BPP-14-257 (2)Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
nspection Number: IISIS P-216013 Permit Number: BPP -2-14-257
Inspection Date: July 14, 2014 Permit Type: Pools/Whirlpools/Hot Tubs
Inspector: Rodriguez, Jorge Inspection Type: Final
Owner: DENNIS LEYVA, CLARK REYNOLDS Work Classification: New
Job Address: 69 NE 102 Street
Miami Shores, FL 33138- Phone Number
Parcel Number 1132060131680
Project: <NONE>
Contractor: ROSMEL POOL INC Phone: (305)592-7900
Buildina Department Comments
BUILD NEW POOL
Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed
� ;, ��
CREATED AS REINSPECTION FOR INSP-215434. CREATED AS
REINSPECTION FOR INSP-206991. Gates must be self closing / locking
with lock 54" high.
Failed
Need to verify child safety alarms on doors
07-11-14
need to pass required pool barrier inspection.
Correction
Needed
Re -Inspection
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
For Inspections please call: (305)762-4949
July 16, 2014 Page 1 of 1
On
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SPA
- One Story
LP.
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20.35 Residence
M
No. 69
= Central Angle
A
b `n
A
o 25.20' a
= Maintenance Easement
N 17.70'
A/C
17.65'
PLANTER P�RCH
ASPH
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(No I.D.) q03 (No I.D.)
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23PARKWAY
m
105.52'
Fnd.%z" I.P.
(/ (No I.D.)
All clearances and/or encroachments shown hereon are of apparent nature. Fence ownership by visual means. Legal ownership of fences not determined.
Underground structures, if any, not located.
Bearings, if shown, are based on assumed meridian or Plat of Record.
Lands shown hereon were not abstracted for easements and/or right -0f -ways of records.
Legal description provided by client.
This certification is only for land as described. It is not a certification of title, zoning, easements, or freedom from encumbrances. ABSTRACT NOT REVIEWED.
There may be additional restrictions not shown on this survey that may be found in the public records of this county. ABSTRACT NOT REVIEWED.
This BOUNDARY SURVEY has been prepared for the exclusive use of the entities named hereon. The Certificate does not extend to any unnamed party.
This survey was based#Sn the mrnuments found on the field. 00
5
1
N.E. 103rd STREET
N.E. 102nd STREET
Location Sketch LME = Lake Maintenance Easement
NTS
LP.
LEGEND
M
A
= Central Angle
MAIM.
= Maintenance
A
= Arc
= Maintenance Easement
A/C
= Air Conditioner
Mon.
ASPH
= Asphalt
N/A
= Not Applicable
BBO
= Barbecue
= Nail & Disc
N°
C
= Calculated
NTS
= Not to Scale
CB
=Catch Basin
O.U.L
= Overhead Utility Lines
CBS
= Concrete Block Structure
PB
= Plat Book
PC
CH
= Chord
2
1
PG
=Page
Chatta.
= Chattahoochee
= Point of Intersection
PKWY
iZn
q
= Center Line
G't PARCF�
PL
= Planter
CLF
= Chain Link Fence
H
r+
P.O.B.
Cl.
= Clear
D
= Point of Commencement
Conc.
= Concrete
= Power Pole
PRC
= Point of Reverse Curvature
D
= Deed
= Point of Reference Monument
PT
I TI
0
= Diameter
Res.
= Residence
Z
R.LS.
DH
= Drill Hole
2Z
23
C
DME
= Drainage & Maintenance Easm't
Easm't
= Easement
Enc.
= Encroachment
F.H.
= Fire Hydrant
FIP
= Found 1/2' Iron Pipe
FIR
= Found 1/2' Iron Rebar
FPL
= Florida Power & Light
ID
= Identification
I.P.
= Iron Pipe
LB
= Licensed Business
Location Sketch LME = Lake Maintenance Easement
NTS
LEGAL DESCRIPTION: R/R = Railroad
Lots 20 & 21, Block 12, MIAMI SHORES, SECTION ONE AMENDED, according to the RSM = Registered Surveyor & Mapper
R/W = Right-of-WayPlat thereof, as recorded in Plat Book 10, Page 70, of the Public Records of Sdwk = Sidewalk
MIAMI-DADE County, Florida. Sec. =Section
T
PREPARED FOR: Clark Reynolds & Dennis Leyva,
69 N.E. 102 Street, Miami Shores, FL 33138
SURVEYOR'S SEAL
Unless it bears the signature
and the original raised seal of
a Florida licensed surveyor and
mapper, this map/report is for
informational purposes only
and is not valid.
REVISED: 02-01-14
BOUNDARY SURVEY
= Tangent
TWP = Township
U. I- = Utility Easement
UTIL = Utility
W.F. = Wood Fence
W.M. -Water Meter
WME = Wall Maintenance Easement
MOJARENA & ASSOCIATES, INC.
N Land Surveyors & Mappers
w<� Certificate of Authorization No. 6698
S P.O. Box 56-0126
Miami, FL 33256-0126 (305) 278-2494
749ei�, FLOOD ZONE: X
NELSON MO NA DATE: SCALE:
Registered Surveyor & Mapper No. 5504
State of Florida 11-02-11 1"= 20'
BASE: N/A
DWN. BY JOB NO.
N.M. 11-0222
LP.
= LUght Pole
M
= Measured
MAIM.
= Maintenance
ME
= Maintenance Easement
Y
= Monument tine
Mon.
= Monument
N/A
= Not Applicable
N/D
= Nail & Disc
N°
= Number
NTS
= Not to Scale
O/S
= Offset
O.U.L
= Overhead Utility Lines
P
= Plat
PB
= Plat Book
PC
= Point of Curvature
PCP
= Permanent Control Point
PG
=Page
P.I.
= Point of Intersection
PKWY
= Parkway
R
= Property Cine
PL
= Planter
PLS
= Professional Land Surveyor
P.O.B.
= Point of Beginning
P.O.C.
= Point of Commencement
P.P.
= Power Pole
PRC
= Point of Reverse Curvature
PRM
= Point of Reference Monument
PT
= Point of Tangency
R
= Radius
Res.
= Residence
R.LS.
= Registered Land Surveyor
RNG
=Range
LEGAL DESCRIPTION: R/R = Railroad
Lots 20 & 21, Block 12, MIAMI SHORES, SECTION ONE AMENDED, according to the RSM = Registered Surveyor & Mapper
R/W = Right-of-WayPlat thereof, as recorded in Plat Book 10, Page 70, of the Public Records of Sdwk = Sidewalk
MIAMI-DADE County, Florida. Sec. =Section
T
PREPARED FOR: Clark Reynolds & Dennis Leyva,
69 N.E. 102 Street, Miami Shores, FL 33138
SURVEYOR'S SEAL
Unless it bears the signature
and the original raised seal of
a Florida licensed surveyor and
mapper, this map/report is for
informational purposes only
and is not valid.
REVISED: 02-01-14
BOUNDARY SURVEY
= Tangent
TWP = Township
U. I- = Utility Easement
UTIL = Utility
W.F. = Wood Fence
W.M. -Water Meter
WME = Wall Maintenance Easement
MOJARENA & ASSOCIATES, INC.
N Land Surveyors & Mappers
w<� Certificate of Authorization No. 6698
S P.O. Box 56-0126
Miami, FL 33256-0126 (305) 278-2494
749ei�, FLOOD ZONE: X
NELSON MO NA DATE: SCALE:
Registered Surveyor & Mapper No. 5504
State of Florida 11-02-11 1"= 20'
BASE: N/A
DWN. BY JOB NO.
N.M. 11-0222
ELEVATION CERTIFICATE
Owners Name:
CLARK REYNOLDS / DENNIS LEYVA
Property Address:
69 NE 102 STREET, MIAMI SHORES, FL. 33138
LEGAL DESCRIPTION: FOLIO #: 11-3206-013-1680
Lot 20 & 21 , Block 12 of "MIAMI SHORES SEC 1 AMD" according to the plat thereof as recorded
in Plat Book 10 at Page 70 of the Public Records of Dade County, Florida.
SURVEYOR'S NOTES:
1) Not valid without the signature and the original raised seal of a Florida Licensed Surveyor and
Mapper.
2) Additions or deletions to this certificate by other than the signing party or parties are prohibited
without written consent of the signing party or parties.
3) This certificate elevation is for the purpose of septic and drains repair and/or construction.
4) This certificate elevation must not be use for the purpose of acquiring flood insurance
5) Elevations are based on the National Geodetic Vertical Datum of 1929.
TOP OF BOTTOM FLOOR:
TOP OF NEXT HIGHER FLOOR:
ATTACHED GARAGE (at the door):
GRADE @ DRAINFIELD AREA
CROWN OF THE ROAD:
Field Date: 12/02/13
13.5'
N/A
11.1'
10.8'
11.2
4#0 -
Pablo J. Alfonso P.S.M.
Professional Surveyor & Mapper
State of Florida Reg. No.5880
MOY/� IP470'
LAND SURVEYORS, INC.
6175 NW 153rd STREET, SUITE 321, MIAMI LAKES, FLORIDA 33014
Phone: 305-822-6062 ** Fax: 305-827-9669
MOUNTING THE SENSORS
Make sure that the arrows of each sensor are pointed towards
each other. Using either the double -sided tape or the screws
provided, mount the sensors so that they are less than h inch
away from each other. Sensors must be mounted flush in
fteighi and depth, so with some doors or windows, special
custom fitting may be necessary. Please make sure that the
wired portion of the magnetic sensor is mounted on the
non-moving portion of the mounting surface and the
standelone sensor is mounted on the door/gate. (See Fig.
5 /Fig. 6)
WOUN77MG OUTDOORS ON WOODEN GATES
Using the provided mounting
template printed in this
manual. mark the position of OV0000"
the screw holes on Ute
desired mounting surface.
Drill the screws onto the
mound surface with
approximately 1/8 inch of
thread remaining. slide the
unit over the screws — FIB. 5
secure rho unit by pushing
it downward as shown in Fig. 5. You may need to adjust Uhe screws
towards or away from the mounting surface to provide a more secure
fit. Make sure that the arrows of each sensor are pointed in uut same
direction. Note: Wooden gates do not require the sensor housings.
MOUNTING OUTDOORS ON METAL GATES
Using the provided zip ties. ,,o a,S
attach tare alarm body to the oNNEru.GareS
metal gate frame (See Fig. 6)
Using a small flat head
screwdriver. gw+th pry fin ; -
the recessed sensor spacer
of the sensor housing. ( Fig.B)
Make sure Uhat the arrows of
each sensor are pointed In Bre
sante direction as the sensor Fl& s
housing before placing the magnetic sensors inside the sensor
housing. Note: Metal gates may interfere with the magnetic sensor
function. Use spacers provided to ensure sensors operate property.
Secure the sensors using lire zip has onto the gate frame. Make
sure that the sensors' arrrwas are pointed towards each other and
that the sensors are less than % inch apart.
When the alarm volume becomes bw, or the unit does not
produce normal alarm sound, the red light will illuminate.
you must replace the 9-vott battery.
The Safe Pool's plastic parts resists ultraviolet rays from
direct sunlight exposure. However, slight discoloration
over time is normal.
1 r r
WARNING!
THE SAFE POOL ALARM IS EXTREMELY LOUD WHEN
ACTIVATED. FOR YOUR SAFETY, NEVER PLACE THE {
UNIT CLOSE TO YOUR EARS. TO TEST THE ALARM,
ALWAYS USE EAR PROTECTION AND DIRECT THE UNIT
AWAY BEFORE TESTINGIACTiVATING THE ALARM.
IT IS PROHIBITED BY LAW TO REMOVE THE INSTALLED
ALARM AFTER IT HAS PASSED INSPECTION I
Important Wumnty Information:
A dated proof of purchase Is regtrired for warranty service
Customer Service :
1-888-8TECHKO(1-888-883-2456)
Website: www.tachkomaid.com
Mfg. By 7XQW'
9767 Research Drive,
Irvine, CA 926184626
MADE IN CHINA c(T�
�"'
9700127
COMPLIES WITH
UL 2017
USA Patent: No. 5,473,310
No. 6,727,818
NOTICE
THIS PRODUCT IS PROTECTED UNDER FEDERAL
PATENT, TRADEMARKAND COPYRIGHT LAWS AND
LAWS PREVENTING UNFAIR COMPETITION. NO
DUPLICATION OR SIMULATION OF THIS PRODUCT
IS PERMITTED EXCEPT BY WRITTEN AUTHORIZATION
OF TECHKO, INC.
TECHKO AND THE CONFIGURATION OF THIS PRODUCT
ARE TRADEMARKS OF TECHKO INC.
COPYRIGHT 1994 TECHKO, INC.
ALL RIGHTS RESERVED
MADE It CHINA
Safe Pool TM
Model S187D
Area Entry Alarm
} t
Md�` 1e (
OPERA i'10��`w"#J
§? y�SA,�
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INTRODUCTION
angratulations on your purchase of the TECHKO Safe
ool model S187D safety alarm. The Safe Pool can be
sed to provide a high volume alarm alert when children
ave entered a pool or spa area. The S187D can be used
utdcors on wood or metal gates, or Indoors on doors and
lrtdow leading directly to pOtentialy dangerous areas.
OPERATION
he Safe Pool is designed to sound a loud alert when
-dkiren enter through a Safe Pool protected doorigate.
/hen property installed, the Safe Pool will allow adults to
ass through the protected damigate and immediately shut
11 the sounding alarm.
/hen powered, the Safe Pool is always in protection mode.
he alarm will activate the instant when the door/gate opens
y more than 112 inch (when the magnetic sensors are apart
y more than 1/2 inch). Once the alarm activates, it will sound
xntinuously until the BYPASS button is pressed.
/hen passing through the doodgate press the BYPASS
utton, then open the door/gate, pass through and close
io doodgate within 8-12 seconds and the alarm will not
ctivate.
FEATURES
Easy installation for gate, door or window protection
Water / weather resistant
9 Volt battery mower (not inducted)
High output 110 115 dB alarm siren
Low Battery / signal LED Indicator
Optional additional BYPASS button for delayed entry from
other side of door or fence
Optional additional magnetic sensor for screen door
exit/entry
Fig.1
114i1 , �tTA(�Ti` AF TIS
Uerm siren Is VERY lord; NEVER place the unit close to
tars.
nstall the unit high enough to be art of reach of children
W or Higher is recommended.
' Keep this manual for future reference.
The Safe Pool can provide valuable protection when
used correctly. However, it cannot guarantee complete
pprroojection against accidents or injuries. Therefore,
Techko cannot be hold responsible for any loss, damage,
or Injury that may occur.
INSTALLATION
WARNING: Read all installation and operation
Instructions thoroughly before proceeding with
Installation. Note: Not all parts included are needed for
installation. Please read the different mounting
Instructions to see what Is needed for your specific
application.
INSTALLING THE BATTERY.•
1. When testing, before installing the battery, use a rubber
band to temporarily secure the two magnetic sensors
together with the arrows pointing toward each other to
avoid setting off the alarm unintentionally. During the
actual installation of the alarm, it's best to install the
battery after it's mounted to avoid the alarm going off
unintentionally.
2. Remove the battery cover of the unit and install a new 9
Volt battery. Replace cover. (See Fig. 2)
3. If you are sensitive to loud sound, please wear ear
protection against the loud alarm siren before testing
the alarm.
4. Once the battery Is connected, the
unit is now ON and working. To test
the alarm siren, make sure you
have ear protection before testing.
After ear protection is in place, 5---4
separate the magnetic sensors Fig 2
apart by more than '%, Inch. The
alarm should sound immediately after the sensors are
separated. Press the BYPASS button and Imnrediatey
secure the two magnet sensors together again to avoid
the alarm sounding off unintentionally.
LED LIGHT WARNINGS
1. When the battery becomes low in charge or the volume
becomes weak, the LED light will Illuminate. The 9 volt
battery must be replaced.
2. Upon battery installation, the unit will beep once and the
LED light will flash 10 times as it prepares to become
armed.
3. When a bypass button is pushed, the LED light
Illuminates to indicate acknowledgement to PASS through.
4. After the bypass button Is pushed in and released, the
LED light will flash 10 times to allow pass through and to
prepare the unit to become armed again.
MOUNTING:
WARNING: The alarm should be positioned close to
the door high enough to be out of the reach of children.
As each mounting application varies, Techko suggests
testing the unit's Installation location and effectiveness
before permanently mounting the S187D.
MOUNTING INDOORS
Using the provided mounting template printed in this
manual, mark the position of the screw holes on the
desired mounting surface.
* The Additional
delay button may
be mounted on the
other side of the
entrance. When
pressed, it will
delay the alarm
8-12 seconds
before alarm is
triggered, allowing
time to secure the
door/gate.
Fie. 3
* The Additional magnetic sensors allow the unit to be
used on sliding door with screens.
* Alarm will sound only when BOTH sets of magnetic
sensors are apart, there for allowing the slider to be open
while still providing protection at the screen door.
MOUNTING INDOORS USING DOUBLE -SIDED TAPE
Make sure that the mounting surfaces for the double -sided
tapes are completely dean. Attach the double -sided tapes
onto the rear of the unit, and then secure the unit onto the
desired mounting surface.
MOUNTING INDOORS USING SCREWS
Using the provided mounting template printed In this
manual, mark the position of the screw holes on the
desired mounting surface. Drill the screws In to the
mounting surface with
approximately 118 Inch of thread
remaining. Slide the unit over the
screws and secure the unit by
pushing It downward, as shown in
Fig. 4. You may need to adjust the '
screws towards or away from the
mounting surface to provide a more Fill. 4
secure fiL
TEMPLATE
MODEL S187D
i
SCREW HOLE j
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
nspection Number: INSP-212977 Permit Number: BPP -2-14-257
Inspection Date: June 12, 2014
Inspector: Dacquisto, David
Owner: DENNIS LEYVA, CLARK REYNOLDS
Job Address: 69 NE 102 Street
Miami Shores, FL 33138 -
Project: <NONE>
Permit Type: Pools/Whirlpools/Hot Tubs
Inspection Type: Survey Final
Work Classification: New
Phone Number
Parcel Number 1132060131680
Contractor: ROSMEL POOL INC Phone: (305)592-7900
Bu
BUILD NEW POOL
Passed
Failed
Correction
Needed
Comments
Re -Inspection
Fee
t
Mi
No Additional Inspections can be scheduled until
re -inspection fee is paid.
APPROVAL IS FOR
POOL ONLY.
LOCATION OF POOL
EQUIPMENT IS NOT
SHOW ON SURVEY
AND MAY OR MAY Ni
BE IN COMPLIANCE
LOCATION OF POOL EQUIPMENT IS NOT SHOW ON SURVEY AND MAY
OR MAY NOT BE IN COMPLIANCE.
For Inspections please call: (305)762-4949
July 01, 2014 Page 1 of 1
105.52'
• All clearances and/or encroachments shown hereon are of apparent nature. Fence ownership by visual means. Legal ownership of fences not determined.
• Underground structures, if any, not located.
• Bearings, if shown, are based on assumed meridian or Plat of Record.
• Lands shown hereon were not abstracted for easements and/or right-of-ways of records.
• Legal description provided by client.
• This certification is only for land as described. It is not a certification of title, zoning, easements, or freedom from encumbrances. ABSTRACT NOT REVIEWED.
• There may be additional restrictions not shown on this survey that may be found in the public, records of this county. ABSTRACT NOT REVIEWED.
• This BOUNDARY SURVEY has been prepared for the exclusive use of the entities named hereon. The Certificate does not extend to any unnamed parry.
• This survey was based on the monuments found on the field.
N.E: 103rd STREET
N.E. 102nd STREET
�I PERMIT
:APPRO'VvED
i1l118f711 St1CrL'S
BY
ZONING D
BLDG DEPT
Location Sketch
SUBJECT i0 Crh(PL{AJyCE
STATE ANJ VUr1N ALL FEDERAL
Lc I�N'i °f ril,LS AND REGULATIONS
NTS
Z
In
N
r+
D
Z
C
M
LEGAL DESCRIPTION:
Lots 20 & 21, Block 12, MIAMI SHORES, SECTION ONE AMENDED, according to the
Plat thereof, as recorded in Plat Book 10, Page 70, of the Public Records of
MIAMI-DADE County, Florida.
PREPARED FOR: Clark Reynolds & Dennis Leyva,
69 N.E. 102 Street Miami Shores, FL 33138
SURVEYOR'S SEAL
Unless it bears the signature
and the original raised seal of
a Florida licensed surveyor and
mapper, this map/report is for
informational purposes only
and is not valid.
REVISED. 02-01-14
06-04-14
06-20-14
BOUNDARY SURVEY
749�_, —2o
NELSON MO NA
Registered Surveyor & Mapper No. 5504
State of Florida
LEGEND
A
= Central Angle
A
= Arc
A/C
= Air Conditioner
ASPH
= Asphalt
BBQ
= Barbecue
C
= Calculated
CB
= Catch Basin
CBS
= Concrete Block Structure
CH
= Chord
Chatta.
= Chattahoochee
q
= Center Line
CLF
= Chain Link Fence
Cl.
= Clear
Conc.
= Concrete
D
= Deed
0
= Diameter
DH
= Drill Hole
DME
= Drainage & Maintenance Easm't
Easm't
= Easement
Enc.
= Encroachment
F.H.
= Fire Hydrant
FIP
= Found 1/2' Iron Pipe
FIR
= Found 1/2' Iron Rebar
FPL
= Florida Power & Light
ID
= Identification
I.P.
= Iron Pipe
LB
= Licensed Business
LME
= Lake Maintenance Easement
L.P.
= Light Pole
M
= Measured
MAINT.
= Maintenance
ME
= Maintenance Easement
y
= Monument Line
Mon.
= Monument
N/A
= Not Applicable
N/D
= Nail & Disc
N'
= Number
NTS
= Not to Scale
O/S
= Offset
O.U.L
= Overhead Utility Lines
P
= Plat
PB
= Plat Book
PC
= Point of Curvature
PCP
= Permanent Control Point
PG
= Page
P.I.
= Point of Intersection
PKWY
= Parkway
e
= Property Line
PL
= Planter
PLS
= Professional Land Surveyor
P.O.B.
= Point of Beginning
P.O.C.
= Point of Commencement
P.P.
= Power Pole
PRC
= Point of Reverse Curvature
PRM
= Point of Reference Monument
PT
= Point of Tangency
R
= Radius
Res.
= Residence
R.L.S.
= Registered Land Surveyor
RNG
= Range
R/R
= Railroad
RSM
= Registered Surveyor & Mapper
R/W
= Right -of -Way
Sdwk
= Sidewalk
Sec.
= Section
T
= Tangent
TWP
=Township
U•E
= Utility Easement
UTIL
= Utility
W.F.
= Wood Fence
W.M.
= Water Meter
WME
= Wall Maintenance Easement
MOJARENA & ASSOCIATES, INC.
N Land Surveyors & Mappers
w e Certificate of Authorization No. 6698
s P.O. Box 56-0126
Miami, FL 33256-0126 (305) 278-2494
FLOOD ZONE: X I BASE:
11-02-11 1 1"= 20' 1 N. M.
N/A
11-0222
-n
�305 - stho- q -q 3 `7 C- (&Y- '\
Miami Shores Village -��cEiv�F-�rY
FED 11 J014
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
Permit Type:
JOB ADDRESS: `i E boa
FBC 20 1 C7
Permit No.
Master Permit No. LA^
City: Miami Shores County: Miami Dade Zip: 3-3 /3 $
Folio/ParceW I I - 3 2-0(o - ®13 - ) (, $o
Is the Building Historically Designated: Yes NO X Flood Zone:
OWNER: Name (Fee Simple Titleholder): CJa f k-. """1 /ojJs - inn; 5 4t. jq Phone#:
Address: to `; 10 Ei 102- :5T -
City: •�.,-+ t 6lire s —State:1�i �.� + i :Oo�L zip; 3 319 $
Tenant/I.essee Name: �j / A Phone#:
Email:
CONTRACTOR: Company Name: Paoli Phone#: 301S S`7
Address: $D 4-5 kJt, 3 Be. -n& -5Ae_ -�.q<n
City: �� Q -Q State: q gip; 3 B l
Qualifier Name: r4 -4A
Phone#: 3,:::>5 7 9 60
State Certification or Registration #: Certificate of Competency #:
Contact Phone#: -296-154-5-4155 Email Address: *IQ 2xn5 @� ro5e)-wd F2!� s, c_o e"
DESIGNER: Architect/Engineer:V rc eii-� ��r�c,o _ E? 2 s
Phone#: 30� 3en 5 -1566 31
Value of Work for this Permit: $ -a5, 9Z5.E0 Square/Unear Footage of Work: 336 --1-?T-41
Type of Work: ❑Addition DAlterat Qn, Whew ORepair/Replace ODemolition
Description -of Woik,-,12z1d
Color thru tile:
Submittal Fee •� Permit Fee CCF $ - $
$ $ 'Mec
Scanning Fee $ v - — Radou Fee $ DBPR $ Bond $ -
Notary $ Trainingl . ucatibn`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 bappvedd a reinspection fee will be charged.
'wiiu V� i—bunaiiy Lt wwn Lu me or wno nas proauce(1
As identification and who did take an oath.
NOTARY PUBLIC:
7y , MAR= A. WR'TM
My Commission Exp ir ; MYCO USSiON@ F0
EdrM,N :►�mbi�
' dS�` Bonded Thn �Otery
Signature
Contractor
The foregoing instrument was acknowledged bgfore me this /510
iday of _20-4!!n% .120 2!1-, by i
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
APPROVED BY 1 3111M Plans Examiner
Structural Review
(Revised 3/12/2012)(Revised 07/10/07)(Revised 06110/2009)(Revised 3/15/09)
Sign:
Print:
b•. MARCUSA M
My Com o aE *yCQWS$0N#FFWM
F
EXPIRES: May 15, 2017
Bonded Tin %tqq p lZrmr ,
[t /LJ_ Zomig
Clerk
r
Date
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
SWIMMING POOL OWNER'S CERTIFICATION
Miami Shores Village
Building & Zoning Department
Attention: Building Official
I certify that I am the legal owner of the property described as
-r1;®. 6hoye5-1ee-,1 AA9 Palo -70 4-crhs20d.�i'bi P-1 located at & Ar vc— r�!�-'P
-H j.c�rn-; T4— 3 3) 3.3
In accordance with Section 33-12(f), Code of Metropolitan Dade County, I certify that I
understand and agree that the swimming pool to be constructed at the above address cannot
be used or filled with water until separate permit has been obtained for an approved safety
barrier, and such barrier erected, inspected and approved.
I further understand that this certification, however, does not eliminate the need for
obtaining a permit and erecting and approved barrier prior to final inspection and use of the
pool. ,
Legal Owner
Note: This certification is to be submitted with a swimming pool permit application in duplicate.
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
NOTICE OF REQUIREMENTS
RESIDENTIAL SWIMMING POOL, SPA AND HOT TUB SAFETY ACT
I (We) acknowledge that a new swimming pool, spa or hot tub will be constructed or installed at
ro.%f U 16 --3T Miami Shores, FL, and hereby
affirm that one of the following methods will be used to meet the requirements of Chapter 515,
Florida Statues and the Florida Building Code R4101.17.
Please initial the method(s) to be used:
The pool will be equipped with an approved safety pool cover that comp lies with ASTM
F1346-91. (Submit Manufacturer's Specifications).
A continuous, one-piece (child) barrier meeting the requirements of Florida Building Code
84101.17.1.15 will protect the pool perimeter. The plans shall show the fence location and method of
attachment, including one end that shall not be removable without the aid of tools. (Submit Manufacturer's
Specifi s).
A combination of non -dwelling walls and fences (screen enclosure, child fence, masonry
fence walls, chain link or wood fence, etc.) will protect t he pool perimeter. The plans must specify t he type
anocation of all non dwelling walls. Florida Building Code, R4101.17.1
Any combination of protection which incorporates dwelling walls with openings directly into the
Wgied eter and all windows and doors will be equipped with exit alarms complying with Florida Building
Code, R4101.17.1.9 (Submit Manufacturer's Specifications).
Any combination of protection which incorporates dwelling walls with openings directly into the
pool perimeter and all doors will be equipped with a self -latching device with positive mechanical
latching/locking installed a min. 54" above the threshold. If this option is selected, submit plans showing all
types and location of all perimeter protection. The plans must also show the location and type of all
openings, and the hardware type for each location. (Submit Manufacturer's Specifications).
In accordance with the Code, the pool may not be filled with water without compliance with the
Private Swimming Pool Safety Requirements, and upon expiration of the permit the pool shall be
presumed to be unsafe. I understand that not having one of the above installed will constitute a
violation of Chapter 515, F.S ., an d will be considered as committing a misdemeanor of the second
degree, punishable as provided in Section 775.082 or Section 775.3 F.S . This form must be signed
by the over la n a e prime contractor.
�r
C TRACTOR'S SIGNATURE AND DATE OWNEA'sAdNATURE AND DATE
• i�(U,-'Lr � ^FITf1RIF.Pf.'(l
Miami Shores Village'
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
RESTRICTIVE COVENANT PROTECTIVE POOL ENCLOSURE
KNOW ALL MEN BY THESE PRESENTS:
WHEREAS, the undersigned �1�2i� / �S istare the fee
simple owner(s) of the following described property situated and being in Miami Shores Village, Florida:
Address: 4/5 5�.UE 4.,4,r24 ,-C.. 3313 a'
Whereas, the undersigned owner(s) CialAK— !1 s
desire to utilize said Lot(s) as a single building site, and the undersigned owner(s) do(es) hereby declare and agree as follows:
I. That the property will not be used in violation of any ordinances of Miami Shores Village or Miami -Dade
County now in effect or hereinafter enacted.
II. That the purpose of the covenant is to induce Miami Shores Village to issue a permit for a pool where the
required enclosure is not on the subject property where the pool is located.
III. That if any of our adjoining neighbors remove any portion of their fence or wall, or if our/my property shall fail
to meet cede requirements for pool barriers, we, as owners will immediately install a protective enclosure to
meet code requirements and will obtain a permit for such fence.
IV. That, Uwe, as owner(s) hold Miami Shores Village harmless for any negligence or injury that results from not
having the enclosure.
V. If enclosure belongs to said property, I agree to maintain & or replace said enclosure in the event that is
damaged or removed by any case.
NOW, THEREOF, for good and valuable consideration, the undersigned do(es) hereby declare that he/she will not
convey or cause to be conveyed the title to the above property without requiring the successor in title to abide by all terms and
conditions set forth herein.
FURTHER, the undersigned declare(s) that this covenant is intended and shall constitute a restrictive covenant
concerning the use, enjoyment and title to the above property and shall constitute a covenant running with the land and shall be
binding upon the undersigned, hMer successors and assigns and may only be released by Miami Shores Village, or its
successo , in accordi7 of said Ville then in effect
ER SI 6N & T OWNER SING & PRINT
I Hereby Certify that on this day personally appeared before me hL r r 1 -.and has produced ID
# ss identification and he/she acknowledge that he/she a ecuted the foregoing, freely and voluntarily,
for purposes there in expressed.
I tART1NQ
SWORN TO AND SUBSCRIBED before me on this Yday of tt��FF
' PIRES: May 15, 2017
-7, eomW Thm Notary Pio Umdlw�ters
VNUA
(Revised 05/2209
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
WNTR CTORS' REGISTRATION
ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED.
IF CONTRACTOR IS A FLORIDA $ ATE CERTIFIED CONTRACTOR:
A COPY OF QUALIFIER'S STATE LICENCES
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. r COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLD; DEPT)
D. "" COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
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 WORKERS COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION)
YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER A3 FOLLOW.
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
r•arrrrarrrrrrarrrrrrrrrarraararrararrasraaaa��aa���aararrraaaaaaarrraarrrrrrarrrrrrrarrrr�
COMPL E CONTRACTOR'S INFORMATION
BUSINESS NAME: 'R�MeJ PbrL J�-�-
BUSINESS ADDRESS: 8 o45 0LJ 2� (- S4 -54. -s4o CITY 1,'b�QJ
STATE 13�4- ZIP CODE 33/( �
BUSINESS PHONE:( 305 ) ::51-2-7 -700 FAX NUMBER ( mss)
CELL PHONE L
QUALIFIER'S NAME: kjave�
QUALIFIER'S LIC NUMBER: -Ae- 4-33 ss 9
E-MAIL ADDRESS OF APPLICABLE): rqonas � eosne6aocCs carn
Crumd on 3H90 9Y W.DV! RV 31AM AUV I RV 6W111 AS
AC# 6338596 STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION l
CONSTRUCTION INDUSTRY LICENSING BOARD
SEQ#L12490541775
e . -
LICENSE NBR
109/05/2012
128069744
CPC1456804
The COMMERCIAL POOL/SPA CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration dates AUG 3.1, 2014
VARELA, MIRTHA
ROSMEL POOLS INC
8M04455 NW 36 STREET,
RICK SCOTT
GOVERNOR
SUITE 540
FL 33166
_DISPLAY AS REQUIRED BY LAW
KEN LAWSON
SECRETARY
Cv
08/26/2013 15:58 3052281525 CITINSURANCE
PAGE 01/01
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HOLY ER. THIS CERTIFICATE DOES N�JT AMEND, EXT/ ND OR I
• , j
'T =921 F4AGLSR 07 =rZ 213 ALTER THE COVERAGE AFFORDED 8Y THE POLICIES ---- --
FL 33144 INSURERS AFFORDING COVERAGE
228-1533
R081I!<EL POOLS, INC. iNsuRsRa COLONY xXSURANCN COMPANY
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DORAL, FL 33166 uvsuRSRa
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COVERiAm
lTHS POLICES OF INSURANCE LISTED BELOW HAVE BEEN )SSUED TO THE INSURED NAMED ABOVE FOR YHE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8E ISSUED OR
Y PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOMONS OF SUCH
LICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
• 7YP6 QR I1�IIRANCB
POLICY NUA96ER
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EACH OX+WRRIENXE a2,000,000
FIRE DAMAGE (AlV am be) s 3 0 d a 00a
GENERAL UAMUTY
ASI'A= 530RSS VILLAGE, FL 33138
E NO OWAAYION OR LIABILITY OF ANY K= UPON THB MURK Ire AGENTS OR
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NOTICE TO THE CERTMCAM HOLDER NAMW TO THB LEFT, BUT FA wm TO DO so SHALL
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E NO OWAAYION OR LIABILITY OF ANY K= UPON THB MURK Ire AGENTS OR
FA%r 305-592--799?
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305-75f-8972
i%�f�
.a AI�r1Dh AMMa wr�►� ��eo
001368
Local Business Tax Receipt
Miami—Dade County, State of Florida
—THIS IS NOT A BILL — DO NOT PAY
6333306
BUSINESS NAM911,00ATION RECEIPT NO. EXPIRES
ROSMEL POOLS iNC RENEWAL SEPTEMBER 30, 2014
8045 NW 36 ST 540 6600176 Must be displayed at place of business
DORAL FL 33166 Pursuant to County Code
Chapter 8A - Art. 9 & 10
OWNER SEC. TYf—: OF BUSINESS
ROSMEL POOLS INC 196 SPECIALTY PLUMBING CONTRACTOR PAYMENT RECEIVED
CPC1456804
Worker(s) t BY TAX COLLECTOR
$90.00 08/02/2013
TXHS1-13-041306
This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license,
ISL or a rmrtifheaton of the holder's quafiftc dons, to do business. Holder must comply with any governmental or
uon9avernmental regulatory laws and requirements which apply to the business.
The RECEIPT N0. above most be displayed on all commercial vehic�rls —Miami—Dade Gado Sec 88—M
For mom Wormeton, visit www miamidadt"" r !
I 03-21-2012
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIJ,..L 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: 03/21/2012 EXPIRATION DATE: 03/21/2014
PERSON: MARTINEZ ALINA
FEIN: 263013092
BUSINESS NAME AND ADDRESS:
ROSMEL POOLS INC
DBA ROSMEL POOLS AND OUTDOOR EQUIPMENT
8045 NMI 36TH ST STE 540
DORAL FL 33166-6687
SCOPES OF BUSINESS OR TRADE:
1- CONSTRUCTION SUPERVISOR (5608) 2- CERTIFIED POOL/SPA CONTRACTOR
IMPORTANT: Pursuant to Chapter 440 . 05{14), F.S., an officer of a sorporstlon who elects axampttox from this chapter by filing a certificate of elastica coder this
section may not recover benefits Of COMPSasation under this chapter. Pursuant to Chapter 440.05U2), F.S., Certificates of election to be exempt•• apply only wltbla 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 ao 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 parsoa
named on the certificate to meet the requirements of this section.
IC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 413-1609
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
;TATE OF FLORIDA
tEPAKTMENT OF FINANCIAL: SERVICES
NVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
;ERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA
VORKE+RS• COMPENSATION LAW
iFFECTIVE 03/21/2012 EXPIRATION DATE: 03/21/2014
,ERSOM ALINA MARTINEZ
EIN: 283013092
-USINESS NAME AND ADDRESS:
ROSMEL POOLS INC
ORA ROSMEL POOLS AND OUTDOOR EOUIPMENT
8045 NW 36TH ST STE 540
}ORAL, FL 33166.6687
COPE: OF BUSINESS OR TRADE
I' CONSTRUCTION SUPERVISOR (Seo6) 2- CERTIFIED POCIUSPA CONTRACTOR
fMPORTANT
0 Pursuant to Chapter 440.05114), F.S.. an officer of a corporation who
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.
H Pursuant to Chapter 440.05512), F.S., Certificates of election to be
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 440.05113), 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 tate 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) 413-1609
CUT HERE
• Carry bottom portion on the job, keep upper portion for your records.
C-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
rN
M
03-21-2012
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
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 03/21/2012
PERSON: VARELA
FEIN: 263013092
BUSINESS NAME AND ADDRESS:
ROSMEL POOLS INC
8045 NW 36TH ST STE 540
DOS- FL 33166-6687
SCOPES OF BUSINESS OR TRADE:
1- CONSTRUCTION SUPERVISOR (5605)
EXPIRATION DATE: 03/2112014
M I RTHA
2- CERTIFIED POOL/SPA CONTRACTOR
IMPORTANT: Pursuant to Chapter 440 . 05114). F.S., an officer of a corporation who etecrs exemption from this chapter by filing a certificate of election under this
section may oot recover beaelits or compensation under this chapter. Pursuant to Chapter 440.05(12). 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 if, at any time after the filing of the notice or the issuance at the certificate, the person named on the notice or
certificate no loager meets the requirements of Ibis section for issuance of a certificate. The department shall revoke a certificate at any lime 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) 413-16(
PLEASE CUT OUT THE CARO 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
EFFECTIVE: 03/21/2012 EXPIRATION DATE. 03/21/2014
PERSON: MIRTHA VARELA
FEIN: 263013092
BUSINESS NAME AND ADDRESS:
ROSMEL POOLS INC
9045 rW 38TH ST STE 540
OORA;. FL 33 186-668 7
SCOPE OF BUSINESS OR TRADE:
I- CONSTRUCTION SUPERVISOR (56061 2• CERT:FiED POOL. SP4 CONTRACTOR
IMPORTANT
F Pursuant to Chapter 440.05(14), 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(11), 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
E Pursuant to Chapter 440.0503). 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) 413-1609
CUT HERE
* Carry bottom portion on the job, keep upper portion for your records.
IWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
03-21-2012
.y
JEFF ATWATER STATE OF FLORIDA
CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF 'd ORKERS' 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' Compensati3n law.
EFFECTIVE DATE:
PERSON:
FEIN:
03/21/2012 EXPIRATION DATE: 03/21/2014
MARTINEZ MARCOS A►
263013092
BUSINESS NAME AND ADDRESS:
ROSMEL POOLS INC
8045 Nil 36TH ST STE 540
DORAL FL 33166-6687
SCOPES OF BUSINESS OR TRADE:
1- CONSTRUCTION SUPERVISOR (5606) 2- CERTIFIED POOL/SPA CONTRACTOR
3- CONTRACTOR -PROJECT MANAGER, CO
IMPORTANT. Pursuant to Chapter 440 '06414), F.S., so officer of a corporative woo elects exemption from this chapter by filing a cortificale of election ander Win
section may not recover benefits or compensation ander this chapter. Pursuant to Chapter 440.05117), F.S., Certilicates of election to be exempt... apply only within We
scope of the business or trade listed on The notice of election to be exempt. Pursuant to Chapter 440.x$03% F.S., Notices of election to be exempt and certificates of
election to be exempt shall be subject to revocation it, at any time after We filing of the notice or We 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 sball revoke a certificate at any time for lailtre of We person
named an the certificate to meet the requirements of this section. QUESTIONS? (850) 413-160
OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE 6F FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO 13E EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE 03/21/2012 EXPIRATION DATE: 03/21/2014
PERSON: MARCOSaA MARTINEZ
FEIN; 263013092
BUSINESS NAME AND ADDRESS:
ROWEL POOLS INC
8045 Nw 36TH ST STE S40
DORAL FL 33186-6687
SCOPE OF BUSINESS OR TRADE:
1- CONSTRUCTION SUPERVISOR (5806) 2- CERTIFIED POOL/SPA CONTRACTOR
3- CONTRACTOR -PROJECT MANAGER CO
IMPORTANT
F Pursuant to Chapter 440.05114), 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 440.0503), 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 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 meet the requirements of this
section.
CUT HERE
QUESTIONS? (850) 413-1609
* Carry bottom portion on the job, keep upper portion for your records.
7
)WC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11