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SGN-09-1649 r Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 126669 Permit Number: SGN -10 -09 -1649 Scheduled Inspection Date: April 27, 2010 Permit Type: Sign Inspector: Bruhn, Norman Inspection Type: Final Owner: CHURCH, Work Classification: New Job Address: 602 NE 96 Street Miami Shores, FL Phone Number (305)754 -9541 Parcel Number 1132060141410 Project: <NONE> Contractor: CD SIGNS CORP Phone: (305)889 -0440 Building Department Comments Install 2 signs on education building on north side and one on east side readint "msoc Elemntary school & parents morning out' Inspector Comments Passed Failed Correction ❑ Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. April 26, 2010 For Inspections please call: (305)762 -4949 Page 1 of 29 �a .� 3 � �3'y a yr' a. r� " .� f ' - 3 �•� r�� ,,: � w �s _ - � z ��� rat '_ r a: ra% Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 �� r u x fl � r Y�2 ary A➢ h , Phone: (305)795 -2204 i A� 9 ' RE Expiration: 0 9/21 Project Address Parcel Number Applicant 602 96 Street 1132060141410 I Miami Shores, FL Block: Lot: MIAMI SHORES PRESBYTERIAN Owner Information Address Phone cell MIAMI SHORES PRESBYTERIAN CHURC 602 NE 96 ST (305)7549541 MIAMI FL 33138 -2742 Contractor(s) Phone Cell Phone Valuation: $ 2, 300.00 CD SIGNS CORP (305)889 -0440 Total Sq Feet: 23.5 Type of Sign: Wall Sign For Inspections please call: Electrical Sign: No (305)762 -4949 Height: Available Inspections: Width: Inspection Type: Color: Elevation: Final Plans Submitted: Additional Info: Classification: Commercial Fees Due Amount Invoice # Total Amt Paid Amt Due CCF $ 1.80 SGN-10 -09-36103 $ 107.80 $ 50.00 Education Surcharge $0.60 •---- - - - - -• Permit Fee $100.00 SGN- 10-09 -36103 $ 107.80 $ 107.80 $ 0.00 Permit Technology Fee $0.00 Scanning Fee $3.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Technology Fee Total: $107.80 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: 1 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. November 24, 2009 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy November 24, 2009 1 Miami Shores Village C Building D ep artmet 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING ' Nerrnit No. S6N� PERMIT APPLICATION ®CT ®.f 2009 aster Permit No. FBC 20 Permit Type BUILDING ROO 3 0 - Liu Owner's .Name (Fee Simple Titleholder) Phone # 3 ® S Sy - IS f Owner's Address t- 0 AJ 6 9 t. S T-r4�e� City yyl , ,n-, i S h oy s State ! Zip 4Z Tenant/Lessee Name Phone # Email Job Address (where the work kis being done) _ ®2 Al e, ' 9( s�• ; City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # _ /t -3-2,oe. - oi4 i-I0d/A.S. See- 2- F$ !v-3 LOAt- [o.t - ne. 0I1<6! Is Building Historically Designated YES N0 Flood Zone V Contractor's Company Name , e A - 516 - Al- 3 <:�G A P Phone # 3P S: 9 " U' 1'--f q Contractor's Address 12 57 Af, W 74Y R 1 LJ /y �,�4 3 � _�L , ' -_ City i�#�! State �G 1p ___,_ Qualifier Name / is /'1/ ` �= e CG 4 4' y Phone # 30 f,_ — g P-- ® CL � State Certificate or Registration No. Certificate of Competenc No. , ®�' 7 C/O Contact Phone G�'" '� G "l �'J E -mail S n 0 Z-- . C C , Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ 2_, ZC0 Q 0 Square /Linear Footage Of Work: Z 3.5 /d am Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair/Replace ❑ Demolition Describe Work: i!✓�M6l l ..r ; J 4) u cgYrs --�' IP h ®� /i�aAM .$ ,, .aC If P A J 4;V r' JJ A45 ,��ff�lN /� J e e LC4&& thy a.i p4 P 4A&i�'-S N44VZ ®P�9' to Submittal Fee $ - Permit Fee $ Ana CCF $ �• CQXC .$ Notary $ Training/Edncation Fee $ Technology Fee $ cq "rte/ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ See Reverse side -� T, Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 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 anti insta),lations 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 ague 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�ob 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 Jj . (//t -� r ., a -✓ Sgnatur Owner or Agent Contractor ' ] The foregoing instrument was acknowledged before me this t-29 The ffl=8oing was acknowledged before me this r day of ,,A& , 200 �' by _ IV YJ L G Gr/ o,0 E/2- day of 19 20 - t , by - ros who is ersonall known to e r who has produced who is personally known to me or - who has produced As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: / 41e& L Sign. '� 4 Print . Print: Y Expires: 'BP sro �. o M Commission NOTARY PUBLIC -STATE OF FLORIDA p Sy 1Vi8ialter My Commission Expires: Commission .....,,..•�' Expires: JUNE 08, 2011 V ��� APPROVED BY . Plans Examiner \ f 2 Zoning Engineer Clerk checked (Revised 07 /10 /07XRevised 06/10/2009) �5 O R � y� Miami shores e Y ills 9 Building Department --- --.- -- 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Permit No: 09- 14fzr6 ��/ S,Z Job Name: 2009 Page 1 of 1 B lding Critique Sheet W Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. Norman Bruhn CBO 305 - 795 -2204 s MIAMI SHORES PRESBYTERIAN G.Krishna Rao, P.E. CHURCH S IG N 1809 SW 87th Terrace 4 . MIAMI, FL. Davie, Florida 33324 SHEET NO. I OF 3 (854) 802 -1267 DATE. j lk-ljoa S%ts Offlorlda P.E. No. 41516 W IND WAD:. wa ll I �sE St L WIPUD LDAV or 60+24 F• Lei Le-Hey &V - 24 X L 2 — ft, 24. Pr WIU 6S A WITH MIN I "2. OF 3 s. Use- MECAWind Version 2.0.2.8 per ASCE 7 -05 Developed by JWCA Enterprises, Inc. Copyright 2009 •mecaenterprises.com Date 11/7!2009 Project No. , Company Name Designed By Z a F .5 Address Description City Customer Name: State Proj Location : File Location: C: \Program Files\ CAWind \Default.vnd Detailed Wind Load Design(Method 2) per ASCE 7 -05 Basic Wired Speed(V) = 146.00 mph Structure Type Other Structural Category = 11 Exposure Category = C Natural Frequency = N/A Flexible Structure = No Importance Factor = 1.00 Kd Directional Factor = 0.85 Alpha 9.50 Zg = 900.00 ft At 0.11 Bt = 1.00 Am = 0.15 BM = 0.65 Cc = 0.20. 1 = 500.00 ft Epsilon 0.20 Zmin = 15.00 ft B - Horizontal Dim. = 5.75 ft Ht- Grade to Top of Sign= 10.75 ft W - Sign Depth = 0.10 ft S - Vertical Sign Dim. = 2.58 ft Bs- Ratio of B / S = 2.23 Sh- Ratio of S / Ht = 0.24 E - Solidity Ratio = 100.00,$ Gust Vactor Category I Rigid Structures - 8aaw p fa ed Method Gustl: For Rigid Structures (Nat. Freq. >l Hz) use 0.85 = 0.85 Gust Factor Category 11 Rigid Structures - Complete Analysis Zm: 0.6 *Ht = 15.00 ft lzm: Cc *(33 /Zm) ^0,167 0.23 Lzm: 1 *(Zm /33) ^Epsilon 427.06 ft Q. (1/(1 +0.63 *((B +Ht) /Lzm) ^0.63)) ^0.5 = 0.96 Gust2: 0. 925*(( 1+ 1.7 *lzm *3.4 *0) /(1 +1.7 *3.4 *1zm)) = 0.90 Gust Factor Svmn ary Not a Flexible Structure use the Lessor of Gustl or Gust2 = 0.85 Design i Pressure - Other Structures Elev Ka Kat qz W fires Cf ( 1.80) ft Pat psi - - 10 75 -- 0..85 - - 1.00 39.374 60.24 10.00 0.85 1.00 39.374 60,24_ , Note: N Pres Cf is Wind Pressure based on Cf(Force Coefficient; c Figure -20: Wind-Loads for Solid Signs a Freestanding Walls , CM e A c4se B rI 3OP-4 Pint Raw Cf - Force coefficient = 1.80 Rd - Reduction Far-tor (1-(1-E)"1.5) = 1.00 Kz 0.85 Kzt 1.00 Qz 39.374 psf Wind p_.-Gssvwe at Elevation 10.75 ft 60.243 pef Notes. 1) Signs with openings comprising < 30% of gross area are considered solid signs 2) Force Coefficients for so lid signs with openings shall be multiplied by Rd 3) Case C only applies when Ss >= 2 cast C S S Balm= Balance S S S TFN M Distance from Cf Its Kat. Qb Wind Pressure 6 Distance leading edge ft. Force Coeff. Pof Pef --------------------- 7 -- 7 ---------------------------------- ------------------ From 0 to 2.6 2.33 0.85 1.00 39.37 77.98 From 2.6 to �5.2 1.55 0.85 1.00 39.37 51.88 From 5.2 to 5.8 1.15 0.85 1.00 39.37 38.49 RdC - Reduction Factor for CMQ C (1-8 - S / Ht) 1.00 Note: When S 1 Ht > 0.8 then Cf must be multiplied by RdC. INDIVIDUAL CUT OUT ALUMINUM LETTERS NON ELECTRICAL SIGN LOCATION: WEST SIZE: 36 SQ. FEET 1/4" Aluminum cut out LOCATION: WEST individuals letters mounted on the wall COLOR:BRONZE MP 20 156 with studs double side tape and silicone painted Bronze MP20156 sea 4t 197 3/4" AREA SIGN 4 AMAI S PptsbTHPIfln ON( T PUS0001, CONCRETE 114" WALL si Ali Thread Stud secured 14'5 To Wall'. hm Epoxy Resin 7 PENETRATtON SlUds are Tapped trap Back Of Letters rn MINIMON 3 FOR EACH LETTER I I 47' i NON ELECTRICAL SIGN EXISTING MONUMENT SIGN LOCATION:SOUTH -WEST Sin existi monument SIZEZ; 3 SQ. FEET g g oes on ex g 1i4 "Aluminum cut out individuals letters mounted on the wall with studs double side tape and silicone painted Bronze MP20156 59 314" T m 1.� PRESBYTERIAN CHURCH I 114" wall Mc ARTHUR MEMORIAL P P ,,, 7 - An DT I " I-n i CHAPEL 67" „ 1 M EAR' RIAL � MIAMI SHORES PRESBYTERIA CHURCH 30" -- All Thread Stud Secured To Wag Thru Epoxy Resin 2' PENETRATION .. , SSbidss�a ds m Tapped Into Be ffl MM 3 FOR EACH T LETTER NEW SIGN INDIVIDUAL CUT OUT ALUMINUM LETTERS LOCATION: EAST NON ELECTRICAL SIGN SIZE: 24 SQ. FEET 1/4" Aluminum cut out LOCATION: EAST individuals letters mounted on the wall .; COLOR:BRONZE MP 20 156 with studs double side tape and silicone ;�.�. painted Bronze MP20156 a 147 112 m 0 E \\ / L f A 0 fl PT S Qn low AREA SIGN � Ld P fl P t n T.�01 0 r I n OUT CONCRETE - -- — -- — - -. —I V4" WALL All Thread Stud Secured I To Weil Thru Epoxy Resin 2' PENETRATION Studa are Tapped Into Back l -- - -� 8 , 8 " 1 MINIMUM 3 FOR EACH LETTER I i - , : EAST LOCATION -- - - 55 , ------ - - - - -- ----------- - - - - -- i -- ------ -_ - - -_ - - - -- INDIVIDUAL CUT OUT ALUMINUM LETTERS NON ELECTRICAL SIGN ` e 1411/2 in 1/4" Aluminum cut out I individuals letters mounted on the wall ' ~� z �` ; O with studs double side tape and silicone o Q o painted Bronze MP20156 , �, ,1 I LOCATION: NORTH � F_ 001 COLOR:BRONZE MP 20 156 °` "' 0) ' `` a I � o 0 ° 1 a r I I � I f { i U� { Q! CONCRETE L - 1/4 WALL 29 _ ! �, W ; ; _ -- - -- — MSPC fLfMfhTflRY SCtI00L ai d PflPfnTS MONIN OUT 31 N; ; - - - - -- - -- ---- - - - - -- ----- - - - - -- ----------------- w; ; f NN T 10' AREAS -_ -„ - - -- - - tQ44 UT'WTALMINUM 2 v PMWED LETTERS w! 1 0 I ! - - -- — -- - - -- 98 0. 1 1 101 All Thread Stud Secured 1 y 1 r - -_ - To Wall Thru Epoxy Resin i yj i — - -. - - -- - -— _ -- - - -- -- - -- - -- — 2" PENETRATION 41 f f f Studs are Tapped Into Back `5 Of Letters f0 C MINIMUN 3 FOR EACH LETTER - ; . i - 0 �� NORTH LOCATION INDIVIDUAL CUT OUT ALUMINUM LETTERS NON ELECTRICAL SIGN 1 1 1/4" Aluminum cut out • �� individuals letters mounted on the wall with studs double side tape and silicone 1 painted Bronze MP20156 ! _� �ZI 1 1 141 1/2 in ! i �i i Of 1 1 i 1 .1 WI I C, Jill °! Vj 0A I ao O� LASP( tLtAtnTfiPT S(flOOL 1 -1 co 1 11 I I AREA SIGN L—d PfiPtnTS A0Pn1n6 OUT � c U Q A U 1 - -- -- -- - -- - CONC - — - - -- -- �- v4° WALL UI 1 1 Z - W; 7 i � __— - -- 114 "THICK OUT OUTALUMINUM 1 1 1 -- __ _ PAINTED LETTERS I MSPC f1fAMIRPT 50001 3111 E j _ -- --- - - - -__ _. -- - - - -- - -Q PflptnTS MORn_ inll OUT - - - - - -- -- 01 1 1 i All Thread Stud Secured W 1 1 { 1 j I To Wall Thru Epoxy Resin o -- —.. 2t dENETRATIOd I t B - - -- - — -- - - -- — - 8 Of Letters aPPe n o Back _ 1 i O Q 1 I MINI) 3 FOR EACH -- - - -- -- -- - LE TTER 1 1 1 0 01 I BEAST LOCATION 55 o l ���. ��� //� CERTIFICATE OF LIAIKJTY INSURANCI: DATE (I1Ymmml MOUC Miami inw atnce Agency THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 3913 NW 7th Strew ONLY AND CONFERS NO RIWTS UPON THB CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Mhun1, FL=25 ALTF.R THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phony 14553 Fax (9QM841 -8442 INSURERS AFFORDING COVERAGE Nm #t INSURED C.D SIGNS CORP. INSURER A: CENTURY SURETY COMPANY 5125 NW 74AVENUI<, UNIT #1 INSURER W . MEDLEY, FL 3;3186 I s ( 889 0440 INSURER E: COVERAGES i THE POLICIES OF INSURANCE UsTED HAVE OWN ISSUED TO TtZ INSURED NAWD ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIR j&mT, TERM OR camiTION OF ANY =TRACTOR OTHER D= ENT WITH RE$P @CT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, T14E INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM, EXCLUSIONS AND CONDmom of SUCH Pt}LIdE$. AGGREGATE LIMITS EMOWN.PAY HAVE BEEN REDUCED BY PAID CLABtl9. !INS AWL POLOYEFFWTIYE 1 TYPE OF INSURANCE POI JCY NUMOER LIMITS GMRAL DUTY EACH ONCE 1,GQ ' 000 1/J COMWERCIAL, GENERAL LIRBtLff CCPS2 8 I 0901=14 PREMISES 000urre� 1 DD CLAM WDE ® OCCUR MED (Any °^ —) EXCLUDED :A ] !' PERSONAL a ADV INJURY 1.0W.00D D i *GENiERALAGGREGATE 1,000,000 GEN'L AGC•it' WE LMT APPLIES PER. PRODUCTS - CMFIOP AGOG ! [} POLICY ❑ PROJECT C! LOG AUTONK ftllt LiARLITY OOMNED SINGLE LIMIT ANY AUTO j (Ea gaaldSrif) ' ❑ ALL OWNED AUTO I I I OWLY INJURY J D BC,°HEDULED AUT06 ! {Per Demon) t ! D HIRED AUTOS ` BODILY INJURY D NON OWNED AUTOS (Peraavidem I ❑ t Fltol'ERTY DAAAAt3E 1 i (p er amwerd) GAIRAGELIMITY i i AUTO ONLY- EAACCIDETIT ' ' D ANY AUTO OTHER TAM EA rl I AUTO ONLY. O IMCE88'I UMBREI.LALIAtltILITY EACH OCCURRENCE AC OOCTIR ] CLAM MADE I AGGIMOATE Ljj DEDUCTIBLE j I (❑ RETENTION 8 II T AND H- ! EAIPLOY' LIABILITY ANY PROPRIETOR t PARTNER t MQlJTNC I ` LL, EACH AMMENT ; OFFICER I MEMBER EXCLUDED? I E.L. DISEASE EA EMPLOYEE (Mandatory IN NH) I a wss d�� e under E.L. DISEASE - POLICY LUT ! SPECIAL PROVISI;; M below ggamPTICNU OF OPBRATUM I LOCATIOMS J VEHIOLEB t BXOLU$M& AMM BY ENDORSEMENT I s pric At, PROVISIONS iSIGN ERECTION REPAIR AND INSTALLATION -SIGN MTG ELECTRICAL � ) 'DEDUCTIBLE 1,000 BIIPD PER CLAIM CERTIFICATE HOLDER CANCELLATION l SNOUI,.D ANY OP THE AROVE DESCRIBED FOUCIm BE cmm.LEO smRs THII EXPIRATION DATE THEREOF, THE ISSUING IN8UR8R VOR TO MAIL I MIAMI SHORES MLLAGE 1 0 DAYS TTEN NGTXX TO THS C.a 1WITE Wo NAMPO TO � 144110 NE SECOND AVE E L T, BUT WRE TO DO $0 SHALL INROSE NO 0WOZON OR LIABILITY MAN SHORE$, FL 33188 2382 OP ANY W THE INSUREK IS ENTll Oa; RI&PR TATIV W 305.756-6972 AUTHM mm W I ACORD 2b (2049!01) OF a 1 -n cngp 9 , 0N. All 1'IghtS l@!'1+8i�. The ACORD nsln� and by are mglstwed narks of ACORD y o OPIR okili . OVA JAWAPl b y att" FLF , cTRic €1G1 .0003 so�am� anw sew t _ n W i y 3 J' �..�fl'�C 43;"`� �`' ' w f��, �� � � � F '� "• '4 ^� �f#lS 4S �1tQ ¢BIB & ! GOT PA's . IJ CC t 37 � .g i DO NOT FORWARD C 0 SIGNS CORP DANIEL COSEANO PEES k 8595 NW 1 LN MIAMI FL 33126 SEE OTHER `` � ��`�°�...; ,�, 1►► i1►„ it►►►► il►► l►l► id.► i►► 1 ► ► ►fi ►, ►►!ll,t, ►l ►1 ► „1 ►I,�1',1 ► sae ► v un-w 11 -04 -2009 ALEX Silvis STATE OF FLORIDA ^.�fiEF 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: 01105/2010 EXPIRATION DATE: 01/05/2012 PERSON: COSEANO DANIEL O FEIN. 650659435 BUSINESS NAME AND ADDRESS: C 0 SItB+IS CORP 8125 NW 74 AVE UNIT #1 MIAMI FL 33188 SCOPES OF BUSINESS OR TRADE: 1- SIGN INSTALLATIONS/MAINTENANCE IMPORTANT: Pursuant to Chapter 440 . 06114), 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 x40.06(12), F.S., Certificates of Slacken to be exempt... apply only within the scope of the business or trade listed an the notice of election to be exempt. Pursuant to Cbspter 440.06113). 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 issaaoeg 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. DWr. -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 QUESTIONS? (850) 413-1601 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES IMPORTANT DIVISION OF WORKERS' COMPENSATION IF Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION To BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS • COMPENSATION LAW D chapter. EFFECTIVE: 01/05/2010 EXPIRATION DATE: 01/05/2012 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be PERSON: DANIEL 0 COSEAND H exempt- apply only within the scope of the business or trade listed on FEIN: 850859435 R the notice of election to be exempt BUSINESS I N� O SS NAME AND ADDRESS: E Pursuant to Charter 440.05(13), F.S., Notices of election to be exempt 8126 and certificates of election to be exempt shall be subject to revocation MIAM I Nw 3a Ave UNIT #1 t if, at any time after the filing of the notice or the is suanc e of the MIAMI, fl 331aa 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 SCOPE OF BUSINESS OR TRADE person named on the certificate to meet the requirements of this 1- SIGN INSTALLATIONS /MAINTENANCE section. QUESTIONS? (850) 413 -1609 CUT HERE Carry bottom portion on the job, keep rapper portion for your records. OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06