Loading...
EL-11-1306M Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 178044 Permit Number: EL -7 -11 -1306 Scheduled Inspection Date: September 17, 2012 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: FORBES, JOHN _ Work Classification: Addition Job Address: 304 NE 99 Street Miami Shores, FL Project: <NONE> Contractor: WELL ELECTRIC TECHNOLOGY Building Department Comments ELECTRICAL WORK FOR NEW ADDITION as per letter from el contractor. ok to place hold in the permit. no inspection for el are allowed until home owner does change of contractor. 2/15/2012 - CHANGE CONTRACTOR Inspector Comments Phone Number (305)757 -7750 Parcel Number 1132060135600 Phone: (305)726 -7098 Passed CREATED AS REINSPECTION FOR INSP- 177978. Stove top and oven need breaker locks. 4 gang wether proof plate is missing. All receptacles in garage to be G, F. I. protected.ln use cover missing. Failed Correction c Needed ❑ / ei �� Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. September 17, 2012 For Inspections please call: (305)762 -4949 Page 17 of 35 hORES VILLAGE Miami Shores Village iww if 2ND AVE NIANI SNORES. FL 33134 Building Department (36) 795 -2207 ' ?""Bunamm 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 L15 ovED Permit No. FU 3 Master Permit No. I " 53 1 Permit Type: Electrical 1 OWNER: Name (Fee Simple Titleholder): n � 6 J Phone #: Address: 3 O A//-F- 99 S % - City: m t&m- / s t oRec5 State: Zip: .�31 Tenant/I.essee Name: _ Email: j*42 &F5, HER JOB ADDRESS: 3 0 y MF 2 9 =,M City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: Is the Building Historically Designated: Yes NO x Flood Zone: 3-3J30 CONTRACTOR: Company Name: X41 Phone #:7e0 —Rl�- Address. ff,3 }` /�i9ir" City k % State: /r�� Zip: Qualifier Name: er? h Phone #: S e. State Certification or Registration #: Certificate of Competency #: Contact Phone#: .544.z -C- Email Address: AJAGAd7i�i��.J%��1���. DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ ® Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace ❑Demolition Description of Work: O GL— 01F LC N-C TCy e Submittal Fee $ - Permit Fee $ 10 Alp CCF $ CO /CC $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ DBPR $ Bond $ Technology Fee $ I-lar Cy, TOTAL FEE NOW DUE $ 1 Bd"niltompai h3rAame (if applicable) _ Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State zip 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. Signature 491, 4d--" V - Owner or Agent The fore going instrument was acknowledged before me this day of (1/1 20(, by O"ti - 'cNPC_QK , who is pe ally kno o me or who has produced As identification and who did Signature ontractor % The foregoing instrument was acknowledged before me this day of , 20 12,by -0 �\J W , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: ..� •.•• 9�j,'�, NOTARY PUBLIC: C-1 NX Sign: = o . �3 ° o ° i cNi� = Sign: GO /oil Print: = �n � C ° • Print• j—z t/ ��- r' O'er o My Commission Expires: '�,��� '• ..`' • p`�1 .. ..• ' My Commission Expires: i q �. to nnn+ 2 G/z APPROVED BY / UG Plans Examiner Zoning (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Structural Review Clerk Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. I ) - Iaokn7 Owner's Name (Fee Simple Title Holder): Jo k'? � �es Phone #: 3()S-- ` 9-12- '?'1ST Owner's Address: '3014 Q G- 95 5"F City: r" i / P+M! �5 t-ID aicS State : 4�C- Zip Code: 3 -�/,� Job Address (of where work is being done): 3 Cam! ?-- 9 1 57- City: Miami Shores State:_Flodda Zip Code: 3 31 3'9 Address: City: '6� � State: "� Zip Code: Qualifier's Name si Lic. Number: dRt 13e, oll ,;rl Architect/ Engineer of Record Name: Address: City: State: c, VJC42,4- 41-yz Phone #: Zip Code: I hereby certify that the work has been abandoned and/or the contractorlarchitect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless for all legal involvement. Signature 011 q�' owner or Agent The foregoing instrument was aknowledged before me this day of �S-0'4 '26 C;by Wh rson ho has produced Signature ontractor or Architect The for going instrument was aknowledged before me this day of l , 2a /C 4--C-- personally known to me .y�u��,as indentification. Y � 1 ,� .�` •• .a�1' earl i Notary Public• ''��`� Notary Pu lic• Sign: - ` • = Sign: �'-�' m Ea W Seal: ��0� ��°' �"'•' Seal: ''oW.b,���'" THIS IS NOT A BILL — DO NOT PAY 556708 -7 BUSINESS NAME! LOCATION WELL ELECTRIC TECHNOLOGY INC 4312 NW 11 ST 33126 MIAMI OWNER WELL ELECTRIC Sec. Type III Business PAYIEW P MIRM =Cmnm TAR 09/07/2011 09010258001 000045.00 SEE OTHER SIDE TECHNOLOGY INC CONTRACTOR FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 RENEWAL RECEIPT NO. 580708-7 STATE# EC13001181 WORKER /S 1 DO NOT FORWARD WELL ELECTRIC TECHNOLOGY INC TONY WELL FIRES 4312 NW 11 ST MIAMI FL 33126 11111111111tHll fill ll list IIIII J d III II111*1111 till t11iva1 JEFF ATWATER CHIEF FWANC1AL OFFICER 11 -02 -2011 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: 1110212011 PERSON: FEIN: 352252781 BUSINESS NAME AND ADDRESS: WELL ELECTRIC TECHNOLOGY INC 4312 NW 11TH ST MIAMI FL 33126 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED ELECTRICAL CONTRACTO EXPIRATION DATE: 11101/2013 TONY lfdp Nf -. Pursuant to Chapter 440 . 05114, F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election ender this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.06112), F.S., Certificates of election to be exempt.. apply only within the scope of the bastoess or trade listed an the notice of election to be exempt. Pursuant to Chapter 440.0503), F.S., Notices of election to be exempt sad 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 pursue named ma the notice or certificate no lodger meets the requirements of this section for issuance of a certificate. The department shell revoke a certificate at any time for failure of the person named an the certificate to most the regofremetus of this section. QUESTIONS? (850) 413 -161 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 " CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF BOWMATION ONLY AND CONFERS NO RIGHTS UPON THE ATE HOLDER. THUS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEOATNELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PODS BELOW. TM CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE NSUINO INSURER(Sh AUTHORED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ImpORTANT: U'the cowicate hwa is an ADDITIONAL. INSURED. the poucy(les) must be emtoLse. a SUBROGATION IS WANED, submit to the term and cat Mans of the poft. certain pogdes may require an endarsenwiL Astabe+nard on th; cerUPicate does not collar rights to the carttlicete hakier In Hsu of such endofsefnerd(4 Rmtlr. x WAA9E PAULETTE BROWN DATE(MM/DWYYY) 5/25/2012 FACT INSURANCE SERVICES LLC PRONE N 954 885 -388 12. N,): (954) 885 -388! 18064 Sid 33 Court ANDDREw impactservtmsn.com Miramar, FL 33029 INSURER(S) AFMRDING COVERAGE NfIICA A032618 INSURER A: NOVA CASUALTY COMPANY ISSUED WELL ELECTRIC TECHNOLOGY, INC. INSURER B: INSURER C: 4312 NN 11 STREET INSURER D: MIAM , FL 33126 INSURER E: (786) 399 -9180 INSURER F: :OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REMJIREMENT, 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, — m � nni irmca i wr a CN[t1NRl MAY I4AVF RFEN REDUCED BY PAID CLAIMS. M v --- — — TYPE OF INSURANCE 13L RIM wo POLICY NUMBER (M LIMITS !!, GENERAL LIABLnY x COMMERCIAL GENERAL LIAGLITY CLAIMS•MADE r " r OCCUR 09AL063141 /29/2012 %2712013 EACH OCCURRENCE $ 1 000 00( PREMISES (Ea occur . ) $ 100.00( MED EW(Arryomperm) $ PERSONAL &ADVINJURY $ 1,000,00( GENERAL AGGREGATE $ 2,000,00( SEWS AGGREGATE LIMIT APPLIES PER: POLK:Y PRO LOC PRODUCTS - COMP/OPAGG $ 1,000,00 $ AUTOMOBILE LIABILITY ANYAUTO ALLOWNED SCHEDULED AUTOS AAU NON-OWN � HIRED AU'T'OS AUTOS accident) $ BODILY INJURY (Pw person) $ BODILY INJURY (PeraaitforM $ (Pet acdde $ UMBRELLA LIAR DCCESS LIAR OCCUR CLAIMS-ME EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ v;ORi(ERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PRCPRMTDRB'ARTN ITNE El @fly EXCWDED7 Ifya% describe urder DESCRIPTION OF OPERATIONS below TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L.DISTASE- POLICYUMIT Is ESCRIPnON OF OPERATIONS /LOCATIONS /VEHICLES (A1Md1ACORD 1M, AUIGOM murfalm3 wwo,v nwrvvvr w -".—) MIAM SHORES VILLAGE SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 10050 NE 2nd AVE. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES, FL. 33138 ACCORDANCE WTH THE POLICY PROVISIONS. AUTHORIZED ATIVE I ®1988-2010 ACORD CORPORATION. All rights reserved. ,CORD25 (2010105) The ACORD rallne and logo are registered marks of ACORD Miami Shores Village C -EINj�A Building Department FEB i o 1� 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. 1� r PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: Electrical / OWNER: Name (Fee Simpl Titleholder): mob4 h / `� Phone#: N 9`2 5-7 ,-7.7 j Zy Address: 30 V tic ri S City: 07 1)m / -S kle_-e�s State: Zip: 3,3 62 5J Tenant/Lessee Name: Email: JOB ADDRESS: i 11 Lf K/ C 9 -11 5 I L ! v r= a C C. City: Miami Shores County: Miami Dade Zip: 3 3 r ?, Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: "C C , /d,% V C, 4 I : f t �; ,fie , Zv ��� ; d Phone#: 3f')` 963-43 Address: �d 7 ? - k4 , v ei� IL City: / "f � �c State: d "" Zip: _3 Qualifier Name: u e, / State Certification or Registration #: zi'S _;0 -..i � Fr � ')Y.s z Certificate of Competency #: � 0 Q 0 1/ Contact Phone #: �1 6 Y 7,f J s- Email Address: ;e-r e de-c ,z c_ DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ J., a 0-0, a u Square/Linear Footage of Work: Type of Work: ❑Address OAlteration UNew ORepair/Replace Description of Work: %� 00 ODemolition Submittal Fee $ mzl Permit Fee $ 1 CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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. I "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. Signature Owner or Agent The fore g in iinstrument was acknowledged before me this day of , 20 �2� by -S 0*4 tJ f who is personally known to me or who has produced As identification and who dd4ie an oath. NOTARY PUBLIC: Sign: Print: My C %. Signature Contractor The foregoing instrument was acknowledged before me this day of 20A, by ty,411(wL , who i ersonally know>to a or who has produced s identification and who did take an oath. APPROVED BY e 1Plans Examiner Structural Review (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) NOTARY Sign: STATE OF FLORIDA My Commissio Comm# EE041139 Expires 12!71201 4 Zoning Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. --- I Owner's Name (Fee Simple Title Holder): Phone #: 5 ® 5s ? Owner's Address: a Ne cl' q4 s s City: AJ Q R,&�?Rs Job Address (Of where work is being done): City: Miami Shores State: -P/i Zip Code: -3 ) Ivy elcl �1 State:_Flodda Zip Code: Contractor's Company Name: 1411 ks 1244 • 5e-eXio c. Phone #: 3 ®r- y4* - ,7,►-,a.2 Address: 11V 73- o y. ,dA City: State:_ ol-'4 Zip Code: 7J /(, 7 Qualifier's Name: .S�..,me / d4.) A%6aarry Q Lic. Number: o s a o 7,y Architect/ Engineer of Record Name: Address: City: _ State: Phone Describe Work: 461e c -26 -,, "/ w aAh f* 0lo ose 4o",r•4-d4, Zip Code: I hereby certify that the work has been abandoned and/or the contractor /architect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless for all legal involvement. Signature 44 Signature «..� owner or Agent Contractor or rchitect The j foregoing instrument was aknowledged before me The foregoing instrument was aknowledged before me thl /s'� day of .20 byd- �� =Z'�� this �� day of �' , 207'Gby Who is personally known to me or who has produced -Oo is pehonally known to a or who has prc as g1elntification. 1 111 as \�0 \ \II jjj� /,/ Notary Pu Notary Public` Sign: _ 03146` \c Sign: Seal: � .. �4 Q��`6594� • : ®Q\ Sear NOTARY Pus> r �'� ®�� • '' ®� �`� /�'''•SP' TE ����` STATE OF FLO' Comm#EED41 OF .: ?. 1 ?1 arlt w W II 98 QUALIFYING TRAUEIS) 0001 ELECTRICAL FIRE ALARM SPECLT �Y NIAMWADE COUNTY 2011 MUNICIPAL CONTRACTOR'S .2012 FIRST- CLASS TAX COLLECTOR TAX RECEIPT U.S. POSTAGE 14 GAR ST MIAMWADE COUNTY - STATE OF FLORIDA PAD MUft 6,.58180 PURSUANT EXPIRES SEFr. 3% 2012 TO COUNTY CODE SEC. 10-24 PEMOTNIM2 "TT A fKL — W..NGT PAY mo� 30- 5807970 CC NO: OSE000478 BUSINESS NAME / LOCATION RECEIPT HOt DER MOW DO ALL QUALITY ELECTRICAL SERVICES BUSINESS AS A CONTRACTOR INC AS SPECIFIED HEREON. 14750 'S RIVER DR OWNER �sALL QUALITY ELECTRICAL SERVICES E BAO OF RECEIPT FOR ELECTRICAL CONTRACTOR ST OF NON — PARTICIPATING CIPALITIES RwW homer mist DO NOT FORWARD regLcftr homw work ALL QUALITY ELECTRICAL SERVICES where warp Is to be �,e. INC i - PAVIOWTAMMVED MWOOMM COMY TAX a�12/2011 02260020002 000200.00 SAMUEL LIGNTBOURNE PRES 14750 S RIVER DR MIAMI FL 33167 foJi111 �99aal ��a��el!! 1lleflifaiff9aa.fiil$alJfe4li}� 55 &799 -6 THIS IS NOT A BILL — DO NOT PAY RENEWAL Bum fYfWftTRICAL SERVICES INC 14750 S RIVER DR 33167 UNIN DADE COUNTY OWIR QUALITY ELECTRICAL SERVICES SnW V& CAL CONTRACTOR Taff 1$ ONLY A LOCAL I TT Im HOLDEp TO TE AMY CC SP 188478 580797 -0 WORKER /S TM ALL QUALITY NOT FORWARD Oft OR r f5c Y ELECTRICAL SERVICES ON UCOM INC t 1w w T" Is fOA SAMUEL LIGNTBOURNE PRES TOM 14750 S RIVER DR MIAMI FL 33167 rwc 09!12/2011 260020001 29` 000082.50 as afa�:�aau� e��flifaeSasf i�ae.Ias011111sf111 Jilts etl9}� SM O1MM ME CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNY) 07/22111 PRODUCER AnneftWEs Insurance 18401 N.W. 27 Ave MWW. FL 33056 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER T119 COVERAGE AFFORD® BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # — . Phone M 625 -2403 _.. Fax (305) 625 -6472 _.._ INSURED ALL QUALITY ELECTRICAL SERVICES, INC AND SAMUEL LIGHTSOURNE 14750 SOUTH RIVERS DRIVE L. MIAMI, F 33167 ------ _ - - - - -- _.._. ". RER N. WESTERN HERITAGE - - 00601 INSURER B: PROGRESSIVE EXPRESS INS CO 11760 USURER C: CASTLE POINTE INUSRANCE _ 13055 INSURER!?: INSURER E .. -- INSURER F: W POLICY L7 PROJECT -1 LOC AUTOMOBILE LIABILITY ❑ ANYAUTO yJ ALLOWNEDAUTOS 9 SC14EDULEDAUTOS HIRWAUTOS N ON OWNED AUTOS COVERAGE$ -- _ THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. ANOING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACTOR 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LUM SHOWN AIRY HAVE BEEN REDUCED BY PAID CLAIMS. - A061 POI ICY EFFECTIVE PDLNCY EXPtF�1T[ON _ - _ TYPE OF IlQSIIRANCE �— POLICY NUMBER ,I no MntrD DATE mpp-n LIMITS A U GENERAL. LIABILITY ,y] COMMERCIAL GENERAL LIABILITY 110 CLAMS MADE &I OCCUR n GENT.AGGREOATE E.1IMITAPPLNES PER: SCP0742537 04/16!11 f ]f 04/16112 1 EACH OCCURRENCE p>z�rus�ES 0 MED ExP (Anyone petsany PERSONAL &ADVtNJURY- _ 1,00 - 5 - 1,00 _ 2 00 1 1,00 GENERAL AGGREGATE - -� PRODUCTS - COMPIOP AGG W POLICY L7 PROJECT -1 LOC AUTOMOBILE LIABILITY ❑ ANYAUTO yJ ALLOWNEDAUTOS 9 SC14EDULEDAUTOS HIRWAUTOS N ON OWNED AUTOS 03729840 -9 04/18/11 10119/11 _ -_ - - COMBINED SINGLE LIMIT Eaaatd g � 8 E] BODILY INJURY (Per ...• .__. BODILY INJURY (Per accNenty PROPERTY DAMAGE Petacddertly -- —! GARAGE IIABLI Y AUTO ONLY - EA ACCIDENT U ❑ ANYAUTO -�._ - OTHERTHAN YEAACC AUTO ONLY: AGG EACH OCCURRENCE - - - EXCESMMBRELLA LIABILITY ❑ CJ OCCUR ❑ CLAIMS MADE AGGREGATE - - ❑ DEDUCTIBLE _ ... _.._.. �.._.. _ -- ❑ RETENTION $ WORMS COMPENSATION AND EMPLOYERV LIABILITY WCP760394801 08/03/11 __.__ 08103112 11 � TATU- = C ANY PROPRIETOR I PARTNER I EXECUTIVE OFFICER t MEMBER EXCLUDED? 11yes.deseribeunder 50( _�Q ...U. E.L. EACH ACCIDENT _ E L DISEASE - EA EMPLOYEE _._..__ 60( E.L. DISEASE ;POLICY LET 50( - -- SPECIAL PROVISIONS I _. WW _ OTHER FORD ECONOLINE VIN# 1FTRE14WX6HA30873 CERTIFICATE HOLDER - - MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 ACORQ 26 (2009/00) QF _ I SPECIAL CANCELLATION — -- SHOULD ANY OF THE ABOVE DESCRIBED POLLCNES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUNG INSURER vW LL ENDEAVOR TO MAO. 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO MjGATION OR LiAB#= OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. 1 AUTHORIMO REPRESENTATIVE ®AGGRO CORPORATION 1988 r NORTH MIAMI B'0 RANCH USPS North Miami Beach, Florida 331609998 1158540123 -0096 02/08/2012 (800)275 -8777 01:17:22 PM Sales Receipt Product Sale Unit Final Description Qty Price Price HOMESTEAD FL 33033 $0.45 Zone -1 First -Class Letter 0.30 oz. Expected Delivery: Thu 02/09/12 Return Rcpt (Green Card) $2.95 Certified Label #: 70101870000053796077 ==W= === Issue PVI: $5.75 Total: $5.75 Paid by: Debit Card mU.S. Postal pService `4 =: XXXXXXXXXXXX4046 CERTIFIED MAI W RECEIPT 790965 Transaction #: (Domestic Mail only; No Insurance Coverage Provided) — For delivery information visif our wehsite at www_usps_ come r r — _ ■ � J. .. t NORTH MIAMI B'0 RANCH USPS North Miami Beach, Florida 331609998 1158540123 -0096 02/08/2012 (800)275 -8777 01:17:22 PM Sales Receipt Product Sale Unit Final Description Qty Price Price HOMESTEAD FL 33033 $0.45 Zone -1 First -Class Letter 0.30 oz. Expected Delivery: Thu 02/09/12 Return Rcpt (Green Card) $2.95 Certified Label #: 70101870000053796077 ==W= === Issue PVI: $5.75 Total: $5.75 Paid by: Debit Card $5.75 Account #: XXXXXXXXXXXX4046 Approval #: 790965 Transaction #: 319 23 903520706 Receipt #: 000351 Order stamps at usps.com /shop or call 1- 800- Stamp24. Go to usps.com /clicknship to print shipping labels with postage. For other information call 1- 800 - ASK -LISPS. � *tr,r *.+w *d.w *, gar * «,►,► «,t. * * * * *��a * * « * *�a *rr� ** Get your mail when and where you want it with a secure Post Office Box. Sign up for a box online at usps.com/poboxes;***.*** a„ra,rar.a.araaaaaraa,r aaaaa ar * * *,raaaaaaaaaaaaaa Bill #: 1000403525321 Clerk: 11 All sales final on stamps and postage Refunds for guaranteed services only Thank you for your business aaaaaaaaaaaaaaaaa aaaaa �, r +rarvrarar+rarar,r,r+rararw+r+r aaaaaaaaaaaaaaaaaaaaa *aaaaaaaaaaaaaaaaa* HELP US SERVE YOU BETTER Go to: https : / /postalexperience.com /POs TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE YOUR OPINION COUNTS aaaaa aaa a era, rtarararara�r ,rr,r+.+raararar,r,twar,rar,r ar arw�.w aaa, raraaaaaaraararaaaaaaaaaaaa *aaaaaaa,raraaaar Customer Copy 1 � 4 contracting core. February 8, 2012 Via email and certified mail Modern Connection Electric Inc. 2312 NE 37' Road Homestead, FL 33033 Re: Forbes Residence — Contract Termination Dear Frank; Pursuant to our conversation you are unable to complete this project and we have agreed to terminate the contract so we can hire another electrician. Sincerely, TCS CONTRALTI ORP. r 14"M Timothy Henry Smith President P.O. BOX 530299 • MIAMI. FL 33153 • TEL 305.756.6700 • FAX 305.756.6707 www.tcecoorp.com Miami Shores Village g JUL 2 0 2011 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 No. PERMIT APPLICATION Master Permit No.f°l� l� FBC 20 (yj Permit Type: Electrical OWNER: Name (Fee Simple Titleholder): JD � �'rd� Phone* A'7.- r % -5%'? ? Address: Soy yo 019 5, � city: InLtim / S 1407 (.7 State: / c_ Zip: / L� Tenant/Lessee Name: Phone#: Email. JOB ADDRESS: Z04: 1 \Y ✓ �� I City: Miami Shores County: Miami Dade Zip: Folio/ParceW. Is the Building Historically Designated: Yes NO J Flood Zone: CONTRACTOR: Company Name: 09U "Wl 1 v 1,41ee ��%� ��L� Phone#: G30 )o �gl Address: ZJ I Z !0-6F- -5? 7�0 City: T�� �a /` —1eA 0 State: mkt �i�,d zip: 3 3 3 Qualifier Name: ... d yQ,07 FA/ y Phone# State Certification or Regis 'on #: 49 D 14 O 2 1 Certificate of Competen Contact Phone#: 30 f �f la— 9 g Email Address: 4/% _ �c � ��oC� • �''��1 DESIGNER Architec lEngmeer: Phone#: Valve of Work for this Permit: $ ��'%'��° loo ms% -- SquarelLinear Footage of Work: Type of Work: OAddress Description of Work: Submittal Fee $ Permit Fee $ ®©' 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 Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 Signature Signature Owner or. Agent Contractor The f g g instrumen was o �eed, jed� befo a The foregoing ins ment was acknowledged before me this day , 20 l� , by wV �`r ! day of 20 LL, by ]V?C4 $= ho is n y o to a or who has produced ho is personally known to me or who has produced 1°'Y 2 eritification and who did take an oath. 1 as identification and who did take an oath. NO LIC: NOTARY PUBLIC: Si °°' Sign: gn: Print: � b� Print cv1 (i ✓Z My Commission Expires: My Commission Ex + „ p1EgAY�IOND C�a�® 5��g�x `�` �� ° Notary Public, State of Florida �u�` •: ,° � ` �5. ��°� /� `c 'g 91k C4MMW0t#DD878702 $ �, ° • �? Ply comm. expires Apr. 1, 20' APPROVED BY L Z � �. Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 110n009)(Revised 3/15/09) E MtA I #00ADE COUNTY 2Qta MUNICIPAL CONTRACTOWS 2011 FIRST -CLASS ! TAX COLLECTOR TAX RECEIPT U.S. POSTAGE 140 W. FLAGLER ST. MIAMI -DA COUNTY - STATE OF FLORIDA PAID 1st FOR PURSUANT TO COUNTY CODE SEC. 10-24 MIAMI, FL MIAMI, FL =130 EXPIRES SEPT. 30, 2011 PERMIT NO. 231 THIS !S NOT A 811 .. j)0 P�(T PAY RECEIPT NO, 02-6516422 CC NO: OBE000254 BUSINESS NAME / LOCATION RECEIPT HOLDER MAY DO BUSINESS AS A CONTRACTOR MODERN CONNECTION ELECTRIC INC AS SPECIFIED HEREON. 2312 NW 37 RD OWNER :MODERN CONNECTIONI ELECTRIC INC RESTRICTED TO THE ELECTRICAL CONTRACTOR CITY OF: MIAMI BEACH Receipt holder must DO NOT FORWARD register in the city where work is to be MODERN CONNECTION ELECTRIC INC done. JUAN F CHIU PRES 2312 NW 37 RD HOMESTEAD FL 33033 PAYMENT RECEIVED GUAM1I -DADS COUNTY TAX `O' 1` A6 /2010 02270010001 000077.65 20 CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDNYYY) 12/03/10 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. .. . .... ... . . .. ...... .. .. IMPORTANT. If the certificate holder Is an ADDITIONAL INSURED, the policy((es) must be endorsed. It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such-endorsarnent(s). ......... ... ...... PRODUCER CONTACT NAME: Sunshine Insurance Agency ohdh�* Fax 2595 SW 87th Avenue NPIPMURR BESS ......................... ......... . Miami, FL 33165 CUSTOMER to ......... .. ... Phone (305)559-7873 Fax (305)559-2237 INSURER(S) AFFORDING COVERAGE NAIC # .... . ....... . .... ... ...... ... . ....... INSURED INSURERA: WESTERN WORLD INSURANCE COMPANY ..... .... . ... . Modem Connection Electric Inc INSURER 8: 2312 NE 37 Rd INSURER C: HOMESTEAD; FL 33033- INSURER .. . . ....... ....... INSURER E: . . .... ...... . .... . .................. (786) 236-8619 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER. THIS IST6C&f0VTWTHE POLICIES OF INSURANCE CISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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 TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1N *; **** *** *- * , , , , - -*** -- - * - - POLICY EO L PR TYPE OFINSURANCE POLICY .. ...... .......... .. .. (MM/DD/YYYY IQ ............ . . .. .... . JNISR WvD.1 GENERAL LIABILITY EACH OCCURRENCE i$ 1,000,000 DAMAGE TO]WRTEW COMMERCIAL GENERAL LIABILITY 50,000 CLAIMS MADE / OCCUR FXVSV MED person) 1$ 5,000 EXP (Any one A 12103r2010 12103r2011 PERSONAL & ADV INJURY 1,000,000 : . . .. ...... ......... .... 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRO DUCTS - COMP /OP AGG 1 $ 1,000,000 POLICY PRO - LOC J AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea amdent) . ......... . ANY AUTO BODILY INJURY (Per person) ALL OWNED AUTOS ------ BODILY INJURY (Per awdent) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS -MADE DEDUCTIBLE RETENTIONI ............... ......... .... . . . . . .... ..... . . . ... .. . .......... ... . ... ...... ... . ............ WORKERS COMPENSATION WC STATU OTH- i AND EMPLOYERS' LIABILITY YIN' ;--Ly0'1JR11Y1JM1T8-.-' LFR-- ANY PROPRIETOPJPARTNERIEXECUTCVEf E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA i (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ i IfasdilasTcribNe under P 0 D OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ . . .............. . ....... ..... . DESCRIPTION OF OP ERAT I ON S I LOCATIONS / VE HiC LES (Attach ACORD 101, Additional Remarks Schedu Is, if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE TCSCO-1 ACCORDANCE WITH THE POLICY PROVISIONS. 10010 NORTH EAST 2ND AVENUE MIAMI, FL. 33138 AUTHOPaED REPRESENTATIVE MARIA E HERNANDEZ ..... . .... I .. . . . ..... - ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 26 (2009109) OF The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(A INDDNYYY) 05110/11 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: B ffiw certificate holder is an ADDITIONAL INSURED, the poky(les) must be andorsed. Il SUBROGATION IS WAIVED, subject to the tents and conditions of tho poky, certain pokles may require an endorsement. A statement on this certificate does not come rights to the oe WIrAte holler in Hsu of such endorsement( ). PRODUCER Sunshine Insurance Agency 2395 SW 67th Avenue Miami, FL 33185 Phone (305)559 -7873 Fax 305)559-2237 137CT Maria E Hemandez IPME. (305)559 -7873 (Fre. N. 1. (306)559 -2237 L sunins@beRsouth.net INSURER(S) AFFORDING COVERAGE NA1c 6 INSURERA; Western WOM InSUMOe COmparry INSURED Modem Conne(lion Ele*o Inc 2312 NE 37 Rd HOMESTEAD, FL 33033- (786) 236 -8619 INSURER B 12I03I2010 INSURER C: EACH OCCURRENCE INSURER D' P I DAMAGE $ o� . awrer —B) INSURER E: � Ems' � " INSURERF PERSONAL &ADY INJURY COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWiTHSTANDINGANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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, EXCLUSIONS AND .CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAD am LTR TYPE OF DWRA14CE ADDLSUSR POLICY NUdBER POLICY EFF POLICY EXP LIMITS A GEN WAL LI UMM Q COMMERCIAL GENERAL LIABILITY ❑ n CLAIMS.MADE R] OCCUR F-1 Fax 305 - 895 -g822 NPP129Z799 12I03I2010 12/038411 EACH OCCURRENCE S 1,000,000.00 P I DAMAGE $ o� . awrer —B) $ 50,000.00 � Ems' � " $ 5,x.00 PERSONAL &ADY INJURY $ 1,000,000.00 ❑ GENERALAGeREGATE s 2;000,000.00 GEWL AGGREGATE LIMIT APPLES PER ❑ POLICY ❑ P ❑ LOC PRODUCTS - comptOP AGG $ 1,000,000.40 $ AUTOMOBILE F VA r ❑ ANY AUTO ❑ U OWNED ❑ SCHEDULED AUTOS 1:1 A MINED ❑ ❑ El INED SINGLE LIMIT iocid B m t) BODILY INJURY (Per person) $ BODILY INJURY (Par 8=klwt $ P P DAMAGE $ $ ❑ UMBRELLALJAS ❑ OCCUR ❑ EXCESS LIAS ❑ CLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ WORRERB COMPENSATION AND EMPLOYERS, Ll48LM YIN ANY ROPRIETOR�ARTNERIEXECUTNE OFFIGER1fNER EXCLUDED? (t mutatory in KH) www DESCRIP PION OF OPERATIONS balsam NIA 11 STATU El OTH I E.LEACHACCIDENIT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATION81 LOCATIONS! VEHMM (Attach ACORD 101, AddWoad Remarks 8chedute, N Mora sRece is required) CERTIFICATE HOLDER CANCELLATION ®1988- RD CORPORATION. All rights reserved. ACORD 26 (2010105) QF The AC a and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE D SCRIBED POLICIES BE CANCELLED BEFORE NORTH MIAMI FLORIDA THE EXPIRATION DATE THERE F, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE PO PROVISIONS. . Department of Building &Zoning 12340 NE 8 Avenue AUTHORR" REPRESE M North Miami, FI 33181 Fax 305 - 895 -g822 MARIA E HERNANDEZ ®1988- RD CORPORATION. All rights reserved. ACORD 26 (2010105) QF The AC a and logo are registered marks of ACORD VC6� ------- - - -' -_ �..� To: Building Department Address: 10050 NE 2"d Avenue. Miami Shores Village, Fl. From: Modern Connection Electric Inc CC #: 08E000234/EC #:13014029 Address: 2312 NE 37h RD. Homestead, Fl. 33033 Who may concern. JAN 3 0 '&'.J-:2 January/25/2012. 1, Juan F. Chiu, owner and president of Modern Connection Electric Inc. l wantftxtate that my Company is no more to service in the direction of. 304 NE 99 Street. Miami Shores, Fl. Permit number which is: EL -7 -11 -1306. Due to failures to follow in contract, with this letter I know that my company can not be held responsible for any kind of work (Electrical) after the date: January/17/2012 (last inspection) so I ask you not to accept any call for inspection, unless I, Juan F Chlu do personally in the Building Department, to avoid any fraud. And /or that the General Contraor requested the service of another Electrical Contractor, and Modern Connection Electric Inc remains free of any service connection Insecure, and also that it is not liable for any damage caused by mother person. Thank you for your attention. STATE OF FLORIDA Sworn to and subscribed before me this day of� 20_ by Signature of Notary- Publ' Print Name_, (SEAL) rtm vhsan Nolm puw, ewe of Paida Personally known or Produced IdentficaU ar - o 06-03 -2010 ALEX SINK STATE OF FLORIDA CHIEF FINANCMOFFICER 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: 06/03/2010 PERSON: CHIU FEIN: 260398823 BUSINESS NAME AND ADDRESS: MODERN CONNECTION ELECTRIC INC 2312 NE 37TH ROAD HOMESTEAD FL 33033 SCOPES OF BUSINESS OR TRADE: 1- REGISTERED ELECTRICAL CONTRACT EXPIRATION DATE: 06102/2012 JUAN F IMPORTANT; Pursuant to Chapter 440 . 05641, F.S., an officer at a corporation who elects exemption tram this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.0502), F.S., Certificates of election to he exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.0603), 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 at 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 most the requirements of this section. QUESTIONS? (650) 413 -1609 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 I m DO NOT FORWARD MODERN CONNECTION ELECTRIC INC . .. C y 4 ; } . 231,2 2 .. "y? <a> y 2 � r 9 + / ƒ HOMESTEAD 6\ 33033