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FW-02-22-489Permit NO.: FW-02-22-489 Miami Shores Village Permit Type: Fence/Wall 10050 NE 2 Ave Miami Shores FL 33138 Work Classification: Wood Fence 305-795-2204 Permit Status: Approved ;. ,...._ tssueQatl4411Q/Z022 Expiration:09/12/2022 Location Address Parcel Number 75 NW 91ST ST, Miami Shores, FL 33150 1131010160120 Contacts ARP ACQUISITIONS CORP TRS Owner MAAFA ENGINEERING CORP Contractor 75 NW 91 ST, MIAMI SHORES, 33150 AURELIO JESUS FERNANDEZ 2129 W 53 ST, HIALEAH, FL 33016 Business: 7864260936 AJFATWIN@HOTMAIL.COM Inspection Requests: Description: 360' WOOD FENCE WITH 10' DOUBLE GATE AND 5Valuation: $ 7,000.00 305-762-4949 PERSONAL DOOR, ALL TO 6' HIGH II4 Total Sq Feet: 0.00 i Fees Amount 100% Permit Renewal Fee $310.00 Application Fee - Other $50.00 Total: $360.00 Payments Date Paid Amt Paid Total Fees $360.00 Credit Card 02/24/2022 $50.00 Credit Card 03/10/2022 $310.00 Amount Due: $0.00 Building Department Copy In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner / Applicant / Contractor / Agent �J I �% Date 0 March 10, 2022 Page 2 of 2 Miami Shores Village u ` . zozz U Building Department EB 24 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 B __ INSPECTION LINE PHONE NUMBER: (305) 762-4949�� FBC 20Zo l BUILDING Master Permit No .�W � ar�_ G2. 4 � PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: ?S A/W -115t City' Miami Shores l� County: Miami Dade Zio: 33 Folio/Parcel#: /7- 3/0/— 0/l10 -y`ay Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type:l"enP- Flood Zone: BFE: FFE: OWNER: Name (Fee Simple / Titleholder):/ 1L 41_zP/ °5�A016 Arirlrp-;- I -iDCI �7 &-it l e_ / /(V( `'JC�il'7`e 0q one#: City: ��a�r State: i'� Zip: t Tenant/Lessee Name: Phone#: Email: VNlaCJi4'�1Pf<�t�v%�L " j�P�{00 CA�1 CONTRACTOR: Company Name: �hQ l�Yl� C!!'l'iLl?�� ,i2C. Phone#: Address: 17'vlea'U City: W,90 ,�� / �,, State: Fz_ Zip: 33 ©al Qualifier Name: ��`�'e- ` 0'nC. Phone#: State Certification or Registration #: Certificate of Competency #: DESIGNER: Architect/Engineer: Address: Value of Work for this Permit: $ Type of Work: ❑ Addition / Description of Work: �/',,17.eCLd, City: one#: _State: Zip: Square/Linear Footage of Work: VAlteration ❑ New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ 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 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. 1 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 Signature _ )6p OWNER or AGENT 0 CONTRACTOR The jj foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of ;� `1't�-�- 20, byy._ �_ day of 1 L- 20 ;� , by .Q� s' .G-as who'is personally known to ' u who i ersonally known,to me or who has produced as me or who has produced` as identification and who did take an oath. NOTARY PUBLIC: ar i� Leiza I. Azar Vazquez Comm.#HH116340 7 Expires: Apri 11, 2025 Print: Seal identification and who did take an oath. NOTARY P LIC: Leila 1• Azar Vazquez `; Comm.#HH116340 �•: _Eacpires,.APM 11, 2025 Print: Seal: APPROVED BY t Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application - Miami -Dade County Page 1 of 2 'w 7 ��V OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11- H01-016-0120 75 NW 91 ST Property Address: Miami Shores, FL 33150-2254 ARP ACQUISITIONS CORP TRS Owner 75 FLORIDA LAND TRUST ..................................................................................................................................................1.... _....... . .................. .... I_................................................................................... 13611 S DIXIE HWY STE 409 Mailing Address MIAMI, FL 33176 USA PA Primary Zone 0800 SGL FAMILY - 1701-1900 SQ ...._..... ............._...._..-_......_.........................._..__........_.............._...................................................................................._..__...._.............._............_.........._.................................. 0101 RESIDENTIAL - SINGLE Primary Land Use FAMILY: 1 UNIT Beds / Baths / Half 3/2/0 .__.._... _... _......... _... _........................ Floors ... _..__._-__..... _-............... ._.._._..__............. _............................................. 1 Living Units 1 Actual Area 2,825 Sq.Ft Living Area 1,447 Sq.Ft Adjusted Area 2,120 Sq.Ft Lot Size 12,600 Sq.Ft Year Built Multiple (See Building Info.) Assessment Information Year 2021 2020 2019 Land Value $365,656 $290,882 $290,882 Building Value ....... __............. -... _...... ....... .._.._..... _...__......... XF Value ......... .........-__.__._..._ __._..___ _ _......._.._ Market Value $159,591 ._._......................... _.........._......_....... $21,441 .__...... _ $546,688 $159,887 ............._....... ........................... $21,481 __......_ $472,250 $160,183 ........................ _..... _.... _............... $21,521 .._._.... ....._.. $472,586 Assessed Value $519,475 $472,250 $149,245 Benefits Information Benefit Type 2021 2020 2019 Save Our Homes Assessment $323,341 Cap Reduction Non -Homestead Cap Assessment $27,213 Reduction __.._...._._._t Homestead Exemption $25,000 Second Homestead Exemption $25,000 Vet Disability Exemption $5,000 ---- --------------------------------- ......_____...._..___......__......_........_......_.._____....................... . Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description MIAMI SHORES MANOR PB 45-13 LOT 12 & LESS W5FT & N1OFT LOT SIZE SITE VALUE OR 12015-945 1183 4 Generated On : 2/24/2022 Taxable Value Information 2021 2020 2019 ..........................__............ _...... ___....... ... ........................... .......... ...... ._________.._-._.._......_............... ... ............ ______.... ____.__.. County Exemption Value $0 $0 $55,000 Taxable Value $519,475 $472,250 $94,245 School Board Exemption Value $0 $0 $30,000 Taxable Value $546,688 $472,250 $119,245 ........... ........................_....................................._...............................................,............_.... City Exemption Value _ $0 $0 $55,000 Taxable Value $519,475 $472,250 $94,245 Regional Exemption Value $0 $0 $55,000 Taxable Value $519,475 $472,250 $94,245 Sales Information Previous OR Book - Price Qualification Description Sale Page Federal, state or local government 07/02/2019 $387,200 31514-4610 agency The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser https://www.miamidade.gov/Apps/PA/propertysearch/ 2/24/2022 Detail by Entity Name Page I of 2 F lor I a D nam?.nt of ........ ....................................................... rg .................. Depai tnieni of Sta€e / MAsion -of Curporatims / Seai ch Records / Seam! i oy E i ibIV Nan.a / DIM'�011 0-- CORPORATIONS https:Hsearch.sunbiz.org/lnquiry/CorporationSearchISearchResultDetail?inquirytype=Entit... 2/24/2022 COUNTY -WIDE LAND SURVEYORS INC. LAND SURVEYORS PLANNERS P.O. HOX 823271 SOUTH FLORIDA, FL. 33082-3271. (305) 772-0766 15358 S.W. 140 St. Miami, Fl. 33196 and horizontal Fences Good Side Out The cad suppohIng members of a fence shall face the interior of the plot orr �'ahich the fence is located ining I and the finish d side r oht of -way e the ad] lot or any ate__ LEGAL DESCRIPTION �'1S� •p Lot 12 LESS the West 5 feet & the North 10 feet of MIAMI SHORES MANOR,��Qi1 0 O according to the plat thereof, as recorded in Plat Book 45 at Page 1�; � � mint 0941n,area S of the Public Records of Miami -Dade County, Florida. �� tQ' the P°°1o�K��g' ate ►��aW�,y tt� se�s�de SURVEYORS NOTES: 5 se\t- o� Pa° SS 1) . Legal description provided by client. tte ��at ted n0 �e 0A 10` 2) . Only record plat easements are shown. de�aoa 10 bo�°'M 1� •1 `' 3). Right of way informationobtainedevfrom record plat. Ito42�'• 4). In Federal Flood Zone X, Panel 0302 last revised 9-11-2009. 'feC BOUNDARY &_-IMPROVEMENTS SURVEY vEY Jose Rivas 75 .NW 91 St. Miami Shores, Fl. 33150 SURVEYORS CERT—FF 'GATE _NOTE: "NOT VALI➢ IINLESS SEALED WITH AN EMBOSSED SURVEYORS SEAL." I H"."Y CERTIFY TUAT THE SURVEY REPRESENTED HEREON COMPLIES WITH TH IMIMUK TECHNICAL STANDARDS ADOPTED BY THE FLORIDA LB # 4680 BOARD OF SURVEYOR NO MAPPERS IN CHAPTER •SJ-17 , FLORIDA ADMINISTRATIVE CO E PURSORANT TO SECTION 472.027, FLORIDA STATUTES., REVISIONS BY DATE JOSEPH L. MARTIN' PROFESSIONAL LAND suRVEYOR ,* 4368 • DRAWN BY I SOLE DATE F.B./PG. JOB40 STATE OF FLORIDA �� 4h ) ",'�O' it-ivto�� ?oil, _ Miami Shrr�sge APF'RO\,ED BY DATE j 6 70NING DEPT _ R f3L_DG DEPT L� SUBJECT i 0 CGNIPLL'NCE WI fH ALL. FED RAL STATE AND C(,IjN i `f rtu_-'S AND REGULATIONS NOT Donny Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. J ' COPY OF LOCAL BUSINESS TAX RECEIPT C. 1% COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. I/ COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. .................................................................. 0 M 0 a 0000000 a...... 00 N 0 w 000 BUSINESS NAME: /tic unit I BUSINESS ADDRESS: /03 0.2 Ala),6 .%Zv* 1>r CITY Adleel STATE FZ ZIP .33 BUSINESS PHONE: ( q54 ) -?Dqe Nell3 FAX NUMBER ( ) CELL PHONE ( ) QUALIFIER'S NAME: 505e— C t5a4cl&z QUALIFIER'S LIC NUMBER: aO 13 6 DOy.32 Construction Trades Qualifying Board BUSINESS CERTIFICATE OF COMPETENCY 20B"Q, 3 Or UNA ORNA SANCHEZ-PEREZ JOSE CARLOS Is certified under the provisions of Chapter 10 of Miami -Dade County QUALIFYING TRADE(S) 0035 ORNAMENTAL IRON Mi�AM� w iii �ymiamida Local Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7288800 BUSINESS NAME/LOCATION TUNA ORNAMENTAL INC 10302 NW SOUTH RIVER DR MEDLEY, FL 33178-1310 OWNER TUNA ORNAMENTAL INC C/O JOSE CARLOS SANCHEZ PEREZ PRFS Employee(s) 1 RECEIPT NO. RENEWAL 7577601 EXPIRES SEPTEMBER 30, 2022 Must be displayed at place of business Pursuant to County Code Chapter BA — Art. 9 & 10 SEC. TYPE OF BUSINESS 213 SERVICE BUSINESS PAYMENT RECEIVED BY TAX COLLECTOR 45.00 08/31 /2021 INT-21-370855 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business, The RECEIPT NO. above must be displayed on all commercial vehicles — Miami —Dade Code Sec Ba-276. MIANI ADE For more information, visit www.miamidade.govAaxcollector Municipal Contractor's Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT A BILL — DO NOT PAY CC NO: 20BS00432 BUSINESS NAME/LOCATION RECEIPT NO. TUNA ORNAMENTAL INC 10302 NW SOUTH RIVER DR 7628404 MEDLEY, FL 33178-1310 MC. EXPIRES SEPTEMBER 30, 2022 Pursuant to County Code See10-24 OWNER TYPE OF BUSINESS TUNA ORNAMENTAL INC SPECIALTY BUILDING CONTRACTOR PAYMENT RECEIVED BY TAX COLLECTOR C/O JOSE CARLOS SANCHEZ PEREZ 175.00 02/22/2022 PRES 0206-22-003019 This receipt is not valid in the following Municipalities: Aventura, Dora[, Hialeah, Key Biscayne, Miami Gardens, Miami Lakes, Palmetto Bay, Pinecrest, Sunny Isles Beach, Town of Cutler Bay. MIAMI�DAM For more information, visit www.miamidede.gov/taxcollector RM A� " CERTIFICATE OF LIABILITY INSURANCE DATE [MMIDD/YYYY) 2/15/2022 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. PHIS 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 CONTACT NAME: Gladys Delgado PHONE (305)825-8580 (A/C7FAXNo; (305)825-8581 Sharp Insurance Agency 6175 NW 153rd St Ste 200 E-MAIL glady s@sharpins.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURERA:Hallmark Insurance Company Miami Lakes FL 33014 INSURED INSURER B : INSURERC: Tuna Ornamental Inc INSURERD: 7220 HAYES ST INSURER E : INSURER F : Hollywood FL 33024 COVERAGES CERTIFICATE NUMBER:CL221311095 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 rypE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 A CLAIMS -MADE 7X OCCUR DAMAGETO ITEM PREMISES Ea o currrrence $ 100,000 MED EXP (Any oneperson) $ 5,000 G09405784-0 12/22/2021 12/22/2022 PERSONAL & ADV INJURY $ 500,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 500,000 X POLICY ❑ PRO JECT a LOC PRODUCTS - COMP/OP AGG $ 500,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIREDAUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ElE.L. N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Contractor License# 20BS00432 CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2nd Ave. Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gonzalez/MF ACORD 26 (2014/01) INS025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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: 12/2/2021 PERSON: JOSE C SANCHEZ PEREZ FEIN: 462247166 BUSINESS NAME AND ADDRESS: TUNA ORNAMENTAL INC. 7220 HAYES ST HOLLYWOOD, FL 33024 SCOPE OF BUSINESS OR TRADE: Welding or Cutting NOC and Iron or Steel. Erection Frame Drivers Structures EXPIRATION DATE: 12/2/2023 EMAIL: JOSECARLOSSANCHEZ31 @YAHOO.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 E01450863 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 — vvomers- L.ompensation insurance mxemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: I. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from 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. Sign re - Owner State of Florida County of Miami -Dade 41 The foregoing was acknowledge before me this � day of 20 By SOX � G(Q�J. who is personally known to me or has produced / y 0 — q3 P. 0-4 091-01111- 0 as identification. Notary: H avez SEAL: �:� Comm. i'HH069947 Expires: Dec. 31, 2023 Bonded Thru Aaron Noto COMPANY LETTER HEAD Date: 2/16/2022 State of Florida County of Broward Before me this day personally appeared Jose Carlos Sanchez Perez who, being duly sworn, deposes and says: That he will be the only person working on the project located at: 75 NW 91 ST Miami Shores, FL 33150 Contra for Signature Sworn to L(r affirmed) and subscribed fb�fore me this 1 day of 2022 by i �J Personally know OR produced Identification Type of identification produced Lab I. Azar Vazquez Comm.#HH116340 • Ft; Fxplo:AprN 11nBonded ThrU AaroNolary M Print, Type or Stamp Name of Notary