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RC-01-22-88Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: RC-01-22-88 Permit Type: Building (Residential) Work Classification: Alteration Permit status: Approved Issue Date: 02/02/2022 1 Expiration:08/02/2022 Location Address Parcel Number 9767 NE 13TH AVE, Miami Shores, FL 33138 1132050090520 Contacts Cooper Florida Estates LLC Owner G.A.V. BUILDERS INC Contractor 9767 NE 13 AVE, Miami Shores, FL 33138 GEORGE ANTONIO VAZQUEZ 9767 NE 13TH AVE, Miami Shores, FL 33138 GAVTEMPO@AOLCOM Description: REMOVE CARPET FROM TWO ROOMS AND Valuation: $ 2,124.00 F Inspection Requests: REPLACE WITH GREY TONES LAMINATE FLOORING 305-762-4949 Total Sq Feet: 720.00 Fees Amount Application Fee - Other $50.00 CCF $1.80 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.60 Permit Fee $50.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $117.90 Payments Date Paid Amt Paid Total Fees $117.90 Check #325 02/02/2022 $67.90 Check# 324 01/13/2022 $50.00 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 all work will be a in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above named con o do the work ed /� Authorized Signature: Owner / Applicant / Contractor / Agent Dat; February02, 2022 Page 2 of 2 2 1` 2o\n�p2 BUILDING PERMIT APPLICATION 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 Master Permit Sub Permit DT0T0T1T UJAN 13 2022 D q L-I,'t FBC 2020 _ iz.c-61,. 22-�i8 OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL F—IPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 97674 NE 13 Avenue City: Miami Shores County Miami Dade Zip, Folio/Parcel#:11-3205-009-0520 Is the Building Historically Designated: Yes NO X Occupancy Type: SF Load: Construction Type: CBS Flood Zone: — _. BFE: FFE: OWNER: Name (Fee Simple Titleholder): Cooper Florida Estates LLC Phone#: Address:200 S Biscayne Blvd.; 7th Floor City. Miami State: FL Zip: 33131 Tenant/Lessee Name: Email: gavtempo@aol.com CONTRACTOR: Company Name: GAV Builders Inc. Phone#: 754-235-5000 Address: 1308 Arthur ST. City: Hollywood State: FL Zip; 33019 Qualifier Name: George Vazquez Phone#: 754-235-5000 State Certification or Registration #: CGC #1507009 Certificate of Competency #: DESIGNER: Architect/Engineer: Value of Work for this Permit: S Type of Work: ❑ Addition Description of Work: Remove 00 j� City: State: Zip: t I rT` 3�1Unear Footage of Work: ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition mrpet from two rooms and replace with gray tones Laminate flooring Specify color of color thru tile: Submittal Fee $ E_�Ql - CC) Permit Fee $ Scanning Fee $. Technology Fee Structural Reviews $ Radon Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary Double Fee $ Bond $ TOTAL FEE NOW DUE $ _3 • _�__ (Revised02/24/2014) Bonding Company's Name (if applicable) Bonding Company's Address city State Mortgage Lender's Name (if applicable) Mortgage Lenders 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. 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 1 0 ERorAGENT The foregoing instrument was acknowledged before me this day of ✓I U q n20 12 by r /Q Vrr who is personally known to me or who has produced �~ as identification and who did take an oath. Seal: ,;1yr.o JANETTE M. GARCIA :`r° • ' Notary Public - State of Florida Commission # GG 353452 ' �. y Comm. Expires Aug 11, 2023 fiiiita<�tiY1♦"4o*W-M dt��rougl�'k3tf8MatRdtlr APPROVED BY Signature .. O CONTRACTOR The foregoing instrument was acknowledged before me this �h day of - 20 09L . by r7rC9l R 1.�(Z, q9C w o is personally known to me or who has produced as identification and who did take an oath. NOTARYPUBLIC:n n Sign:_ Print: • ''... GISEU SANT05 Seal: Notary Public - State of Florida t ® Commission # HH 30781 an . My Comm. Expires Aug 16, 2024 Bonded through National Notary Assn. Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) c�ClNAR A.i?;t�: a �: tQpi; •. }� �i i iii:'�1 � ti^ '�:hS_ )1iLt:r� '{•'.3•- f '?/f . � � }i� hztA . �i:t'i! ib.'1•:�fll}! r�X' A: f.1!:,tk." •� Buz rasr.��r'e?rsv.,r':ts:• Y L ....9G...d€7wra�h..d�'i...+drr'tr.�t+..r.:s....f�+..a•.L..et'�,..!(r•.•:iN... �. �;.''g�F'�qr�1M•'71Ar+.Y>�v't1JM'Vp��ef+"�i"'Sb�'YSi"'o0,y, �'; OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11-3205-009-0520 Property Address: 9767 NE 13 AVE Miami Shores, FL 33138-2545 Owner COOPER FLORIDA ESTATES LLC Mailing Address 200 S BISCAYNE BLVD 7TH FLR MIAMI, FL 33131 USA PA Primary Zone 1700 SGL FAMILY -4001 SOFT & Primary Land Use 0101 RESIDENTIAL -SINGLE FAMILY: 1 UNIT Beds / Baths / Half 4/4/0 Floors 1 Living Units 1 Actual Area 7,984 Sq.Ft Living Area 5,094 Sq.Ft Adjusted Area 6.257 Sq.Ft Lot Size 28,047 Sq.Ft Year Built Multiple (See Building Irdo.) Assessment Information Year 2021 2020 2019 Land Value $3,506,096 $3,506,096 $3,380,941 Building Value $740,860 $438,060 $811,249 XF Value $55,270 $55.844 $0 Market Value $4.302.226 $4,000,000 $4,192,190 Assessed Value $4,302,226 $4.000,0001 $4,192,190 Benefits Information Benefit I Type 2021 2020 2019 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). Short Legal Description EARLETON SHORES PB 43-80 LOTS 7 & 8 BILK 4 LOT SIZE 186.980 X 150 OR 16863-2142 0795 1 Generated On : 12/28/2021 Taxable Value Information 2021 2020 2019 County Exemption Value $0 $0 $0 Taxable Value 1 $4,302,226 $4,000,0001 $4,192.190 School Board Exemption Value $0 $0 $0 Taxable Value 1 $4.302,2261 $4,000.000 $4,192,190 City Exemption Value 1 $0 $0 $0 Taxable Value1 $4,302,2261 $4,000,0001 $4,192,190 Regional Exemption Value $0 $0 $0 Taxable Value 1 $4,302,2261 $4.000,0001 $4,192,190 Sales Information Previous Price OR Book- Qualification Description Sale Page 07/20/2021 $7,400,000 32650.1601 Qual by exam of deed 06/11/2021 $100 32578-2324 Corrective, tax or QCD; min consideration 03/22/2018 $0 30911-3674 Corrective, tax or QCD; min consideration 07/01/1995 1 $600,000 16863-2142 1 Sales which are qualified The Office of the Property Appraiser is continually edifing and updating the tax roll. This ml site may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http:/Aw .miamidade.gov/info/disclaimerasp Version: Detail by Entity Name Page 1 of 2 Florida Department of Slate ,M �.org Department of Stale I Division of Corporations / Search Records / Search by Entity Name / Detail by Entity Name Florida Limited Liability Company COOPER FLORIDA ESTATES, LLC Filing Information Document Number L20000261539 FEI/EIN Number APPLIED FOR Date Filed 08/24/2020 Effective Date 08/23/2020 State FL Status ACTIVE Principal Address 200 S BISCAYNE BLVD 7TH FLOOR MIAMI, FL 33131 Mailing Address 200 S BISCAYNE BLVD 7TH FLOOR MIAMI, FL 33131 Registered Agent Name & Address FLORIDA REGISTRY SERVICES, LLC 200 S BISCAYNE BLVD 7TH FLOOR MIAMI, FL 33131 Name Changed: 04/17/2021 Authorized Person(s) Detail Name & Address Title MGR BRANT, BARRY M 200 S BISCAYNE BLVD 7TH FLOOR MIAMI, FL 33131 Annual Reports Report Year Filed Date 2021 04/17/2021 Document Images 04/17/2021 — ANNUAL REPORT I View image in PDF format 08/24/2020 -- Florida Limited Liability View image in PDF format DiviSION OF CORPORATIONS https:Hsearch. sunbiz. org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entit... 1 / 13/2022 6A0' iI L1AN3 2022 l.iPs-ol-22-� is i Shores Village Building D Ing Dept. Date Building Dept. Date, Subject to com nce with all State and Coun rules and re(. ------------------ 16.t51 i I �5�s�fs-BAGIV 1 16.t51 i I �5�s�fs-BAGIV 1 i Ida -------- I! li I, tali bi y �[it. 5.S i II I i P I I•` _K I II I I� I rip i li - �i 2J IO ]535-(5-BKK) '.w.LveWtir EX15TING GB51•EW-E 5 150.01 C' lid I rz WATER 9fGE--__.5�._._ L. I SC I U I id : W ! If� 1 ail rW L.� I I O ! (5ET'J.ACJV 4!50' eooe 0 0 ooeeoo 0000 e o 0 0 0 0 0 o e 0 00 0 000000 000000 0 ooeeoo 0 0 s e 000000 000000 0 0 e e eooe 060000 0 0 00000 o eooe o e 00000 e 0 0eeeee o e e o 0 0eeee4P 00 00 es se 0 e o 000009 0 0 0 000000 a es 0 e e s e 0 0 00 0 0 ooesee e e e 0 0 0 oe a 0e e o 0 00 0 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. 7 COPY OF LOCAL BUSINESS TAX RECEIPT C. �OPY 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. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT D. 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. .................................................................................... a....... BUSINESS NAME: S \ BUSINESS ADDRESS: 1�.�D� i1��lCl� CITY 1� LtTrd, STATEL ZIP BUSINESS PHONE:( �� 1 a35-�C� FAX NUMBER CELL PHONE( QUALIFIER'S NAME: ��z fZ% ul�ZGl1PZ QUALIFIER'S LIC NUMBER: STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! (850)487-1395 STATE OF FLORIDA DEPARTMENT db'pr ROF BUSINESS EGULATION AND PROFESSIONAL CGC1507009 ISSUED: 06/15/2020 CERTIFIED GENERAL CONTRACTOR VAZQUEZ, GEORGE ANTONIO GA.V. BUILDERS INC Signature LICENSED UNDER CHAPTER 489, FLORIDA STATUTES EXPIRATION DATE: AUGUST 31, 2022 Ron DeSantis, Governor Halsey Beshears, Secretary STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER: CGC1507009 EXPIRATION DATE: AUGUST 31, 2022 THE GENERAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES VAZQUEZ, GEORGE ANTONIO G.A.V. BUILDERS INC 1308 ARTHUR STREET HOLLYWOOD FL 33019 ISSUED: 06/15/2020 Always verify licenses online at MyFloriciaLicense.com Do not alter this document in an form. This is your license. It is unlawful for anyone other than the licensee to use this document. BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100. Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1,,2021 THROUGH SEPTEMBER 30, 2022 DBA: Business Name: G A V BUILDERS INC Owner Name: GEORGE A VAZQUEZ Business Location: 1308 ARTHUR ST HOLLYWOOD Business Phone: 754-235-5000 Receipt #:GENERBAL9 CONTRACTOR Business Type:CONTRACTOR) Business Opened:04/12/2004 State/County/Cert/Reg:CGC15 07009 Exemption Code: Rooms Seats Employees Machines Professionals 2 For Vending Business Only Number of Machines: venelna Tvoo! 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: GEORGE A VAZQUEZ 1308 ARTHUR ST HOLLYWOOD, FL 33019 2021 - 2022 Receipt #30A-20-00010256 Paid 09/20/2021 27.00 ' MY %AIA MM , I— .. ."...A.\. r/. 1. TA./ ACCOR& CERTIFICATE OF LIABILITY INSURANCE DATE A �iMIDDIY ) 021 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 endorsements . PRODUCER Emmanuel Insurance&Associates, Inc. 2370 E 8TH AVE HIALEAH FL 330134236 CONTA Sarai Medina PHONE (305) 693-0003 FAx (305) b91-4381 . No): ADDRESS: saral@emmanuelinsurance.com INSURERS AFFORDING COVERAGE NAIC # INSURER A : U.S. Specialty Insurance Company 29599 INSURED G.A.V. BUILDERS, INC. George A. Vazquez 1308 Arthur Street Hollywood FL 33019 INSURER B : INSURER C : INSURER D : INSURER E INSURER F: CeVERAr.Es CERTIFICATE NUMBER: 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. LTR TYPE OF INSURANCE SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP !ld LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FRI OCCUR U21AC138446-00 08/14/2021 08/14/2022 EACH OCCURRENCE $ 1,000,000.00 DAME TO RENTED PREMISES Ea occurrence $ 100,000.00 MED EXP (Any one Person) $ 5,000.00 PERSONAL &ADV INJURY $ 1,000,000.00 GENL AGGREGATE LIMIT APPLIES PER: POLICY � JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS -COMP/OP AGG $ 2,000,000.00 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ A UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE U21AC138446-00 08/14/2021 08/14/2022 EACH OCCURRENCE $ 1,000,000.00 X AGGREGATE $ 1,000,000.00 DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE D OFFICERIMEMBEREXCLUDED? (Mandatory In NH) If yes descrcbe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE SR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonal Remarks Schedule, may be attached if more space Is requ[red) Remodeling General Contractor. r`FRTICICATF I4nLnER CANCELLATION Miami Shores Village SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 Avenue AUTHORIZED REPRESENTATIVE Miami Shores Village FL 33138 45a4a-, . O 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD � e 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: 2/24/2020 PERSON: GEORGE A VAZQUEZ FEIN: 200661386 BUSINESS NAME AND ADDRESS: G.A.V. BUILDERS INC 1308 ARTHUR STREET HOLLYWOOD, FL 33019 SCOPE OF BUSINESS OR TRADE: EXPIRATION DATE: 2/23/2022 EMAIL: GAVTEMPO@AOL.COM Door and Window Installation Ceramic Tile, Indoor Slone, Carpentry Installation Of Carpentry Detached One or All Types Residential and Marble, or Mosaic Work Cabinet Work or Interior Trim Two Family Dwellings Commercial 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 E01100932 QUESTIONS? (850) 413-1609 4n ENT�rlP`7-' ��O wR�� JUL 1 5 ZOIL JIMMY PATRONIS CHIEF FINANCIAL OFFICER STATE OF FLORIDA BY:- _ 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: 2/23/2022 PERSON: GEORGE A VAZQUEZ FEIN: 200661386 BUSINESS NAME AND ADDRESS: G.A.V. BUILDERS, INC. 1308 ARTHUR STREET HOLLYWOOD, FL 33019 SCOPE OF BUSINESS OR TRADE: Door and Window Installation Ceramic Tile, Indoor Stone, All Types Residential and Marble, or Mosaic Work Commercial EXPIRATION DATE: 2/23/2024 EMAIL: GAVTEMPO@AOL.COM Carpentry Installation Of Carpentry Detached One or Cabinet Work or Interior Tnm Two Family Dwellings 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 E01485833 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 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. Signature: // i� h�m Owner State of Florida County of Miami-Dade15r- �(�' The foregoing was acknowledge before me this S1 k day ol'L(G (-!, , 20 Z 2. By%j((/ � who is personally known to me or has produced as identification. SEAL: _ _ 1 _ _ . ,•:Slew. JANETTE M. GARCIA My Comm. Expires Aug 11, 2023 ed through National Notary Assn. i L -r �� r,�p4�lrli'Ai>Sd�bG�'b �'�Gu6R:t; fr�iyhlEit�...�. at,.a,;�...M � f Ala„L �� ;. .: ,. y. .; h} mac. �,� • '....::i mC , ;',Z;. '-` . Licensed and Insured G. A. V. BUILDERS, INC. 1308 Arthur Street Hollywood, Florida 33019 Tel: 754-235-5000 or Email: aavtemooCaol.com January 16, 2022 State of Florida County of Broward County .Kereff.13 &-flyLrsy] Before me this day appeared George A Vazquez who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 9767 NE 13 Ave., Miami Shores, FL 33138 O/I"Ltit Contractor Signature [/ Sworn to (or affirmed) and subscribed before me this %6/4day of J6* 20a,;.— Personally Knowny Or Produced Identification Type of Identification Produced NotatSELS ry P - State Florida �. Commission 0 HH 30782 a F 'Iomm. Expires Aug 16, 2021 Bonded rough National Notary Assn. Print, Type or Stamp Name of Notary