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PL-12-1126 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INISP-174980 Permit Number: PL-6-12-1126 Scheduled Inspection Date: December 17,2013 Permit Type: Plumbing - Residential Inspector: Diaz,Osvaldo Inspection Type: Final Owner: FERNANDEZ, DENISE Work Classification: Addition/Alteration Job Address:1077 NE 96 Street Miami Shores,FL 33138- Phone Number Project: <NONE> Parcel Number 1132060143680 Contractor: ALDAN PLUMBING INC Phone: (305)829-3031 Building Department Comments PLUMBING WORK FOR BATHROOM REMODEL 07/08/2013-PERMIT EXTENDED PER LAST APPROVED INSP. Inspector Comments Passed JIJ,7 Failed Correction ❑ Needed Re-inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. December 16,2013 For Inspections please call: (305)762-4949 Page 1 of 30 Miami Shores ����Village g JUN 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 l BUILDING Permit No. PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: PLUMBING / OWNER:Name(Fee Simple Titleholder): 0-J21 I 3) 3 ® 3 Address:_/ 7 7 e 1 ,,;� 5;: City: `G State: Zip: 3 S J Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Z - ® °° 0 Is the Building Historically Designated:Yes NO Flood Zone: CONTRACTOR:Company Name: CB" �l yw+fpiv+yG►e Phone#: `� 3 +D 3 ( C 3 1,) Address: /?SOU IVV �� "°� Co city: 6o rok^S State: zip: -7305- Qualifier Name: !� (�r2 pro �'a��`��e 7jj_ Phone#: 23`-60 3-7 State Certification or Registration#: f;'-G 1 Lt 2 V'j t Certificate of Competency#: Contact Phone#: 2-A-(oOS-3 15--"3 Email Address: Y A"0• co" DESIGNER:Architect/Engineer: r Phone#: 3 Value of Work for this Permit:$ _? rU® Square/Linear Footage of Work: Type of Work: DA'ddress DAlteration ONew ORepair/Replace ODemolition Description of Work: Q Submittal Fee$ Permit Fee$ � " CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ pt TOTAL FEE NOW DUE$ )(0- 1 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signatur Signature Owner or Agent Contractor yy The forego' i trument was acknowledged this The foregoing instrument was acknowledged before me this Z C/ day of ,20 �,by �--�I� day of _Sft ,20 J by , who is p onall known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. ��, t d Aid take an oath. NOTARY PUBLIC: NOTARV*, l�Wt AW 1p1+Y Pugh �° '"'•° #DD 917312 Sign Sign: Print: �g �°� 8TtVU5 Prin My Commission Expires: My Commission Expires: ��:x:������:�:��:�:��::x�:���:x�/��:x�:x:r.•I:���:x�:��:�::x�::x��:���������:x��:���::x:x�:x�x�x�x�::x�:x�:x���:x��x::x��x�x:��xx::x�x:�:x�:�:x��:x:x:x:�:x:x�:x��x�x��x APPROVED BY ,\ / �' ��/ Plans Examiner Zoning Structural Review Clerk (Revised 07/10 107)(Revised 06/10/2009)(Revised 3/15/09) 10/1612012 02:24 3058299109 SAADHOMES PAGE 08/08 �"„�.r✓" CERTIFICATE OF LIABILITY INSU NC! CER , — -- ---- 08/20111 F1C�1TE IS IS�E A�A flMA7TER t? iNF{NtMATIaN ONLY ANSI+CONYBRS NO R1GIi E3 UYa4N YidB CLRTIFICA,hE FICl1.bER.TIi18 r�hmO tTFtQATE I�CtEB NM AFFIRMATIVELY OR NEGATIVELY AMEND,FJCfENit OFI ALTER THE Ct��fERA01~AFFtLRDSD BY TWf:POLICIES O1N. THIS CERT�l10ATE OF'N$fJRANCE DMS NOT CONSTITUTE A CONTMCT'BSTMEN TNf«tSSU1Nt11NSU KESENTATME OR PRODUCRK AND THE CERTIFICATE BOLDER.. mil$).AUTHOMM •d conditions ortha o4 lED A Crl. aace� ,holder to u�u of such "�"' '!rA an emfars�rt�enc A abM amens an this catMeg&dogs nat ctlnfar T(ghts to thnsurance Ina, Lt Many lcgtegor BNrd Sups 109 eo . {23g}M,FL 33908 r . ESR;—_9�d�sine®g(2 939-+'687�, FI1x {2 - .. fA1sIR20q =- CGldent frlSllrg Company — .�....� t7AIC _ Aldan Plamblrtg Inc - 47800 MW 42nd Lour! IMF SIMI 011►deaa,FI,33055 _n78 fig• -,.w._•---.•�---.._.�..__—„� , C�t't'IPICATt=NUM�1>=1�.._____.,--_-... Qa F�: �...�_ .,.,.,..^...m.•_,,.,,_.,. -- PHIS IS TO Cl {TIR1'1 FIA ANDI G ANYES dF REQUIREMENT, RMtip p�LtjW y 4W�M 1S8UEO TO n�INSi'�REti NAMED A60VE Fdlz YWE FbL(GYAKA —---�- RIDf1�A'iED. NtT7WlTHS7�1NDIfdCt ANY RE4UIREMENT,TERM OR COND17'14f+1 OF ANY C REVtSICiN NIiIUIBEI� CBtTIFICA•1E MAY Be MVED OR MAY AERT °• —" EXCLUSIONS AI THEIN$LIfso-,- AFFORfjEDgY7Hf:Z OO LN j ESDF t�IBED EIN�$ G7 TOEALLT41NW1CF1TMS E7fflONS OF St1CH p OLICES.L%ff6$14o rN NIAY i IA �� TYPE.4f INSURANCE --•.•-�, � " ?�IdLEN REDUCED RY PA1D Ci.A1fd1S. THa_T�iM$, -- AI.LUlBILrry IPPA�,i Mr-�WEACIALQS@ MAL LIMILn-1 f OQQ OI�{I.fld M A L I 4�l C IVU1D6 ME1:3. sRETiT -- --t—.,.tom. -.. ❑ CPPO000751 co ^^ t S S 1IDD.000.00 02!1012097, CkeyiDl2t}13 M ..ESU!t artso�++on} 4 5,000.00 PmRdrau aa.�!n%R! • f eNVl.aac GATE!Iror�r'AVRAO aER s.aO Iggq�oo q!RLQ?tM.AC ❑ PRO. - cn 2.0010 oo.Oli R�;M N z ��:�_�?4_.. ? �RODUes's-Cat�sPror±niu3 s 9,t]D0 OQO.t3t1 LMMLrry ❑ ANYAUTO ..._....-._ —s3il��inmr-_ xa ..; AUTOS f Si70lLYIN.rGRy�p�rpeteoh} b NfRSbAUTC8 ❑ gWN® m�UILYlNdLIRYrepgGeml e — i UM M' ' _-OCCUR 1. I ®ifAe „P,J�C{iOC AREWCE�..- • AND EMPLOyERV ..-- C�YE�f�PLIAgntr,r�jy --- •---..._ •-.a.�..--,,.._._.. „ CA Fr+t4PR1�1 gtzfPARTNER/E%LtCfJf�l�/M I - w-�G—A -•_ O �.- RWJMRDfCLUDED? r,. idlA, 1..13ORYI,IMII�. fnm�>;R .� Iyyea�9@doaand �under O_d_ OIV 9F Ci'FF(A'PICNS below j E.L DMWE. _ 1 CN DIP 0 Ranerwsi�c ;ilioivsrvEnlciESf°._�_"""__ - _ (A7tecttACORt7107.AtldllianalRUn�e:Sshedute,8maro__ speaels rogy�} •-�---„-... Aill[trnE ShOms Building DspeNfiant allOULD ANY OF'n'tE,AROVE DESC19I8ED p0UCM 6E CANCHUiM SEFORE i OM NE 2nd Avenue THE'XdtATION DATE THEREOR,No-naR VII&L OR IjELRMRP:D IN ACCOROANCE Yfidl�i niLr PCILICY pRO,4610N6, Nliartti Sharlae,FL X3188 _ ACORD 28(201W05)Ql= The'ACC7Ra naq arOF2ATIQN.Ail ills teaerved. 9o:t registar+3ct 7narka+a4 ACORD 10/16/2012 02:24 3058299109 SAADHOMES PAGE 06/08 02-282012 I;i= .aTwATEi3 S-1 ATE OF FLORIDA CHIEF FINANCIAL or-FlcE R 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 low. r WFECTIVE DATE- 02/28/2012 EXPIRATION DATE; 02127/2014 PERSON: CARMONA SIN„ ALFREDO JR 271610831 BUSINESS NAME ANlrt ADDRESS: ALDMt PLUMBING INC 2442 dOHKSON ST HOLLYWOOD FL 33020 SCOPES OF BUSINESS OR TRADE;, 1- PLUMBTM IUMTANT. Fnrment to Ceaptor 440 . o6(f4y F.S.. 4a eEFtcer of If co section may Not recover baeofitg or compees°ttoo under this �o tDO who oiectg esempttert from tots chapter by flung a certlHaate of election andar this mope of the business or trade fisted t "�• Fursamar to Chapter 44o,05F12I, F.s., Congicatam of election to be exempt.., erection to be art the eo ice of election my to be ,,tent a Fttrseeet ro Chetter 440.05113), F.3., Notices of erection to be exemapply aand rtoe"If� t of otempt seas to equine n revocation if, at coy time clear the Ettiag aF the aelieo or the imoenee of the cerufirat, ceriffiegta no rnegot meets the rapuiremotltm of this names art the certificate to mast the re slim mectFart for tssoance of rt certiftcato. The depatr the send revoke ° % the Farsoa named on the Relics or Q °tents of MIS Section. certfrcate at ANY time for failure of the prrsoa -- OWC-25,2 CERTIFICATE OF MECTION TO BE EXEMpT REVISEC 01-1 t _.. EtIlES7ION5i (850) 41: vF 1a PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STAT'� t}iiEi1A f PARTMENT OF FINANCIAL SBRvI ES Q�SFON OF S,COMPUMTION IMPORTANT CNTIFIC Eft:T*iZN OTION TRY O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who WORK IGbtTl3 OF EL�Tfr)N rO BE OCLFAPT FFtppfi FLORfbA elects exemption from this chapter by 1NORIlERS COMPENSATpAf LAW filing a certificate of election L under this section may not recover benefits or compensation under th E>=FECTIVlS; OZ128/2012 EXPZRAT=ON PATE: +02/27/2014 9 © chapter PERS0NI: ALFRCOO GARMONA dlZ Pursuant to Chapter 440.05112!. F.S. Certificates of election to he ! (I� 27181083! H exempt- Apply only within the scope of the business or trade listed BUSINESS N the notice of election to be exempt NAME AND ADDRESS. 2"2 PLUMBING me Pursuant to Chapter 440.05113), F.S., Notices of election to bo exemp• QU N000.n and certlflames of election to be exempt shall be subject to revocati HvuvwooD, s3DSe ft' at any time after the filing of the notice or the issuance of the certificate, the person mimed on the notice or certificate no the requirements of this section for issuance longer n The of a ceraf SCOPE OF SUSINSSS OR 7`RADEE department shall revoke a certificate at any tint: far failure of the section. ffcate +. aruntatroc person named art the certificate to meet the requirements of this I ' QUESTIONS? (850) 413-le CUT HERE Carry bottom portion on The Job, keep upper portion for your records' . bWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 i 10/16/2012 02:24 3058299109 SAADHOMES PAGE 07/08 w: .Local Ubsiness Tax Payment Received Confirmation page 1 or i From: Al Carman:{aldanpiumbing @yshoo.00m> To:saadhomes s8aadhomesQ9ol.com7 Subject: Fw:Local Business Tax Payment Received Confirmation Date:Tue,Oct 16,2012 3:01 pm Here is the confirmation that Is active. There should be no problem using this,l have not had a problem. I'm waiting for the actual Local Business Receipt.. --Forwarded Message--�- ! From: Local Business Tax(FIN) <localbusinesstax miamidade.qov> To: aifi�st�?'.:Irrhint� .` hoa.ttln3 Sent: Monday, October 1, 2012 8:19 AM Subject: Local Business Tax Payment Received Confirmation Thank you for using the Miami-Dade Local Business Tax online payment system to pay your Local Business Tax. Your transaction confirmation.is as follows: Agency Name: Miami-Dade Local Business Tax Section Receipt Number(s): 723173-1 Payment Date/Time: 10/01/2012 08:19:23 EDT Ambd'&*Paid: $49.50 Payment Type: Visa-xmcxxxxxxxxx2475 Payment Confirmation Number: 67082 If you have questions pertaining to your payment,please contact us. You can also click bore to view your LBT Receipt status. If you have suggestions for products or services,please contact usus. This is an automated response-DO NOT reply to this message. .If you wish to contact us, click !l M http://mail.aol,com/37096-111/aol.-6/en-us/mailfPrintMessage.aspx 10/16/201: c�t1ORES SZZG'914 allot" Miami shores Village L�= R 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. L/ 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) D. ✓ COPY OF WORKERS COMPENSATION(EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR 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 DEPT) 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 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: c BUSINESS ADDRESS: 6'471,�s STATE R ZIP CODE 770�� BUSINESS PHONE: ( fir 1 ) J�0,7 - 3fS�3 FAX NUMBER(!FT) -7e 7- 6--X F-T-7 CELL PHONE( ®�) 31 310 QUALIFIER'S NAME: QUALIFIER'S LIC NUMBER: eFG 1 Y?-'9l -7/ E-MAIL ADDRESS(IF APPLICABLE): r���G�C��•.�;�� Created on 3119109 BY MLDV I RV 3126109 MLDV , , � < �;. dr .� _ - I '� i i i o .. ,;a .� S �t.j s ? � f� i �, L�. `j t � t ` �, I ��/' { � � � '`?� , � � xlt :d � y , I �:�" '•,...,_ _ A t� v� hr vate�'t' €,.. 0`1u ( JI. d Y 3 Pw INC ` v a d kf �,, �T l � j F �'M -qm 00 NOT FORWARD ALDAN PLUMBING INC CARMONA ALFREDO JR PRES 1780€ Mkt 42 CT MIAMI GARDENS fL 33055 ,• -rAx a Wo ��- I3 pp qq jg $$ gg jFgg ( gg j jj(( jjjj �' '� Pffit @ €ItlCii2Qffiiilfil2if7iYf EI&$! @Iffitiffi F3titS.El ... SEE OTHER SIDE CERTIFICATE OF LIABILITY INSURANCE DAW 06120111 TIiiS CERTIFICATE IS ISSUED AS A. 6F INF - TION ONLY AND CONFERS NC/RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXPEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($),AUTMO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER. iQdPOFYfANT:III f:8t@ holder!8 an ADDtT NAL INSUItECtrthe P6tL{vf )1MIW3 pf1U193dd.If w�U8RdC3Q71tlN I$ fAAlll ta,8t�b[ f the c mia.;md conditienrs of the policy,cer�in Pailciea may require an end A ttt oa thia�e�r"Cate W confer rights to this a�ffrBtMcate holder in 11W of Guth end e), PRODUCER Tiffaafq Dania Danis Insurance Inc {2398 934-7887 (239 939-7789 15085 Mcgregor Blvd Suite 109 Ft.Myers,FL 33908 Phone 239)939.7697 Fax (239 939-7789 s NAIL# rNSUREta INSURER A: idet insurance Company Elt u Aldan Plumbing Inc c 17800 NW 42nd Court D: Miami Gardens,FL 33055 uRER E; COVERA(3E3 F s CERTIFICATE 1NUtkP�6t 1 REVISION NUMBF: THIS lSTd CERTIFY THAT THE POt ICIES OF 1HSURANCE LISTED BELdYirHAVE SEEN INUED TO THE IIdSUREO NAMED ABOVE FOR THE POLICY PEftIOO .. INDICATED. NOTVWTHSTANDINa3 ANY REQUIREMENT,TERM!OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT T,WHICH THIS' CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 6Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IMITS SHDwW MAY HAVE BEEN REDUCED EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. BY PAID C AIM& ; rvaE QP tNawRILNCk s° _ EFP Li ®ENBRALUA fTy .. F°�LICYNUfA9 R M �,� sncti 1 t)Otl COWMROAL GENERAL UABILI lY DAMAGE RENTEl3�..� '$. Q EJ CLAIMS-MADE W OCCUR A CP P0000759 QO ExP(a, �} ffi 5,OW.00 02/10)2012 02t9flt2413 PER 3.. &ADUiNJURY $ 910001900.00 GeOgt&AGGRIEGATE s 2.000;5 0.00 4EN{AROREAATE LtlburAPPr lES r+ER aR IDUCUS GOWIOP Aaa $ 1.00W0,00040 AUTOMOMS tIABIt:TTY —M, [� ANYAUTO ALL M SGWO L BDDUY INJURY psi HIRb AUTOS O W WWD BADS Y aN fURY(Per w >a E�- _...._, L �lq a UMBRELLA LIAB El OCCUR EACH'OCCURRENCE L L" 1j CLAWS-SHADE AGGREGATE $ RETENTION� -- ANAJUMI NA TION YIN 1MCBlATU - ANY PROPRIETO"A WRMXECtl rM $ Y.LlYt.B_.� OFFIcOMAEMBErt"CLUDh�7 NIA,< _EL EACH ACCIDENT E fbe u ider -' E.L DISEASE-EA£Mn.OYE Ca RIPTif�l ryF OPERA'1'IONB E.L DfBEAffiE-P_�11.iCYirpklT >6 I LL OF OPEaa'rvsac06iVroNS aVc>.1?s tAn AooRlt ion,aaascra„ar Rftmmft °.---�--_...,--�---�—� ar r ts+re�rea! CERTIFICATE HOLDER —- " - v CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 11EFORE Miami Shores Building Department THE EXPIRA710M DATE THMOF,NOTICE WILL BE DELWERED IN 10060 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHMEDRIMESENTAIWE ACORD 28(2010108)QF x-2090 ACORD CORPORATION. All rights reserved. The ACORD name and logo We registered(marks of ACORD I 02-28-2012 JEFF ATWATER 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 j This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 02/28/ 2 EXPIRATION DATE: 02127/2014 PERSON: CARMONA ALFREDO JR FEIN: 271610831 BUSINESS NAME AND ADDRESS: ALDAN PLUMBING INC 2442 JOHNSON ST HOLLYWOOD FL 33020 SCOPES OF BUSINESS OR TRADE: 1- PLUMBING IMPORTANT: Pursuant to Chapter 440 . 0504), 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 440.05021, F.S., Certificates of election to be exempL.. apply only within the scope of 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 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. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 41: PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS!COMPENSATION O Pursuant to Chapter 440.05114), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY 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 th WORKERS'COMPENSATION LAW D chapter. EFFECTIVE: 02/28/2012 EXPIRATION DATE: 02/27/2014 H Pursuant to Chapter 440.0502), F.S., Certificates of election to be PERSON: ALFREDO CARMONA JR exempt.. apply only within the scope of the business or trade listed FEIN: 271610831 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.0503), F.S., Notices of election to be exemp- ALDAN PLUMBING INC and certificates of election to be exempt shall be subject to revocatij z44z JOHNSON sr if, at any time after the filing of the notice or the issuance of the HOLLYWOOD, FL 33020 certificate, the person named on the notice or certificate no longer rr 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- PLUMBING section. ' QUESTIONS? (850) 413-1E CUT HERE Carry bottom portion on the job, keep upper portion for your records. i OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11