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FW-10-23-2700Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: FWA0-23-2700 Permit Type: Fence/Wall Work Classification: Ornamental/Metal Permit Status: Approved Issue Date: 02/14/2024 Expiration: 04/29/2024 Location Address Parcel Number 1418 NE 104TH ST, Miami Shores, FL 33138 1122320320280 Contacts BRALIA INVESTMENTS Owner Lemay Sanchez 1418 NE 104 ST, MIAMI SHORES, FL 33138 Home: 7865140776 lemaysanchez@gmail.com SUPREME DESIGNS INC Contractor PEDRO MACHIN Business: 3057910163 supremedesigns0@gmail.com Ins a Description: FENCE GATE ON BOTH SIDES OF HOUSE Valuation: $ 2,000.00 ction Re uests: Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $1.20 DBPR Fee $3.75 DCA Fee $2.00 Education Surcharge $0.60 Engineer Fence Systems $200.00 Planning and Zoning Review Fee $70.00 Scanning Fee $12.00 Structural Review ($60) $60.00 Technology Fee (Manual) $25.00 Total: $424.55 Date Paid Amt Paid Total Fees $424.55 Credit Card 02/14/2024 $374.55 Credit Card 10/31/2023 $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 that all work will be done in compliance with all applicable laws regguula/tin9,cgnstructi d zoning. theonore authorize the above named contractor to do the work stated. / � Z� t A'btltorized Sig ture: Ownerk Applicant / Contractor / Agent Date February 14, 2024 Page 2 of 2 Miami Shores Village P.�F.CFUVED Building Department 0 � T 31 2023 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 2020 BUILDING Master Permit No. EW— to- 23 - 2--7r) PERMIT APPLICAtMN- - — -- Sub Permit No. BUILDING Ij ELECTRIC E3 ROOFING I3 REVISION I3 EXTENSION ®RENEWAL PLUMBING O MECHANICAL CHANGE OF CANCELLATION E3 SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1418 NE 104 ST City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#:11-2232-032-0280 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name (Fee SimpleTitlehplder):BRALIA INVESTMENTS phone#:786-514-0776 Address: 6161 MIAMI LAKES DRIVE CitylAMI LAKES Stat�L Zip: 33014 Tenant/Lessee Name: N/A Phone#: Email: LEMAYSANCHEZ@gmail.com CONTRACTOR: Company Name: SUPREME DESIGNS INC Phone#: 305-791-0163 Address: 13310 SW 17th CT MIRAMAR FL 33027 Email: supremedesignsfl@gmail.com Qualifier Name: PEDRO MACHIN Phone#: 786-877-5644 State Certification or Registration #: Certificate of Competency #: 22BS00518 DESIGNER: Architect/Engineer: Phone#: Address: Value of Work for this Permit: $ 2,000.- Square/Linear Footage of Work: Type of Work: 0 Addition 0 Alteration ® New ® Repair/Replace Description of Work: DOOR FENCE ON BOTH SIDES OF THE HOUSE tate: Zip: 19' 2" M Demolition Specify color of color thru tile: Submittal Fee $ `,�b - erg Permit Fee $ ZCb - « CCF $ CO/CC $ Scanning Fee $ 1 2- co DCA Fee $ Z. 0;) Technology Fee $ Z S' W Training/Education Fee $ DBPR$ 3. ZS Notary • 6O Double Fee $ Structural Reviews $ t' 0 ' W (Revised04/05/2022) P&Z Review $ ZD' Bond $ TOTAL FEE NOW DUE $ .3-i .LA • SS Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 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 OWNER or AGENT The foregoing instrument was acknowledged before me this Signature CONTRACTOR The foregoing instrument was acknowledged before me this 30 day of oGT09e?- .20 Z3 by -,;O day of 0Ct-a97W7L .20 by tanM`r ci,�E , who is personally known to •PWVJ o MAUU-Z N who is personally known to me or who has produced �L �t S 522 2c�-44-��-� me or who has produced identification and who did take an oath. NOTARY PUBLIC: Print: , Seal: tip..... s �. PilarMasdModes Comm.: HH 154527 My Commission Expires: oriv 0, July15, 2025 'pnnmM }#R##}lRRR**#**R!s#RYRlRlRR!!RR#R#R!#}k}!}#!}!! APPROVED BY identification and who did take an oath. NOTARY PUBLIC: as Sign: `6 - Print: o`a "" • ar BixAlWeles Seal: _�;•_ Comm.: HH 154527 In My Commission Expires: .. July 15, 2025 !R####RR#RR#####R#RRR##R##}###}}#}}}###!!!!!R#R!#RRRR Plans Examiner 0 Structural Review A fZtr) I ( / I C{ 123 Zoning A ppv,red . (Revised04/05/2022) Clerk NAY rtoXd /J .cJ67— ))A t: o.2 M1Atti 1"k /ad ( Anti-Child Latch at 48" to 54" 3/4" Self drilling screws attaching both posts 4' Fence Good Side Out. The vertical and horizontal supporting members of a fence shall face the interior of the plot on which the fence is located and the finished side shall face the adjoining lot or any abutting right of way. 1"x3"x.093 tubings ro c .o 33. � � � r Q 2"x3"x.125 frame o a) w 0 CM Ca My 3 mM �-+ Existing walls /� m ro - _ �_� CD 0W ° "ci �_ a o y a) ❑ a COa�E E C = CU S NrflU)(nd 2"x3"x.125 posts attached to existing walls 2"x3"x.125 posts attached to existing walls Self Closing Hinges 1418 NE 104th ST. MIAMI SHORES, FL 33138 0-1 M ALUMINUM 4FT FENCE WITH HORIZONTAL I X 3 TUBING WITH a" SPACING LEMAY SANCHEZ LEMAYSANCHEZ@gmail.com 786-514-0776 w —Ls r%t—!I_l I _L_1_ _L wntl L_ r' All x2 1 "x3"x. 2"x2"x.125 1418 NE 104th ST. MIAMI SHORES, FL 33138 10-19-23 x ALUMINUM 4FT FENCE WITH HORIZONTAL I X 3 TUBING WITH 2" SPACING js ?5 frame using Hinges ,5 posts LEMAY SANCHEZ LEMAYSANCHEZ@gmail.com 786-514-0776 BASIS OF BEARING (ASSUMED)_ 450.00' C:. + P.R.M. F.I.R. 1/2" F.I.P. 1/2" 0•58'— (OUT) 0.59'(OUT) ON PL NOTE B.M. USED: B-26—RA ELEVATION: 17.23 (N.G.V.D. 29) VERTICAL DATUM SHOWN: N.G.V.D. 29 . _ uuuu o � CB vi CONE :. �:' 12'1 PARKWAY " a` W" 75.0011` - - R&-M 4.1' - --S-- - - ❑ °: .. F.I.R. 1/2" C' . MH $ C 0 P o CON C N MH N ,DRIVE 0 10.11' 15.05' 20.50'zo o t 0.39' i n (IN) � a 0.3i' a (IN) ir LOT 6 v BLOCK 4 9.81' 11,30' O c6 PA RS/ r 0 0.19'(IN F.I.R. 1/2" "IF x- (0/S 0.50' S) a (0/S 0.20' E) CROSS LOT LINES. MAP OF BOUNDARY SURVEY Property Address: 1418 NE 104TH ST MIAMI SHORES, FL 33138 ,i nlineLand SURVEYORS,INC. 6175 NW 153Td Street, Suite 401 Miami Lakes, FL 33014 www.Onl ineLa ndS u rveyors. Com 19.53' n K' o ONE STORY RESIDENCE - # 1418 O LOT 8 F.F.E.=6.78 0 BLOCK 4 'outh gates opening , 00 outwards r- 43.78' a' CONC ci: �n LOT 7 0,92' BLOCK 4 I1 (IN) 75.00' (R) A F.I.R. 1/2" 1 HEREBY CERTIFY THAT AS SET FORTH BY THE STATE OF APPER /N CHAPTER 5.147.01. FLORIDA FLORIDA STATUTES. �V T STATE OF SIGNED 's)-J#1'1� FOR THE FIRM GUILLERMO A. o� P.S.M. No. 6453 STATE OF FLORID NOT VALID WITHOUT AN AUTHENTIC ELECTRONIC SIGNATURE AND AUTHENTICATED ELECTRONIC SEAL AND/OR THIS MAP 15 NOT VALID WITHOUT THE SIGNATURE AND ORIGINAL RAISED SEAL OF A LICENSE SURVEYOR AND MAPPER. Survey Date:I Ill12022 Survey Code:0-93224 Page 1 of 2 Not valid without all pages. clqction Trades uatifying Board CERTIFICATE OF COMPETENCY ME DESIGNS INC MACHIN PEDRO Is certified under the provisions of Chapter 10 of Miami -Dade County QUALIFYING TRADE(S) 0018 FENCE AM R cm m, r.E /V /"1 .�_—��'^'� se. sromywue m�a ww.mi.mmm.awmcmmn naemFinae mvry n W ne .0 p�vpvnr n0m n��. Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 7377741 BUSINESS NAME/LOCATION SUPREME DESIGNS INC 2476 W 64TH PL HIALEAH,FL 33016-4386 OWNER SUPREME DESIGNS INC C/O PEDRO MACHIN QUALIFIER Worker(s) RECEIPT NO. NEW BUSINESS 7673257 Fry:,k � ix7}�rto LBT EXPIRES SEPTEMBER 30, 2024 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 196 SPECIALTY BUILDING CONTRACTOR 22BS00518 PAYMENT RECEIVED BY TAX COLLECTOR 45.00 02/07/2024 INT-24-298388 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 Sa-276. Ri®� For more information, visit www.miamidade.aauAazcallectar Municipal Contractor's Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY CC NO: 22BS00518 BUSINESS NAMEMOCATION RECEIPT NO. SUPREME DESIGNS INC 2476 W 64TI-I Pt. 7673329 HIALEAH, FL 33016-4386 MCl EXPIRES SEPTEMBER 30, 2024 OWNER TYPE OF BUSINESS SUPREME DESIGNS INC SPECIALTY BUILDING CONTRACTOR C/O PEDRO MACHIN QUALIFIER Restricted to City of Miami Shores ma For more information. visit wWw..mismidade.BFvAaxcoIIeetPt Pursuant to County Code See 10-24 PAYMENT RECEIVED BY TAX COLLECTOR 37.50 02/08/2024 INT-24-296962 ® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNM) 10/31/2023 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(ies) 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 endorsement(s). PRODUCER CONT C NAME: BIBERK GONE 844-472-0967 Alc No : 203-654-3613 P.O. Box 113247 E-MAIL customerservice@biBERK.com Stamford, CT 06911 ADDRESS: INSURER A: Berkshire Hathaway Direct Insurance Company INSURED Supreme Designs Inc. 13310 SW 17th Ct Hollywood, FL 33027 INSURER B : INSURER C : INSURERD: INSURERE: COVERAGES 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 [_FRTIFI�.ATF MAY RE 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 TYPEOF INSURANCE ADDL SUER POLICY NUMBER MOMILDICDI EFF MMIDD POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR N9BP612250 07/02/2023 07/02/2024 EACH OCCURRENCE $ 1,000,000 TO PREMISES Ea oN u TED ence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ Included GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 X $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY(Per COMBINED SINGLE LIMIT accident $ BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE accident $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y 1 N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE I I ER E.L. EACH ACCIDENT $ E.L. DISEASE- EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ Professional Liability (Errors & Omissions): Claims -Made Per Occurrence/ Aggregate DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) FENCE CONTRACTOR 22BS00518 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 Northeast 2nd Avenue 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 0 1988 2015 ACORD CORPORATION. All rights reserved. ACORV CERTIFICATE OF LIABILITY INSURANCE �0. 10 31 (zo23 ) / / 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(ies) 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 endorsement(s). PRODUCER BIBERK P.O. Box 113247 Stamford, CT 06911 CONTACT NAME PHON C.a 844-472-0967 ) No : 203-654-3613 E-MAIL customerservice@biBERK.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC O INSURER A: Berkshire Hathaway Direct Insurance Company 10391 INSURED Supreme Designs Inc. INSURER B : INSURER C INSURERD: 13310 SW 17th Ct INSURERE: Hollywood, FL 33027 INSURER F : COVERAGES 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. INSR LTR TYPE OF INSURANCE J= SU D POLICY NUMBER Map EFF MPMIDD ©(P LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED PREM SESOEa occurrence) $ MED EXP (Any one son) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- 7 LOC JECT OTHER: GENERAL AGGREGATE S 1,000,000 PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT ga $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ A UMBR0.LALIAB EXCESS LIAB X OCCUR CLAIMS -MADE N9UM845898 07/02/2023 07/02/2024 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE S E.L. DISEASE - POLICY LIMIT $ Professional Liability (Errors & Omissions): Claims -Made Per Occurrence/ Aggregate DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is inquired) CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE 10050 Northeast 2nd Avenue 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 e, 4��"' &+'>-� 01988 2015 ACORD CORPORATION. All rights reserved. ACORD 26 (2016103) 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: 6/22/2022 PERSON: PEDRO J MACHIN JR FEIN: 871556670 BUSINESS NAME AND ADDRESS: SUPREME DESIGNS, INC 13310 SW 17TH CT HOLLYWOOD, FL 33027 SCOPE OF BUSINESS OR TRADE: Fence Installation and Repair - Metal, Vinyl, Wood or Prefabricated Concrete Panel Fence Installed By Hand EXPIRATION DATE: 6/21/2024 EMAIL: SUPREMEDESIGNSFL@GMAIL.COM IMPORTANT: Pursuant to subsection 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to subsection 440.05(12), F.S., Certificates of election to be exempt issued under subsection (3) shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to subsection 440.05(13), F.S., notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at anytime 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 E01553949 QUESTIONS? (850) 413-1609 Miami Shores Village - BUILDING DEPARTMENT 10050 NE 2 Ave Miami Shores, FL 33138 305-795-2204 www.msvfl.gov 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 Phe Di�visiioon. Your contractor: CQ�� PJ 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' pensat, insurance coverage from the contractor's company for day labor, part- time employees or ubcont actor . BY SIGNING BELO YOU KIN LE GE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. g Si nature: Address: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this 5 day of By Ja^ ca-z who is personally known to me or has produced as identification. Notary: V �r SEAL: o"°arru' vivienneYao '`= Comm.0222410 B Expires: Jan.31,2026 Rev 121220F,. Notary public. State ofFlbrldatice to Owner Page 1 of I ��arrnna`. Miami Shores Village - BUILDING DEPARTMENT 10050 NE 2 Ave Miami Shores, FL 33138 305-795-2204 www.msvfl.gov BusinessName: Address: Phone: ( ) E-mail: Qualifier Name: Contractor Registration Form Qualifier Lic Number: Contractor may register license and insurance information with the Village on an annual basis. The initial fee will be $50 with an annual update fee of $30. Contractors that elect not to maintain their information on file will need to provide their information with each permit applied for. Please confirm if you would like to register your Contractor for a fee of $50. A FLORIDA STATE CERTIFIED CONTRACTOR: A. Copy of Local Business Tax Receipt B. Copy of Qualifier State Licenses C. Copy of Liability Insurance* D. Copy of Workers Compensation Insurance* Provide proof that the contractor has secure compensation for its employees as required under section 105.3.5 of the 6th edition to the 2017 F.B.C. (Workers Compensation FEIN EXEMPTION must have Notice to Owner form and Contractor Affidavit) A MIAMI DADE COUNTY CONTRACTOR: A. Copy of Certificate of Competency of Qualifier B. Copy of Local Business Tax Receipt C. Copy of State Registered Contractor Licenses or Miami Dade County Municipal Contractor's Tax Receipt. D. Copy of Liability Insurance* E. Copy of Workers Compensation Insurance* Provide proof that the contractor has secure compensation for its employees as required under section 105.3.5 of the 6tn edition to the 2017 F.B.C. (Workers Compensation FEIN EXEMPTION must have Notice of 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 SUPREME DESIGNS TOP QUALITY FENCING Date: -.-10. I'l State of�"�•�.. County of Before me this day personally appeared �CoO�c.�irt who, being duly sworn, deposes and says: That he or she will be the only perso working on the project located at: 141'1 IVf. tqf �U .I �....�. roL '�313R w Contractor Signature Sworn to (or a armed) and subscribed before me this IV day of 20. Zy, by Personally know OR Produced Identification Type of Identification Produced r Type or Stamp Name of Notary Pint Maki Morales ''•� Comm : HH 154527 - . • : • = My Ccxnmissian Expires: ",'' •0' P-4�' July 15, 2025