RC-11-1740Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 164750 Permit Number: RC -9 -11 -1740
Scheduled Inspection Date: November 09, 2011
Inspector: Bruhn, Norman
Owner: ,
Job Address: 10070 N MIAMI Avenue
Miami Shores, FL
Project: <NONE>
Contractor: PAHER CONSTRUCTION CORP
Permit Type: Residential Construction
Inspection Type: Final Building
Work Classification: Alteration
Phone Number (305)220 -6990
Parcel Number 1131010210100
Building Department Comments
1 BATH AND KTICHEN RENOVATIONS
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
(tr-----
November 08, 2011
For Inspections please call: (305)762 -4949
Page 7 of 32
NOTICE OF COMMENCEMENT
A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TiME OF FIRST INSPECTION
PERMIT NO
STATE OF FLORIDA:
COUNTY OF MIAMI -DADE:
TAX FOUO NO. //3/0/0?-1 O/ O D
THE UNDERSIGNED hereby gives notice that Improvements will be made to certain real
property, and in accordance with Chapter 713, 'Florida Statutes, the following information
is provided in this Notice of Commencement
1. Legal d
,1 0
pfilon of property and street/address:
2. Description of Improvement:
Lb
111111111111111111111111111111111111111111111
CFN 2011R06925$7
OR 8k 27859 Ps 36981 Ups)
RECORDED 10/14/2011 13:05 :03
HAR1JE- RUVIN, CLERK OF COURT
HIANI -DARE COUNTY, FLORIDA
LAST PAGE
Space ereserved for use of recording office
—
3. Owner(s) name and
Interest in property: %Ls
Name and address of fee simple titleholder:
4. Contractor's name, address and phone number.
6 0 �J
l�u. -% 3314+5
5. Surety: (Payment bond required by owner from contractor, if any)
Name, address and phone number.
Amount of bond $
6. Lender's name and address:
7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by
Section 713.13(1Xa)7., Florida Statutes,
Name, address and phone number.
8.. In addition to himself, Owners designates the following person(s) to receive a copy of the Uenor's Notice as provided In Section
713.13(1)(b), Florida Statutes.
Name, address and phone number.
9. Expiration date of this Notice of Commencement
(the expiration date is 1 year from the date of recording unless a different date Is specified)
WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED
IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE FOR
IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE.
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK
OR RECORDING YOUR NOTICE OF COMMENCEMENT.
Signature(s) of • J, �s or Owner(s)' Jl orized /Director/Partner/Manager
Prepared By / :�....._ It& Prepared By
Print Name - 11'1%>t'i���i s -��
�� Print Name
Title /Office <<7 5WA Title/Office
STATE OF FLORIDA
COUNTY OF MIAMI -DADE DC/45/2,-/- �� (1
The fo oing in 1--. ent was oAl ed before me this 1 T day of �
Y �� �'!' lug -
❑ Individually, or ,=� Pe-67-1e..--t— for
Careersonally known, or 0 produced the following type of identification:
Signature of Notary Public:
Print Name:
(SEAL)
VERIFICATION PURSUANT TO SECTION 92425. FLORIDA STATUTES
Under penalties of perjury, I declare that I have read the foregoing and
that the facts stated in it are true to the best of my knowledge and belief.
Signatur. ) •f Owner(s) or •I s)'s • ed cer/Dir or/Partner/Manager who s fined above:
44m'; . By
I
JEANNEITETEY -D12
MY COMMISSION 9 DD 914519 2013
` Bow Nam 6, de
123.01 -32 PAGES 310
FATE OF FLORIDA, COUNTY OF DADE
1 HEREBY CERTIFY that this fa a true copy of the
ongtnpjttr ftth s oft ifs,
dey 01
��JJI.! 'Y , AO 20
WITNESS
HARVE
By
.;$0; Seal.
t and County Courts
D.C.
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
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: BUILDING ROOFING
Permit No.
RECEIVED
SEP 2 32011
c
Master Permit No.
OWNER: Name (Fee Simple Titleholder): ' �" id 7r/i.0 C ot Phone #:
Address: (00 2 /V 141 iat-• r, 7 igvw-
aJ _ �ZZ — 1(672
City: e1eed-ori tAkeire-4 State:
Tenant/Lessee Name: Phone#:
Email:
Zip:
31`-50
JOB ADDRESS: 1 Db7 0 JU % , /41-4/•&--
City: Miami Shores County: Miami Dade
Folio/Parcel #: l / 3 / 0/0 r / 00 / b CD
"
Is the Building Historically Designated: Yes NO �,,/ Flood Zone:
CONTRACTOR: Company Name: Pr-\14 — CON s v 7 tea) eat • Phone #: ?F(0 2.56 37-SS
Address: '3C0 5 0' W 8 E e31'
City: -° %.0- l 44 . \ State: 'F' L Zip: 3i t t
Qualifier Name: ?Mb LAD E . 1-A, 3 (2-P4 era_ Phone #: —334 2,..s(, 11
State Certification or Registration #: C. & l.. 0.0123 S9, Certificate of Competency #:
Contact Phone #: )1 Co 2. 5 6 37 .) '-'t-mail Address: lA 1�6"1-4-''a83 Q Yu. tel.0 e - C-0"1
DESIGNER: Architect/Engineer: p1. C X70 Phone #: TIP r9 P'4o "Tel .
CO 000
•
Zip: .3 G D
Value of Work for this Permit: $
Type of Work: ❑Addition
Description of Works
❑Alteration
Square/Linear Footage of Work:
New %Repair/Replace
❑Demolition
* ** *. x�. �x. a�x+ x. �x+ x�x�x.+ x. a��x.. �x+ x�xa�. �x. �a. K:. �x+ r+ xFees+ x+ x. a�a�a��x+ x+ x�x+ xa.w. x��x.... �x. e�+ �a�x+x.s��a..+x+x.+nx�+x.�x.�x.
n y,
Submittal Fee $ 1,449 Permit Fee $� CJ `�CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ Zed ° ®�
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 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 $
promise in good faith that a copy of the notice of commencement and construction lien law brochure wil
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencemen
for the first inspection which occurs seven (7) da s after the building permit is issued. In the abs
inspection will nyt be approved and reins,?ec :on fe ' .ill be charged,
Signature •
Signature
owner or A "t
The foregoing i ent was acknowledged be me is / r The foregoing ' stuument was acknowledged before me this Z,Z
day of ( t 20( , by he , day of � , , 20•1/ , by
•s
e delivere
ust be posted
nce of such p
applicant must
to the person
at the job site
sted notice, the
wh
a r
ho has produced who is pRersonally 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:
Sig
Print:
My Commission Expires:
NOTARY PUBLIC:
A.e �
♦, r -r,r t
41/4k4> JCANNCFFETEY -DIEZ
* � MV COMMISSION # 00 91451
'
a EXPIRES: August 16, 2013"''
•�.y, i doe` Bonded Thru Notary Public Underwriters
ommission
MARIA MAYRA CEDERS
MY COMMISSION AE0351123
EXPIRES: OCT 19, 2014
Bated tough 1st State Islam
********** * * * * * * * * * ************+ +x**** ****** x** ****+ x************** **+s+r***>x***wr+say+x*a ** *xis:s,s,************** * * **
APPROVED BY
/0r�T4ft/ Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
THIS INSTRUMENT PREPARED 13Y AND RETURN TO:
Laura Betancourt
Emerald Title Group, Inc.
3613 S.W. 87th Avenue
Miami, Florida 33165
Property Appraisers Parcel Identification (Folio) Numbers: 1131010210100
1111111111111111111111111111111111111 11111111
CFH 2Ct11,+:064-532 1
OR Ek 2783E Pss 0931 - 932; (lass)
RECORDED 09/26/2011 12J06:34
DEED DDC TAX 300.00
HARVEY RUVIN, CLERK OF COURT
MIAMI-DADE COUNTY, FLORIDA
Space Above This Line For Recording Data
THIS WARRANTY DEED, made the `!j day of July, 2011 by Milagros 0 Collard, a single woman,
whose post office address is 1199 North Avenue Bridgeport, CT 06604 herein called the grantor, to Emerald
Title Group, Inc. a Florida Corporation, whose post office address is 3613 SW 87th Avenue, Miami, Florida
33165, hereinafter called the Grantees:
(Wherever used herein the terms "grantor' and "grantee" include all thej parties to this instrument and the heirs, legal
representative! and assigns of individuals and the successors and assigns of cr)rporations)
W I T N E S S E T H: That the grantor, for end in consideration of thelsum of TEN AND 00/100'S (310.00) Dollars
and other valuable considerations, receipt whereof is hereby acknowledged, hereby grants, bargains, sells, aliens,
remises, releases, conveys and confirms unto the grantee all that certair; Iand situate in MIAMI-DADE County, State
of Florida, viz.:
Lot 3, Block 2, Hamilton Terrace, according to the map or plat thereof, as recorded in Plat Book 15, Page
75, of the Public Records of Miami -Dade County, Florida.
TOGE1 HER, with all the tenements, hereditaments and
appertaining.
ances thereto belonging or in anywise
TO HAVE AND TO HOLD, the same in fee simple forever.
AND, the grantor hereby covenants with said grantees that the grantor4 is lawfully seized of said land in fee simple;
that the grantor has good right and lawful authority to sell and convey said land, and hereby warrants the title to said
land and will defend the same against the lawful claims of all personsiwhotnsoever, and that said land is free of all
encumbrances, except taxes accruing subsequent to December 31, 2010.
IN WITNESS WHEREOF, the said grantor has signed and sealed these presents the day and year first above
written.
Signed, sealed and delivered in the presence of:
Witness Si re ,
l'A roe" rg4reto
With.,_ #1 Printed
tness #2 Si
/4-4 4—
c:EsC/i.2/
Witness #2 Printed Name
11'4 `.
rim 0 9
:e:
and A Milagros A Canard •
119 North Av Bridgeport, CT 06604
5r
The foregoing instrument was acknowledged before me this day of Ju
Milagros 0 Callard who is personally known to me or has pr•Huced
identification.
SEAL
1 Notary sy FOX
t My Conlsslon
m spun) May 31.2016 I
File No: 11 -02799
kth. -I a
Printed Notary Name
OR Bk 27838 PG 1D932
LAST PAGE
MIAMI SHORES VILLAGE
Building Department
10050 NE 2 Ave, Miami Shores Fl, 33138
Tel: 305 -795 -2204• Fax: 305 - 756 -8972
Permit No. REOC -8- 11.1515
Certificate of Re- Occupancy
Address: 10070 N MIAMI Avenue
City: Miami Shores Village
State: Florida
?gyp: 33138
This certificate verifies that the reference property has been inspected by Miami Shores
Village and has been determined to presently comply with schedule of regulations of
Miami Shores Land and Development Code pertaining solely to the requirement that
each one - family dwelling is used and intended to be used for a one - family dwelling
purpose only; however, this certificate does not constitute any representation or
warranty as to the condition of the dwelling or other structures on the premises
described herein, or any aspect of such condition, and interested persons are advised
and encouraged to make their own inspections of the premises in order to determine the
condition thereof.
Building Officials Approval:
,df,6
✓toiu ZaG1L ✓✓ZGA2tt. CBO
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION FORM
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS
SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR.
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. COPY OF QUALIFIER'S STATE LIC CARD
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT)
COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION)
IF ' TRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT
C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPTl
D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION),
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
BUSINESS NAME:
COMPLETE CONTRACTOR'S INFORMATION
?M -tr 1-4e CoN -toto Cove.
BUSINESS ADDRESS: 3C0 50 Sew e s eQ CITY
STATE C. ZIP CODE -b-.1 (0S--
BUSINESS PHONE: (4 - ) 2.5C. 39-55- FAX NUMBER (3QS) 2 2 0 ?OS�
CELL PHONE (4-V) SS QUALIFIER'S NAME: a LA £- 1-1 .-
QUALIFIER'S LIC NUMBER: ezde. 0 Co 2,3S-9
E -MAIL ADDRESS (IF APPLICABLE): ?,4- 6i2- ZOOS Q., yo.itt. 0,„ . C v,
Created on 3119109 BY MLDV I RV 3126109 MLDV
AGORA. : • CERTIFICATE OF LIABILITY INSURANCE
PRODUCER .
OVERSEAS INSURANCE AGENCY
P. O. BOX 162936
MIAMI, FLORIDA 33116
Serial# .. B2163
DATE eilF/DIYM
09/22/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND COP#FERS ND RIIGMTS VFOON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
INSURED
PAHER CONSTRUCTION CORP
P.O. BOX 450176
MIAMI FLORIDA 33245
. INSURE.. AFFORDING COVERAGE.. .
INSURERA: WESTERN :WORLD INSURANCE COMPANY
INSURER B:
INSURER C:
{ INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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 TP ALL THE TERMS; EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY.HAVE BEEN REDUCED BY PAID CLAIMS.
MSR
TYPE OF INSURANCE
•
POLICY NUMBER
i L . ,
1 ("'t tt� t,, iii
LIA01S
. A
GENERAL
LIABILITY, .
COA YIERCIAL GENERAL LIABILTIY
NPP 8029994.
0511412011
EACH OCCURRENCE
E
. 300,000
ta
FIRE DAMAGE (Am omit*
$ • . •
. 50,000
C AIMS MADE 1 X I =Os
05/14/12
MEW EXP (Any aneI! +)
$
5,000
PERSONA. D ADV INJURY
$ ..300,000
-1,000 DED •
GENERAL AGGREGATE
$
300 000
GEN'L
AGGREGATE UMITAPPLtES PER
POLICY Ti jECtT n LOC
.
PRODUCTS - CoMPIoP AGG
$
300,000
X
.
'
AUTOMOBILE
L1ABIUW .
ANYAUTO •
ALL OYMED AUTOS
SCHEDULED AUTOS
HIRED AUTOS -
1{RJNi70PREb>o9Tltib
•
0
-
cossissio )SU�GI H L91Ai1 -"
BODILY INJURY
(mo)
$
• .
BODILY INJURY
acak tl
$
PROPERTY )DAMAGE $
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY- EAACCIDENT $ •
OTHER THAN • EAACC $
. AUTO ONLY: • AGG • $
EXCESS
LIABILITY
•
EACH OCCURRENCE $
AGGREGATE . S "
.
'OCCUR - :1 I :CLAIMS MADE
>8
..
$
.
DEDUCTIBLE
$
RETENTION 8
•
WORKERS
EMPLOYERS'
COMPENSATION AND
LIABILITY
:
A •
1 J.�S £
E:L. EACH ACCIDENT S
_
EL DISEASE - EA EMRLO -- $
E.L. DISEASE - POI. CY LIMIT $ .
OT>E
•
D E S C R I P T I O N OF O)'ERATI IS LOCA ADDED BY PROVISIONS
OPERATION AS GENERAL CONTRACTOR
CERTIFICATE. HOLDER 1 1 ADDITIONAL INSURED; INSURER LETTER
MIAMI SHORES VILLAGE
BUILDING -DEPARTMENT
10050 NE 2 AVE
MIAMI SHORES, FL 33138
ACORD 25-S (7/97)
CANCELLATION.
SHOULD ANYCWTHEAgave IDESGMBEDPCXXXES BEGANCE IEDBEFORETHE ExPIRATION
DATE THEmeoF, THE Iii INSURER MI„ ENDEAVOR TO MAIL 0 DAYS WRT[iEN
NOTICE TO THE GERTIFICATE HOWEt NAMED TO 111E LEFT. BUT FAILURE TO DO so SHALL
IMPOSE NO OBUGA1TON OR LUUBIJW OF ANY RIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
eACORD CORPORATION 1988
ADE MY
TAX COLLECTOR
14 W R
GL. ST. st
5 , MIAMI, 331
45 735 —
2011 LOCAL BUSINESS TAX RECEIPT 2012
MIAMI -DARE COUNTY - STATE OF FLORIDA
EXPIRES SEPT. 30, 2012
MUST BE DISPLAYED AT PLACE OF BUSINESS
PURSUANT TO COUNTY CODE'CIHAPTER BA - ART. 9 910
THIS IS NOT A BILL DO NOT PAYMPIrigariffWi
�USIN ! LOCATION
P ERONSTRUCTION CORP
3 50 SW 88 CT
33165 UNIN DADE COUNTY
OWNER 1
PA ER CONSTRUCTION CORP
Sec. T olluttiesit
1 GENERAL BUILDING CONTRACTOR
vas is ONLY {A LOCALS
DIMNESS TAX IT[ .,
GOES NOT
,DOES TO TE ANY ...,
EXISTING _n" TORY 05
ZONING LAWS OS THE ,
COUNTY OR _. NOR
DOES IT
HOLIER FROM
PERMIT OR
THE s a °4_,,
TIC. 7 r l
MYIIEW
IEURNUM
amiamut
07'/06/011
09 t 1051!3001
00 075.1 00
SEE OTHER SIDE
FIRST -CLASS
U.S. POSTAGE
PAID
MIAMI, FL
PERMIT N0.231
"° RECEIPTNO. 470561 -3
STATE* CGC062359
WORKER /S,
1
DO NOT FORWARD
PARER CONSTRUCTION CORP
PABLO E HERNANDEZ PRES
3650 SW 88 CT
MIAMI FL 33165
1.,ihu limildlhuh hill.hdLul,hllmIldhaakil
04-05 -2011
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE of RECTION TO IE EX PT 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: 05/07/2011
PERSON: HERNANDEZ
FEIN: 651070048
BUSINESS NAME AND ADDRESS:
PAHER CONSTRUCTION CORP
3850 SW 887H COURT
MIAMI FL 33185
SCOPES OF BUSINESS OR TRADE
1- CERTIFIED GENERAL CONTRACTOR
EXPIRATION DATE 05/06/2013 %
PABLO E
IMPORTANT: Persnent to Chapter 440. 0504) F.S., as officer of a corporation who elects esamptien from this chapter by tiling a certificate of eladian tinder this
section may not recover benefits or compensation ader this chapter. Pursuant to Chapter 440.0502I, F.S., Certificates of election to be exempt... apply only within the
scope of the bnsinass ar trade tided on the notice of election to be exempt. Pursuant to Chapter 440.081* F.S., Redoes of election to be
exempt and certificates of
election to be exempt shell be subject to revocation 0. at any time after the Ming of the notice or the issuance of the certificate the person named an the notice of
certificate no logger meets the requirements of Ibis section for Issuance of a certificate. The dent shell revoke a certificate a any time for failure of the person
awned on the certificate to meet the requirements of this section.
QUESTIONS? 1850? 413 -161
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
PLEASE CUT OUT THE CARD
BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKINar COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE 05/07/2011 EXPIRATION DATE: 05/0 8 /2013
PERSON PABLO E HERNANDEZ
FEINE 851070048
BUSINESS NAME AND ADDRESS:
PARER CONSTRUCTTOR CORP
3850 SW ROTH COURT
MIAMI, FL 33185
SCOPE OF BUSINESS OR TRADE
1- CERTIRED GENERAL CONTRACTOR
F
IMPORTANT
Pursuant to Chapter 440.05(14), F.S.. an offices of a corporation who
O elects exemption from this chapter by filing a certificate of election
L. team this section may not recover benefits or Con under this
D
H Pursuant to Chapter 440. 05(12), FS., Certificates of election to be
exempt.. apply ratty within the scope of the business or trade listed on
Rthe notice of election to be exempt.
E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt
and certificates of election to be exempt shag be subject to revocation
if, at any thne 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 shalt Revoke a certificate at any time for faiiwe of the
person named on the certificate m meet the requfremennts of this
section.
QUESTIONS? (850) 413 -1609
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11