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RC-1-18-247, 1284 NE 94th StMiami 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 BUILDING PERMIT APPLICATION ❑ BUILDING ❑ ELECTRIC ❑ ROOFING 0 C 1 2 3 aw FBC 20 Master Permit NOC 18-247 PL-3-18-653 Sub Permit No. ❑ REVISION ❑ EXTEND ❑RENEWAL 0■ PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑■ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1284 NE. 94th St. City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: 11-3205-010-0140 Is the Building Historically Designated: Yes NO Occupancy Type: SFR Load: Construction Type: CBS Flood Zone: BFE: FIFE: OWNER: Name (Fee Simple Titleholder): Suzanne J. Glller f/k/a Suzanne Jacobs Phone#:305-754-4482 Address: 1284 NE. 94th St. City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: N/A Phone#: Email: CONTRACTOR: Company Name: Della Rossa Plumbing & Solar, LLC Phone#: 954-479-4270 Address: 4667 Orange Drive City.. Davie State: FL Zip: 33314 Qualifier Name: , " — — „��,, ,�„k C—FC- I �Z / 7C�ificate of Competency #: State Certification or Registration #: DESIG v . Architect/Engineer: Address: Phone#: — Value of City: State: Work: Addition -0 Square/Linear Footage of Work: ❑ 0 Alteration ❑ New X❑ Repair/Replace Description of Work: Replace bathroom fixtures, Iavatory,W/C, shower, replace existing tank water heater with tankless. Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $_ Structural Reviews $ Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $— DBPR $ 03 ❑ Demolition CO/CC $ Notary $ Double Fee $ _ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City N/A N/A State WE 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, 5: Si ture OWN ' ER GENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing. -instrument was acknowledged before me this . rC day of V 20 1 1 by !�T 0 ay of 20 by Suzanne J. Giller , who is personally known to ��C �f •��cifQS�who is personally known to me or wh ha5 prod ced ` FL Driver's License as me or who has produced L as i entific ion and w o did take an oath. n nd w o did t e an oath. identificarU:BLIC: \\\\1N11 N1 / 1 � ��DD1( pR�FTO��i��� \\\\\\\\\1YIl TARY UBLIC: �P 1SS10 R7c�r��/� N TARY `\��y_ \ ••G4a� ON �.•• i� \\���� pMN 24 o F Z Sign: — -_ Sign: r. Z s cc 2872ss Print: 1, Print: na thCl �.g•: 0 .. NO - O Seal: •i�f •• A`blic Under . O� \�� Seal: icUn �� ''•OF �\ 11111111N\\\ APPROVED BY Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk "'i, Ar-k T [At4evw _4„ JUL. 01 2019 Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. PL-3-18.653 Master: RC 18-247 Owner's Name (Fee Simple Title Holder): Suzanne J. Giller F KA Suzanne Jacobs Owner's Address: 1284 NE. 94th St. City: Miami Shores State: FL job Address (Of where work is being dome):_ City: Miami Shores 1284 NE. 94th St, Contractor's Company Name: Molz Plumbing Address: 820 NORTHEAST 123RD ST City. NORTH MIAMI, Qualifiers Name : LEE rvI OJOTZ Architect/ Engineer of Record Name: Address: City: State: —Florida. Phone #: 305-754-4482 Zip Code: Zip Code: 33138 Phone #' d6 - CQP-4oX-13 State: FL Zip Code: 33161 Lic. Number:G'f�G�i;/ej State: Describe Work: Replace bathroom fixtures, laundry etc. Phone #: Zip Code: 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 legal !*pyolvement. Signature ,.1 � Signature T- ll Owner' or Agent J Contractor or Architect The foregoing inst; ument was aknowledged- before me The foregoing instryine t was aknowledged before me Jantra Suzanne Giller th f"C VGY t `` Lee Motz this day of ry 20(f ,by_ this �� day of f' J . MCI by Who is personalty known to who has produced Florida driverscensa liBaal' ��11 `t/ f`�,, � ._AESA .S i. as indentification. ldotar Public: A` Sign: r-� c7 : ) •-p ,j*�z,-„�_T` Seal: tNTyI. //tllllll who is personally known to me or who has produced Florida drivers license as indentification. Notary Public: Seal: cyst Notary Puapc State of Honda LUISJAVIER LAVALLE My Commission GG 161310 OF ti Expires 01/01/2022 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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING Master Permit No MAR 1 18 FBC 2011 -rq-2V7 Sub Permit No. P U �; �DS3 ❑ REVISION ❑ EXTENSION ❑RENEWAL ERKUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: f -)S 7 L -,(t' City: Miami Shores County: Miami Dade Zip: 3 d 3 8' Folio/Parcel#: �/ " . !% t ` C 3 Is the Building Historically Designated: Yes NO Occupancy Type: -le-3 Load: Construction Type: Flood Zone: BFE: FFE: (, 51. za A n e �. 6 lei° f�OWNER: Name (Fee Simple Titleholder): e' �- t � J. �� c� s: Phone#: � �� �/� Address: C -Z-- �"/ hr` L—: 9 ' fil ' , City: ` d & lm 1 y L" State: "' — Zip: Tenant/Lessee Name: 6czd�- Phone#: Email: CONTRACTOR: Company Name: G�� plyn? IRyG LC C Phone#:'301V' 91U fie, 21-3 Address: iao Ne k-.n t'0 L&4 City: % )dcmep hoi. State: rr ia(Ll D A Zip: Qualifier Name: �k '640t'e- Phone#: State Certification or Registration #: G`�+C /Yaq S—t/ Certificate of Competency #: _ DESIGNER: Architect/Engineer: Address City: hone#: s=qclp-wag 0 Value of Work for this Permit: $ /S� . a"' Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New [/Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Permit Fee $ CCF $ Radon Fee $ Training/Education Fee $ DBPR $ CO/CC $ Notary $. Double Fee $ Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ ACOR" CERTIFICATEOF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1 Q/2312019 THIS CERTIFICATE IS ISSUED AS A MATTER-'OF'tNFORILIATION 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 INSURANCE 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 policy(ies) 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 endorsement(s). PRODUCER BB Insurance Marketing Inc 10167 W Sunrise Blvd 3rd Floor CONTACT NAME: Certificates Department PHONE FAX A/C No EXt : 888-728-0817 Arc No): 954-452-0450 ADDRESS: Certificates@bbimi.com INSURERS AFFORDING COVERAGE NAIC # Plantation FL 33322 INSURER A: Florida Citrus, Business & Industries Fund INSURED DELLROS-01 Della Rossa Plumbing & Solar, LLC 4667 Orange Drive INSURER B: AmGuard Insurance Company 42390 INSURER C : INSURER D : Davie FL 33314 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 481771006 REVISION NUMBER: THIS IS TO CERTIFY THAT THE 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. INSR LTR OF INSURANCE ADDLTYPE INSD SUER POLICY NUMBER EFF MM/DD/YYYY MMPOLICY L ICY EXP DDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY OEBPO79803 7/12/2019 7/12/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS -MADE I X I OCCUR PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ INCLUDED GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑ X JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccident $ NON -OWNED HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DIED I I RETENTION $ $ q WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N 10658694-2018 3/3/2019 3/3/2020 X PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N I A (Mandatoryin NH) E.L. DISEASE - EA EMPLOYE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Plumbing Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E. 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 United States dr ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD RICK SCOTT, GOVERNOR JONATHAN ZACHEM, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE PLUMBING CONTRACTOR HEREIN IS CFRTF.IED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES DELLA ROSSA, JOSEPHL A&ItWO DELLA ROSSA PLUMBING & SOLAR LLC 4667 ORANGE DRIVE DAVIE FL 33314 LICENSNU'I'vl' EC1 ,740 %, -x �uawue+saunv.n H e.. zomrxalfi?a':"mcmuusmss.�, Es.r.mssnmv.m EXPIRATION D TE`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. Y LZ 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-�.95 — 954-831-4000 VALID OCTOBER 1, 2019 TH1ROUGHs SEPTEM R 30, 2020 DBA:DELLA ROSSA PLUMBING & SOLAR LLC Receipt#:PLUMBING/LWN SPRNKL/CONTRACTOR 1-82-1633- Business Name: Business Type: (PLUMBING & SOLAR LLC) Owner Name: JOSEPH DELLA ROSSA Business Opened:07/07/2008 Business Location: 4667 ORANGE DR State/County/Cert/Reg:CFC1427740 DAVIE Exemption Code: Business Phone:954-479-4270 Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vendina Tvoe: 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 BECOMES.A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when 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 that it.is in compliance_ with State or local laws and regulations. Mailing Address: JOSEPH DELLA ROSSA 4667 ORANGE DR DAVIE, FL 33314 2019 - 2020 Receipt #04C-18-00001498 Paid 07/22/2019 27.00 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2019 THROUGH SEPTEMBER 30, 2020 DBA:DELLA ROSSA PLUMBING & SOLAR LLC Receipt#:182-1631 Business Name: Business Type: PLUMBING/LWN SPRNKL/CONTRACTOR Owner Name: JOSEPH DELLA ROSSA Business Location: 4667 ORANGE DR DAVIE Business Phone: 954-479-4270 Rooms Seats (PLUMBING & SOLAR LLC) Business Opened: 07/07/2008 State/County/Cert/Reg: CFC142774 0 Exemption Code: Employees Machines Professionals 1 Signature For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee I NSF Fee Penalty Prior Years I Collection Cost Total Paid 27.00 0.001 0.001 0.001 0.001 0.00 27.00 Receipt #04C-18-00001498 Paid 07/22/2019 27.00 `yaOR£s Miami Shores Village 10050 N.E. 2nd Avenue NE . . ... Miami Shores, FL 33138-0000 Phone: (305)795-2204 tottto� Project Address 1284 NE 94Street Miami Shores, FL Owner Information Address Parcel Number Applicant 1132050100140 SUZANNEJACOBS Block: Lot: SUZANNE JACOBS 1284 NE 94 ST MIAMI SHORES FL 33138-2947 Contractor(s) Phone Cell Phone MOTZ PLUMBING LLC (305)992-4223 Type of Work: REPLACE BATHROOM FIXTURES, LAUNDRY Type of Piping: Additional Info: REPLACE BATHROOM FIXTURES, LAUNDRY Bond Return : Classification: Residential Scanning: 1 Fees Due Amount CCF $1.20 DBPR Fee $2.25 DCA Fee $2.00 Education Surcharge $0.40 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $165.45 Phone Cell r----- _--- a -" _..�__ "., Valuation: $ 1,500.00 Total Sq Feet: 0 : Pay Date Pay Type Amt Paid Amt Due Invoice # PL-3-18-66772 03/26/2018 Credit Card $ 115.45 $ 50.00 03/13/2018 Credit Card $ 50.00 $ 0.00 Hvauaoie inspections: Inspection Type: Top Out Final Review Plumbing Underground 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 constructigb and zoning. Futhermore, J authQA7e the/Above-gamed contractor to do the work stated. March 26, 2018 Authorizepjignature:OknJr / AppKc'd t / Contractor / Agent Building Department Copy March 26, 2018 1 BUILDING PERMIT APPLICATION Miami Shores Village Building Department MAR 1 18 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 14, ' INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 20►1 6 Master Permit No. � c— / " / g' 2 7 Sub Permit No. R. 1 �, — �DS > ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL �LUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: �-E. q A/ City: Miami Shores County: Miami Dade Zip: 3 31 38' Folio/Parcel#: (% o5 - i'Is the Building Historically Designated: Yes NO Occupancy Type: S Load: Construction Type: Flood Zone: BFE: FFE: kt /� OWNER: Name (Fee Simple Titleholder): 1 L✓ tl Jev _I �5 K Phone#: Address: L 2 ,��� /1{ �' '�' �t• City: V"Vl\ r. & W(! "d"-e �z State: (" L-- Zip: Tenant/Lessee Name: Email CONTRACTOR: Company Name: H—ritz- L�L°?�/�G �L C Phone#:-301V- 91a "4�)L-'X3 Address: Sao 1- 1 \':34-p L';�4 City: jnc A4fA&,,%. State: V:6Mk O A Zip: 07;5�, (M r Qualifier Name: (_ez /40t--'Z_ Phone#: State Certification or Registration #: C��C /5/7,c% Certificate of Competency #: DESIGNER: Architect/Engineer: Address hone#: City: State Zip: Value of Work for this Permit: $ zS�tr as Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New UV Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Permit Fee $ CCF $ Radon Fee $ Technology Fee $ Training/Education Fee $ DBPR $ CO/CC $ Notary $ Double Fee $ 3 Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ - Bonding Company's Name (if applicable) Bonding Company's Address City State 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 such posted notice, the inspection will not be approved and a reinspection fee will be charge Signature A10 k1ld-A, OWNE pr AGENT The foregoing instrument was acknowledged before me this day of G'i r �1 20, by c� ? c�n r`-e r who is personally known to me or who has roduced bY,y V \ I C y, �� /` as identification and who did-ta -ean oath. NOTARY P Sign Print W d. Signature CONTRACTOR The foregoing instrument was acknowledged before me this -� day of �"IL1 {c h , 20 (� by .-e t �q c k(Ae C l 7 who is personally known to me or who has produced I'L Llc tnsc as identification and who did take an oath. NOTARY PUBLIC: Sign: I , Print: Seal: tFF A`n f >i, Seal: i,h [h4 ' �� cf,� Notary Public State of Florida ;AFX ,� E 4� n �s ?� 7� c I LUIS JAVIER LAVA LE +�My Commission GG 161310 -- +r� Expires 01/01/2022 APPROVED BY /% Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) MOTZ PLUMBING LIC # CFC1429581 820 NE 123rd St. N Miami FI. 33161 MollaPlumbing@gmail.com 305-992 4223 Date 03/20/2018 State of Florida County of Dade Before me this day personally appeared Lee Motz who, being duly sworn deposes and says: That the or she is the only person working on the project located at : 1284 NE 94th St. Miami Shores Florida. Contractor signature Sworn to (or affirmed) and subscribed before me this day HWC 2018, Personally Known Or Produced Identification Type of Identification Produced FL I).,tv�e - Lc.-f - /J 7N Notary Public State of Florida LUIS JAVIER LAVALLE Ex Commission 22 161310 Expires 01/0112022 Print, Type, or Stamp Name of Notary 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. Re: Electrical Permit Signature: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 26 day of March , 20 18 . By Suzanne mill .r a k a Suzanne la cobs who is personally known to me or has produced Florida drive rs license as identification. Notary: 19:l (4R, L\) SEAL: . ,. . �ps�r Pu, Notary Public State of Florida r° Sindia Alvarez K MvC-j m �iaeivo FF 156750 F