EL-06-23-1449Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795.2204
Location Address
Permit NO.: EL-06-23-1449
Permit Type: Electrical - Residential
Work Classification: Service Change
Permit Status: Approved
Issue Date:06/21/2023 Expiration:12/21/2023
Parcel Number
53 NE 105TH ST, Miami Shores, FL 33138 1121360060130
Contacts
Bernard F Mathon Owner BENCHMARK ELECTRIC LLC Contractor
53 NE 105 ST, Miami Shores, FL 33138 MARC AU RELE LORTHE
Home: 7865123935 bfmathl@gmail.com 1391 NE 161 ST, MIAMI, FL 33162
Business:7867525007
Description: UNDERGROUND ELECTRIC SERVICE Valuation: $ 2,000.00 Ins ection Re uests:
Total Sq Feet: 0.00
Fees
Amount
Application Fee - Other
$50.00
CCF
$1.20
DBPR Fee
$2.00
DCA Fee
$2.00
Education Surcharge
$0.60
Permit Fee
$50.00
Scanning Fee
$9.00
Technology Fee
$10.00
Total:
$124.80
Payments
Date Paid Amt Paid
Total Fees
$124.80
Credit Card
06/21/2023 $124.80
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: 1 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.
4-
Authorized Signature: Owner /,/ Applicantd�`Contractor / Agent Date
June 21, 2023
Page 2 of 2
Miami Shores Village FUj:1;CE V-E1D
Building Department dUN 0 z023
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972 $Y: ..-rs
INSPECTION LINE PHONE NUMBER: (305) 762-4949
BUILDING
PERMIT APPLICATION
®BUILDING 'ELECTRIC t3 ROOFING
FBC 20 Master Permit No j1-dP 0 1 — 14"M
Sub Permit No
® REVISION ® EXTENSION ®RENEWAL
PLUMBING ® MECHANICAL CHANGE OF []CANCELLATION [71 SHOP
CONTRACTOR DRAWINGS
�+r
JOB ADDRESS: �J .� N � 10 St+'Ce't H, rrr7.' FL -5'3 / 3
City: Miami
Shores County: Miami Dade Zip: 33 / 3 9'
Folio/Parcel#: 11 — L.,17 6 —00(o - Q 1 3 Is the Building Historically Designated: Yes NO ✓
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): 73&RAj-A< k%t3'rHJ;J Phone#: SJ�.`3y39—
4
Address: 7\% L' / U 'J S f�YZ.Z-i
City: "/ /4 H 15 !./C it 0-5
State: Fl— Zip: 33 / 3 Y
Tenant/Lessee Name: Phone#:
Email: .43 FHA'TH1 (2'
CONTRACTOR: Company Name:
Address: 113 21 IN
() J Email: 1, rc I_(9 ✓ ,
Qualifier Name: Ma
State Certification or Registration #: 4 L 1 3 00 76 Z Certificate of Competency #:
DESIGNER: Architect/Engineer: _
Address: City: State: _Zip:
Value of Work for this Permit: $ /7-! /";)iN Square/Linear Footage of Work:
Type of Work: I3 Addition
,l Alteration ® New ® Repair/Replace ® Demolition
Description of Work: Undp f (T r�171ii/� eh( ✓ice ���1�1 �D
Specify color of color thru tile:
Submittal Fee $ �� Permit Fee $ O V CCF $ t•2-0 CO/CC $
Scanning Fee $ "l DCA Fee $ 2 • DBPR $ 2• C'O Notary $ Y'
Technology Fee $ I Training/Education Fee $ O • (Pc) Double Fee $
Structural Reviews $ P&Z Review $__ Bond $ Q o�
TOTAL FEE NOW DU 1 `� •Sa
(Revised04/05/2022)
Bonding Company's Name (if applicable)
Bondir-g Company's Address
City
State
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.
Signature
.01 WAGENT
The foregoing instrument was acknowledged before me this
—�;k_ day of . 20 �2 , by
'tiDti'Vq0%,',4ho is personally known to
me or who has producedV ""� as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: 0-0000
Signature
-.e�& �2 A
CONTRACTOR
The 5may
g instrument was acknowledged before me this
f 20 -Z 3 , by
who is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print: Print:
Seal: ORLENIS Svem
IV
.� v� OMMISSl0t4 #GG950a77 Seal:
� MY C etch 6,2C"�
�, QK EXPIRES: M
bonded Thtu Natary Public U''
APPROVED BY l Plans Examiner
SEDORNY FRWN
Notary Public - State of Florida
Commission # HH 233781
My comm. Expires Mar 21, 2026
ad throush National Notary Assn.
Zoning
Structural Review
(Revised04/05/2022)
Clerk
Miami Shores Village
Building Department
SURVEY AFFIDAVIT
STATE OF (FLORIDA)
COUNTY OF (DADE)
10050 N. E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
The undersigned Affiant, �j L A N "-p does hereby attest that
(Property owner)
The attached survey, performed by - �D I i.' Y" z' 4S,
(Name of surveyor's company)
For address: 5 N 6-
Performed on 0 -, j1W (date of survey) is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of any such
structures may affect final inspections as applicable to this or other permits.
Further Affiant say ht.
Property Owner Signature Property Owner Print Name
SWORN TO AND SUBSCRIBED before me this day of
Affiant is personally known to me, _produced as identification.
(,!j �t !ev1I2v
Y
Notary
Revised on 5/22120091 Revised on 6/12109 i
V'rvienneYao
Comm.:HH222410
Expires: Jan. 31, 2026
Notary Public • State O Florida
23 (PAC
�fA/CLU9eS LOCATr'c✓vOF O)VpJ 4.'�0
i2"'rFFr�5'�rz�/r'rr
fj iEAT4 !-9 A''r lP N
N; r-h9i S N-vRry
L/ 7•
R
1"o RT 11✓ '9) ��A$
15,
L'
17'
FIM FW,
21635gC
�?w
Miami
State
p A -Z 3 fl
24,k1
DxhFt � I
Pule
►a�
VIJ G
b-0-lys0
,es Village
Building Department
pt.
Date
ept.
Date
n compliance with all Federal,
County rules and regulations
v. �1z Q�'A L
r
swx =t
LU
ELEG-l-KICAL REVIEW
c I
APPR°VE DATE WORES VILLAGE
r PUBLIC WORKS REVIE
VEf�! �--0TE
mwllppqp�
nfl-�
a--
Overhead to Underground Conversion Sketch Form
PPL.
MMING TODAY. FMPOWFRING TfSIdMOW."
Customer Name: 06AW'qd?j) ".-r#v a/
Service Address: 5- 3 A/ e / 0 5✓'�Jf
Example
#X
(6(
#2
#6
5-3 Ne io✓ St,
Hl-' �O% 5'i�, ." CS
�Z
3�
Instructions:
Daytime Contact '
Phone: g6� SIa - 3 93 6'
1. Building address
City: , �tMi ,�a�� Zip:
2. Pole location
3. Indicate existing meter location on your home
4. Existing overhead wire to property
(Indicate with solid line)
5. Cable route for new underground conduit
6. Street name
7. Indicate how many underground risers
are on pole: 0 (see FAQ #10 for detail)
Street name (ex. First St.)
Instructions:
1. Building address
33/ 3r
2. Pole location
3. Indicate existing meter location on your home
4. Existing overhead wire to property
(Indicate with solid line)
5. Cable route for new underground conduit
(Indicate with dashed line, show cable route footage)
6. Street name
7. Indicate how many underground risers
c f. are on pole: 0 (See FAQ #10 for detail)
rcac
eji9Ck !44L Cy A/v ICT'/4 OF 140$-tAs7`re -
Rev. 11 /07
�� ,� �,�o /''lam d •ci
/v 5-S -T
I:
•>6
FL
I` P�
BOUNDARY SURVEY
n
&I
LEGAL DESCRIPTION
LOT 1 BLOCK zo z
SUSDIVISION, pV►J►.�t")C�rS F-t�/.Mi St�!�2+rS E,c"�t.3si Jr� tiJ�z_
ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT BOOK-:,' A T PAGE g
OF THE PUBLIC RECORCS OF �A '�� COUNTY, FLORIDA.
(J o t- g i
a *-L
1
IA
Q.,e. \oS i'- ST
LOCATION SKETCH
�c; i,�.G.( 10•
PROPERTY OF:
FLORIDA LAND SURVEYORS, INC.
LAND SURVEYORS LANE) PLANNERS
P.O. BOX 440782 MIAMI FL. 33144
WE HERISY CIRTIrn TRst an stbCted BOUNDAAY SURVEY Of ttw proomw In ma seta canes to me be= at
Our knc�sdge and Herlef n twonny uuv" anew our dhectiom am t w dire tr nd scow ground srwoscnm�is ur,ess
clroww. and'. d» Rummum taoutKst sacs- so IaM by me FLOA[OA BOARD OF Wt0 SUAVEYCM Pursuant to Sm=cn
4r207T Fta Statutes and G1mtw 27 t+t td of Ftoreds AdrrteninrtiNe Coae Hasmessda+ O! tito tmaact a! tt4 .nd nave tc Sa tau to
daaawu rewrrcod 4m rum= H sM, eftec 1 em prom. Loco-4-on am idmc4cmwt of r "b" 0n ar4tor ACtarart to re
Prop" vn was not maw=om Ownw%NO D sublda t0 00rnwn of title.
/O0/T33 xxuLow Wxvvp go. OATH SCALE DRAWN BY .,'• ..ro.
STAti Of FLO1t0A r
Kn
C:
Z
Q
<
W
Benchmark
Electric
I�RMOTNN
JUN 13 2023
rer„,� �v EL- 06-a3-/449
address
Job address
date
1391 NE 161ST
Miami, FL,33162
53 NE 105 st
Miami shores
06/11/23
E-
1Y
conduit
with
i Replace 200A
3#1cu
Meter can
existing
I
. Grd. Bridge
i
Service by FPL
H� lavlLw
APPFOVE t
I
iTv
COPY
Existing 150A
Main Disconnect
1 Y, Conduit
Feeds Inside panel
With 3# iCu
existing
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 06/21/2023
Location Address Parcel Number
53 NE 105TH ST, Miami Shores, FL 33138 1121360060130
Contacts
Permit NO.: PW-06-23-1450
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 12/21/2023
Bernard F Mathon
Owner
BENCHMARK ELECTRIC LLC Contractor
53 NE 105 ST, Miami Shores, FL 33138
MARC AURELE LORTHE
Home: 7865123935
bfmathl@gmail.com
1391 NE 161 ST, MIAMI, FL 33162
Business: 7867525007
Description: UNDERGROUND ELECTRIC SERVICE Valuation: $ 500.00 Ins ection Re uests:
Total Sq Feet: 0.00
Fees
Amount
Education Surcharge
$0.30
Public Works Permit Fee
$100.00
Scanning Fee
$9.00
Technology Fee
$50.00
Total:
$119.30
Payments
Date Paid Amt Paid
Total Fees
$119.30
Credit Card
06/21/2023 $119.30
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 construction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
7jE22rfnt� h/q-T.�/,�nl
Authorized Signature: Owner
Contractor / Agent
June 21, 2023 Page 2 of 2
RECEIVED
Miami Shores Village JUN 0 2 2023
Public Works Department
(305)795-2210 BY:
Public works forms are available from the building department, 10050 NE 2Id Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Name of Applicant (if utility see below): /v C g Ar'q R ±i t7,q w4 r) 4/
Owner off the following described property:
Legal Description: Lot / Blocky_ ri k✓ y,'l7r7;syaa�c�icrc�sSr'a�
—� a Subdivision PLfh
Folio#; I/-LI3G-O0(-Cf"O of a
Address: 5 3 A/&= /o 5 ` �lYrt2� W/; ter/; 5'/-/0e Fl- , 3 3 r 3 8
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone: Email:
State Certification or Registration #:
CONTRACTOR NAME
State:
Qualifier/Authorized Agent: y `
Address:
City: mlr2m J,State:
Telephone: • % _ Email: ftarc,
State Certification or Registration #&C13%; 2bZL r'Pr
ZIP:
Certificate of Competency #
ZIP:
Competency
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: Ti CC'v' J ive: iF« 1 i'� �«:
�. � ' Jr9 j'V'c:. /IL iJN(r fr'z P G-♦V?-rgy)
r.��.—E UN T!•f<r PIC Oi':�-C: Y ANA 2'•
Type of Work: ❑ Paving ❑ Utility
❑ Landscape ❑ Antenna
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State:
Email:
❑ Sidewalk [I Electric ❑ Irrigation
["Other: Tz c;/C.,f/ To i'WS r-rl-41 Prto✓l�a9
P vc.
ZIP:
Value of Work for this Permit: $_5 uJ Square/Lineal Footage of Work: (, 4 f �,,q a&- 1
h**k* Fees ***** ZV✓ / J
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 4
Bonding Company's Name (if applicable):
Bonding Company's Address:
City:
State:
ZIP:
Application is hereby made to obtain a public works permit to do the work in the right of way 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, regulation construction in
this jurisdiction. I understand that separate permits must be secured for
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with applicable laws regulating construction and specifically construction in the
right-of-way.
"WARNING TO APPLICANT: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. 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 public works permit with an estimated value
exceeding $2,500, 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 the
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 public works permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature
Applicant or Authorized Agent
The foregoing instru t was a knowledg�Sojlefore
hi day of 20L/ • by
who
is pers-�onally known to has produced
as
identification.
NOTARY PUBLIS'
.;,,,:,,, LENI
sl' 950477
,
:.:
EXPIRES: March 6, 2
Pr t. ......o.. Thru NotaryPublic Undeiwdlers
SE .
Signatur
1--,' Company/Utility Agent
The foregoin instrument was acknowledged before
me this;2 day of . 20 ,;3 • by
Rn a f e,- Lr532—T1, Q who
is personally known me or who has produced
v-t J�.f co t --Q— as
identification
, 7T�1�
n.
��,i>•E�
i •
SEAL
i�x *
SEDORNY FREZIN
�?
Notary Public - State of Florida
y
Commission F HH 233787
'a n
-Bonded
My Comm. Expires Mar 21, 2026
through National Notary Assn.
APPROVED By: \ Public Works Director, or Designee
2017-04-15
Ron DeSantis, Governor
STATE OF FLORIDA
Melanie S. Griffin, Secretary
d b
a
pr
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
ELECTRICAL CONTRACTORS' LICENSING BOARD
THE ELECTRICAL CONTRACTOR HEREIN IS CERTIFIED UNDER THE
PROVISIONS OF CHAPTER 489, FLORIDA STATUTES
LORTHE, MARC AURELE
BENCHMARK ELECTRIC LLC
1391 NE 161ST STREET
MIAMI FL 33162
LICENSE NUMBER: EC13007626
EXPIRATION DATE: AUGUST 31, 2024
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.
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2022 THROUGH SEPTEMBER 30, 2023
DBA:
Business Name: BENCHMARK ELECTRIC LLC
Owner Name: MARC AURELE LORTHE
Business Location: 13 91 NE 161 ST
MIAMI DADE COUNTY
Business Phone:
Rooms Seats
For
Number of Machines:
Tax Amount Transfer Fee NSF Fee
27.00 0.00 0.00
Receipt #:181-278704Q
Business Type: ELECTRICAL/ALARMS/CONTRACTOR
(ELECTRICAL CONTRACTOR)
Business Opened: o 8/ o 9/ 2 016
State/County/CertlReg:EC 130 07 62 6
Exemption Code:
Employees Machines Professionals
1
anding Business Only
Vending Type:
Penalty Prior Years Collection Cost Total Paid
0.00 0.00 1 0.00 27.00
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non -regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location. This receipt does not indicate that the business is legal or that
it is In compliance with State or local laws and regulations.
Mailing Address:
BENCHMARK ELECTRIC LLC
1391 NE 161 ST
MIAMI, FL 33162
2022 .2023
Receipt #WNW-21-00249160
Paid 08/24/2022 27.00
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1, 2022 THROUGH SEPTEMIBER 3% 2023
DBA: Receipt #: 181- 2 7 8 7 0 4
Business Name: BENCHMARK ELECTRIC LLC Business Type. L/•ELECTRICAALARMS/CONTRACTOR
(ELECTRICAL CONTRACTOR)
Owner Name: MARC AURELE LORTHE Business Opened: 08 / 0 9 /2016
Business Location: 1391 NE 161 ST State/County/Cert/Reg: EC 13 0 0 7 6 2 6
Business Phone: MIAMI DADE COUNTY Exemption Code:
Rooms Seats Employees Machines Professionals
1
Signature IFor Vending Business Only
Number of Machines: Vendin T a:
Tax Amount Transfer Fee NSF Fee Penalty Prior Years I Collection Cost Total Paid
27.00 0.001 0.00 0.00 0.00 0.00 27.
Receipt #WWW-21-00249160
Paid 08/24/2022 27.00
A �® CERTIFICATE OF LIABILITY INSURANCE
DATE/(MMI OIY Yn
23
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
Acentria Insurance- Coral Springs
3775 NW 124th Avenue
Coral Springs FL 33065
CONTACT
NAME: Certificate Department
_
PHONE FAX
, 954-731-5566 ac No: 954-731-8438
ADDRESS: Wfr.Certificates acentria.com
INSURERS AFFORDING COVERAGE
NAIL#
INSURER A: American Builders Insurance Company
11240
_
INSURED BENCH-1
INSURER B:
Benchmark Electric LLC
1391 NE 161 st Street
INSURERC:
INSURERD:
Miami FL 33162
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER:349100355 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.
LTp
TYPE OF INSURANCE
AIN DDL'SU
D
POLICYNUMBER
MP�pYEFF
POLICY
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIM MADE [k] OCCUR
GLP 030568502
R/6/2022
8/6/2023
EACH OCCURRENCE
$1,000,000
PREMISES Ea ocoumencal
$300.000
MED EXP (Any one person)
$10,000
PERSONAL &ADV INJURY
$1.000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X POLICY ❑ JET LOC
OTHER:
GENERAL AGGREGATE
$2,000,000
PRODUCTS -COMP/OPAGG
$2,000.000
$
AUTOMOBILELIABILITV
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
COMBINED SINGLE LIMIT
Ee accident
$
BODILY INJURY (Per parson)
$
er accident)
BODILY INJURY (Per
$
PROPERTY DAMAGE
Per accident
$
UMBRELLALIAB
EXCESS LIAR
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DELI I I RETENTION$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
/EX
ANYPROPRIETOR/PARTNERECUTIVE
OFFICER/MEMBEREXCLUDEDT
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
NIA
I PER OTH-
STATUTE ER
E.L. EACH ACCIDENT
$
EL. DISEASE -EA EMPLOYEE
$
E.L. DISEASE -POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached Hmom space Is required)
License# EC13007626
Miami Shores Village Bldg Dept.
10050 NE 2nd Ave.
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.
AUTHD REPRESENTATIVE
CORPORATION. All rinhfe racor .d
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
• ado oato�
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: 8/23/2022
PERSON: MARC A LORTHE
FEIN: 812588518
BUSINESS NAME AND ADDRESS:
BENCHMARK ELECTRIC LLC
1391 NE 161ST
MIAMI, FL 33162
SCOPE OF BUSINESS OR TRADE:
Electrical Wiring Within
Buildings and Drivers
EXPIRATION DATE: 8/22/2024
EMAIL: MARCLORTHE@YAHOO.COM
IMPORTANT: Pursuant to subsection 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a cedificate of election under
this section may not recover benefits or compensation under this chapter. Pursuant to subsection 440.05(12), F.S., Certificates of election to be exempt issued
under subsection (3) shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or
trade listed on the notice of election to be exempt. Pursuant to subsection 440.05(13), F.S., notices of election to be exempt and certificates of election to be
exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate
no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01569565 QUESTIONS? (850) 413-1609