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RC-09-23-2368Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 10650 NE 11TH AVE, Miami Shores, FL 33138 Cantacts Permit NO.: RC-09-23-2368 Permit Type: Building (Residential) Work Classification: Alteration Permit Status: Approved Issue Date:09/26/2023 Expiration:03/26/2024 Parcel Number 1122320280670 James Defede Owner 10650 NE 11 AVE DIVINA CONSTRUCTION LLC Contractor LUCA POLIMENI 7928 E DRIVE 1607, NORTH BAY VILLAGE, 33141 Busi ness: 7862900247 lucapolimeni@divinaestate.com Description: REMOVE TUB, INSTALL NEW SHOWER AND TILE Valuation: $ 2,500.00 Ins ection Recuests: WALL INSIDE THE SHOWER, EVERYTHING STAY THE SAME BOS-762 494gut Total Sq Feet: 88.00 Fees Amount Payments Date Paid Amt Paid 50%Renewal Fee $50.00 Total Fees $50.00 Total: $50.00 Credit Card 09/26/2023 $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 regulating const ion and zoning. Fu hermore, I authorize the above named contractor to do the work slated. '. Owner / Applicant / Contractor / Agent September 26, 2023 Page 2 of 2 ECEIVED Miami Shores Village R Building Department SEP 2 6 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 20Z0 BUILDING Master Permit No. R(-- GS22 -1ju PERMIT APPLICATION Sub Permit No. ?C-Qq-Z3-23(Q BUILDING [j ELECTRIC ® ROOFING I3 REVISION ® EXTENSION ®RENEWAL PLUMBING I3 MECHANICAL ® CHANGE OF I3 CANCELLATION ® SHOP CONTRACTOR DRAWINGS JOB ADDRESS: I L hs G WIES It ;Ail I City: Miami Shores County: Miami Dade Zip: ??Ala Folio/Parcel#: II —%7 3Z -yZZ-0 4010 Is the Building Historically Designated: Yes NO _ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): -SA jj ,5 J)E Phone#: 740 4 d 1 Address: f hESII N E 11 twe City: (I.I Lllli ShO k s State: ��, Zip: 331 31? Tenant/Lessee Name: Email: t CONTRACTOR: Company Name: i,) i (../ C fl 1'C{4A C �j -6tj Ll C _ Phone#: 7V ,(901 12 / 41 Address: /h ZX '1= -1)2l d d Z 160 / A444h Jqo- l 11, I Email: - Qualifier Name: Uta 1�C)L 1 fir �q (1, Phone#: /f4 2U 1 12 11 State Certification or Registration 5 3 (� Certificate of Competency #: DESIGNER: Architect/Engineer: Value of Work for this Permit: Square/Linear Footage of Work: _Zip: Type of Work: M Addition M Alteration ® New [I 3 Repair/Replace ® Demolition Description of Work: I2C move 7:,;b 1, 1 nSt-cut fie -LA) SLinj)" anA t- -iI le - Specify color of color thru tile:, Submittal Fee $ Permit Fee $ Scanning Fee $ Technology Fee DCA Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary Double Fee $ Structural Reviews $ (Revised04/05/2022) P&Z Review $ Bond $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien low 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 inspectro hick occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not bf a4broved and aAinspection fee will be charged. OWNER or AGENT The fcieKiing instrument was acknowledged before me this 25 day of Si (TEi-ME-(Z _20 Z3, by �I (q ClF—%S rn P FC- rh Lwho' personally known t me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: A.F,;k d l +Lo-r—�- Signature CONTRACTOR The foregoing instrument was acknowledged before me this 2S day of SEPTC"15EIR.._ by LUCA Po I men ( who personally known t me or who has produced as identification and who did take an oath. NOTARY PUBLIC: 4Print:LE v Seal: Notary Public State of Florida Seal: Alexa Chloe Aloisi Illl My Commission RH 299948 Expires 8/1112026 40ory Public State of Florida #########*# #######*#*#*####### ** *<*«*C mission HH 294*** *********##*#*## l My Commission 8 11 20 2999�8 I D�WOINLSLJ(�S Plans Examiner Expires anv2ozs APPROVED BY _ Zoning Structural Review (Revised04/05/2022) Clerk z 6.u�UilKk1 •37:S�r tl: 2er::x� Lil•�i ,,,. inn ,r 1',�� ,w�^' d `u !. __ 1 Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 10650 NE 11TH AVE, Miami Shores, FL 33138 Contacts Permit NO.: RC-05-22-1197 Permit Type: Building (Residential) Work Classification: Repair Permit Status: Approved Issue Date:08/01/2022 Expiration: 02/01/2023 Parcel Number 1122320280670 l James Defect e Owner DIVINA CONSTRUCTION LLC Contractor ! 10650 NE 11 AVE LUCA POLIMENI 7928 E DRIVE 1607, NORTH BAY VILLAGE, 33141 Business: 7862900247 lucapolimeni@divinaestate.com ! Ins Description: REMOVE TUBE, INSTALL NEW SHOWER AND +TILE Valuation: $ 2,500.00 ection Requests: -:.y,;,a:;3•= WALL INSIDE THE SHOWER, EVERYTHING STAY THE SAME Total Sq Feet: 88.00 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 Credit Card 08/01/2022 $67.90 Credit Card 05/12/2022 $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 pennit 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 *noalpre-SJWher / Applicant / Contractor / Agent Page 2 of 2 Miami Shores Village RECEIVED Building Department MAY 12 2022 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 BY: INSPECTION LINE PHONE NUMBER: (305) 762-4949 nFBCyy2��0 BUILDING Master Permit No.KC�UJ~�O I PERMIT APPLICATION Sub Permit BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP � CONTRACTOR DRAWINGS JOB ADDRESS: I t IU ��) �'`-• 'F")'� pV P QQ City' Miami Shores County' Miami Dade Zip: 3 U Folio/Parcel#: �� — Fli 3r n&S O (n+(Z) Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder):TC me S DP (�QAP- Phone#: 341Io--4PA —4 15 Address: 1O 5Ci NF;-- I 1.1-h AQP-- City: w Iar6 5�na State: LI - Zip: 2i�� Tenant/Lessee Name: Phonew Email: Ae fQL (j� aoi - COrn CONTRACTOR: Company Name:LVfla (b� l l'(121'1t( Iile6— U yl rd UnCM U(hoo L LC, Phone#: Addre! Email: Qualifier Name: I owr Pi- i (A G:N I Phone#: +47_� — iq n-caqq- State Certification or Registration #: DESIGNER: Architect/Engineer: Value of Work for this Permit: of Competency #: City: State: Zip: c�Zip: lS /1 S 1 Square/Linear Footage of Work: F Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: c/�t /� Submittal Fee $I Permit Fee $ �� CCF $ � • VV CO/Cc $ /71 Scanning Fee $ `. 0) DCA Fee $ ').a DBPRR $ Z• Notary $ , Technology Fee $ L. S D Training/Education Fee $ too Double Fee $ Structural Reviews $ P&Z Review $ Bond $ TOTAL FEE NOW DUE $ W 1 - l/ _ (Revised04/05/2022) Bonding Company's Name (if applicable) Bonding Company's Address City S1 Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be pproved and a reins pection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this 9'1 day of AhQY i 1 , 20 2 Z. by SQMPJS "D2.•(f. who is personally known to me or who has produced"Z)L'• b 130 445 LnUl10 as identification and who did take an oath. NOTARY PUBLIC: Sign: VV,:v Print: V Seal: ��nR NICOLE ORTIZ Notary Public o z = State of Florida = 6CoMmmm# HyH1y6y999553. esell APPROVED BY The foregoing instrument was acknowledged before me this day of � _20 by j�Ll6k t wh s personall own to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: O Ilil he Print:'8,l ML2 •rrs. �1L 1� Seal: =*; ?O''s'pa,'•, %S' m 4RH0739y3 ; x Plans Examiner STATE OF ################ Zoning (Revised04/05/2022) Structural Review Clerk Q W N N 0 N W c� C �lcwl �m> NC)w t❑ m �cno�so, m O o 5NO 5; 20 s � C r CLI LL E J �J (L o Y rc Z CD::3 L cc m �_ o v oQo( �l zxcc CS Z U � oz J O CC a Z � O Sao O}F- ¢ m x O U O ? .... Jd O °_ �� P}V-C-a t Z A U a N W U V ¢ Cl X. Q O Q m -ZZ F—{ 5101 22 Sf�pDirC- 17URoc,�.�W0.�eY (R�,o� -rhly) sal �Se►- iq-- RE-b) 1Zflll�l (VIIoou� `.ECEIVED i 2022 k3Y:�_ PLUMBING PLANS Approved Date �-�. Disapproved Date ••� „•'• > V. P TO H-iC# r U F V-C- �L��k�v�� RAv1G-1 i .J suSFloVti y2 ,5.X � O-RAvcLTo Ok (m C R"O �6 W.V \f, (nDNFJP, wrup %0 [TS To V10 � D Tt(O N Li NCAC, �rl L1 - a 00 00 a 0 0 0 00 0 o 000aao 0 O O O 00 0 0 O O O 090060 -. -; 000oao o 0 *a 00 0000 0 0 O 0000 00000 000000 a9000 O • 0 00 00000 o0900 O0 O O00000 000000 0 0 0 0 00 0 000000 000009) 0 0 0 0 00 a 0 000 Oo 0 a O Oo00 000000 0 0 0 0 0000 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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! STATE OF FLORIDA DEPARTMENT dEl OF BUSINESS AND PROFESSIONAL bjar REGULATION CGC1531336 ISSUED: 12/13/2021 CERTIFIED GENERAL CONTRACTOR POLIMENIAUCA DIVINA CONSTRUCTION LLC Signature LICENSED UNDER CHAPTER 489, FLORIDA STATUTES EXPIRATION DATE: AUGUST 31. 2022 Ron DeSantis, Governor Julie I. Brown. Secretary STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER: CGC1531336 EXPIRATION DATE: AUGUST 31, 2022 THE GENERAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 489, FLORIDA STATUTES POLIMENI, LUCA DIVINA CONSTRUCTION LLC 7928 EAST DR UNIT 1607 NORTH BAY VILLAGE FL 33141 - - - ISSUED: 12/13/2021 Always verify licenses online at MyFloridaLicense.com Do not alter this document in any form. This is your license. It Is unlawful for anyone other than the licensee to use this document. Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 7340111 BUSINESS NAMEMOCATION DIVINA CONSTRUCTION LLC 901 PENNSYLVANIA AVE STE 4 MIAMI BEACH, FL 33139-5431 OWNER DIVINA CONSTRUCTION LLC CIO LUCA POLIMENI MGR WBrl er(6) 1 LBT.11 EXPIRES SEPTEMBER 30, 2022 Must be displayed at plow of business Pursuant to County Code Chapter SA — AM 9 d 10 o` SEC. TYPE OF BUSINESS PAYMENT RECER/EO 196 GENERAL BUILDING BY T" COLLECTOR CONTRACTOR 45.00 032MG22 CGC1531336 0206.22-003466 RECEIPT NO. NEW BUSINESS 7632579 This local Business Tex Receipt only confirms payment of the Local Business Two. The Receipt is not a license, permit, or a certification of the holdn's quelificedmIL to do husiflM. Holder most comp4 with any govemmepml or nongovernmental regulatory laws and requirements which apply to the business. 101110go1v�G qG 11 1 11 M I �I$R�hd�„, i ACORL> CERTIFICATE OF LIABILITY INSURANCE !`.. DATE (MMIDD/YYYY) 05/10/2022 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. 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 endorsements . PRODUCER CONTACT NAME: _ PHONE (888) 202-3007 FAIC. Noli., HISCOX Inc. 5 Concourse Parkway Suite 2150 E-MAIL contact@hiscox.com ADDRESS: Atlanta GA, 30328 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Hiscox Insurance Company Inc 10200 . INSURED � Divina Construction LLC 901 Pennsylvania Ave INSURER B : -•--- _ _ __ .__ _ INSURER C : Suite 4 INSURER D : INSURER E : MIAMI BEACH, FL 33139 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. INS TYPE OF INSURANCE ADDLSUBR WVo POLICY NUMBER POLICY EFF IMMIDDNYYYI POLICY EXP 1MMIDDIYYYY)LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR N Y UDC-4892965-CGL-21 07/07/2021 07/07/2022 EACH OCCURRENCE _ $ 1.000,000DAMAGE TO RENTED PREMISES Eo occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 _ PERSONAL 8 ADV INJURY $ 1,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY JPERC LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOP AGG T, $ 2,000,000 Y $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accede t $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ -- •--• $ PROPERTY DAMAGE Per accident) $ UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE ! i EACH OCCURRENCE $ $ $ _ AGGREGATE DED RETENTION $ �_ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUMVE 7 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N ! A STATUTE LORH E.L. EACH ACCIDENT $ $ E.L. DISEASE - EA EMPLOYEE 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) GENERAL CONTRACTOR CGC1531336 Miami Shores Village 10050 NE 2 AVE Miami Shores fl 33138 %OMM. 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 V I V60-LV70 AL:VKU UUKrUKA 1 IVIY. Ali rignis reserves. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 10650 NE 11TH AVE, Miami Shores, FL 33138 Contacts Permit NO.: PL-05-22-1198 Permit Type: Plumbing - Residential Work Classification: Repair Permit Status: Approved Issue Date:08/01/2022 Expiration: 02/01/2023 Parcel Number 1122320280670 James Defect e Owner 10650 NE 11 AVE EDWARD ROJAS PLUMBING CORP Contractor EDWARDO ROJAS 880 NE 1115T, BISCAYNE PARK, FL 33161 Business: 3059446788 EDDIE.ROJAS@HOTMAIL.COM Home: 7864439846 Description: REPLACE SHOWER VALVE -REMOVE TUB TO Valuation: $1,500.00 SHOWER Total Sq Feet: 88.00 r� Fees Amount Application Fee - Other $50.00 CCF $1.20 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.40 Permit Fee $50.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $117.10 Ins ection Requests: 305-762-4949 Payments Date Paid Amt Paid Total Fees $117.10 Credit Card 08/01/2022 $67.10 Credit Card 05/12/2022 $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 1 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 SigDatdW.-Owner _ / Applicant / Contractor / Agent Date Page 2 of 2 Miami Shores Village I?--ECEiVED Building Department MAY, d z Zz 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 F B (Cyy20 BUILDING Master Permit No. P1 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP /� CONTRACTOR DRAWINGS JOB ADDRESS: I DVJ; )() �E I Y h PN p City: Miami Shores County: Miami Dade zip, Folio/Parcel#: { a a a — ii=(�(Ei� Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): t'oe,�" 1%'? Phone#: Address: pI F ..I th Fc V P City: (mil arc(l State: L Zip: Tenant/Lessee Name: Phone#: Email: AP ooAQ 4�), CA COY0, �(�n1 CONTRACTOR: Company Name: [g CGCCc�? u r r "Z!A S lG7 mt � Phon #: Addre: Email: Qualifi State Certification or Registration #:. Ctif c 9 Certificate _ of Competency #: DESIGNER: Architect/Engineer: Phone Address: City: State: Zip: Value of Work for this Permit: $ Minn Square/Linear Footage of Work: 8g9r Type of Work: ❑ Addition Description of Work:e TO.. ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Specify color of color thru tile: 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 $ _ (Rev,sed04/05/2022) Bonding Company's Name (if applicable) Bonding Company's Address City SI 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. ,--1 Signature Signature OWNER or AGENT CON RACTOR The foregoing instrument was acknowledged before me this Zn day of!PVV1, 20 2Z .by -XiY� lr—f Ck— , who is personally known to me or who has produced "U— + 70130 44SU ZZAI O as identification and who did take an oath. NOTARY PUBLIC: Sign: (;XC�F Print: Seal: aa NKXXE OFITIZ o Notary Public State of Florida Comm# HH169953 ss#sssssssssssss�'1F%F1 4sss&xpff�p6$jit6/�Y)@6sssssssessssss &,foreinginstru ent was acknowledged before me this day of 20 �r� . by who i ersonally kno to me or who has produced identification and who did take an oath. NOTARY PUBLIC: 1 Sign: Print: P . ' R ��4 Seal: *: NHH 0T3993 APPROVED BY " s�X)Jyti Plans Examiner as ############ Zoning Structural Review (Revised04/05/2022) Clerk V 4 W Edward ROias Plumbing 29 Date: State of 2 f County of A el e Before me this day personalty appeared a s' who, being duly sworn, deposes and says: That he or she will be the only person working on the project Jocated at M ho u� J-1 )a b;, Contractor Signature - s sworn to (or affirm and ribed before me this day of t "" • 20A by \L 21, 410 AN Z Z ; #HH 073993 ti _ q h �� • • �blic UndB�• • OQ- `�� ;V�llllSTA Personalty know OR Produced Identification Type of Identification Produced Print Twna nr Stamn Name of Notary Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: EL-09-23-2370 Permit Type: Electrical - Residential Work Classification: Alteration Permit5tatus: Approved Issue Date: 09127/2023 1 Expiration:03/27/2024 Location Address Parcel Number 10650 NE 11TH AVE, Miami Shores, FL 33138 1122320290670 Contacts James Defede Owner DIVINA CONSTRUCTION LLC Applicant 10650 NE 11 AVE LUCA POLIMENI 7928 E DRIVE 1607, NORTH BAY VILLAGE, 33141 Business: 7862900247 lucapolimeni@divinaestate.com JANIER GONZALEZ 7350 Cleveland SL HOLLYWOOD, FL 33024 Business: 7864868796 gcrucci@icloud.com Description: REMOVE TUB, INSTALL NEW SHOWER AND TILE WALL INSIDE THE SHOWER, EVERYTHING STAY THE SAME Fees Amount Application Fee - Other $50.00 CCF $1.80 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.90 Permit Fee $50.00 Scanning Fee $6.00 Technology Fee $10.00 Total: $122.70 Valuation: $ 2,500.00 Ins ection Requests: 305-762-4949 Total Sq Feet: 88.00 Payments Date Paid L$122.70 Total Fees Credit Card 09/27/2023 Amount Due: 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 donstruction and zoning. Futhermore, I authorize the above named contractor to do the work stated. N 1.11( Owner I Applicant / Contractor / Agent Date September 27, 2023 Page 2 of 2 RECEIVED Miami Shores Village SEP 2 62023 Building Department BY: 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 20Zo BUILDING Master Permit No.RC-05-22-1197 PERMIT APPLICATION Sub Permit No. EL - 0 q - 23 ' 2-310 BUILDING ❑■ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [:]MECHANICAL ❑ CHANGE OF []CANCELLATION SHOP CONTRACTOR DRAWINGS JOB ADDRESS:10650 NE 11TH AVE City: Miami Shores County: Miami Dade Zip: 33138 folio/Parcel#: j j -ZZ 32 - 0Z0 —0l. 70 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Tiitleholder):JAMES DEFEDE Phone#: Address:10650 NE 11TH AVE City; MIAMI SHORES State: FL Zip: 33138 Tenant/Lessee CONTRACTOR: Company Name: GC ELECTRICAL ONE LLC Phone#:786-486-8796 Address: 7350 CLEVELAND ST, HOLLYWOOD FL 33024 Email: GCRUCCIQICLOUD.COM Qualifier Name:JANIER GONZALEZ Phone#: State Certification or Registration #: S C 130 (I 2-4ILj Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: State: Zip; Value of Work for this Permit: $'•OuV Square/Unear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New /Re lace air X Re ❑ p p ❑Demolition Description of Work Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $. Technology fee DCA Fee $ Training/Education Fee CCF $_ DBPR $ Co/CC $ _ Notary Double Fee $ Structural Reviews $ (Revlsedp4/os/2022) P&Z Review $ Bond $ TOTAL FEE NOW DUE S. Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State ZIP Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspecti hick occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not Loved and a reinspection fee will be charged. / `OWNERorAGENT The / foregoing instrument was acknowledged before me this day of 20 1-3 by �- — e r�l�.0 PFI�, who is personally known to me or who has produced_ identification and who did take NOTARY PUBLIC Sign: Print: i cC Seal: ON �2027 as A Signature - The foregoing instrument was acknowledged before me this day of 1 20 Z 3 . by ��1�i02 C�I-) 6' C�� who is personally known to me or who has produced ,,," was identification and who did take an oath.� � QOytj pV' ' �O % NOTARY PUBLIC si W COMMISSION EXPIRES 3--2.2027 Print: Seal: ♦•rrsrrsrr rssss rsrrrrrrrr rrrssssrsr prrrrssrsrrsrssrsrsrrssrrra rsrrrrresprrrs rrrrrsrrrsrssssrsrgsssrsrgsr APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revlsed04/05/20221 ni Melanie S. Griffin, Secretary FLORIDA STATE OF OF i PROFESSIONAL ELECTRICAL COt R ", R$'wi:10ENSING BOARD THE ELECTRICAL PROVISION rA D UNDER THE 4TUTES i y� r� s ♦. .r A EXPIRATION DATE: AUGUST 31, 2024 Always verify licenses online at MyFloridaLicense.com Do not alter this document in 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 — 954-357-4829 VALID OCTOBER 13 2023 THROUGH SEPTEMBER 3B, 2024 Business Name: GC ELECTRICAL ONE LLC Owner Name: am izit GoNzmaz Business Location: 7350 CLEVELAND ST HOLLYWOOD Business Phone:786-486-8796 Receipt #:181--32561.3 ELECTRzcAL ALARKS/CONTRACTOR Business Type: (nzcTRrcAL coNTRAcToR ) Business Opened:04/16I2021 State/County/Ceri/Reg:EC 13011294 Exemption Code: Rooms Seats Employees Machines Professionals 1 For VendingBusiress Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty I Prior Years Col*cbon Cost Total Paid 27.00 0.00 0.00 0.00 1 0.00 0.00 27.00 Receipt Fee 27.00 Packing/Processing/Canning Employees 0.00 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 andlor 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: GC ELECTRICAL ONE LLC 7350 CLEVELAND ST HOLLYWOOD, FL 33024-5425 2023 -2024 Receipt #Wlor 22-00275466 Paid 09/13/2023 27.00 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-3574829 VALID OCTOBER 10 2023 THROUGH SEPTEMBER 3Q, 2024 Business Name: GC ELECTRICAL ONE LLC Owner Name: JANIER GONZALEZ Business Location: 7350 CIZVELAND ST HOLLYWOOD Business Phone: 786-486-8796 Rooms Seats Employees 1 Receipt #:181-325613 Business Type: ZL2cTRrcAL/ALARHs/c0NTRAcT0R (ELECTRICAL CONTRACTOR) Business Opened: 04/16/2021 Strate/County/Cert/Reg: EC13011294 Exemption Code: Machines Professionals Signature For Vending Business Only Number of Machines: Vending Tme: Tax Amount I Transfer Fee NSF Fee Penalty Prior Years Collection Cost I Total Paid 27.00 0.00 0.00 0.001 0.00 0.00 27.00 Receipt #WW-22-00275466 Paid 09/13/2023 27.00 'OR& ..$, CERTIFICATE OF LIABILITY INSURANCE a►TtrYm THIS CERTIFICATE IS ISSUED AS A MATTER OF IN O MATWN ONLY AND CONFERS NO RXKTB UPON THE CBRTm= HOLDER. T" CERTIFICATR DOES NOT AFFIRMATNELY OR NEGATMY AUM# EXTEND OR ALM THE COVERAGE AFFORDED BY TH5 POLICM BELOW. THIS CERTIFICATE OF INSURANCE DOER NOT CONSTITUTE A CONTMCT 90WEM THE MW O INGOWt(ON AUTHOMt M .PRESENTATIVE OR PRODUCER. AND THE CERWICATS MOLDER. SPoRTAMr. If a* **rWWM Aoidsr Is an ADDITIONAL INSURED, the potlgtpn) must hm AtlDti"10M INSURED ptovbbm ar be end=*& V SUBROGATION IS WAIVED, subjoat to #w to fts and o+a ns -dMoof tW pofto GWWn POOH" MO +e4** an endorssnnent A sbwnw4 oA Ws eallflo "dons nat oonter dutft to rho owafteto holder M Sou of such ondoeunw qs). Gam Iftswanos Ina 2711 SW 137th Ave SUR* 95 MbsN onwm GC ELECTRICAL ONE LLC 7350 ClEVMAND ST I HOU.Yw0OD FL 33024 I « y- I COVERAGES CERTIFICATE NUMBER: RE:VUWN NIUMBEJt ?HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELLOW HAVE BEEN ISSUED TO THE DiStIRED NAIAC ABOVE FOR THE POLICY PERIOD INDICATED. NOI MT WAND(NO ANY REQUIREMENT, TEAM OR CONDITiOM OF ANY CONTRACT OR OFTENER DOCUMENT WTH RESPECT TO V"CM THM CERTWICATE MAY BE ISSUED OR MAY PERTAIN. YK INSURANCE AFFORM BY THE POLICIES DESCRIBED HEREIN Is SULIECT TO ALL THE TERMS,, EXCLUSMS AND CONDITIONS OF SUCH POLICIES. LUM SHOYW MAY HAVE BEEN REDUCED BY PAID CLAIMS. wLTR sa TYKE OR qls RAM AM am Q312W2023 Q3121 A esLowitc .OENS"t oKm wms�„y m 19 mew RFLA=13"1 TEA Moa LWJt0 lama Iaol�a► W. 58 004 s o00 r+� mxxa&mwo&km s t m— IL care wrT�sPat. POLwY � �ir ❑ �oC MAM)NOMIUAMUN GENE" "m 000 004 s-c�aroaala tI00 s e aW AM &AWD SCHEDt"D Auras oe+�Y AM ONLY ; rooEYsu�Awtry ro««►� aals.Youu�rv+�«+er�or.rt t = UN&RJ ALL INoaEss Ups Oct 4� P ow id Aoa�►ra ryolt�cERs oolr�Ir:Anon AIIo �ruoW wewn « im �rdib) OPER&TWM bola* NIA EI. EA�Ot EMT E1. dSSJ1-sA E L D*t^U -poucv uw I •EsdRvilON O/ OrERAZiM 1 LOCArANS I V80CLUi {AC01lp q1, lld��l Nwiks idr M dM! � � l/.�is� ELECTRICAL C MTRACTOR - M" SHORES VM AQE B= DEPT 10050 NE 2HD AVE MWMI SHORES^ 33138 SHOLA,Q ANY OF THE ABOVE DESRRWfD POLICIES BE CANCELLED BOOK THE EXPIRATION OATS THEREOF, NOTICE WILL BE DELIVERED a ACCORDANt'.E WK01 THEPOLICY PRoMISIONL AMORM IFaITSTMe O 1EE3-M6 ACORD CORPCRAT10K All 09ft hsivod. ACORD 26 (20103) The ACORD Dame and $"a as registered marts of ACORD 41 JIMW 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 R' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the Individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: W&2023 PERSON: JANIER GONZALEZ FEIN: 863471811 BUSINESS NAME AND ADDRESS: GC ELECTRICAL ONE, LLC 73M CLEVELAND STREET HOLLYWOOD, FL 33024 EXPIRATION DATE: 614i2025 EMAIL: GCRUCCI@ICLOUD.COM This certificate of election to be exempt Is NOT a license issued by the Department of Business and Professional Regulation. To determine if the certificate holder is required to have a license to perform work or to verity the license of the certificate holder, go to www.myfloddallloense.com. 4PORTANT: Pursuant to subsec Gon 44MOS(13), F.S., an officer of a corporation who elects exemption from this tamer by"a certificate of election under ds section may not womw benefits or compensation under tMs chapter. Pursuant to subsection 440AXI 1), F.S.. CedificaW of etecdan to be exempt issued afar subsection (3) =ordytoft ocrpooffiwnamedonVienoticeofelectiontobe exempt. Pursuant to subsection 440.OS(12). F.M. notices of ecdon to be exemptcertir+cates of efedion to be exempt sf rail be subject to r evocefiM ff, at antr time dW the fig of the notice or the bstm= of de stride, the person named on the ratios or cer66cM+e no bnger mess the r+equkements of this section for bumnee of a oe dit0te. The ftSft erd shall &-vice a certificate al any time for fatiure of the person named on the certificate to meet Vie requirements of Uft secdcn. FS-F2•DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT E01733583 QUESTIONS? (850) 413.1609 ULE 69L-6.012.. F.A.C. REVISED 01rAW Notice to Owner — Workers' Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 nsation Insurance 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 conanucion 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 Dcparment of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Depammnt of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Conswrction 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, pan -time employees or subcontractors foryour pmjecL 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 Shorn Village does not require verification of workers' compensation insurance cov ge from the contractor's company for day labor, part-tirne employees or subcontractors. BY SIGNING BELOW YOU ¢IOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. AI // Signature: County of Miami -Dade The foregoing was acknowledge before me this l day of A,—) S , 20 2_3, who is personally known to me or has produced k1na,.1h asidentiLcatioa �yBRACC(p"'� Nry:YPUB(� ota SEAL: r S020 437= OC W& WMnawA Ong. LLQ GC ELECTRICAL ONE LLC 7350 CLEVELAND ST HOLLYWOOD FL 33024 CELL PHONE:786-486-8796 QUALIFIER'S:.ZANIER GONZALEZ LIC EC13011294 08/01/2023 STATE OF FLORIDA COUNTY OF fV%avn'30ac-- BEFORE ME THIS DAY PERSONALLY APPEARED GIANCARLO CRUCCI WHO, BEING DULY SWORN, DEPOSES AND SAYS: THAT HE OR SHE WILL BE THE ONLY PERSON WORKING ON THE PROYECT LOCATED AM 10650 NE 11 "AVE MIAMI SHORES FL 33138 SWORN TO (OR AFFIRMED) AND SUBSCRIBED BEFORE ME THIS 01 DAY OF AGOSTO 2023 PERSONALLY KNOW- 0000-11 OR PRODUCED IDENTFICATION TYPE OF IDENTIFICATION PRODUCED NAME OF NOTARY $iwoou 0HV...0, E!)r%. 344fv .a ...: )op