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FW-08-23-2135Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 186 NE 107 ST, Miami Shores, FL 33161 Contacts Permit NO.: FW-08-23-213 Permit Type: Fence/Wall Work Clossification: Wood Fence Permit Status: Approved Issue Date': 09/27/2,023 Expiration: 03/27/2024 Cameron Grace Owner SAMADA FENCE INC Contractor 186 107 Sergio Samada 110 W 31 ST, HIALEAH, FL 33012 Business: 9545594355 samadal@msn.com Ins ection Requests: Description: WOOD FENCE 6' HIGH, 3 GATES 48" WIDE AND 1 Valuation: $ 8,400.00 ROLLING GATE 15' 30 762,4949' Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $5.40 DBPR Fee $2.97 DCA Fee $2.00 Education Surcharge $2.70 Planning and Zoning Review Fee $70.00 Scanning Fee $9.00 Technology Fee $19.80 Wire and Wood Fence Fee $148.00 Total: $309.87 Payments Date Paid Amt Paid Total Fees $309.87 Credit Card 08/29/2023 $50.00 Credit Card 09/27/2023 $259.87 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 regulal/ng construction, and zoning. Futhermore, I authorize the above named contractor to do the work stated. k�� ==::� Auth rized Signature: Owner / Applicant / tractor / Agent Date September 27, 2023 Page 2 of 2 Miami Shores Village RE�CEIVED Building Department AUG 2 9 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. FW.-X.•. Z3. 2 13j PERMIT APPLICATION Sub Permit No. OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: $ 104 S City: Miami Shores 1 County: Miami Dade Zip: Folio/Parcel#: it � 1 3 (//o ©Q "� ®� �� Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: / Flood Zone: BFE: FFE: 4 OWNER: Name (Fee Simple Titleholder): L�C�-r��� r�'/"� �j Y-O--C Phone#: 41Y" S`� 1— 69 Address: 19 p k/ F- l 9 S� City: GM-`1 ��� State: g., Zip:3 6 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Samada Fence, Inc Address: 110 W 31 ST Hialeah, FL 33012 Email: samada1 @msn.com Qualifier Name: Sergio M. Samada State Certification or Registration #: DESIGNER: Architect/Engineer: Address: Value of Work for this Permit: S '51_(Q© Type of Work: ❑ Addition ❑ Description of Work: &Qe f� o L �c W*1 0 Specify color of color thru tile: Phone#: 954-559-4355 Phone#: 305-720-6344 Certificate of Competency #: 11 BS00347 Phone#: City: State: Zip: Q � Square/Linear Footage of Work: 1 18 ration �d New ❑ Repair/Replace ❑ Demolition Submittal Fee $ i` b ' vo Permit Fee $ I LA42t • f;r� CCF $ rJ - L`) CO/CC $ - Scanning Fee $ f�. trC� DCA Fee $ % DBPR $ 2 • Notary $ Technology Fee $ Training/Education Fee $ 47 • -7U Double Fee $ _ Structural Reviews $ P&Z Review $ 10 Cx7 Bond $ _ TOTAL FEE NOW DUE $ �C (Revised04/05/2022) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip, 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. Signatur\ P —)e:1— e Signature OWNER or AGENT CO The foregoing instrument was acknowledged before me this The foregoing ihstrument was acknowledged before me this I day of vSA-V 20 6-3 by I, dayofv S 20 Y�, by 14Y,2,rOM\ l'� ,rp-L -f2 who is personally known to 1 f e�1% o , 1. G�-n��,.uvho is personally known to me or who has produced t✓ as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: (T' Print: .��a'l" ���i..blefy a„a., Seal: Comm.:HH284856 . o� Expires: July 17,2026 %0qF e' � Notary Public - State of Florida g1IH10 identification and who did take an oath. NOTARY PUBLIC: Sign:_ Print: Nery Avila Seal: Expires: July 17,2026 Notary Public - State of Florida APPROVED BY Plans Examiner ��`'� G Zoning Structural Review Q Clerk (Revised 04/05/2022) T w 2� 4-1 �6'�' DECEIVED AUG 2 9 2023 GFN 201BRO262401 OR EKE 30962 Pss 320-322 (3Pss) Return to: RECORDED 05/02/2018 10:13:44 Simpson &Mena, P.A. DEED DOC TAX $2 r 208.00 2250 SW Third Avenue, Suite 204 HARVEY RUVINY CLERK OF COURT Miami, Florida 33129 MIAMI-DADE COUNTYP FLORIDA Instrument Prepared By: Christopher P. Kelley, Esq. Christopher P. Kelley, P.A. 11098 Biscayne Boulevard, Suite 205 Miami, Florida 33161 Folio No. 11-2136-007-0170 WARRANTY DEED THIS INDENTURE, Made this day of 2018, Between 186 NE 107 STREET, LLC, a Florida limited liability company, and 1225 NE 124 STREET, 28A, LLC, a Florida limited liability company, GRANTOR, and CAMERON GRACE and JENISSE GRACE, whose post office address is: 186 NE 107th Street, Miami Shores, Florida 33161, GRANTEES, WITNESSETH, That said GRANTOR, for and in consideration of the sum of Ten and 00/100 Dollars, and other good and valuable considerations to said GRANTOR in hand paid by said GRANTEES, the receipt whereof is hereby acknowledged, has granted, bargained and sold to the said GRANTEES, and GRANTEES' heirs and assigns forever, the following described land, situate, lying and being in Miami -Dade County, Florida to -wit: Lot 1, Block 208 DUNNING'S MIAMI SHORES EXTENSION NO. THREE, according to the Plat thereof, as recorded in Plat Book 42, Page 33, of the Public Records of Miami -Dade County, Florida. SUBJECT TO: Applicable zoning and/or restrictions and prohibitions imposed by governmental authority; Conditions, Restrictions limitations, reservations, easements, and other matters appearing on records, if any; Utility easements of record, taxes for the year 2018 and subsequent years. and said GRANTOR does hereby fully warrant the title to said land, and will defend the same against the lawful claims of all persons whomsoever. Page 1 of 3 Warranty Deed 186 NE 107 Street, LLC, et.al. s/t Grace IN WITNESS WHEREOF, GRANTOR has caused these presents to be executed in its name and its corporate seal to be affixed by its proper officer thereunto duly authorized, the day and year first above written. Signed, sealed, and delivered in our presence: Witness signature �Wk_ G. Print Witness signarfure CIIRIST")'21MP P. KELLEY Print STATE OF FLORIDA COUNTY OF MIAMI-DADE 186 NE 107 STREET, LLC, a Florida limited liability company By its Managing Member: THE DUFFY FAMILY LIMITED PARTNERSHIP, a Delaware Limited Partnership By; - % PATRICK L. DUFFY VA rantor Managing Member 501 Grand Concourse Miami Shores, Florida 33138 I HEREBY CERTIFY that on this day, before me, an officer duly authorized in the State aforesaid and in the County aforesaid to take acknowledgments, personally appeared PATRICK L. DUFFY as Managing Partner of THE DUFFY FAMILY LIMITED PARTNERSHIP, a Delaware Limited Partnership, as the Managing Member of 186 NE 107 STREET, LLC, a Florida limited liability company, who produced as identification, and who executed the foregoing Instrument anacknowledged before me that he executed the same freely and voluntarily, under authority duly vested in him by said limited liability company. Witness hand and official seal in the County and State last aforesaid this � I�� day of / 12018. NOTARY PUBLIC, State of FLORIDA at Large My commission expires: DALIA E. MADRID Page 2 of 3 P�. Notary Public • State of Florida ` . Commission M FF 919347 ° My Comm. Expires Sep 17, 2019 Bonded through National Notary Assn. f a� ra OR BK 30962 PG 322 LAST F•AGE LL ,Q Hui Ho r0 Q .f iC Q O.J Warranty Deed 186 NE 107 Street, LLC, et.al. s/t Grace Signed, sealed and delivered in our presence: AW4&�� By: Witness signature �IliGr � . /�GtGir� CG Print Witness signature / C 1 _ _. _ " P. KELLEY Print STATE OF FLORIDA COUNTY OF MIAMI-DADE 1225 NE 124 STREET, 28A, LLC, a Florida limited liability company By its Managing Member: THE DUFFY FAMILY LIMITED PARTNERSHIP, a Delaware Limited Partnership PATRICK L. DUFFY Grantor Managing Member 501 Grand Concourse Miami Shores, Florida 33138 I HEREBY CERTIFY that on this day, before me, an officer duly authorized in the State aforesaid and in the County aforesaid to take acknowledgments, personally appeared PATRICK L. DUFFY as Managing Partner of THE DUFFY FAMILY LIMITED PARTNERSHIP, a Delaware Limited Partnership, as the Managing Member of 1225 NE 124 STREET, 28A, LLC, a Florida limited liability company, who produced 1�Cr�M/,/ LlV GnrwyI _ as identification, and who executed the foregoing instrument bnd acknowledged before me that he executed the same freely and voluntarily, under authority duly vested in him by said limited liability company. ftness m� hand and official seal in the County and State last aforesaid this 21ay of ri / , 2018. O ARY PUBLIC, State of FLORIDA at Large My commission expires: DALIA E. MADRID age 3 of 3 Notary Public • State of Florida 9 Commission M FF 919347 My Comm. Expires Sep 17, 2019 '''f,q ,,',„ Bonded Through National Not Assn. DOCUMENT COVERPAGE For those documents not providing the reg_ aired 3 x 3 inch space on the first page, this cover page must be attached. An additional recording fee for this page must be remitted. Document Title: (Mortgage, Deed, Etc.) Return Document To / Prepared By: I'llllil Illtl Itlll 11111'�in� iln� inrt n�i'llll GFW 2171SR0621221 OR EK,31176 p9s 3873-3876 Wqs) RECORDED ir)/11/2018 0925/00!, DEED DOC TAX $552.00 HARVEY RUVIN, CLERK. OF COURT MIAMI-DADE COUNTY, FLORIDA L------------------------------ (Space above this line reserved for recording office use) Y Coq-,reC_i- _SS0.�� �ri'L�_ Rule 2-520 (d) On all ... documents prepared ...which are to be recorded in the public records of any county ... a 3 -inch by 3 - in&sp ace at the top right hand comer on the first page and a I - inch by 3 - inch space at the top iight-hand corner oneaeh subs equentpageshallbele8blank andreservedfor use by the deck of court CLJACT 155 Rev. 0e/16 Clerks web address: www,mlarnl-dadeclerk.com W" k F THOMSJ KELLY. INC .1.1 tp ;>iIRVFYOR+ V' CERTIFY TO: Miami Shores Vil (ding D 51MF50N t MENA LAW Date CRO55 COUNTRY MORTGAGE INC.,ITS SUCCESORgoning Dept. Date AND/OR ASSIGNS/ A.T.I.M.A Building Dept. Subject to compliance with all eda'i LEGAL DESCRIPTION: LOT: I State and County r les and regulatfc L13� BLOCK: 205 Permit# SU13DIV15ION: DUNNINGS MIAMI SHORES EXT NO.3 ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK: 42 PAGE: 33 PUBLIC RECORDS OF MIAMI-DADS COUNTY, FLORIDA I PROPERTY ADDRESS: 186 NE 107th STREET MIAMI SHORES, FLORIDA 331 6 I SURVEYOR'S NOTATIONS: NONE I FLOOD ZONE INFORMATION: THE NFIP FLOOD MAPS HAVE DESIGNATED THE HEREIN DESCRIBED LAND TO BE SITUATED IN: FLOOD ZONE: X PANEL NO/SUFFIX: 302/L COMMUNITY NO.: 1 20G52 , W DATE OF FIRM: 09/1 1/2009 THE SUBJECT PROPERTY DOES NOT LIE IN A SPECIAL FLOOD HAZARD AREA Notes: A) All Clearances and I or encroachments shown hereon are of apparent nature. fences ownership by visual means. Legal ownership of fences not determined. 5) This survey is intended for mortgage or refinance purposes only exclusively for this use by those to whom it rs certified. This survey is not to be used for con5truct,on, permitting, design, or any other use without written consent of Thomas J. Kelly .Inc. C) Code restriction and title search are not reflected on thr5 survey. D) The flood information shown hereon does not imply that the referenced property will or will not be free from floodmg or damage and does not create liability on the part of the firm, any officer or employee thereof for any damage that results from reliance on said information. E) The lands depicted hereon were surveyed per the legal description and no claims as to ownership or matters of title are made or implied. F) Underground encroachments, if any, not located. G) I hereby certify that the survey represented hereon meets the mmimum technical standards t set forth by the Board of Land Surveyors in Ohapter 5J-17.050 to 17.052 Florida s' .Y Admrnif3tratwe Cod© persuant to 5eet,on 472.027 Fla, Statutes. �10 57$7 N) If Shown, Weinngs are to an assumed meridian Ilro f 5hown, e01..Won'arGe reefe�A9It9vGS.WoeIj JW0 S # is: J U L'r0a 3nPj IarA PITA STATE Or Date: 2018.04.181 t`tc9r. 0 R f, _04D0' _04/1V"T8 JULIO S. PITA, F.S & M # 5789 > STATE OF FLORIDA NOT VALID UNLESS IMPRINTED WITH EMBOSSED SURVEYOR'S SEAL CPU RUNNINGS MIAMI SHORES EXTENSION N 2 41--78 -------------------- - ---- _ �.- 75_DO'�R��---------------------------- ------------- -------- e- 15' ALLEY (9' PA V) F.R. 1L-- _ 5' M'D� �'C1L1'�1GS i� r XI�Q � 99 171 J W ON PL. �n O/ �I LOT 2 BLOCK 208 1� 21,7' o of do ^� 10.2' 10.6' / 3.0 0 4.0' 33.01Y i �"i C. S N "f 20.00' S LEI ONE STORY RES. No.186 LOT 1--BLOCI(,' 208 & o Y� -� 1r3.4.5'313'L=2 �7.2W ta80' 11.8' 0.65' 4.75 I 1 F. P — I J 3 U CV CONC. r�111 d. CV I M �12 I I PC 75.00'(Er')(M) 5' SWK 1 ' I 23.6' Pwy ASPH.Lq I o I I � 19.0, I EVE 1 07fh S T 17' ASPHAL T PA CEMENT 75' TOTAL R/W F.I.P 1/2" 50UNDARY SURVEY SCALE: 1"= 2 0' VIEW OF SUBJECT PROPERTY VICINITY MAP. --t- cvv 40--p &' 3 bps YB " J LEG80 OF %FM ABBMMTICM ' CEIVED AUG 2 9 2023 i 4 N «, w (n fY d z 0 d m ID DESCRIPTION SIZE REMARKS BD Board 1" x 6" Pressure Treated (ffD Concrete Footing 10"0 x 24" 3,000 psi (Minimum) cFz Concrete Footing 12"0 x 36" 3,000 psi (Minimum) 0 Concrete Footing 12"0 x 12" 3,000 psi (Minimum) with 3/4"0 Galvanized pipe DR Drop Rod 3/8"0 x 24" Standard Drop Bolt (Lockable) FA1 Fastener (Screw) #10 x 1-3/4" Stainless, Galvanized, or Coated Wood Screws FAz Fastener (Screw) #12 x 1-3/4" Wafer Head TEK Screws cF Gate Frame 2" x 2" x 0.125" EMS#:19-63-209 (At corners fully welded) GP Gate Post 4" x 4" x 96" No. 2 Select Structural - SYP HI Hinge 4" Self -Closing Hinges Iv Intermediate Vertical 2" x 2" x 0.125" EMSM 19-63-209 (Fully welded to Gate Frame) ® Latch NIA Self -Locking Latch LP Line Post 4" x 4" x 96" No. 2 Select Structural - SYP " \ " �rComponent Scheme and Generan Notes V I Scale: Not to Scale. "� Double Swing Gate Details Scale: 1/2" = V-0" DESIGN GENERAL NOTES: A. LOCATION: This design is for AT GRADE railing installations ONLYII Installations above grade shall be designed for specific conditions for the location. B. COMPLIANCE: Designed using the requirements of the FBC 2020, 7th Edition & ASCE 7, Using V if = 115 MPH / Vasd = 90 MPH (3 second gust) Exposure C or D, Risk Category I. C. GATES: Gate leaf (single or double) widths can be installed up to the allowable size as shown in Gate Details. Should a double leaf gate be installed then the Latch and Drop Bolt shall be installed (per the local requirements). D. SOIL: All soil around footings shall be compacted to a 90% optimum density (2,000 psf minimum capacity) and shall be classified or verified by others to be sandy gravel class or better. E. CONNECTION METHODS: See FA1 & FA2. F. POOL AREAS: All horizontal rails shall be 45" apart minimum and all openings shall be less than a minimum width of 1-3/4". POOL CODE DESIGN NOTES: (FBC 454.2.17) A. GATES: All gates shall open outward, be 48" high and have no opening more than 1/2" within 18" of the latch. Shall be self -closing allowing the latch to fully engage securing the gate leaf. B. RAILS: Horizontal rails are to be spaced so that the top of rails shall exceed 45". Bottom rail shall be maximum 2" above grade. C. PICKETS: The typical gap spacing shall be 4 inches or less. D. HARDWARE: LATCHES: Shall be a minimum of 54" above finished floor, lockable and self -latching. DROP RODS: Shall be lockable on the inactive leaf. 7OLCODE COMPLIANT H Can be used around pools but must adhere to the HEIGHT & GAP SPACING Required by the FOOL CODE REQUIREMENTS! Single Swing Gate Details (Typical) [_21Scale: 1/2" = V-0" (Typical) MATERIALS GENERAL NOTES: A. WOOD: All wood used for pickets & posts shall be #2 SYP Pressure Treated.CONCRETE: All concrete used for footings or post grout shall reach a compressive strength of 2,500 psi within 7 days. B. SOIL: All surrounding soil used for structural installation purposes shall be well compacted by mechanical means to optimal density and shall be free of deleterious or organic materials. C. FASTENERS & ACCESSORIES: All fasteners shall be A300 non-magnetic alloy, stainless steel, or other corrosion resistant material unless specified otherwise. Any hinge or latch shall be of structural quality molded polymers or or zinc coated metal and shall be installed in accordance with manufacturers recommendations. Drop rod may be pipe style or pre -manufactured style. D. HARDWARE: All hardware used shall be automatically, self -closing and self -latching when used around pool enclosures. E. SUPPORTING STRUCTURE: • Wood Line Posts shall be 4"x4" Pressure Treated • Wood Gate Posts shall be 4"x4" Pressure Treated B. HINGE ATTACHMENT: • Concrete: 1/2"0 x 6" wedge anchors • Wood: 1/4"0 x 3-1/2" Lag Screws • Steel: Welded or 1/4"0 Carriage bolts with washer and nut. INSTALLATION GENERAL NOTES: 1. POST CONNECTION: Anchored in 12" x 30" (2,500 psi) concrete. 2. BOARD / POST CONNECTION: 2.1. (2) 16d Nails (galvanized common) or 2.2. (2) #10 x 1-1/2" Stainless, Galvanized, or Coated Wood Screws 3. BOARD / GATE FRAME CONNECTION: 3.1. (2) Self -Tapping SMS #12 @ each connection point (24" o.c. maximum). ATION: PUBLIC SIDE i D 6D LP �� I -- CFt -AN: SECTI_O�_ RECE rencing uetans Scale: 3/8" = V-0" BY: (Typical) J. Cc �nn',IA 9 #9i737 E 0 o 0, o cn j0 v� O o `o � o V 3 LL mot^ V co 0 o� 0m 0� a 0 U 0 v 0=0 L co rn LO �n rn ci C O i a Q M 0 V a) 0 I L' f6 c ILL m m aa_U E a M N d fA U in U vJ .�- -W IS\ N IJ a E L Qi m p D_ 3wwo VJ m' O t✓ � � � a O Q LL • N 2 _0 O o O 2 O o 0 FBC 2020, 2th EdM. W2.0 01 .4- 0 > a) Q)r,o O ` a) N N CO rv)W) (a 0 NnM'E I M (o N 03 C,00 E O N � W o L� .6 �-, .. 0 0 N d7 a) Ir F— N Q w 0= �� z W_ w ♦� LL. Y z� OJa 0 CL 0 Q 2 Q ZF 0 p 0 (D Q F 0 A n ui W r c�u Q L�71 U LD CM N O N N 00 O H tz 00 C) z z J W U z W w L CO x O w x W U z w w M w } O N U Q w W Q rF W o Lj x 00 WQ d = J O Z U ri O r 3 w N 0 W LLI 9 N OO r U ma M= m w F- Z) Q a; O O} K �z Q w Q 1=- p Q 30 v) J Q 2 } Q L� N zm x 0 Lo O U O it t m _j = W U Uvz) 3 * ova w N tr W gym= � M LL,O m wLa 0 O C) w= z m zw w m J ZwrQON U0 O o ¢r¢ o Uj m mO�O Fn J O W Q U N O UU� r N Q O Q g 0 z0 w w �t�awo� x =Z�oL¢ O Y Z m f) O O O Z O w O LL z C..9wO Z , �QJ W O O a =00 0 O 1= 0FU-Wa90 a Q U g x o W J 0 M O m z I,W mW O Z N W 3 a r¢F F- m Z N N W Z O �Z Z Q ) U Q Z � (-) 0 w O 3 I rmvi W Lal 23 C7 ow�W (r/q(Q/��m z J LLI > Qz(Uj W W a O O J W 0 z a�,oWr vim 0LLJ F-m 3a5 W m ¢x m LL m laJ 0 Q Q Q d J a J Z z m cnC, 7:co�gJ` jr J W Q W U = w W J M 0 Q 2 J Z co (In Q Q W > 3 W O CD F-M z a m rwm �+ - O U)0 :2 O O g f 00 V) LLJ tttaq�q�,���+i z o 3 o 4wx0 FS F=-F- F=-F- U) z O =>Z O w m x W F W U �_ W Wz w N J p(U/)U or N°doz as W p aoa �oz Ld -0 j xWaa! �m J J Q o �N Z O W t 0 N 0 N U m L� W Q O U w U U U N Z 0 0 0 mQ t�U 000 Xl oa l I 1 O U a N d in io W Q z (a a U)Q, g � wag N0N mo 003 e c t z3oLIj 000 xrOWmmm`r ,* U- w Q r F= J a 3 Q J z W W Ow L—Ji 53 O �zo32U K QrF X m g OgZZg?� U aa�zO�W O U \ U}mOr a' M O za �UF p m I z v)U JJ LLJ Q z OOY (xONAJUO mW `00 N 3 .. , a Q V) 0 x z O H W (n z 0 W a' Ci W cr- z O U W a In Z W J O z O Q z D O F- U) O 1-4 N O N _O 'd a) b CRIVE AUG 2 9 2023 IM iami 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this /�_ day of 14'�% S , 20 By �cl-v-% -e__r !' , ✓fie "�_ who is personally known to me or has produced I— n as identification. Notary: Nery Avila Comm.AH284856 SEAL: =z �= Expires: July 17, 2026 Notary Public - State of Florida