,1 IS MAPET Tape Adhesives " lecontact'" SRT d-Reduction, Moisture -Resistant Tape for Resilient and Wood Flooring Installation apecontact SRT is a double -sided, foam -core, dry -film tape for rapidly and permanently installing lid vinyl sheet, vinyl file and vinyl plank flooring, as well as prelinished engineered or solid wood. oviding sound reduction for multifamily living, it has also been specifically designed for instant noting and instant utilization in residential and commercial floor installations. MapecontactSRT unaffected by high moisture conditions in concrete and can be installed without moisture testing. is, it provides sublloor moisture protection for wood and bamboo flooring. lltrabond ECO° 985 ybrid-Polymer-Based, Moisture -Control and Sound -Reducing Wood -Flooring Adhesive Ultrabond ECO 985 is MAPEI's premium single -component, hybrid -polymer -based wood -flooring adhesive that is formulated without water, solvents, amines, isocyanates, phthalate plasticizers or epoxy resins, and has an extremely low emission level of volatile organic compounds (VOCs). Ultrebond EC0985's formulation provides excellent sound -reduction properties that are required for multi -unit housing. Ultrabond EC0985 is also a moisture -controlling woad -flooring adhesive that protects wood flooring from moisture vapor emitting through concrete slabs in a single application. lltrabond ECO® 995 remium Moisture -Control, Sound -Reduction and Wood -Flooring Adhesive Ullrabond EC0995is MAPEI's premium,100%-solids, one -component, moisture -curing urethane adhesive for all types of wood flooring and bamboo. Ultrabond EC0995can be used in a single -coat application method that provides a superior bond and moisture vapor emission control on concrete slabs. Ultrabond EC0995also provides sound -reduction properties, making it suitable for use in multi -unit housing projects. Finished Flooring Features I Advantages Benefits Ceramic tile, stone and glue- A 40-mil, lightweight, peel- Installs faster than Peel -and -stick feature saves down wood flooring and -stick membrane forcrack membranes with 1-piece contractors time on the job isolation and sound mitigation liners; easy to position on the floor and cut to size; lower build height when compared to traditional 1/4' (6 mm) cork Mapesonlc2 Ceramic tile, stone, glue -down A 76-mil, lightweight, peel- Installs similadyto Mapeguard2 Peel -and -stick feature saves wood flooring and LVT/LVP and -stick membrane for crack but with better sound -mitigating contractors time on the job isolation and sound mitigation properties Mapesonic RN Depending on thickness A rubber underlayment made Relatively inexpensive and Save costs and gains points — Ceramic tile, stone, glue- from recycled tires available in scares points for diverting for sustainability dawn/floated wood flooring 3 thicknesses (2 mm, 5 mm, used tires from going into and LVT/LVP 10 mm), requiring adhesive to landfills bond to substrate Mapecontact SRT Resilient and wood flooring A double -sided, lightweight, Ready for instant use; no Saves contractor on material foam -core, dry -film tape that waiting for adhesives to cure cost and labor vs. systems serves as a high moisture and no subfloor moisture that require priming and an barrier with sound -reduction testing required underlayment properties; does not require a primer U/trabond EC0985 Wood and bamboo flooring A trowel -on, single-step, Moisture -control, sound- Saves contractor on material hybrid -polymer -based wood- reduction and bonding system cost and labor vs. systems flooring adhesive with sound- in a single product that require priming and an reduction and moisture- underlayment control properties; doesn't require a primer Ultrabond ECO 995 Wood and bamboo flooring A trowel -on, single-step, Moisture -control, sound- Saves contractor on material moisture -curing urethane reduction and bonding system cost and labor vs. systems adhesive with sound -reduction in a single product that require priming and an and moisture -control underlayment properties; doesn't require a primer MAPEI 160-sq ft Premium 76-mil Flooring Underlayment Item #4912180 Model #04140000 OVERVIEW Mapesonic 2 reduces transmission of impact sound (such as footsteps and dropped objects) and airborne sound (such as voice and TV) through floors when installed under ceramic tile, stone, vinyl and wood floorings. It also helps to prevent existing or future in -plane floor cracks (with movement up to 3/8" or 10 mm wide) from transmitting through grout, ceramic tile and natural -stone assemblies. Boxed roll: 39-in x 49.2-ft Sound -reduction performance with less weight and thickness • Easy to position on floor and cut to size • Prime, peel, stick and then install tile, vinyl or wood immediately SPECIFICATIONS For Use with Concrete: Yes Thickness Unit of Measure: Mills IIC Rating: N/A Grade: Premium STC Rating: More than STC-50 Mold/Mildew Resistant: Yes Length (Feet): 49.2 Package Quantity: 1 For Use with Porcelain: Yes Thickness: 76 Enhancements: Sound proofing Construction Type: Felt Type: Roll Width (Feet): 3.25 R-Value per Inch: 0 Square Footage Per Roll (Sq. Feet): 160 UNSPSC: 30161700 Vapor Barrier. X Coverage Area (Sq. Feet): 160 Sound Absorbing: Yes For Use with Laminate: X 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. EFFECTIVE DATE: 5/2/2022 PERSON: RICHARD A RUBI FEIN: 811791552 BUSINESS NAME AND ADDRESS: ALL STATE CONSTRUCTION GROUP CORP 7420 SW 38 ST MIAMI, FL33155 SCOPE OF BUSINESS OR TRADE: Contractor -Project Manager, Construction Executive, Construction Manager or Construction superintendent EXPIRATION DATE: 5/1/2024 EMAIL: RICHARDARUBI@GMAIL.COM IMPORTANT: Pursuant to subsection 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 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 E01490168 QUESTIONS? (850) 413-1609 ENTERED gd 1v� i� AUK 1 8 "cuZ2 �-- PtORN� Notire to Owl,7^r — Wforkp1s' Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 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 rfS State of Florida County of Miami -Dade The foregoing was acknowledge before me this By Ak,ForA 3 Nz� (D i 1--- 4G day of U 20 Z t, who is personally known to me or has produced '^ r as identification. Notary: •"'" a....." ARLENISSILVERA SEAL: ;�'• •o� Fo EXPIRES: March 6, 2024 P% Bonded Thm Notary Public Undemdlem ENTER nn AL,i�; ,', ALL STATE CONSTRUCTION GROUP CORP yt - August 15, 2022 State of Florida County of Miami -Dade Before me this day personally appeared: Amaury Alfonso who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 1700 NE 105'h ST Unit 302, Miami Shores, FL 33138. LL - Contractor Signature Sworn to (or affirmed) and subscribed before me this 14 day of 2022, by �Y(1G1UY� PI�OhS� Personally know OR Produced Identification li L@ 11 Type of Identification Produced - GC ROEL W CNNO pL��*q� _tt' Nctary PUCK � ]2 Fl Ccm—istim re GC EACI,fS Afl, 149 9. 2023 A), ` 9c.n', !YL'g".arc^a Ict" au-. int, type or Stamp Name of Notary