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PL-10-1206Inspection Number: INSP- 147566 Permit Number: PL -7 -10 -1206 Scheduled Inspection Date: July 09, 2010 Inspector: Hernandez, Rafael Owner: SCOTTI, ALYSON Job Address: 803 NE 91 Terrace Miami Shores, FL 33138- Project: <NONE> Contractor: SOUTHERN SEPTIC CONTRACTORS INC Building Department Comments DRAINFIELD REPLACEMENT Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments PLEASE PICK UP GREEN TAG FROM JOB SITE. THANKS! July 08, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number (305)751 -0714 Parcel Number 1132060050230 Phone: (305)598 -8266 Page 6 of 11 Project Address Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Address Parcel Number Phone Expiration: 01/03/2011 Applicant 803 NE 91 Terrace Miami Shores, FL 33138- 1132060050230 Block: Lot: ALYSON SCOTTI 1 Cell ALYSON SCOTTI 803 NE 91 Terrace MIAMI SHORES FL 33138 -3217 (305)751 -0714 Contractor(s) Phone Cell Phone SOUTHERN SEPTIC CONTRACTORS I (305)598 -8266 Type of Work: DRAINFIELD REPLACEMENT Type of Piping: Additional Info: PLUMBING Bond Retum : Classification: Residential Scanning: 1 Fees Due CCF Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $0.40 $5.00 $150.00 $3.00 $1.60 $161.20 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Pay Date Pay Type Invoice # PL -7 -10 -38319 07/01/2010 Cash 07/07/2010 Cash Amt Paid Amt Due $ 50.00 $ 111.20 $ 111.20 $ 0.00 Available Inspections: Inspection Type: HRS Approval Abandonment Final Rough Landscaping 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. July 07, 2010 Date July 07, 2010 1 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Address ®O 3 1\ E ?,/ City /V 91a vii a `51.1.Vre - 'Tenant/Lessee Name 1 t Email ( ' State Contractor's Address 7, o Qlo0 b Ob Architect/Engineer's lame (if applicable) Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Owner's Name (Fee Simple Titleholder) A SO*, Sc a`# Phone # 70 — off` �' 302 Zip Job Address (where the work is being done) YO 3 ME g / 7 C' cam. City Miami Shores Village County Miami -Dade Zip 27')137 FOLIO / PARCEL # Is Building Historically Designated YES NO X Contractor's Company Name So".3 L c q,t of. Phone# S S AL o City \ p.�. \ State 4 L+ Zip - 131a). Qualifier Name gta.1 a RI) D (2-1 Cwt) L Phone # State Certificate or Registration No. Certificate of Competency No. 1 Contact Phone 30$ S 943- �9&L E -mail �( ONDE /A Y" O� ' fi�J � � pc7�11. V� e 1 Permit No. ( `` (2 Master Permit No. 32/3 Phone # Phone # l{a Flood Zone X Value of Work For this Permit $ Z .'O ° Square / Linear Footage Of Work: 300 Type of Work: ❑A ddition ['Alteration ❑Neew ] Repair/Replace ❑ Demolition Describe Work: coN c% \ GAN) ******* * * * * * *** * * * * * * * * * * * * * * * * ** ** ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Submittal Fee $ - Permit Fee $ .5...v CCF $ ( • 2-° CO /CC $ Notary $ 5.c Training/Education Fee $ C.). i 'l 0 Technology Fee $ t •l90 Scanning $ 5 .0 Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ l 11 • See Reverse side - Bonding Company's Name (if applicable) Bonding Company's Address City Mortgage Lender's Name (if applicable) Mortgage Lender's Address kS1P 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 Ie absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. APPROVED BY Owner or Agent The fo egoing instrument was acknowledged before me this Z.) day o , 20/0 , by who 's personally known to me or who has produced , produced mt I VL L -f _ C- L.'mr1 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: 10\1 • • �� c oo S� \;' #' �`� ► `� Plans Examiner Zoning My Commission Expir: • ••G t 0. S• 4 ef • *" c • •* (Revised 07 /10 /07XRevised 06/10/2009) State Engineer Signature Zip Contract° The foregoing instrument was a .. before me this day of U ( , 20 (0 bALLN6C•caZ 2c fco' who is personally known to me or who has produced as identification and who did take an oath: NOTARY PUBLIC: Sign: Print: My Commission Expires: Clerk checked I AWL OF I E N 1 ANSI POLICY NUMBER POLICY EFFECTIVE POLICY DA POLICY EXPIRATION DATE (MM/DD/Yf LIMITS A GENERAL LIABILITY ARTE026713 11/07/09 11/07/10 EACH OCCURRENCE S 500,000 X COMmERCIAL GENERAL LIABILITY P E (Ea oocurence) $ 50,000 ■� CLAIMSMADE X OCCUR MEDEOCP (Any one person) S 1,000 S 500,000 • PERSONAL &ADVINJURY _ GENERAL AGGREGATE $ 1 0 0, 000 GENL AGGREGATE LIMIT APPLIES PER POLICY n sa_ n LOC PRODUCTS - COMP/OP AOG 5 500,000 AUTOMOBILE LIABILITY ANYAUTo ALL OWNED AUTOS SCHEDULED AUTOS HIREDAUTOS NON -OWNEDAUTOS (E as ci SINGLE LIMB $ III ■ BODILY INJURY (Perperaon) S BODILY INJURY (Piracciclest 5 ■ ■ PROPERTY DAMAGE (Pe/accident) 5 GARAGE LIABILITY ANYAUTO AUTO ONLY- EA ACCIDENT S OTHER THAN EA ACC S AUTOONLY: AGO S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S OCCUR _ CLAIMSMADE AGGREGATE $ DEDUCTIBLE RETENTION S 5 5 WORKERSCOMPENSATIONAND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNERAMEC TINE OFFICERACKIEN D(CUJDED M wee. deacrtbeunder SPECIAL PROVISIONS below I TORYUAdIUTS I 1 ER EL EACH ACCIDENT 5 E.L. DISEASE • EA EMPLOYEE 5 EL DISEASE - POLICY LIMIT 5 OTHER ` DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS /� I Jul, 7. 2010— 3:57PM ACORDT, CERTIFICATE OF LIABILITY 12040 SW 118 ST MIAMI, FL 33186 PRODUCER Jimenez & Co. 8000 Coral Way Miami, FL. 33155 305 264 9900 INSURED SOUTHERN SEPTIC CONTRACTORS, INC. INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER k. LLOYDS OF LONDON INSURER B: DATE(MMIDD/YYY 1 Y) 7/7/2010 NAIC/ INSURER C: INSURER D: INSURER E COVERAGES No. 6269 —P. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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, EJCCLUSONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CERTIFICAT HOLDER 4CORD 28(2001/08) VILLAGE OF MIAMI SHORES 10050 NE 2 AVE MIAMI SHORES, FL 33138 FAX: 305 -756 -8972 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIS POLICI DATE THEREOF, THE ISSUING INSURE WILL EN NOTICE TO THE CERTIFICATE HOLDS NAMED T IMPOSE NO OBLIGATION OR UABIL OF ANY REPRESENTATIVES. AUTHORBED REPRESENTATIVE B C • CELLED BEF 'RE THE EXPIRATION 70 �� DAYS WRITTEN BUT AIL E TO DO SO SHALL N TH - INSU - - ITS AGENTS OR ORPORATION 1988 WILL CALL FOR TRI COUNTY CIO TITLE GUARANTY OF S. FLORIDA, INC. THIS INSTRUMENT PREPARED BY AND RETURN TO: Title Guaranty of South Florida Inc. 4430 Weston Road Davie , FL. 33331 Property Appraisers Parcel Identification (Folio) Numbers: 1132060050230 111111111111111111111111111111111111111111111 CFN 2010R04-02144 OR lk 27319 Pss 4372 — 43731 (298s) RECORDED 06115/2010 09:47:54 DEED DOC TAX 1,470.00 . HARVEY RUVIN, CLERK OF COURT MIAMI —DADE COUNTY, FLORIDA Space Above This Line For Recording Data THIS WARRANTY DEED, made the 21st day of May, 2010 by FERNANDO E. ROJAS and JEANETTE MARTINEZ, husband and wife , whose post office address is 1111 SW 1ST AVENUE, PH 125, MIAMI, FL 33130 herein called the grantors, to ALYSON SCOTTI, a single woman , whose post office address is 803 NE 91 TERRACE, MIAMI SHORES, FL 33138, hereinafter called the Grantee: (Wherever used herein the terms "grantor" and "grantee" include all the parties to this instrument and the heirs, legal representatives and assigns of individuals, and the successors and assigns of corporations) W I T N E S S E T H: That the grantors, for and in consideration of the sum of TEN AND 00/100'S ($10.00) Dollars and other valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens, remises, rel eases, conveys and confirms unto the grantee all that certain land situate in MIAMI-DADE County, State of Florida, viz.: Lot 15 and the West 1/2 of Lot 16, Block 2, Golden Gate Park Addition, according to the plat thereof as recorded in Plat Book 6, Page(s) 130, Public Records of Miami -Dade County, Florida. Subject to easements, restrictions and reservations of record and taxes for the year 2009 and thereafter. TOGETHER, with all the tenements, hereditaments and appurtenances thereto belonging or in anywise appertaining. TO HAVE AND TO HOLD, the same in fee simple forever. AND, the grantors hereby covenant with said grantee that the grantors are lawfully seized of said land in fee simple; that the grantors have good right and lawful authority to sell and convey said land, and hereby warrant the title to said land and will defend the same against the lawful claims of all persons whomsoever; and that said land is free of all encumbrances, except taxes accruing subsequent to December 31, 2008. IN WITNESS WHEREOF, the said grantors have signed and sealed these presents the day and year first above written. 2° page of 4 File No: G 10 -332 Book27319/Page4372 CFN #20100402144 Page 1 of 2 Signed, sealed : i delivered in the STATE OF FLORIDA COUNTY OF MIAMI -DADE The foregoing instrument was acknowledged before and JEANETTE MARTINEZ who are �.L,. as identification. SEAL My Commission Expires: A s /7ieYj't File No: TG10 -332 NOTARY PUBLIC•STATE OF FLORIDA ii Gustavo Piheiro Commission #DD935580 Expires: OCT. 25, 2013 BONDED TB= ATLANTICSONDING INC.. RNANDO L RC #e TTE MARTINEZ OR SK 27319 PG 4373 LAST PAGE me this 21st day of May, 2010 by FERNANDO E. ROJAS personally known to me or ha - produced .f7/1/ A-7/20 Printed Notary Name Book27319/Page4373 CFN #20100402144 Page 2 of 2 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: PROPERTY ADDRESS: 803 NE 91 Ter Miami, FL 33138 LOT: 15 PROPERTY ID # : 11 - 3206 - 005 - 0230 SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ 1 D [ 200 ] SQUARE FEET SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [X] BED [ ] N F LOCATION OF BENCHMARK: F.F.E.: 10.30' NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 22.00 ] [I INCHES V FT ] ABOVE /J BELOW bBENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 58.00 ] [I INCHES {' FT ] [ ABOVE A BELOW BENCHMARK /REFERENCE POINT D FILL REQUIRED: 0 T H E R STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT Fernando Rojas [ 0.00 ] INCHES 1— Install 900 gal. category-3 septic tank equipped with an approved filter. 2 -The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with sec. 64E- 6.013(3)(f). 3- Install 200 sf of drainfield in bed configuration. 4- Install 12" of slightly limited soil under the bottom of drainfield. 5- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. 6 -Invert elevation of drainfield to be no Tess than 5.90' NGVD. 7. Bottom of drainfield elevation to be no less than 5.40' NGVD. THIS PERMIT IS NOT FOR ADDITION(s) SPECIFICATIONS BY: PEDRO N OSPINA APPROVED BY: BLOCK: 2 SUBDIVISION: Pedro N Ospina DATE ISSUED: 06/15/2010 EXCAVATION REQUIRED: [ 48.00] INCHES TITLE: TITLE: DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E- 6.003, FAC PERMIT #: 13 -SC- 1147969 APPLICATION #: AP968869 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #: PR813354 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] Dade EXPIRATION DATE: 09/13/2010 Page 1 of 3 '; CHD z4,1 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statues. Such proceedings are governed by Rule 28 -106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty -one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN # A02, Tallahassee, Florida 32399 -1703. The Agency Clerk's facsimile number is 850 - 410 -1448. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a'fnal order' Should this order become a final order, a party who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law, with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. DATE: 06128/2010 TIME: 12: 20: 29 MIAMI - DADE COUNTY, FLORIDA LOCAL BUSINESS. TAX LBT YEAR: 2011 OCLM9107 PUBLIC ACCOUNT INQUIRY ACCOUNT : 604570 -2 COMM -DATE: 05 /2007 ENTRY -DATE: 05/30/2007 B U - S I NESS : DELETE -ST: ENTRY -TYPE: W NAME: SOUTHERN SEPTIC CONTRACTORS INC ADDR: 30 SW 57 CT SUITE: ZIP: 33144 MUN: 01 C O R P / OWNER ( M A I L I N G ) : NAME: SOUTHERN SEPTIC CONTRACTORS INC C /O: ROBERTO RODRIGUEZ PRES ADDIS: PO SOX CITY: MIAMI STATE: FL ZIP: _ 3 O T H E R I N F O R M A T I O N : PP- -FOLIO: 00 000000 RE-FOLIO: 01 4001 001 0390 PG i RECEIPT DESCRIPTION AMOUNT-DUE D/R PD LEGAL X 630665-8 SPECIALTY PLUMBING CONTRACTOR 45.00 U FINANCE DII;:PARiMENT TAX COLLECTION DIVISION 140 W. FIAGL ER STREET MIAMI, FLORIDA 33130 F 1 MENU CLEAR''REV SCR F4 =MORE RCT ENTER = RECEIPT IIMPORTANT:nmemonumornistatiooestiormansawcorniumwornamsrskosimmuunanDs 10 REAL ESTATE WARNS ME O11R OMAR =MUM Registered Septic Tank Contractor ROBERTO RODRIGUEZ 12040 SW 118 ST. MIAMI FL 33188 - SOUTHERN SEPTIC CONTRACTORS, INC. Business Authorization: SA0071412 SR0021421 Registration Expiration Date: September 30, 2010 ICONTRAC BUILDING CODE COMPLIANCE OFFICE BNZM2101 06/29/2010 INQ CONTRACTOR BBY 15:38:39 CCN NO. SEP071412 ISSUE DATE 05/30/2007 TEMPORARY LIC (Y /N) N EXAM OR. BOARD APPROVAL DATE COMPANY NAME SOUTHERN SEPTIC CONTRACTORS INC D /B /A NAME INSURANCE EXPIRATION DATE 11/07/2010 STATUS A LAST RENEWAL 06/28/2010 CONTRACTOR TYPE S STATE BUSINESS TYPE C - CORPORATION ADDRESS 12040 S0 STREET PONE: 305 598 -8266 FAX: 305 598 -8266 CITY NT= S'Z'L `- C LASS EXP DATE 03770/2010 ZIP 33186 PHONE 786 - 736 -0539 WORK COMP DATE 06/08/2011 EMAIL: WORK COMP EXEMPT (Y /N) N - -- Q U A L I F I E R - -- SKILL CAT ST REG NUMBER EXP DATE TRDS 200301292 CLASS PLUM LEVEL S NAME RODRIGUEZ ROBERTO CLASS STATUS A EXP DATE 09/30/2010 SSN 000004106 PF3 = INQ TRADSMAN PF2 = INQ ALL QUAL PF7 = NEXT QUALIF NEXT SCREEN NEXT KEY NO MORE QUALIFIERS, 110 MORE TRADE CLASS, 0006 PFS - Z - AUDIT INQ PF8 = NEXT TRDCLS PF9 = NEXT CAT NO MORE CATEGORIES ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: PERSON: FEIN: 020803086 BUSINESS NAME AND ADDRESS: SOUTHERN SEPTIC CONTRACTORS INC 12040 SW 118TH ST MIAMI FL 33186 SCOPES OF BUSINESS OR TRADE: 1— REGISTERED SPECIALTY CONTRACTO 3— INSTALLATION SERVICES IMPORTANT Pursuant to Chapter 440. 05110, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05112►, F.S., Certificates of election to be exempt... apply only within the scope,o( the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certificates of election to be exempt shell be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named an 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. QUESTIONS? (850) 413 -16 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 2— MAINTENANCE 4— SEPTIC TANKS 06/08/2009 EXPIRATION DATE: 06/08/2011 RODRIGUEZ ROBERTO 06 -08 -2009 * * Employer ID: 001859100 STATE OF FLORIDA DIVISION OF WORKERS COMPENSATION BUREAU OF COMPLIANCE EMPLOYER EXEMPTIONS REPORT Name: SOUTHERN SEPTIC CONTRACTORS INC Streetl: 12040 SW 118TH ST Street2: City: MIAMI First Name MI Last Name SF Title Effective Date Expires /Revocation Date Form Type PRESIDENT 06/08/2009 ROBERTO RODRIGUEZ ROBERTO RODRIGUEZ PRESIDENT 06/04/2007 06/08/2011 06/03/2009 CONSTRUCTION CONSTRUCTION atintati JUN 2 9 0 of Mi ,,, FEIN/SSN: 020803086 State: FL Zip: 33186-