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FW-08-23-2045Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Contacts Permit NO.: FW-08-23-2045 Permit Type: Fence/Wall Work Classification: Ornamental/Metal Permit Status: Approved issue Date: 09/12/2023 1 Expiration:03/12/2024 ANNA SAMPAS Owner MR BAEZ METAL CORP Contractor 9767 NE 13TH AVE, Miami Shores, FL 33138 ARSENIO BAEZ Mobile: 9542405575 anna.sampas@gmail.com 690 NW 32 ST, MIAMI, FL 33127 Home: 7542449880 Business: 3058128031 mrbaezl3@yahoo.com Mobile: 7867759499 Description: INSTALLING SLIDING METAL GATE IN FRONT OF Valuation $ 4 200.00 Inspection Requests: PROPERTY 305-762-4949 Total Sq Feet: 0.00 ems;: Fees Amount Application Fee - Other $50.00 CCF $3.00 DBPR Fee $3.75 DCA Fee $2.00 Education Surcharge $1.50 Engineer Fence Systems $200.00 Planning and Zoning Review Fee $70.00 Scanning Fee $9.00 Structural Review ($60) $60.00 Total: $399.25 Payments Date Paid Amt Paid Total Fees $399.25 Credit Card 09/12/2023 $349.25 Credit Card 08/17/2023 $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 constm79"zing. Futhermore, I authorize the above named contractor to do the work stated. r Toem 15gvz T i/z lz 3 / Applicant / Contractor / Agent September 12, 2023 Page 2 of 2 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 BUILDING PERMIT APPLICATION E�BBUILDING ❑ ELECTRIC ❑ ROOFING 0 FBC 20)0 Master Permit No. 1-W -C�-a3 -6 T6 Sub Permit ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR � DRAWINGS l %J 10B ADDRESS: Kl N �' I ycc City' Miami Shores �t /� County Miami Dade Zip: �3 i 3Q Folio/Parcel#: I ' �ZVS- b 6 q- OS^ ? is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 0110 ki)2 IS Czlnd 4 5 Phone#: - i . I.1A City: Miam l . �) l'1State: Tenant/Lessee Name: Email: CONTRACTOR: Company Name: 11 /l/// • /- Address: L200 AL 3211 Email: I'✓ f beZ /3#c/C/1i60, -Z�s/'5y 8lc %2S-7 ff Qualifier Name: f-1/ i'C/l/V Phone#: l�ccnnrr�� c' State Certification or Registration #: Certificate of Competency #: [3 .x�V Z l✓ DESIGNER: Architect/Engineer: Value of Work for this Permit: $ 2" Square Type of Work: ❑ Addition ❑ Alteration New Description of Work: 2%7 J`)ei11"n . Shill l Q �G Specify color of color thru Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ State: _Zip: r Footage of Work: -3o r ❑ Repair/Replace ❑ Demolition Permit Fee $ CCF $ CO/CC $ DCA Fee $ DBPR $ Notary Training/Education Fee $ Double Fee $. P&Z Review $ Bond $ _ TOTAL FEE NOW DUE $ _ (Revised04/05/2022) Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lenders 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. Signature Signatu OWNER or AGENT The foregoing instrume t was acknowledged before me this j'A dayof OVi] 20 23 by It)Zg 1 4/rM 6 who is personally known to me or o has produced D, f' / 114 as identification and who did take an oath. NOTARY PUBLIC: JOAN S. BAEZ Seal: a'"'�„ MY COMMISSION #GC920533 EXPIRES: OCT 08, 2023 Bonded through 1st Slate Insurance •*a«. +.... �».sssssssssgsssesss •+ 7"Fi APPROVED BY i 1 (Revised04/05/2022) The foregoing inhwas acknowledged before me this day oi4 20 by who is personally known t me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: �" /OL'or--"—.;;.a Print: /T 1 . ,11t,?4 S Seal: ELISHAWILL"MS MMyCOMMIS GGR"' zaEXPIRESSAPR1 202620 awe Rnnded through lsl State Insuranc ..+...•+.. s. s.ss Plans Examiner Structural Review T 1r127;) as Zoning Clerk OFFICE OF THE PROPERTY APPRAISER Summary Report Generated On: 08/17/2023 Folio 11-3205-009-0520 9767 NE 13 AVE Property Address MIAMI SHORES, FL 33138-2545 Owner GEORGE J SAMPAS , ANNA KUZMIK SAMPAS 9767 NE 13 AVE' Mailing Address MIAMI SHORES, FL 33138 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 Info.)I 0: Year 2023 2022 2021 Year 2023 2022 2021 COUNTY Land Value S6,029,931 $4,067,387 $3,506,096. Exemption Value $0 $0 s0 Building Value S1,957,189 $1,891,178 $740,860 Taxable Value $6,614,590 $6,013,264 $4,302,226 Extra Feature Value $54,125 $54,699 $55,270 SCHOOL BOARD -------- ---- -------- -.......-..._.--- ----._._._._....... Market Value $8,041,245 $6,013,264 $4,302,226 Exemption Value $0 $0 s0 Assessed Value S6,614,590 $6,013,264 $4,302,226 Taxable Value $8,041,245 $6,013,264 $4,302,226 > .. .:� LAW -CITY Benefit Type 2023 2022 2021 Exemption Value $0 $0 s0 Assessment Taxable Value $6,614,590 $6,013,264 $4,302,226 Non -Homestead Cap Reduction $1,426.655 REGIONAL Note: Not all benefits are applicable to all Taxable Values (i.e. County, : Exemption Value $0 $0 SO School Board, City, Regional). -;- Taxable Value $6,614,590 $6,013,264 $4,302,226 EARLE I ON SHORES PB 43-80 LOTS 7 & 8 BLK 4 Previous OR Book - Price Qualification Description LOT SIZE 186:980 X 150 Sale Page OR 16863-2142 0795 1 : 03/30/2023 $8,695,000 33653-4368 Qual by exam of deed 07/20/2021 $7,400,000 32650-1601 Goal by exam of deed - — Corrective, tax or QCD; min 06/11/2021 $100 32578-2324 consideration 03/22/2018 $0 30911-3674 Corrective, tax or QCD; min consideration The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at http://wvvw.miamidad e.gov/info/disclaimer.asp S1 v RaalWt! v ALTAREP9 Imrza 4iyYllpr PiL. �aA 1� oWiBMX.Tgl1 OQMWNW oT60WNPIF vWILaWaillE BEARING REFERENCE: NONE RECORD INFORMATION RELIANT UPON ANGULAR DATA ONLY. ALL ANGULAR DATA SHOWN HEREON REFERENCED THERETO. Miami Shores V' I Build, g Depa e t Zoning Dept. Dale l Z3 Building Dept. Dat� Subject to compliance Fed I, tate and County rules and regulations. Permit# I mul ANs .wu YAex oTgr �;: Yxr �mane rovrrt xm DC5 rce'ai :.z • I OLCN WF( YJV,R Ji :: GtOI � &91 Y.V. CSW.`4' � 0K J:.JS 9R19 arrex w.0 g I M _ IIJA 2 111 1 1� Sluila -.' l _ IIIIISI I�111111!l11 1!!`F� 1 r�y1, 1 1 1 1 ''1; 11 Pad 11 1'..1"'llllll___Ill,llaa 11 11 11 111 11-1 1 1191 1 1 1 11 /1 1!� 11 1!y ��;,h�?r��t� Lla'1'l 1�1li1l�IS. aEmalaxoraaavx wrxnrsnon urzsz,uvFovartxr Ino�.roscvE� AUu 17 CO23 BY. --- -- CIT COP tR.0 i2 a 54 IN) ,eq Z IXM.T. VE J.1'Nf2 WI'Y T39 A•, 0 'cv"� � o ,, CP=NtRRg1NG WIlf Oi ROIA - 10RNKiIBB lAR N10B6fYMYB11H'1 Plafled bsanmts dNd+de LmdN'ons (unyatted alw NsbE 51016RA'aBBS REOIP 150PTHISSURYEI' REVIEW THE OF AMYffNCE UNE SHOWN ANO THEIR RELATIONSHIP TO THE BOUNDARY UNE. .5'U.E. ALONG NORTHERLY BOUNDARY LINE OF SUBJECT LOT. -WOOD OO . TIESWNDARY LWE ON EASTERLY SIDE OF LOT AS SHOWN, CONCRETE WALK, PAVER WALK AND WALL EXTEND THROUGH THE NORTHERLY EASEMENT. INaane,l.usi N �,y , —_ _ .wanwowYao wr IUWY9lsilee9nM9ma w.uww �,•�unwa ®•.ear 0 •mnwr rxwc sawm eaz 10pWmIl�baaBWmA9LlIW wR�, .mnelu[ �•� OrhtleNT.0.a3M1 V =waxmax� Q•.n wc.xcrnmve� wwuamrs—.—.— aW:DI11x+J5BT �`wuwwo °'°me31 faclsaq+wlas .w ®•anww _y_.arnwmeei '�ljj'' eancmc www.l anAlecsurvev.can �.wuw.u.rM ..mow ��..iw ..,,a..w prwm�w� �Y, °scram IB9SSSE IO+mavalswa: mnYAID Ia b,.D.c eed+�t BNtlneFEhA: KG.V.D.n OmAi®aeD. LAND_TEC N.G.VD29 ❑ NAVDJIB ❑ S U R V E Y I N G a J�YtQ� LICENS®aWNE55Nn Q5W Y oc 2 Tneaarrrtr: BmaDa! BWrSIPoILInN omtaae4a o NTMara olaaAwrC oSRQLLRaw)SE 1L DESCRIPTION: 7 and 8, in Block 4, of EARLETON SHORES, according to the map or plat thereof, as recorded in Plat 43, Page 80, of the Public Records of Miami -Dade County, Florida. TERTY ADDRESS: NE 13TH AVENUE AI SHORES , FL 33138 HCE NUMBER: 163205-SE OF FIELD WORK: 03/15/2023 NT FILE: 2023-012 fIFIED TO TITLE INSURANCE COMPANY ZONE: VE MAP: 12086C 0306 :L DATE: 09/11/2009 ����� �:.°��` •••,•• umnwe • 'm�ia Mawr Mreammrna&nua °W" 9ew4Naetl�.RDNI �o m•wn rx y ,� t ®.w apxlNllaelasn �wW1O,o mnoe� • •canoe `a1O1e4' eoe.�oeos�u inert —.— ir1a114Li11a�— y uuwlanMwsnrvovmm ,..moo.... w.�mw ®rm w•wn �.e®�..m •enam n ,_. _._ wtt aseenaewowieunmwowimz�apm BarJnak xa _- ewmpetea,: x Digitally signed k0abnc LANDTEC by Pablo Alvarez Bx�wemuwo9aeie Date: 2023.03.16 N.G.VD29 ❑ NAVDA D 09:19:14-04'00' S U R V E Y I N G „,�o3/tsnoz3 �r,'raweEwoovae®eraceeemcpx CHtO� f.�o.� uceLsmRBrssstae9t TYP TOP CUIDF RO 1 ERc Co SPHE REJECI E ALUM. POST ST 2's ',J' ALUM. PICKELS RT 2"x1"a0.062" ALUM. FRAME ST 2"x2"wl' -S-1W�0 - ALL TUBES AND PIPES TO BE ALUIMJUM ALLOY 6WI-76. ALL PLATES TO BE AWIIINUM ALLOT 6661-T6. - ALL CWNECRWS TO BE FULLY W DEO il!-ERS]56 - ALL STRUCTURES om9 N ACCq mm UN: F.B.0 2o1T AS C E 7-10 AIUVHUM OESIW MANUAL 2005 ORE PREYENTIW CODE 2015 15TH MT N NOTIFY ENONEEA OP ANY ERRORS / OIRSSIWS FOUND W IF My PART Of THE DRAWNGS IS NOT UNDERSTOOD BEFORE PROREDNG MITH THE MDR,,. - ALUMINUM SURFACES N CONTACT W N CWCREIE M MMISCRY MATERIALS SHMI. BE PROIEC MYTH HEAW-BOOIEO BITUMINOUS PAINT. - CW MC7M MUST VriBFY DIM SMS W JOB SITE BEFORE MMrtIFACTURE. -------------------- ROLLING V-TRACK ` I I CEYAL 1 I I I O ALUM. FRAME ST I •a •d• II ALUM 2.1'. PICKETS R1 I 21T"x0.062" I I I I I 1 PULE j'a3'x10-f• I I I ROLLING V-TRACK ' I ' I I ALUM S INDIN . QATE b.. ALUM SLIDING GALE CUIDE ROLLER ALUM POS 30'-0" ST 2 ad' ALu 3TRUi,TUkAL RE APPROVED A UMIN TNT clOnvrtNINDIN • GAT 30'-0 ALUMINL_ IM FENCF Bswo 6'-0" L" O.0 II ALU ST ALUM. RT 2"xi ll 6� IT � ra I I e. 7 FIRE a I I 1 JC I I W xp SE � s a owl UW N I 0 GI 5 Q Z Q m0K b M W th z m 1- Q WM LL Q 0 � t N r O Q: Wy W D- Z ._ E O Of W m m W f a SHEET DESCRIPTION ELEVATION/SECTION SHEET. I of T •p •ETC ETys 0.0 LAND'TEC S U R V E Y 1 N G .a This Survey has been prepared for: Anna Kuzmik Sampass PROPERTY ADDRESS: 9767 NE 13th Avenue Miami Shores , FL 33138 On your behalf, and as a reyulreinent for your a ansaiAion, ilii� dxum( III e ue_n ,.cuwmaL2d with us by the Nii ,hown below. Landtec Surveying, Inc. is a private firm and remains entirely responsible for this document's content. STRANGADAMS REAL ESTATE LAW AND TITLE INSURANCE Construction Tradesualifying Board IINESS CERTIFICATE OF COMPETENCY 13BS00275 MR BAEZ METAL CORP 101,►-1 • Is certified under the provisions of Chapter 10 of Miami -Dade County VALID FOR CONTRACTING UNTIL 06/3012024 NO2tll N3WVN210 9£00 (S)90VHI EJNIAdrivno Municipal Contractor's Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT A BILL —DO NOT PAY CC NO: 13BS00275 MC) BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES MR BAEZ METAL CORP 690 NW 32ND ST 7643917 SEPTEMBER 30, 2023 MIAMI, FL 33127-3644 Pursuant to County Code Sec 10-24 OWNER TYPE Of BUSINESS PAYMENT RECEIVED MR BAEZ METAL CORP SPECIALTY BUILDING CONTRACTOR BY TAX COLLECTOR C/O ARSENIO BAEZ VALLE PRES 175.00 1 1 /02/2022 INT-23-021561 This receipt is not valid in the fallowing Municipalities Aventura. Donal. Hialeah Key Biscayne, Miami Gardens. Miami takes, Palmetto Bay. Pinecrast. Sunny Isles Beach, Town of Cutlar gay. MTA t ADE uT For more information, visi(yyyyw m'amideda,9avhaseatlector 002331 Local Business Tax Receipt Miami -Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY 4366787 BUSINESS NAMHLOCAMON MR BAEZ METAL CORP OPERATING IN DADE COUNTY MIAMI FL 33999 LE31m RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2024 4557741 Must be displayed at place of business Pursuant to County Code ©0, Chapter 8A - Arta 9 & 10 =-I OWNER SEC.TYPE OF BUSINESS PAYMM RECEIVED MR BAEZ METAL CORP 220 TANGIBLE PERSONAL PROP DLR BYTAXCGLUCTOR $75.00 07/19/2023 Employee(s) 0 INT-23-409219 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 goyammental or nongovemmental regulatory laws and requirements which apply to the businOSL The RECEIPT NO. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 88276. For more information, visit www.miamldade,gov/taxcoliector s _ DocuSign Envelope ID: 70AB6443-FOD54123-A643-2D5217779254 �1 ACill CERTIFICATE OF LIABILITY INSURANCE DAMfMWDDNYYY) 08/17/2023 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(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 CONTE:ACT Nadia Nicolas NAM Nicolas Bms Insurance Group PHONE 1, (305) 393-8999 _ FM No: 1101 BRICKELL AVE EDoIRess: insurance@nb-ig.com INSU S AFFORDING COVERAGE NAIL# STE G 1 INSURERA: GRANADA INSURANCE Miami FL 33131 INSURED INSURERS: INSURER c : MR BAEZ METAL CORP INSNSURER D : 690 NW 32 STREET URER E INSURER F: MIAMI FL 33127 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. ILm TYPE OF INSURANCE Auto SUER POLICYNUMBER MPmCYEFF POLICY UDNYYY LIMITS A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FXI OCCUR N N 0185FLOO100503 - 6 08/30/2023 08/30/2024 EACH OCCURRENCE $ 1,000,000 PREMISES(Eaccemence) $ 1,000,000 MED EXP (Any one Person) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GEN-LAGGREGATE LIMIT APPLIES PER X POLICY ❑ JPO- ECTT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS-GOMP/OPAGG $ 2,000,ODO $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOSONLY COMBINED SINGLE LIMIT Eeaccident) It BODILY INJURY (Per person) $ BODILY INJURY(Peraccident) $ PROPERTYADAMAGE $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ OED I I RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' UABILRY IN ANY PROPRIETORIPARERIEXECUTNE -] OFFICERIMEMBER EXCLUDED? (Mandatory In NH) If yes. describe under DESCRIPTION OF OPERATIONS below NIA OTH- PER I ER STAM E.L. EACH ACCIDENT It E.L. DISEASE -EA EMPLOY $ El DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 1111, Additional Remarks Schedule, may be attached if more apace is required) License: 13BS00275 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.E 2nd Ave I AUTHORIZED REPRESENTATIVE Miami Shores FL 33138 I Michel Nicolas U TSBN-YOTb ACUKU (:UKYUKA I II All ngnts reserve0. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Miami Shores Village - BUILDING DEPARTMENT 10050 NE 2 Ave Miami Shores, FL 33138 305-795-2204 www.msvfl.qov 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 industrywho 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 revokedby the Division,F�c'W./' G /� Your contractor: AA 60, / �/ f O is requesting a permit under this workers' compensation exemption and has acknowledge t1fat 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 CKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND /UNDERSTAND ITS CONTENTS. Signature: Address:/�7 Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this. day of �U 20-n. / By /� Aa / 6M P10 5 who is personally known to me or has produced .a [)G as identification. Notary: / �A �� //109I.S SEAL: ELIS14A MLLIApec„! GRIFF r WCOMMISS! - '11251720 EXPIRES: APR 1+ _02S Notice to Owner Page 1 of 1 Re 1 ceded through JSt State lnaurance ki 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 6`h 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. Mr. Baez Metal Cor Date: 8/16/23 State of Wdti County of dIW�affij " Jade Before me this day personally appeared 1YZ who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 97 d 7 A)-6 13 Eve - Contractor Signature Sworn to (or affirmed) and subscribed before me this day of .20 1-3 by �qiD ��t ersonally known OR Produced Identification Type of Identification Produced ELISHA WILLIAMS MCGRIFF ° VIV COMMISSION #HH251720 EXPIRES: APR 11, 20 Ins urance ance Print, Type or Stamp name of Notary