RC-08-22-1927Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
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ri rr Expiration:02/10/2023
Location Address Parcel Number
166 NW 98TH ST, Miami Shores, FL 33150 1131010260040
Contacts
Julio Abarca Owner Julio Abarca Applicant
166 NW 98TH ST, Miami Shores, FL 33150 166 NW 98 Street, Miami shores, FL 33150
Other: 3057332893 julioa@nipromed.com
M2K SERVICES INC Contractor
CARLOS PALENZUELA
Business: 9548854854
Mobile: 9546515980
Description: REPLACING RC-07-21-1736 NEW CLICK FLOORING Valuation: $ 2,400.00
OVER EXISTING
Total Sq Feet: 600.00
Inspection Requests:
��•SL
v£
Fees Amount
Payments
Date Paid Amt Paid
100% Permit Renewal Fee $114.00
Total Fees
$114.00
Credit Card
08/10/2022 $114.00
Total: $114.00
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.
0 IE AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regula mg construction and zoning. Futhermore, I authorize the a ove named contractor to do the work stated.
Signature: Owner / Applicant / Contractor / Agent
Date
August 10, 2022 Page 2 of 2
Miami Shores Village
AUG 01 2022
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY..
Tel: (305) 795-2204 Fax: (305) 756-8972 II_
INSPECTION LINE PHONE NUMBER: (305) 762-4949
FBC 2020'
BUILDING Master Permit No. ke- 68 - 2z' lei
PERMIT APPLICATION Sub Permit No.
'BUILDING ❑ ELECTRIC E ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
p .�y CONTRACTOR DRAWINGS
JOB ADDRESS: 16 to w �a ✓' C,j• "�
r:.... nni..,.i County Miami Dade _._ Zip:
Folio/Parcel#: 11 - 3101 -026 - 004 0 is the Building Historically Designated: Yes NO
dG Occupancy Type: Load: Construction Type: GxV flood Zone: SFE: fFE:
OWNER: Name (Fee Simple Titleholder): U ir0
Arlrirncc- 14(6 Nw 9? .S�teJe
City: �rl ia.t u 5bccn State: 1 )— Zip: _ 31 s�
Tenant/Lessee Name: Phone#:
Email: O N i r0 )- eA W 'k
CONTRACTOR: Company Name: M2K Services Inc
Address: 14003 SW 32nd St —
Miramar FI
Qualifier Name: Carlos Palenzuela
State Certification or Registration #: CGC1517533
DESIGNER: Architect/Engineer:
Address:
Va-ru-e-oTWork for this Permit: $ $2,400.00
Type of Work: ❑ Addition ❑ Alteration
Description of Work: 04.) C 1V
Specify color of color thru
33027
Phone #: 954- 651-5980_
Certificate of Competency #: _
Phone#:
State: Zip:
Square/Linear Footage of Work: �Co X rod-3-vs❑ New ❑ Repair/Replace ❑ Demolition
1%l00 r% NP Ou tr fix+ S!�"
Submittal Fee $_—— Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $ —
_ CCF$ CO/CC$
_ DBPR $ Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE$ IL-OO
(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
State
M.
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.®/J�
Signature M/ Signature - _ _
NERorAGENT CONTRACTOR
The foregoing instrument was acknowledged before me this
L (/ dayofJ k� X 20 �, by
II U A D 9✓ O 9 . who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC: //•�
Sign: n
Print: 9 I21 v rl l 0 ci
Seal:
APPROVED BY
SAMUEL COLA
Notary Public • State of Florida
Commission Y HH 114463
My Comm. Expires Apr 6, 2025
as
The foregoing instrument was acknowledged before me this
2' 1 day of 41 Y 20 22 by
T—
eef TgIfnZvCA,who ispersonally know
me or who has produced as
e
identification and who did take an oath.
NOTARY PUBLIC:
Sign: L
Print: r"rl'
Seal: r SAMUELCALA
'yet Notary Public •State of a cn:a
;N Commission k HH llset:
= My Comm. Expires Apr 5
+r++++++*r rrr�rim�e6Nreugh�ytMse}*�*,**rrrr rrrrrr++++*
Plans Examiner
Structural Review
Clerk
(Revised02/24/2014)
1 I ♦ � ' ♦ 11
..}. :. yr ... a,.'= y: •� _.�
About this item
Product details
&A2,0G1:-
RECE�i QED
AU[ d 1 2022
BY: 1 Q o .._
'KC-0y- 27 _ lei 2�
n
Mohawk's Honey Glen Oak luxury vinyl plank offers great water-resistant performance and an incredibly
realistic wood look. The golden -brown color is a soft neutral base for any decor and the character marks, like
cracks and knots, give the look and feel of authentic oak planks. A protective surface layer with scratch -
resistance built in means your beautiful floor will look new for years to come. Its also stain -resistant, easy to
clean and low maintenance for your active lifestyle. Vinyl planks are quiet and comfortable underfoot, so
Honey Glen Oak can be used in any room of your home. The easy to cut and easy to install click together
product is perfect for the DIYer with minimal tools needed.
• With great Performance, Style and Beauty, this easy -to -clean luxury vinyl tile repels liquids and stains and
is pet friendly.
• 100% Waterproof Waterproof - Optimal for wet areas, such as basements and bathrooms.
• Family -friendly and resists scratches.
• Ideal for any level and any room in your home including basements, bathrooms and high -traffic areas.
• Plank size- 5 83" x 35.8" x 4.2mm, 20 34 sf per case.
• Easy to Install Interlocking planks make installation a snap.
• Case weighs 3114 lbs.
• This premium LVT includes a 25 Year Limited Residential Warranty and 6 Years Limited Light Commercial
Warranty.
• On -screen colors may vary by device; we recommend ordering a sample to view in your home.
QQ We aim to show you accurate product information. Manufacturers, suppliers and others provide what you
see here, and we have not verified it. See our disclaimer
Specifications
Features
Scratch Resistant
Brand
Mohawk
Manufacturer
Mohawk Carpet Distribution, Inc.
Manufacturer Part Number
WMT99-450
Color
Yellow
n
Material
Ll u;iyu�
Product Overview
Benefits
The Oak Wide Plank Coilection from Vanier offers lasting surface performance and warm natural hues, all on a strong and elegant Oak canvas. A great option
for wood floors above, on, or below grade, these engineered floors look and perform great almost anywhere.
Extra Wide Width Planks: These planks feature an impressive 9 Y a' width, this will show fewer and compliments larger opens spaces. Not to mention wider
planks cut down on installation time.
Wirebrushed Surface: gorgeous Oak grain pattern and enhances the overall aesthetic of the floor.
25 Year Residential Warranty: each purchase is backed by 25 year finish and structural warranties in residential spaces, and 5 year warranty in commercial
spaces.
Fillers color may vary
Hide
Warranty. Installation & Other info
rot Engineered Hardwood Floor Warranty
�o� Engineered Hardwood Floor Installation Instructions
roi Engineered Hardwood Floor Care & Maintenance
LE Engineered Hardwood Floor Pre -Installation Checklist
You will need Adobem Reader to view documents. Download it from the Adobe Web Site
Specifications
Dimensions
Maximum Length (in.) 84
Minimum Length (in.) 15
Width (in.) 9.50
Thickness (in.) 0.56
Wear Layer Thickness (mm) 4
Packaging Dimensions (inches) Height: 6 Length: 84 Width: 9
Details
Flooring Type Prefinished
Species Oak
Color
Gray
Shade Medium/Neutral Shade
Finish Type Urethane
Gloss Level
Low -Gloss
Manufacturers Grade
ABCD
Application
Residential
Core Type
Birch
Profile
Tongue & Groove
Edge Type
Micro Bevel
Top Layer Type
Oak
Radiant Heat Compatible?
Yes
Product is Stained Or Tinted
Yes
Installation
glue /nail/ floating
Certification
CARB tl
Country of Origin
China
Proposition 65
Attention California Residents
Sq Ft / Box
35
Warranty
Residential Warranty (in years) 25
Commercial Warranty (in years) 5
C_ - --- Y
ENTIEnE D TT R FJD
AUG O 1 Z02Z PLAN NOTES /SCOPE:
BY. NO WORK IN SHADED AREAPY'-
cc?y
NEW WIDE PLANK FLOOR COVERING
=IN LIVING / DINING ROOM & TWO
BEDROOMS
ALL ELECTRICAL, MECHANICAL &
PLUMBING EXISTING TO REMAIN
3y
Bedroom
145sf '
Bathroom
`��
No work are
Bedroom
145sf
't
Family Room
No work area
Kit
No wox
Living / Dining Room
246 SF
SNOIl'd1f cai ONV S-PIY ),I.NrI —1 CNV 31V1S
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Garage
JULIO ABARCA RESIDENCE
REPLACE FLOOR COVERING
166 NE 98 STREET
MIAMI SHORES, FL 33150
CITY OF MIAMI SHORES
FLOOR PLAN
Miami Shores Village
Building Department JUL 20 2022
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. RC-6-7 -zl - 173�
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING REVISION ❑ EXTENSION RENEWAL
❑ PLUMBING ❑ MECHANICAL ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR J DRAWINGS
JOB ADDRESS: I `arc N W I.h -,5 L
City: Miami Shores County: Miami Dade Zip:
the Building Historically Designated: Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name (Fee Simple Titleho�lldyyer): � t7 i 10 t A R.C—Iti Phone#:
Address: �� ew �T• A�i--
City: M i Am y '5 ikmO� State: 1`�. Zip: 3 3t s
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name: Phone#:
Address:
Email
Qualifier Name:
State Certification or Registration #:
of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ 3 �'�' Square/Linear Footage of Work: loUO
Type of Work: ❑ Addition ❑
Alteration
❑ New
❑ Repair/Replace ❑ Demolition
Description of Work: n?_ta:
(iAIc._L `
' r
Specify color of color thru
Submittal Fee $
Scanning Fee $
Technology Fee $
Structural Reviews $
Permit Fee $
DCA Fee $
Training/Education Fee $
CCF $
CO/CC $
DBPR $ Notary
Double Fee $
P&Z Review $ Bond $
TOTAL FEE NOW DUE $ _
(Revised04/05/2022)
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
Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 fob 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 Signature
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of .20 , by
me or who has produced
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of .20 , by
who is personally known to , who is personally known to
identification and who did take an oath.
NOTARY PUBLIC:
as me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign: Sign:
Print:
Print:
Seal: Seal:
as
************************************************************************************************************
APPROVED BY
Plans Examiner
Zoning
(Revised04/05/2022)
Structural Review
Clerk
JUL 2 0 2022
July 20, 2022
Building Department
Miami Shores Village
10050 NE 2ntl Avenue
Miami Shores, Florida 33138
RE: Building Process No. RC-07-21-1736
To whom it may concern,
As indicated by a Building Department Associate, I am here by writing to request the
cancelation of expired process #RC-07-21-1736.
A year ago, I was intending on updating some flooring at my property address 166 NW
98 Street. I went to the village to start the permit process, however within days of
submitting the application my mother-in-law got very sick, was hospitalized in intensive
care and ultimately passed away. We were out of town for several weeks due to the
hospitalization, a funeral and settling her affairs (attached find a copy of the Death
Certificate).
Upon our return to Miami Shores, we determined that after dealing with such tragedy
and Covid, we could not possibly have strangers (contractors) working in our home and
therefore, we never continued with the process. I was unaware that a formal cancelation
request had to be made.
T nk you
N�
_ju o Abarca
166 NW 98 Street
Miami Shores, FL 33150
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
❑PLUMBING FIVIECHANICAL ❑PUBLICWORKS
JOB ADDRESS: 166 N '_) S�"
ZNTERED
JUL 0 G 2021
BY.—G-
CFF BnC 20
Master Permit No. 1 W `(7 T Qkh�A
Sub Permit N
❑ REVISION ❑ EXTENSION RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade Zip: 111-VO
Folio/Parcel#: H — 2> 101 " t 00 �. 0 Is the Building Historically Designated: Yes N( O 9
Occupancy T e: Load: Construction Type: CAL) Flood Zone: BFE: FFFFE:
�esi
OWNER: Name (Fee Simple'Titleholder): ��V117 60LC_�� Phone#:
City: I kj.'IA'_A /--I State: :2�i� Zip: 331 S�
Tenant/Lessee Name: Phone#:
Email: �V�Ty— IA9.4 -
CONTRACTOR: Company Name:
Address:
one#: 30T 6-1 q
City: w � State: T c� Zip: i!�3
Qualifier Name:
State Certification or Registration #:
DESIGNER: Architect/Engineer: _
0
of Competency #:
Address: 2 �+ City: State: Zip:
Value of Work for this Permit: $ 3� O oz> Square/Linear Footage of Work: tgff i 600 /F
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: n) IFyty C L'1 LIB F l VB 09) " O V Eft F Js 1 I L/4
Specify color of color thru
Submittal Fee $
Scanning Fee $
Technology Fee $
tile:
Permit Fee $ CCF $ CO/CC $
Radon Fee $ DBPR $ Notary $
Training/Education Fee $
Double Fee $
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
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 apRNved and a reinspection fee will be charged.
or AGENT
The foregoing instrunTen4*asacknowledged before me this
Z Cf day of % U h l 20 Z I by
J0 1® A b 9 -cq , who is personally known to
me or who has produced
as
Signature 4—
CONTRACTOR
The foregoing instrument was acknowledged before me this
2 1 ++ day of f e 20 24 by
✓,e 1 c e ci viol h O who is personally known to
me or who has produced C 15 U -200 - 69 - 445-Gas
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Il�d 0 W
Sign: // Sign:
Print: SGvnu c.+ `h19 Print:
;,xr AMu L Au
Seal: Notary Public - State of Florida Seal: r'i SAMUEL CALA
Commission d HH 114463 £ W.
't®d(?.� ±F/,•� Y;! Notary Public - State of Florida
My Comm. Expires Apr 6. 2025 Commission a HH t 14a63
Bonded through National rota Assn.
v4 Notary `....� r. My Comm, Expires Apr 6. 2025
################################################################## # n tr hNa Tonal Nota Assn. ############
APPROVED BY
Plans Examiner
Zoning
(Revised02/24/2014)
Structural Review
Clerk
CTOtConstruction Trades ualifying Board
SINESS CERTIFICATE OF COMPETENCY
OOBS00108
PREME WOOD FLOOR INC
EVELIO
Is certified under the
-
Municipal Contractor's Tax Receipt
Miami -Dade County, State of Florida
THIS IS NOT A BELL - DO NOT PAY
CC NO: OOBSOO10a
BUSINESS NAMEMOCATiON RECEIPT NO. EXPIRES ,
SUPREME WOOD FLOOR INC"
3164 SW 26TH sr 761384-2 SEPTEMBER 3012022
MIAMI, FL 33133
Pursuant to County Code
SeC 10-24
OWNER TYPE OR BUSINESS PAYMENT RECEIVED
SUPREME WOOD FLOOR INC SPECIALTY BUILDING CONTRACTOR BY TAX COLLECTOR
C/O EVELIO CHAVIANO PRIES 175.00 07/01/2021
0205-21-0035 1 9
This reeaipt is not valid is do (01knviap Mooldpatiilat Aves=6 Donal, Hialeah. Key Biscayne.
t�t�M Miami Gardena. Miami Lakes. Pabu to Bq. Pinecrest, Sumq bias SaWk Town of War Bay.
CAfar more inioro adwx vhIt
Local Business Tax Receipt
Miami Dade County, State of Florida
—THIS IS NOT A BILL. -- DO NOT PAY
4238739 RECEIPT No.
RENEWAL
BUSINESS NAME/LOCATION 4425856
SUPREME WOOD FLOOR INC
3184 SW 26TH ST
EXPIRES
SEPTEMBER 30, 2022
Must be dleplayad at place of business
MIAMI, R. 33133 .. Pursuant to County Code
Chapter BA - Art. 9 & 10
0 '+
OWNER SEC. TYPE OF BUSINESS PAYMENT RECEIVED
SUPREME WOOD FLOOR INC 196 SPECIALTY BUILDING BY TAX COLLECTOR
CIO EVELIO CHAVIANO PRES CONTRACTOR 45.00 07/01/2021
Worker(s) 1 00BS00108 0205-21-003519
This Local Btaimss Tax Ra W Cary conffrms MOW of the Local l inheess Tex. The Receipt is M a 5011 .
Pa m,% or a MUllestioo at tine holders qual:catiam to do bnhwas. Holder alest oomph wiM ash 9ovse3=W*I
or aoaQ"MmeMel rggd&Wry taws sad MgWheMcW which aply to them bushass.
Tho RECEIPT N0. above am et be displayed an all co=ercial vehicles - Mlmi.-Cade Code Sec Se-M.
®a for mom lafonaatiam visit
ACOR 7 a
` C.) CERTIFICATE OF LIABILITY INSURANCE
DATE (MIMIMaNn-Y)
O6/30/2021
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 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(les) must have ADDITIONAL INSURED provisions or 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 endorseme s .
PRODUCER
USA GENERAL INSURANCE
13631 SW 26st
Miami FL 33175
Martha Rlvero
-WEr
PHONE 305 386-3305 FAX 888 330-1123
Lft gmtell@usagenemlinsurance.com
INSU AFFORDING COVERAGE
NAIC S
INSURER A: HISCOX INSURANCE CO
INSURED
SUPREME WOOD FLOOR INC
3184 SW 26 ST
Miami FL 33133
INSURER 13 :
INSURER C :
INSURER 0 :
INSURER E :
INSURER F :
f%nvc0A9%-Gs 91-aa?T19ICATF MIIMRER- 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.
IRSR
TYPE OF INSURANCE
DL
8UBR VwjMwn
POLICY NUMIBER
POLICY EFF
POLICY EXP
LIMITS
A
X
COIdMERCIAL GENERAL LIABILITY
CLAMS -MADE D OCCUR
UDC-4511032-CGL-21
06/10/2021
06/10/2022
EACH OCCURRENCE
$ 11000,000
DAMAGE TO REM
PREMISES E
$ 100.000
MED EXP one
$ 5,000
PERSONAL &ADvINJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
X PEO LOC
POLICY ❑
OTHER
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - coMP/OP AGG
$ 2,000,000
$
AUTOMOBILE LIABILITY
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
(Es sockkMI) COMBINED SINGLE LIMITS
BODILY INJURY (Per person)
$
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks SdmxW o, may be attached If mom space is )
Contractors License 00BS00108
Miami shores Village Hail
Building and Zoning
10050 NE 2nd Ave
Miami Shores
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE VALL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
1
FL 33138
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ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
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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: 6/7/2021
PERSON: EVELIO CHAVIANO
FEIN: 453207320
BUSINESS NAME AND ADDRESS:
SUPREME WOOD FLOOR, INC.
3184 SW 26 ST
MIAMI, FL 33133
SCOPE OF BUSINESS OR TRADE:
Fioar Covering Installation -
Resilient Flooring- Carpet and
Laminate Flooring
EXPIRATION DATE: 6/7/2023
EMAIL: ZSASSOCIATES17@YAHOO.COM
IMPORTANT: Pursuant to subsection 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by fling 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 F01362796 QUESTIONS? (850) 413-1609
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
h77777,
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 fp
obtaining a 61ding 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 the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING' BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this day of & n to , 20 Z
J
By A 1 t 0 u L q - r `) who is personally known to me or has produced
as identification.
Notary Public - State of Florida
Comminlm 0 HH 114463
Mr Comm. Expires Apr 6, 1025
d ttaouab National Notary Assn