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EL-12-1871 (2) Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-179605 Permit Number: EL-10-12-1871 Scheduled Inspection Date: September 16,2013 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: GROPPER,ADAM Work Classification: Pool - Private Job Address:9901 NE 13 Avenue Miami Shores, FL Phone Number Parcel Number 1132050090480 Project: <NONE> Contractor: O AND J ELECTRICAL CORP Phone: (305)326-8892 Building Department Comments POOL ELECTRIC Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed E�r Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. I September 13,2013 For Inspections please call: (305)762-4949 Page 5 of 38 Miami Shores Village E' ,VY ' Building Department OCT 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 No. -�� PERMIT APPLICATION Master Permit No. I Z°[ YSfO FBC 20 LQ Permit Type: Electrical OWNER:Name(Fee Simple Titleholder): Phone#_30 S — 50-S gl� Address: 9_q 01N N 15 AU a— M t'!.t/[I l S k ore-5 r— City: Me am i _S°c reS State:P. Zip: 3'3�3c Tenant/Lessee Name: A d/z e- Phone#: no e)-e- Email: no h-e- JOB ADDRESS: q4101 AJ E 13 A u e,- City: Miami Shores County: Miami Dade Zip: '157313& Folio/Parcel#: . //— Is the Building Historically Designated:Yes NO Flood Zone: CONTRACTOR:Company Name: 0 C en. (` NCO��r,'T r yr [ Phone#: Address: J A(D NJ ,1 4.1 II i City: wt 1 ay" State: Zip: Qualifier Name: I_-ems ii 4d Phone#:Lj or) P-4,4 'EML . State Certification or Registration 4. & C 0000141— Certificate of Competency#: J Contact Phone#:fib,Par) ?U-V p S` Email Address:� � � Q Qf 44�T Cl2G�r . ED •r DESIGNER:Arc Phone#: Value,o ` br forrtl}is;P�Xnut 3 �o Square/Linear Footage of Work: 150 o yS'prki q X11r'es C1 P Iteration L lew ORepair/Replace ODemolition t Ilesci i tagtt4 of Work. Submittal Fee$ Permit Fee$ 3 45'a e m _ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 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 pproved and a reinspection fee will be charged. SignatureX PY4 Signature �4ca caner or Agent Contractor The foreg rg 1.nstrument was acknowledged before me this The foregoing instrument was acknowledged before me this:5 day of ,by 1 day of ,20/,by o is personally knowe or who has produced who is personally known to me or who has produced As identification and who did take an oath. 'fi tion and who did take an oath. NOTARY 1!�ARi A GROPpIEoR _ NOTARY P ' YU01t)ROORIQUEz -•• �°: MY COMMISSION#EE032278 v Notary public•state of Flo a �. � � EXPIRES October 05,2014 ExPlr®s apt 80.9013 Sign: Sign: �' Issloa�DD �53 rou Na at Nat Print- Print vl, azl' ssa. o ssion fires: My Commission Expires: d � jr ��!►`� APPROVED BY 11iZ /si`L*:9—G Plans Examiner Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) 03/07/2014 11:28AM 3053268853 0 & J ELECTRIC PAGE 01 '05 t -� OJELE-1 OP ID:E0. CERTIFICATE OF LIABILITY INSURANCE °A osrozii2 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 (NSURERM AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDi110NAL INSURED,the poliey(ies)must 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 eartificate does not confer rights to the certificate holder in lieu of such endorsement(s). PROrgiem Brown 8,Brown of Florida,Inc. 854-776-2222.cNAOU CT Jose Rodriguez 1201 W Cypress Creek Rd 0130 954-776-444 AKIT �,�:306.326-$852 Arc Na P.O.Box 6727 r. FL Lauderdale,FL 333105727 Denise P.Morris #4540"S)AFFORDING COVWAGE NAKI/F INSUREKA:FCCI Commercial Ins Co 33472 INSUR® O 8r J Electric Corp. INSURER B tFCCI Insurance Compaq 10178 Jose Rodriguez INSURER C 2164 NW 19th Avenue Miami,FL 33142 INSURER D. INMMr.R 13: INSURER F -COVERAGES CERTIFICATE NUMBER: REVISION NUM ER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE=RIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS CP-k'r[FtCATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN Is sUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONPMQNS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF INSURANCE POUCYNUNBFJt IMPURM lINiTB GExveRAAL uAep 11Y EACH OCCURRENCE 1,000,00 A X cOUnnA(Rr,WI GENERpI LIABILrTY OJfwI,E-1 z OsroiHa 05/o1MS FMIE s R a 5 900,00 OLAIMB-MAM [K]OCCUR Met)EXP(AnY— -) S 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAz4g REGATE S 2,000,00 [iEN'LAGaREOAT6IIMIT APPLIES PER PRODUCTS-COMPIOPAGt3 S 2,000,00 POLICY X F LOC mp Ben. B 1,000,00 AUTOMOBILE LFABIUTY 6ABiNED St E LIMIT I'' a acct ANY AUTO BODILY INJURY(Par parm n) S ALL NF17 _ _ AUTOS NONaO�WNEO BODILY INJVFtY(Pracddwd) 6 HIREDAUTOS AUTOS PROPERTY S UUM-IA LIAB OCCUR EACH OCCURONCE 6 OtC=UA8 HC"t"ADE AGGREGATE S EO I I RiTENTION 1HORKEr42COMPE mnON WafSTA 10TH. AND EIdPLOYEAS'LIABILITY X Y LIMIT" R B AN�t. `A UDW? rursve Yr��-H, NIA OJELE 1.1• 05/99112 05/18/13 G.L.EACH ACCIDENT s 1,000,00 yea dcaai6eupr E.L.DISEASE,EAEMPLOYE S 1,000,00 DESCRIPTION OF OPERATIONS E.L.DIWASE-P01JCYLIMIT s 9,080,00 DESCRIPTON OF OPERATIONS I LOCATIONS 1 VEHICLES OWtuh AC11iD 1(11,Additional Rema is Sehadula,if mote space ie tegbirad) Electrical Contractor i i CERTIFICATE HOLDER CANCEL.LA7ION MIAMISH SHOULD ANY OF THE ABOVE DCSCRUB90 POLICIES tSfi CANCBLLEO BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attu'Building Dept ACCORDANCE WITH THE POUOY PROV151ON3. 10060 NE 2nd Avenue AUTHORREd REPREsQ+TATIVA i Miami Shores,•FL 33138 ' 01888-2018 ACOAD CORPORATION. Ali rights reserved. ACORD 25(2010105) The ACORD name and food are registered marks of ACORD s , 03/07/2014 11:28AM 3053268853 0 & J ELECTRIC PAGE 02/05 AC;#C 30 7 5 61 STATE OF FLORIDA �� s � RICALSCQZ T>�ti+18g S�L���s��i��G9I' SEM142082702541 c s 11M27 2'012 1 045 54 Ob00122 TbR VL$G°1zRI0AL CO3ETRAC= N mmd belay 10 MmTxFIzp Vhder the pxovisimm Of Ch�tew 489 F3. Zvviratlon date: ALUM 31, 20 4 RUWSSL IX=m V_ 0 & *7 st2c=c CORP la 19 AVBI�pM AAXT MUM FL 331.49 xzcK ©R XM L>!i4 aN s�»Gr�x pl3Pl_8Y AG fl tOUIRED f3Y 1AVV 03/07/2014 11:28AM 3053268853 0 & J ELECTRIC PAGE 03/05 ���•':ire...,r.,�,�'�"? •., Y,''fi�' :�'+S ��T'ViRW� 'f•:+..';:;• r is i Q•. E T: QLEft i-%:. ) . i .n lJ.S.POSTA(it 9 .,, :-a;....';„, �w, Jc` p' PASri MIAIGl1,.FF-;'d3fef0.:' :: )• r.~ ?? c�(AA�%NO,231 FL 231 fat PERIAr1 • R 539568-'6 THIS IS NOT A BILL—DO NOT PAY RENEWAL ,3u� r8Fff&f NCORP STATE Nff o 22 563451-5 2164 NW 19 AVE 33311412 MIAMI '?% -J& -J ELECTRIC CORP 'wIfLWMCAL CONTRACTOR WORKER/S RUM IS ONLY A LOM 1 Mi59 TAX REOWT.R FEqRL,MpiT THE N H O Ul:ATORY Y zoe N on O c Tee DO NOT FORWAPM r�uNSV OR cm� gals . H°' &?m WANY a. O A J ELECTRIC CARP Fm= �°►�'�W nub 'JOSE A RpDRIG(!E2 PRES WW a cER[vacpT�N OF OUAUFM& 2164 NW 19 AVE MIAMI FL 33142 �ae�FWjt TAX oR: 07/23/2012 60010000079 l=a�{r::�#�===e1{:lee{=:fejle=s�eleel►{el=elt{,{l:er{=eljsle,{ 000045.00 78 SEE OTHER SIDE i 03/07/2014 11:28AM 3053268853 0 & J ELECTRIC PAGE 04105 08-23-2012 .0 JEFF ATWATER STATE OF FLORIDA CHISF FIMIfTahICIAf.0MCER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF ELECTION TO PE 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: 081231201 :EXPIRATION DATE: 08/23/2014 PERSON: HANDSEL. LENARD FEIN: 681081774 BUSINESS NAME AND ADDRESS: 0 & d •EL•ECTRIC CARP 2184 NW 18TFf AVE MIAMI FL 35142-7452 SCOPES OF SUSINI=SS OR TRADE:• 1— l: .=R'tCAL CONTRACTOR IMPORTAIM Poracsot to Chapter 440 . 06(1*, F.S., on officer of a corporation who alacls exemption from this chapter by fflfag a ceri;ficate of election under this sStdaa may not recover bandits or compensation utter ibis chapter. Parsoaot to Chapter 440.06(12), F.9„ Cortfflcates of elactfoo to be exempt... apply only erithtn the :cape of the bmsimess or trade listed an the notice of election to he examl L Pormat to Chapter 446,6sov, p.s., Notices of election to be.exempt and certificates of election to be exempt shall be sabjeet to revanduo Il, at any time after the twag of the notice at the isssenes at the eartificato, The person named on the notice or cerdlloote no longer meets the requirements of this sewaa ter Issuance of a certificate. The deparbnent shall revoke a certificate at nay time tow failure of the person named ad the cwtilicate to meet the requirements of this seed". a11ESTIONS? (850) 413-7501 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-77 03/07/2014 11:28AM 3053268853 0 & J ELECTRIC PAGE 05/05 s. 08-23-2012 012 JEFF ATWATER STATE OF FLORIDA. CHIEF IMMICIAL0MCER 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 fisted below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE•DATE:: 08,12312012 EXPIRATION DATE: 0812312014' PERSON: 'RODRIdUE Z- :' JOtE' .A' FEIN: 651081774 BUSINESS NAME AND ADDRESS: 0 & J ELECTRIC'CORP 2164 NW 19 AVE MIAMI FL 33142 SCOPES OF BUSINESS OR TRADE 1^ ELECTRICAL WIRING WITHIN BUILD IMPDRTANT7 Poraaaot•to Chaptet 44D . 11504 F.S., an officer of it corporstion woe elects exemption from this chapter by flliag a certificate of election.under this nation may not rocover bandits or compensation aoder this chapter. Pursuant to chapter 440,05021, F.$,•Certificates of election to he exempt.., apply only within the Mpg at.the business or trade listed cis the notice of election to be exempt. Puronaot to Chapter 44U.USII*. F.&, NaGeas of election to be o4ampt gad Certificates of election to be exempt shill be eueiect to revosatloo If, at nay time after the filisg of the notice or tba issuance of the certificate, the person named an the notice or certificate ac ioager meets tae requirements of this section far issnsoee of a certificate. The department shall revoke a cenificate at any time for failure of the person named an tda ceraticate to meat the muttsmont& of this section. (IUFST10NS1 (850)•413-16 OWC-252-CERTIFICATE OF ELECTION TO BE EXEMPT REVISED DI-11 • illl I 03107/2014 11:36AM 3053268853 0 & J ELECTRIC PAGE 01/05 OJELE.-4 OP 10:EO• DATE(01021 A'YYY) Y CERTIFICATE OF LIABILITY INSURANCE asro2r�z 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"BETWI=EN THE ISSUING INSURER(S), AUTHOM290 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the pollcy(lea)must be endorsed. tF SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an enldorsoment A statement on this certificate doom!not confer rights to the certificate holder In Ileu of such endorsements. PR(=QAR 9 -2222.11AME.GT .lose Rodri uez Broom&Brown of Florida,Inc. 854-776.4446'PRONE 305-326-8852 arX No. 1204 W Cypress Crook Rd 0 130 P.O.box.5727 E.m Ft Laudardaie,FI-33310.6727 IMSU!MMGI AFFORDING COVERAaff NAIL A Denise P.Morris INSURER A:FCC!Commercial Ins CO 33472 INSURED O&d Electric Corp. INSURERS:FOCI Insurance Company 10178 Jose Rodriguez INSURER C: 2164 NW 48th Avenue wsuREZD: Miami,FL 33142 INSURER E i IN F: COVERAGES CERTIFICATE NUMBER! REVISION NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTeD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 9E ISSUED Oli. 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. MjR TYpE DP INSURANCE POLICY NUMEWR MM F� M 11MiTa SM401ALLtABIITY EACH0CCURRENCE $ 1.000,0 A• X cowlnnERCIAL GENERAL LIA131LITY O.IELE-1-2 05/01/42 05/01/13 s 100,00 OLAIMS IADE FX1. OCCUR MED EXP AnY one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 13WGAAL 6RgR2CATE 2,000,00 GEN'L AGGREGATE UMlT APPLIES PER: PRODUCTS-DOMPIOP AGGG $ 2,000,0 POLICY X PRO- UFO Em Mon. $ 1,000,00 AUTOMOBILE LIABILITY NdED SiNrft E Ll ANY AUTO BODILY INJURY(Per person) 3 ALL OWNED 60KEDULED tIODILYINJIIRY( wwAdSM) $ AUTOS p er RTD HIRED AUTCS AAAUTTO EO 9 UMBRELLA LlA6 pC,UR _!A02 H OCCURRENM $ E ccm UAB OLAIMS-MADE AGOWGATE S $ REfENTIO WORKERSCOMPENSK'nON X YT.M OT- WORKERS EMPLOYRRB'LABILITY E ANY PROPRIET0WAWMERIEXEDUrMEYIN OJELE_14 06/18/12 06/18/13 ELL EACH ACCIDENT $ 1,000,00 OFFICERIME MM EXCLUDED? NIA (Manutm in NH) E.L DISEASE EMPl4YE8 $ 43000,00 0 y-os dcacrii m under E.L DISEASE-POLICY LIMIT 8 1.0aa,oaa r);SdMPIION PERATIONS Dms=PMON OF OpMtATWW9I LOCATIONS I VEHICLES(At ah ACORD Iin,Additional Remarks Schedule,if more Spam ts MgLdred) Electrical Contractor i CERTIFICATE HOLDER CANCELLATION ' M.IAiuIISH SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village ACCORDANCE! TVaTH THE POLICY PROVWIONse W!LL BE DEI IVERED IN Attu:Building Dept 10050 ICE 2nd Avenue AUTHORU=REPRESENTATIVE ' Miami Shores,FL 33138 '� d�%���,• � _ . 931988-2010;.ACORD CORPORATION. All rights reserved. }ACQRD 25(2010106) The ACORD name and logo•are registered marks of ACORD i 03/07/2014 11:36AM 3053268853 0 & J ELECTRIC PAGE 02x'05 # 6 3 0 7 5 61 �g �QSTATE OF FLORIDA y QD LI AR�R;CAL E T O PRIM B TASE09 D12089702541 BF •rie' 27 2612 1. ams:2a4 0000.0 22 ThS CWRzeAZ c �A Named below IS CUTIFIRD 'ceder the grovivima of Mapiesx 9 BA FS. Rxpirai ian Utes AUG 311 2016 AA1�1nSRL. T.�? -CORP 2154].09 9 AVEMM APT MIAMI YL 93142 RtRCO SCOTT KEN SCR LU1 MON ..__ - - - _ ......... . . .. . . . ,. ., . ,piSPLAY AS REOqIRPP BY 1 AW. 03/07/2014 11:36AM 3053268853 0 & J ELECTRIC PAGE 03/05 FIRST-CLASS :,rax:CO> i�FC'..:.:: ;1�,,y a,x• t - 4 U,s-POSTAOS I!10,�1iV(r. QL"RR d:;'' -s r:. ,.?y;`t a z:'' "'�'' i yF"• A31AAI .f!$ •r � ,'� .. ••v.. •ii• •7.(F•iy'° j ..r ry, h FL :1f�Aml1; 9Q•'�;,`'e>• c d� PERMIT NO.231 5.19568-6 THIS IS NOT A DILL—DO NOT PAY .RENEWAL I�u Ita ss QHCORP STATEIE0000122 563451-5 2164 NW 19 AVE 3314? MIAMI 0'1% 'J'J ELECTRIC CORP ' IY60 1 06 CAL CONTRACTOR WORKS/S TIN fS ONLY LOM MOT PERIIQI' THWIT ' KIADIR TO VIOLATE ANY EXiSiiNG QtA"ATOUpar7aNRe DO NOT FORWAftFs W'71ES. tali DOES m �o� 0 8 J ELECTRIC CORP MMM SLAW..' JOSE A RODRIGUEZ pRES TIM yo�jA 2164 NW 19 AVE Mora. MIAMI PL 33142 PAYMBU RECEIVEA 1pU LTZADE OORMV TAX 60010000079 IA;Itllfp#widl f7asa . a ::e sa i •Is 000045.00 78 SEE OTHER SIDE I 03/07/2014 11:36AM 3053268853 0 & J ELECTRIC PAGE 04/05 08-23-2012 JEFF ATWA'TER STATE OF FLORIDA CHIEF PINMIGML OFMER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF ELECTION TO ,1E 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. EFFr=CTIVS DATE;. 0812312012 9XP•IRA4TJON DATA 08123/2014 PERSON: HANDSEL •LENARD FEIN: •651081774 BUSINESS NAME AND ADDRESS: 0 & J SLECIrRIC CORP 2184 NW 18Th AVE MIAMI FL. 33142-7452 SCOPES OF BUSINESS OR TRADE: 1- ELECTRICAL CWRACTOR 1MPQATARTi Parsuast to Chapter 440 . 06114), F-S., art aflicar of a earporaxion who erects exemption from this chapter by filing a certificate of election under this section may not recover besel€ts or compensation under this chopter. Parsusut to Cbapter 440.05(12), F.S., Cartlflcates of election to be oxempt... apply aaiy within the scope at the business or trade list&# on the notice of election to be exempt. Pursuant to Chapter 440.05681, F.S., Notices Of election to be exempt and certificates of election to be exempt Shall he subject to rovocmian if, et any tioie attar the filing of the sauce or the issuance.of the certificate, tits person named on the notice or certificate no longer meets the r000iromeam of this section for issuance of a certificate. the department shalt revoke a certificate at say time for failure of tba porsuo aamsd as ft comyfcsto to sleet the regniremeats of this section. QUESTIONS? (850) 413-1009 DWC-252 CERTIFICATE OF ELECTION TO 'RE EXEMPT REVISED 01-11 • 4 03/07/2014 11:36AM 3053268853 0 & J ELECTRIC PAGE 05/05 AS 08-23-2012 JEFF ATWATER STATE OF FLORIDA CHEF IMMIClAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF GLECTION TO'BF' IXIEMPT 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: 0812312012 EXPIRATION DATE: 08/2312014 PERSON- RODRIG= ' J631 E,'. " A. FEIN: 6510817/4 BUSINESS NAME AND ADDRESS; 0 & J ELECTRIC CORP 2164 NW 19 AVE MIAMI FL 331.42 SCOPES OF BUSINESS OR TRADE: I- ELECTRICAL WIRING WITHIN BUILD IWMTAfth Pursuant-w Chapter 440 . cooAf F.s., an officer mt a earparation who elects exemption from this chapter by filing a cannicate at election under this section may not ruaver benefits or compensation under this chapter, personal to Chopw 44a.a6ilzl, F.S., Certificates of election to be exempt•., apply only within the scope of $6 tmtSineas or trade listed on the uetice of election to be exempt, Pursuant to Chapter 440,01>j13l, F.s., Mines of electlma m he exempt mad caniifestes of elactian to he exempt shard he subject to revocation if, at any time atcer the filing of the native at Ike issuunce of the cenifisate, the person amnted an the notice or Certifiete no longer meets the requirements at this section for issuance of a certificate. The department shall revoke a certificate at any clot 4or.failure at the pomp named so the Certificate to meet the requirements, of this section. auFSnoNS7 (850),413-180 OWC-252 CEiiTIFICATE OF ELECTION To BE EXEMPT REVISED C1-11 L.Wft l.S.f. .t. .,L..e ..'�..'.•'.. 1 I