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RC-12-2200Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 205592 Permit Number: RC -11 -12 -2200 Scheduled Inspection Date: January 13, 2014 Permit Type: Residential Construction Inspector: Rodriguez, Jorge Inspection Type: Final Building Owner: , Work Classification: Alteration Job Address: 79 NW 92 Street Miami Shores, FL Phone Number Parcel Number 1131010170150 Project: <NONE> Contractor: HUFFCO CONSTRUCTION LLC Phone: (786)273 -0536 I5wla comments PARTIAL DEMOLITION OF ROOF AND FLOORING AT FRONT PORCH TO THE EXIT END INDICATED IN PLANS. APPLY STUCCO FINISH ON NEW ROOF END. REPAIR AND REFINISH TO MATCH EXISTING. ALL AFFECTED AREAS BY DEMO. INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re- inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. January 10, 2014 For Inspections please call: (305)762 -4949 Page 22 of 23 Miami Shores Village Building Department 7BY- 10050 AN 07 2014 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 No. Master Permit No Kn /J Permit Type: BUILDING ROOFING JOB ADDRESS: % 1 A V !2 ? 6� City: Miami Shores County: Miami Dade Zip: Y Folio/Parcel#: Is the Building Historically Designated: Yes NO X Flood Zone: Al OWNER: Name (Fee Simple Titleholder): A,eSir 7ann50-o Phonet, Address: 1i/ In/ e? City: ��e State: C. Zip: 3 is a Tenant/Lessee Name: Phone#: " 7 ? ( j3`- V -Jr 0 Email: CONTRACTOR: Company Name: � � Phone#: 714 2,7-3 4� 3e Address• Ay/ City: o�� �� cd2a' State: Zip: s Qualifier Name• V State Certification or Registration #. a Contact Phone#. "_ .3 i% 6` of Competency #: DESIGNER: Architect/Engineer: VI A-g (L� ,7 Phone#: Value of Work for this Permit: $ 7l` 04 >- Q&," SquareUnear Footage of Work: Type of Work: OAddition DAlterado New ORepair/Replace `gDemolition Description of Work: r / ^ COZOP thru tlx: Submittal Fee $ Permit Fee $ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Edueation 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 Zip 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Si ature� Si Owner or Agent Contractor The foreg ' g instrument was acknowledged befoorre me this , i16 The foregoing instrument was acknowledged before me this day of , 201, by -�%�cS / /(l/ISL�Ii day of .20 _, by w o is personally known to me or who has produced who is personally known to me or who has produced 11CVAs identification and who did take an oath. as identification and who did take an oath. ,r NOTARY PUBLIC: Sign: Print: -- '— Q'1MINX LOZINSCHI" Notary Public - State of Florida My Comm. Expires Jul 31, 2015 APPROVED BY i� i� s` Y' ' *A, Monica Swim NOTARY PUBLIC: COMMISSION#EE06674 3 G. ­EXPIRES: FEB. 22, 2015 www.AARONNoTAR1Gwm Sign: Print: i y`✓ I l t S i f'e i Y17 fires: o °;RYP,, "AOn", c,7 ueiro aeiro I ;Q.. ,, _:^66743 , :56743 0,95- ;���, , 2015 Plans Examiner Zoning Structural Review Clerk (Revised 3 /1212012)(Revised 07 /10/07)(Revised 06/10rM)(Revised 3115/09) lot¢ �pRf�th aey gpvemmentai or U ii9t111+# peYCode Sec a rl�ff-ff CERTIFICATE OF LIABILITY INSURANCE DAMtMMOMM) I (M1=4 ;iiif z; �� i:� �� �::: j AS � i i i AMATTER INFORMATION ONLY AND CONFERS No RIGHTS UPON THE CERTIFICATE HOLDEILTHIS CiR''TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEW, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIMME OF MURANCE DOE$ NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUM MnMqS) AWMRMW REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. WIPMANT, N the certificate holder is an A=TKML MURED, the poky(les) must be endorsed. 9 SURROGATION IS WANW, sLqM to the terms and conditions Of the Pollm certain policies may require an andorsemenL A statement on this certificate does not confer tWft to the cartilkate holder In lieu of such endorsemenqsl MODUCIER Kiv Insurance Agency 2652 SW 87th Ave Miami, Fl, 33165 Phone M=-MW (305 Fax �=,4981 (305)227-8956 00a=74011 luaniteuroosxrm C-OVOWE N�ARMA: Mmu"woommerow Imumme company INSURED llu fbo Contructlon, Inc. 1165 NeI35 Av E Miami, FL 33161• 222 WW REFt 0,, INSURERC: WWRER 0: INSUREM Miami Shores Villap Building Deparbvent 10050 NE 2nd Ave Mlarrd Shores, Fl. 33138 ACORD 25 (MOM) GIF @ INO-2010 ACORD CATION. M rights reserved. The ACORD nante and logo we fegisbuid rnaft of ACORD I, A6Nf} �1P�Al ��Zlr� 1�-� �', of_�l` - � i� 11r� %L�UT1T .S9CV, appoint -rte. ■ C1, fi r- j'" 7ARv 4 ; ,p 3o IJS ,�_ to act in my place for the purposes of: This power of attorney takes effect one 0/$ 10 1 1 and shall continue until terminated in writing or until � "l V ■ 10 . J W� , whichever comes first. I grant my attorney -in -fact full authority to act in any manner both proper and necessary to the exercise of the forego- ing powers, and I ratify every act that my attomgy -in -fact may lawfully perform in exercising those powers. I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attor- ney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. Signed: This &44day of dam' State of -- County of. Signature: Principal 11 AA Social Security number: 3 Witnesses On the date written above, the principal declared to me that this instrument is his or her finance,.. wer of attorney and that he or she willingly executed it as a free and voluntary act. The principal signed this instrument in my pres- ence. LF240 Limited Power of Attorney 1-09 onolo I= www nolotom , Certificate of Acknowledgment of Notary Public State of County of r SM On u f�a _ a D I 1 before me, public, personally appeared M M , a notary who proved to me on the basis of satisfactory evidence to be the person(s) whose name(S) is= subscribed to the within instrument and acknowl- edged to me that he /she /they executed the same in his/her /their authorized capacity(ies), and that by his/her /their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of „ S that the foregoing is true and correct. Witness my hand and official seal. Signature °Aaa°° °° s r+9 **ROT Fr f ROZO*s�� . a 10 iNa. 97694 ° o v.*.My Comm. Expit" Nov. 23, 2014 � $Oi® CO O ... Acl$ 9VI t of Attorney -in -Fact iOM By accepting or aciftader the appointment, the attorney -in -fact assumes the fiduciary and other legal responsibili- ties and liabilities of an agent. Name ofAttorney -in -Fact: Signature of Attorney -in -Fact: f5 �/ (act Miami Shores Village . Building Department Nov W012 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 -P-0 INSPECTION'S PHONE NUMBER: (305) 762.4949 FBC 20 10 BUILDING Permit No. PERMIT APPLICATION Master Permit No. G ° (� Permit Type: BUILDING ROOFING JOB ADDRESS: y � i.t , 4 %t City: Miami Shores County: Miami Dade Zip: '3 -1 ! C� Folio/Parcel#: /,i Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): V tES►°`6 �fi eA,__ Phone#:2�' Address``: - . 6 mt P14 L4 ,: f—A ! ) City: --R I � " / State: a5� Zip: Tenant Email: 9 CONTRACTOR: Company Name: 14 _(_�y i_— c"�'o Phone#: 1796 :217-5,65-36 Address: ! �� P 17. 6 6 6, 3 4.6 6 -, City: Qualifier Name: G ' � DA 6 j Phone# �g� .✓ ;2 c State Certification or Registration #: i ,h / 4" L, 0 `i Certificate 6� �'% cc;' of Competency -3 #: Contact Phone#: �� ''� 0 Email Address: 1441 `a' �� L�= d < co M DESIGNER: Architect/Engineer. Value of Work for this Permit: $ Sgwn e/Linear Footage of Work: �� f Type of Work: ❑Addition ❑Alteration ❑Nets ❑Repair/Replace ❑Demolition z. Description of Work: 20- �'�IDAI DIN 0 1J. /i I '�) .6 Q0 F /"OJ 3 (--Z Ua IA1 C— &T I Fee $ Permit Fee $ o 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. "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, —die inspection will not be approved and a reinspection fee will be charged Signs V A Ddi /a Owner ,6..t Contractor The foregoing instrument was acknowledged before me this 3 � The foregoing instrument was acknowledged before me this, i day of�A uu r, 20 �, by �/ I Y'Q.Y1 L «'� C �l� r . day of I VNhl) lVt' 20 t.�J,, by who is personally known to me or who has produced t ) iwho is personally known to me or who has produced FL As identification and who Jid tMw-aiq oath. identification and who did take an oath. NOTARY PUBLIC: �4:.•0t NUMPy •'SJ' NOTARY PUBLIC: •1,�;' `�� � ri0,e ; rA'y N'''•,, Monica Sueiro •� TpRYPUBLIC •;r�. 1 /^ ':�C'MlMWON#EE066743 Sign: Sign: °n Print a COMM. Expito�. °' °F ���,+N�+'>ti�.AARONNOTARY. if 02 2014 Print: � My Commission APPROVED BY I )N C� •age Plans Examiner Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) My Commission Expires: P-e..b Zoning Clerk .L Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 RECEIPT PERMIT #: ;� AO 0 DATE: 1, f�--S f2 A -7 0 • Contractor • Owner • Architect Picked up 2 sets of plans and (other) e 1, Address: From the building department on this date in order to have corrections done to plans And /or get County stamps. I understand that the plans need to be brought back to Miami Shores Village Building Department to continue permitting process. Acknowledged by: PERMIT CLERK INITIAL: RESUBMITTED DATE: PERMIT CLERK INITIAL: Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 November 26, 2012 Permit No: 12 -2200 Building Critique 1. 1) The plans do not represent the work proposed. 2. 2) The roof is a structural element of the building and the altered area must be repaired or rebuilt. 3. 3) Provide detail of construction and roofing permit. NB STOPPED REVIEW Norman Bruhn CBO 305 - 762 -4859 Plan review is not complete, when all items above are corrected, we will do a complete plan review. If any sheets are voided, remove them from the plans and replace with new revised sheets and include one set of voided sheets in the re- submittal drawings. 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 JAN 29 2013 eo��_ FBC 20 l� Permit No. A00 Master Permit No. ® 13 Permit Type: BUILDING ROOFING JOB ADDRESS: - 11 M V) 2 n4 S+• �_U_CLVVl� City: Miami Shores County: Miami Dade Zip: 33'50 Folio/Parcel #: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): " 1 r--Q 1, A T��C.wLr Phone#: Address: ::m �3 1_o e;(%1".0 3f City: �b' a VVU —A&Dr LS State: zip: _334S O Tenant/Lessee Name: Phone #: Email: CONTRACTOR: Company Name: `a t _Q> Rjl Ld_ti2 �U+ 'p m, byPhone#: 305- Address: V310 Ai LO (e l TP-f City: W © 0 Qualifier Name: 61 U State: Zip: Phone #: 30 S MS'S g State Certification or Registration #: CCC 1329T(96 gi Certificate of Competency-� #: Contact Phone #: 3p S. 44'- -M33 Email Address: Q d IOU t I ��f' 501 Dh S ��rriCt -c � • �►�'i DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ Alm- ©0 Square/Linear Footage of Work: ¢S S. F Type of Work: ❑Addition ❑Alteration ORepair/R(enpl_ace ❑Demolition 1 Description of Work: Par0otj ` A k. ,A,0k l k ()V1 ��UNew &" Ot ter& lj-� 6 L� e& 04.,w1-o LA_d-1-1�-A . Color thru tile: Submittal Fee $6b • ' Permit Fee $ Scanning Fee $ Radon Fee $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ CCF $ CO /CC $ DBPR $ Bond $ 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 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 a_ bsence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature i Wwner or Agent The fo egoing instrument was acknowledged before e this�— day , 20 � �, by J 1 YQJ _ �a Q,T- , who is person own to me or who has produced 'M'�-) dr��e�s 1• CA.Y\� As identification and who did take an oath. NOTARY PUBLIC: Print: k � 1V.r l My Commission Signature ontractor The foregoing instrument was acknowledged before me this � �� day of a , 20 �, by 6['Lt A-b SZlY��ii`�Q who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: `3�•Sd'f* Print: r y9 yCommission :�LIC'STh OF FLORIDA Aracelia A. Gomez Commission #i)D881213 laxpirts: f APR,16 2013 N�Ma;9r rxA /Ian i a! � + ° ° °gj.o�a APPROVED BY Structural Review (Revised 3 /12/2012)(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15109) 29t �-) Zoning Clerk I I ;,*: =Teor-noitm AC#: G;4.55"7�&o on ations! With this license you become one of the nearly one million 1 11 . I DE PAR TMMU-07-BUSINESS AND Congratulations! or g"4'u' Floridians licensed by the Department of Business and Professional Regulation. PROVESSIONAIL- RING' LATION Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. 32876 Et T, 110418821 Every day we work to improve the way we do business In order to serve you better. For information about our services, please tog onto www.m~dalicense.com I tERTIFTED tA00, M R' FEPMAME2 4 There you can find more information about our divisions and the regulations that -0W* B1 - - i 0109. 4 Impact you, subscribe to department newsletters and learn more about the G&D, Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. I 19 CERTIPliD .A.. the Pgavisio W af:ah.409 rs Thank AUG L126667001118, you for doing business in Florida, and congratulations on your now license! . 1 .1 , ;x4rauan date 31, 20,14 AC# 6.15 5 7 8 O' DEPA DETACH HERE rE OF FLORIDA CSS, MW PROFMI19M �'7 CITY OF HOLLYWOOD LOCAL BUSINESS TAX RECEIPT PRINT DATE: 9/20/12 THIS IS YOUR LOCAL BUSINESS TAX RECEIPT. PLEASE DETACH AND POST IN A CONSPICUOUS PLACE AT THE BUSINESS LOCATION. PLEASE DO NOT REMIT ANY PAYMENT. THIS IS NOT A BILL, Business Name: G & D BUILDING SOLUTIONS, INC. Business Lotatk= 1310 N 67 TER Business Class: CONTRACTOR/GENERAL Tax Basis: 1 WORKER (OWNER) Receipt Number. 13 00,042066 Receipt Year 10/01/12 Expiration Date: 09/30/13 NEW CHARGES: (itemized Below) 190.00 Comments: Base Fee -190.00 Additional Charges: TOTAL NEW CHARGES: 190.00 Penalty Amount: .00 Previous Balance Due: .0 00 TOTAL AMOUNT PAI[k 190.00 * * 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: 0112712012 PERSON: FERNANDEZ FEIN: 421722437 BUSINESS NAME AND ADDRESS: G&D BUILDINGSOLUTIONS INC 1310 NW 67TH TER HOLLYWOOD FL 33024 SCOPES OF BUSINESS OR TRADE: 1- CONTRACTOR - PROJECT MANAGER, CO EXPIRATION DATE: 01/2612014 2- ROOFING o IMPORTANT: Pursuant to Chapter 440 . 051141, r,S„ so officer of a corporation who elects exemption From this chapter by filing a certificate of election ender Ibis section may not recover benefits or compensation ander this chapter. Pursuant to Chapter 440.05112), F.S., Certificates of election to be exempt.., apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation €t, at say lime alter the filing of the notice or the issuance of me 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. QUESTIONS? (850) 413 -1509 OWC -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 WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS* COMPENSATION LAW 9 EFFECTIVE: 01/27/2012 EXPIRATION DATE: 01/26/2014 PERSON; G;UIDO FERNANDEZ FEIN: 421722437 BUSINESS NAME AND ADDRESS. G &O BUILDINGSOLUTIONS INC 1310 NW 67TH TER HOLLYWOOD, Fl 33024 SCOPE OF BUSINESS OR TRADE: 1 - CONTRACTOR - PROJECT MANAGER, CO 2- ROOFING IMPORTANT F Pursuant to Chapter 440.0504), F.S., an officer of a corporation who 0 elects exemption from this chapter by filing a certificate of election L under this section, may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S„ Certificates of election to be H exempt... apply only within the scope of the business or trade listed on E the notice of election to be exempt. R E Pursuant to Chapter 440.05031. 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. QUESTIONS? (850) 413-1809 CUT HERE * Carry bottom portion on the job, keep upper portion for your records, OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 F°I AeOWhP -- •CER.TIFICATE, OF LIABILITY INSURANCE 11/17/201i 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(SL AUTHORISED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE :HOLDER. IMPORTANT: If the certi$cate holder is as ADDITIONAL INSURED, the PoGcy(iva) must be endorsed. E SUBROGATION IS WAIVED, su6.t to the I7enns and condMons of Ma policy, oaftin policies may esquire an andoraoma lL A statement on this certificate does not confar dghts to the certificate holder in lieu of surd endomenm*s , PRODUCER T= SOLVTION INSURANCE SVCS I11TC NAME: P (305) 485 -9090 ,AX NO;(305) 485 -9083 Eg. 9900 SST 40th Street ,MD ESS :aolutianinsura>nc6bellacuth. net Miami, FL 33165 wsURIMM AgFORD NO fOVERASE I weoa INSURER A: ACCIDENT INSURANCE PREMISES Ea oxunertt� INSURED G iy D BUILDING SOLUTION, INC. INSURER 9: PTDEI.ITY iOLI` I I%Zd?JLNT I I 1310 NN 67 TERRACE INSURER G I HOLLYWOOD, FL. 33024 INSURER D: S 5,000 INSURER E: !7 x INSURER F: � AOL 9004337 502/23/2012 I COVERAGES CERTIFICATE NUMBER; REVISION NUMBFR' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE 111911 1) BELLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TLRIbt: OR CONDMON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSEIRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCL,U910NS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y FAIR CLAIMS. IPM; TYPe OF INSURANCE R K,yD Fo4,ICY NUMBER MME= UMITS (i- 6NERg1 LIABILITY I ! EACH OCCURRENCE S 1, 000 000 PREMISES Ea oxunertt� ' x I COMMEROIAL GENERAL LIMLrrY GLA�vIS AAAD6 OCCUR ( I $ 50 OOO MED EXP (Any ona l n) S 5,000 A !7 x E � AOL 9004337 502/23/2012 I 02/23/2013 1 PERSONAL & AOV INJURY s 1j000'000 ( GENL AGGREGATE i.Wrr APPLIES PER: `X ' PODGY JX711 JFM EX] Wo GENERAL AGGREGATE s 2,000,000 PRODUCTS • COMPMP AGG S I r 000 r 000 S AUTOWBILE LMIUT! M IN M BOOILY INJURY (Per Deleon) Is I ANYAUTO„ SCR t AWOG t AUTOS DULM DODILY INJURY (Per ewadaM); $ 5 NON -OWNED HIRED AU•FOS 1-- AMU Peracadt3ltt � LIM$RELLA UAg H OCCUR EACH OCCURRENCE 9 AGGREGATE $ EXCESS LIAR CtAINGyMgDE j DED ftffTENMON $ B j t WORKERS C M.PENSATION AND EMPLOYERS' LIABILITY YIN war PROPRIErORRARrNE149 Lmr. OFFICI771E W'wfk EtCCLUMW rcyes, describe wrder DESCRIPTION OF Or-ERATION4 below NIA � I I WCSTRTIr OTH- Y 6.L, PCH ACCIDENT Is RL„ DISEASE - EA EMPLOYE@ $ I Ek. DISEASE - POLICY Unit C Presirfesioaal Liability ' 092211 02/22/2012 02/23/2013 I LET $ 500,000 OCCURANCE $ 500,000 AGGREGATE DESCRIPTION OF OPERAnoNS 1 LOQATIONS I VEHICLES (Attach ACORD ;1C1, AdM&* Remwks Bcttedule, if rneae space is requited) I i MIAMI SNORES VILLAGE BuiLDING DEPARTMENT 10050 NORTREAST 2ND AVEN= MiAX1 SHORES, FL. 33138 SHOULD ANY OF THE ABOVE THE EXPIRATION DATE, ACCORDANCE WITH THE I AUTHORIZED 01988-2010 ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD :D POLICIES HE CANCELLED BEFORE NOTICE WILL BE DELIVERED IN CORPORATION_ All dahts reservwd