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DS-14-1505Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-218345 Scheduled Inspection Date: October 09, 2014 Inspector: Rodriguez, Jorge Owner: , Job Address: 1550 NE 104 Street Miami Shores, FL 33138 - Project: <NONE> Permit Number: DS -7-14-1505 Permit Type: Driveways/Sidewalks/Slabs Inspection Type: Final Work Classification: Addition/Alteration Phone Number (305)905-6800 Parcel Number 1122320320380 Contractor: A A RELIABLE CONSTRUCTION INC Phone: (305)804-3933 sunning Department comments STAMPED CONCRETE DRIVEWAY AND WALK WAY Infractio Passed comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-215869. Restore all sod Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. October 08, 2014 For Inspections please call: (305)762-4949 Page 13 of 40 B 1. nr 1 aw ..- 1 )V/ D VITV JUL 16 914 nnnu S8905629"E P C_): 4'C,L.F 75.00' CO CN: LIMIT OF PLAT JOB # 13-367 DATE 06-01-2014 PB 40-72 Surveyor Notes: Surve ' v is Incomplete without sheer I of 2 Scale of'Dravving 1 —20' Drawn Hv: R. Sanchez Date: 06-01-2014 Completed Field Suncy Date: 06-01-1014 it Fit & COAIAANY, INC. 1,13 #7498 Professional Land Surveyors and Mappers 13050 SW' 133rd CT Miami, Florida 33186 Pit: 305-2.34-0.1588 FX: 206-495-0778 AFA &---- Company, Inc. J. P. 4'C.B.S . - Cdr;?4c "pxzr P E R M, IT <7-7 Miami Cres Villms - APPROVED BY DAT9 ZONING DEPT BLDG DEPT e7 -q- ' SUBJECT70 COMPLIANCE WITH ALL FEDERAL TATE ANi3COU MAV44MQFWaW'n0NS leplubts. Ld ul knowledge of MSubject y,'notes 'io oWlpdge and belie and Notations shown hereon .q1ex.viallal Suri'l, Afalper #5526 slve qJ-Florida Nat I Wid unless Si{ lied 9, SlampedwAlli Elliha.medSeal LO C-'��,}Jri �J) -J � T' ✓Jft-1, �:1 rI�J SJ C3J$�YJatz a1 2 16 Biscayne Canal i 17 1819 20 21 — -ME 104th STREZT-- — PROPERTY ADDRESS: 1550 Northeast 104th Street Miami , Florida 33138 18 SUBJECT PROPERTY SURVEYOR NOTES #1 Lands Shown Hereon were not abstracted for Easement and/or Right of Way Records The Easement / Right of Way Brat are shown on survey are as per plat of record unless Otherwise noted #2 Benchmark. MIam,-Dade County Public Works Dep B -26 -RA, Elev 1723 #3 Bearings as Shown hereon are Based upon Northeast 104th Street N89°56'29'W #4 Please See Abbreviations #5 Survey is incomplete Without Sheet 2 of 2 #6 Drawn By R Sanchez Dale 06-01.2014 #7 Complete Field Survey Date. 06-01-2014 #B DISC No 2014, Station Surveying Scion #9 Last Revised. #10 Legal Description Furnished by client #11 This Certification is only for the lands as described. It is not a certification of Title, Zoning. Easements, or Freedom of Encumbrances. ABSTRACT NOT REVIEWED #12 There may be additional Restrictions not shown on this survey that may be found in the Public Records of Miami -Dade County, examination of ABSTRACT OF TITLE will have to be made to determine record instruments, if any affecting this property #13 ACCURACY. The expected use of the land, as classified in the Minimum Technical Standard (5J-17 050), is "Residential" The Minimum relative distance accuracy for this type of boundary survey is 1 foot in 10.000 feet The accuracy obtained by measurement and calculation of a closed geometric figure was found to exceed this requirement #14 Foundations and/or footings that may cross beyond the boundary lines of the parcel herein described are not shown hereon. #15 Not Valid without one signature and the original raised seal of a Florida Licensed Surveyor and Mapper. Additions or deletions to Survey maps or reports by other than the signing party or parties Is prohibited without written consent of the signing party or parties #16 Contact the appropriate authority prior to any design work on information #17 Underground utilities are not depicted hereon. contact the appropriate authority prior to any design work or construction on the property herein described Surveyor shall be notified as to any deviation from utilities shown hereon. #18 Ownership Subject to OPINION OF TITLE 4 � 1 • 20 I 21 ABBREVIATIONS A ARC DISTANCE AVE AVENUE ASPH ASPHAL' AC . AIH CONDiTK)NEH SLOG BUILDING 8 COR SLOCKCORNEH L:8 -CATCH BASIN CLF CHAIN LINK FENCE __ONC CONCHE TE COICOLUMN C U PCONCRETE UTILITY POLE CL PCONCRETE LIGHT POLE CBS CONC RETE BLOCK STRUCTURE C SCONCRETE SLAB CME CANAL MAINTENANCE EASEMENT C P CONCRETE PORCH U -DIRECTION U:W 10RIVEWAT DME - DRAINAGEBMAIN TENANCT �:ASEMENr ENC :ENCROACHMENT E T P =ELECTRIC TRANSFORMER PAG FPL 'FLORIDA POWER AND LIGHT FMFIRE HYDRANT FIP =FOUND IRON PIPE FF=FINISHFLOOR FDH =FOUND DRILL HOLE FR =FOUND REBAR FID =FOUND DISC FIN =FOUND NAIL IF -IRON FENCE L 'LENGTH L P -LIGHT POLE MEAS =MEASURED M H =MAN HOLE N G V D -NATIONAL GEODETIC VERTICAL DATUM NTS -NOT TO SCALE OE =OVERHEAD ELECTRIC LINE OIL=ON UNE PCP =PERMANENT CONTROL POINT PC =POINT OF CURVATURE R -RADIUS RES =RESIDENCE SOWLK =SIDEWALK T :TANGENT U E =UTILITY EASEMENT WIF=WGODFENCE W V -WATER VALVE WUP =WOOD UTILITY POLE IU P) =IRON FENCE I I F T =CHAIN LINK FENCE I C L F I ��`�-+�+� •WOOD FENCE I W F I 'CBS WALL IC BW 1 OVERHEAD ELEC —'—'— 'CENTERLINE (i EASEMENT 3400. rOENOTES ELEVATIONS BUILDING a — -DISTANCE FEH =CATCH BASIN (C B I 5Q =WATER METER ( W M I m =WUP �i =STATE ROAD =US HIGHWAY =M TE RSTATE (9 =MON17 OHY WELL 22 23 22 24 EL E VA TION INFORMA TION National Flood Insurance Program FEMA Elev. Reference to NGVD 1929 Comm Panel 120652 Panel # 0306 Firm Zone: 14 Date of Firm: 1 15 9.00' 16 16 Biscayne Canal i 17 1819 20 21 — -ME 104th STREZT-- — PROPERTY ADDRESS: 1550 Northeast 104th Street Miami , Florida 33138 18 SUBJECT PROPERTY SURVEYOR NOTES #1 Lands Shown Hereon were not abstracted for Easement and/or Right of Way Records The Easement / Right of Way Brat are shown on survey are as per plat of record unless Otherwise noted #2 Benchmark. MIam,-Dade County Public Works Dep B -26 -RA, Elev 1723 #3 Bearings as Shown hereon are Based upon Northeast 104th Street N89°56'29'W #4 Please See Abbreviations #5 Survey is incomplete Without Sheet 2 of 2 #6 Drawn By R Sanchez Dale 06-01.2014 #7 Complete Field Survey Date. 06-01-2014 #B DISC No 2014, Station Surveying Scion #9 Last Revised. #10 Legal Description Furnished by client #11 This Certification is only for the lands as described. It is not a certification of Title, Zoning. Easements, or Freedom of Encumbrances. ABSTRACT NOT REVIEWED #12 There may be additional Restrictions not shown on this survey that may be found in the Public Records of Miami -Dade County, examination of ABSTRACT OF TITLE will have to be made to determine record instruments, if any affecting this property #13 ACCURACY. The expected use of the land, as classified in the Minimum Technical Standard (5J-17 050), is "Residential" The Minimum relative distance accuracy for this type of boundary survey is 1 foot in 10.000 feet The accuracy obtained by measurement and calculation of a closed geometric figure was found to exceed this requirement #14 Foundations and/or footings that may cross beyond the boundary lines of the parcel herein described are not shown hereon. #15 Not Valid without one signature and the original raised seal of a Florida Licensed Surveyor and Mapper. Additions or deletions to Survey maps or reports by other than the signing party or parties Is prohibited without written consent of the signing party or parties #16 Contact the appropriate authority prior to any design work on information #17 Underground utilities are not depicted hereon. contact the appropriate authority prior to any design work or construction on the property herein described Surveyor shall be notified as to any deviation from utilities shown hereon. #18 Ownership Subject to OPINION OF TITLE 4 � 1 • 20 I 21 ABBREVIATIONS A ARC DISTANCE AVE AVENUE ASPH ASPHAL' AC . AIH CONDiTK)NEH SLOG BUILDING 8 COR SLOCKCORNEH L:8 -CATCH BASIN CLF CHAIN LINK FENCE __ONC CONCHE TE COICOLUMN C U PCONCRETE UTILITY POLE CL PCONCRETE LIGHT POLE CBS CONC RETE BLOCK STRUCTURE C SCONCRETE SLAB CME CANAL MAINTENANCE EASEMENT C P CONCRETE PORCH U -DIRECTION U:W 10RIVEWAT DME - DRAINAGEBMAIN TENANCT �:ASEMENr ENC :ENCROACHMENT E T P =ELECTRIC TRANSFORMER PAG FPL 'FLORIDA POWER AND LIGHT FMFIRE HYDRANT FIP =FOUND IRON PIPE FF=FINISHFLOOR FDH =FOUND DRILL HOLE FR =FOUND REBAR FID =FOUND DISC FIN =FOUND NAIL IF -IRON FENCE L 'LENGTH L P -LIGHT POLE MEAS =MEASURED M H =MAN HOLE N G V D -NATIONAL GEODETIC VERTICAL DATUM NTS -NOT TO SCALE OE =OVERHEAD ELECTRIC LINE OIL=ON UNE PCP =PERMANENT CONTROL POINT PC =POINT OF CURVATURE R -RADIUS RES =RESIDENCE SOWLK =SIDEWALK T :TANGENT U E =UTILITY EASEMENT WIF=WGODFENCE W V -WATER VALVE WUP =WOOD UTILITY POLE IU P) =IRON FENCE I I F T =CHAIN LINK FENCE I C L F I ��`�-+�+� •WOOD FENCE I W F I 'CBS WALL IC BW 1 OVERHEAD ELEC —'—'— 'CENTERLINE (i EASEMENT 3400. rOENOTES ELEVATIONS BUILDING a — -DISTANCE FEH =CATCH BASIN (C B I 5Q =WATER METER ( W M I m =WUP �i =STATE ROAD =US HIGHWAY =M TE RSTATE (9 =MON17 OHY WELL 22 23 22 24 EL E VA TION INFORMA TION National Flood Insurance Program FEMA Elev. Reference to NGVD 1929 Comm Panel 120652 Panel # 0306 Firm Zone: "AE" Date of Firm: 09-11-2009 Base Flood Elev, 9.00' F.Floor Elev. 6.75' Garage Elev. 4.68' Suffix: "L" Elev. Reference to NGVD 1929 CER TIFIED ONL Y TO: D LAS 2 LLC, a Florida limited liability company First American Title Insurance Company Bilzin Sumberg Baena Price & Axelrod LLP LEGAL DESCRIPTION: Lot 17, Block 4 of RIVER BAY PARK ADDITION, according to the Plat Thereof as Recorded in Plat Book 40, Page 72 of the Public Records of Miami -Dade County, Florida This certilics thou the survey ol'the property JOB # 14-367 described hereon a as made under Illi super j— Ll tl that the 11111 the iFlotil,ai» irlh Surveyors & Mappers LB 7498 set b technical standards tit linlh by the Florida tec a AFA & Board of Professional Land Sun'eyors & Inc. Mappers in Chapter 5.1- t 7.050 LTi Florida .ompany, Administrative Code. pursuant to Section ar ada F.. et 472.027, Florida Statutes. That the Sketch hereon is it true and Projersiaaal Sarveyar & Mapper 0526 accurate representation thereorto the best of ofnly knowledge and Belief', subject to notes stateafrlorida and notations shown hereon. JOB # 14-367 Professional j— Surveyors & Mappers LB 7498 DATE 06-01-2014 13050 S.W. 133rd Court ;'::�77pr' PB 40-72 Miami Florida, 33186 ar ada F.. et Email: afaco@belIsouth.net Projersiaaal Sarveyar & Mapper 0526 Ph. # (305) 234-0588 stateafrlorida Fax # (206) 495-0778 Not l alidualessSr,'gned & Starirped with EiabmvedSeal Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (30S) 762-4949 BUILDING PERMIT APPLICATION OBUILDING n ELECTRIC ❑ ROOFING JUL IS 2014 FBC 2010 Master Permit No. s 1,9`- l,'5 -0, -'5= - Sub Permit No. ❑ REVISION ❑ EXTENSION RENEWAL []PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP y� CONTRACTOR �kofyV DDRAWINGS JOB ADDRESS: Q ' V (04 ,,� SIAZT(5 City: Miami Shores County: Miami Dade zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: SAIZ Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): �(A ) -, I Lc,G Address: / S 5' CD 0V C' e Z> t /' City: State: - /15 / Zip: Tenant/Lessee Name: Phone#: Email: 051909,6 jT"7,F- CONTRACTOR: Company Name: /T 109/ 2@ Z,.'7C d Z4 -yt74-S /? C_ Phone#: Address: / 6 7 -! /1/ C f % �/ r -"- City: "City: AJ /A-/ /.3 f /�/ / State: /�� Zip: 3 3 / 6c�2. Qualifier Name: /.� /74 � < c/•py Phone#: (3ar, e® !- 19 3 State Certification or Registration #: /C< ! (ova of Competency #: DESIGNER: Architect/Engineer: Phone#: Address City: State: Zip: Value of Work for this Permit: $ 3F -10c) OS? Square/Linear Footage of Work: / `11 Type of Work: ❑ Addition ❑ Alteration ErNew ❑ Repair/Replace Description of Work: Sic/ Ct Uf ❑ Demolition >� Specify color of color thru We: Submittal Fee $ Orj Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Technology Fee Structural Reviews $ (R&Ased02/24/2014) Radon Fee $ Training/Education Fee $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $G1++ 9 -C"113 • W' 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 Zi A 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 $2500, the applicant must promise in good faith that a copy of the noti a of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. so, a certified copy of the recorded notice of commencement must be posted at the job site for the first ins c n which occurs ven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will of be pproved an a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of UL 20 0' by e—,4 'who is personally known to me or who has produced —F— L 1--) 1' as identification and who did take an oath. NOTARY PUBLIC: The foregoing instrument was acknowledged before me this 0 0 day of ' U L 20 Q by g, mA6 EJB who is personally know or who has produced as identification and wbjdid take an oath. NOTARY Sign: Sign: v • Print: 617 A t LR' ,%) 1 Print: f a4q 2A H 1 `'4 Seal:S BARS AI�A MIL.ANB$ BARBARA MILANEB �,.� ,'bU ` MY COMMISSION # EE060749 « `: MY COMMISSION # EE060749 ril 08, 2015 Pa EXPIRES April 08, 2015 = EXPIRES AP 4071308.0153 (4 328.0153 �f APPROVED BY Plans Examiner L ' Zoning Structural Review (Revised02/24/2014) Clerk Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY Whereas, (owner)hereinafter referred.to as the owner of the following described property (address): S A-lrc� ,v -+o, S%1�r�� , //"—/ 333 & Legal Description Lot / -7 Block q� Folio # Requests permission to install (describe work): _5_7t4 0" Subdivision ✓?/ ��' ��r/� ��"% Within the public right of way of (address) IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said items within public right of way including restoration of street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from any and all liability, which may rise by virtue of permitting the installation of these items within the public right of way. 1 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village (or his fully authorized representative). SIGNED, SEALED, EXECUTED AND ACKNOWLEDGE or SIGNED, SEALED, AND DELIVERED in the pr s e of: =��9='! NES :4PpY PU$i% MY C0MNIIs$IONI O8, 2015 Es AP Ae Ey.P�R _ ,carv�oe.eom Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. X COPY OF QUALIFIER'S STATE LIC CARD B. X COPY OF LOCAL BUSINESS TAX RECEIPT C. --X--COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT) D. X COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT) D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTION) YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW. MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrri COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: A A Reliable Construction Inc. BUSINESS ADDRESS: 1679 NE 174TH ST CITY NMB STATE FI ZIP CODE 33162 BUSINESS PHONE: (__) CELL PHONE3! 05 ) 804-3933 FAX NUMBER (�1 QUALIFIER'S NAME. Abel Almaguer QUALIFIER'S LIC NUMBER: CGC1517602 E-MAIL ADDRESS (IF APPLICABLE): Almaguer553@aol.com Created on 3119109 BY MLDV 1 RV 3126109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET •`�� TALLAHASSEE FL 32399-0783 ALMAGUER, ABEL A A RELIABLE CONSTRUCTION INC 1679 NE 174TH ST NORTH MIAMI BEACH FL 33162 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you bettE For information about our services, please log onto www►.myiloridallcensexom. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and team more about the 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. Thank you for doing business in Florida, and congratulations on your new license! ----- -- --- -- - DETACH HERE_ STATE OF FLORIDA AC# 62718 DEPAR.TMENT OF BUSINESS AND i PROFESSIQNL.REGULATION C©C151760Z :0S/T5/12 1280363: CERTIFIED, �GEijTEUL '.CONT ACTOR As:raGUER, A$EL' f A A RELIABLE °CONSTkUCTION INC t j IS CERTIFIED under the provisions of chA89 f Exgaretion date. AUG 31, 20 14 L180815b2137 A 627182,0 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD . _ SEML3.20815023.2 . • LICENSE 013 ,15 2012 128036323 CGC1517602; Tkie GENERAL CONTRACTOR Named: below T3 CERTIFIED Tinder the provisions of Chapter 48 FS Expiration date: AUG 31, 2014 r :ALMAGUER, .ABEL A A RELrIABLW CONSTRUCTION INC 1679 NE174 TH ST NORTH.. _MIAMI BEACH FL 33162 N JEFF ATWATER CHEF FUMCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT SROM. 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; 1012712013 FEIN; 2081 58558 BUSINESS NAME AND ADDRESS: 9579 NE 174 ST 03,141, . 9 • Pursuant to Chapter 441.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover beneft or compensation under this chapter. Pursuant to Chapter 440.05(12), .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 . o n to be exempt shall be subject to revocation if, at any time after the film of the notice or the issuance of the certificate, the person named on the notice or certificate no longer mem the requim ments of this section for lssuance of aficate. 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. MCC! c°) f'nlAff% nc- n 4-r-n-r$r-ir%A-rr- Miami shores V Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:, An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect ' to be exempt if - 1 . f: 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation injuries of M person allowed to work under this permit. Please check with your insurance carrier since most property insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Print Name: 45�a /C=J- Signature: State of Florida ) County of Miami -Dade ) Sworn to aA subscribed day of M (SEAL) Type of Identification Contractor Print Name: /'1 Signature: State of Florida ) County of Miami -Dade ) Sworn to and subscrib day of �TL SARaARAF By MY COh4MISSION # E 065749 (SI _. 10=R Aned 08, 2015 me this 14 20J BARBARA MILANES MY COMM15t5ION #E0607A EXPIRES April 08, 2015 CERTIFICATE OF LIABILITY INSURANCE ,riu wu w THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RNOHTS 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: N the certificate holder Is an ADDITIONAL INSURED, the pollcyllel) must be endorsed. 0 SUB IS WAIVED, suwct to the terms and conditions of the policy, certain POlicles may require an endorsement A statement on lids cefficate does not confer rights to the callficate holder In IIAu of such endorsemengs} PRODUCER AN Insurance ServicesE 1548 W. 37 St. Hialeah, FL 33012 Phone 305) 822.4472 Fax 305) 5554354 874-4472 558.4354 Jfemandez�ry aae► s APFOROaRi CO aA♦c S INSURER A: REPUBLID-VANGUARD INSURANCE COMPANY INSURED A A Re&Ue Construction Inc. 1679 NE 174 St North Mlaml Beach, FL 33162 (305) 804-3933 INSURER s- A NSURER D: INSURER E: 1 P' W V Cr{MgC0 UMP IMATE NUNBER: RFIARIM allMPA:'R- 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 REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCLMIENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AUX. THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAOAS. INt �R TYPE OF INSURANCE ADM SM POLICY NUMBER 041111=15 LIMITS A GENERAL LIABILITY ® COMMERCAL GENERAL LIABILITY ❑ [I CLAMMSMADE ] OCCUR ❑ ❑ GENT. AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ ❑ LOC PGL003902-13 04/111=4 EACH f 1,000,00D.00 S 100,000.00 MED EXP one p man $ 5,000.00 PENAL &ADV INJURY $ 1,000, 00 GENERAL AGGREGATE s 2,000,000.00 PRODUCTS- comploP AeG S 2,000,OOD.00 s AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ AAUUTOS OWNED ❑ AUT SCHEDULED ❑ HIRED AUTOS ❑ AUT0 8I SIWCvLE LIMIT 16�BI1 SOMLY KWRY (Par pmt $ BODILY mm (Per eeeslmtl $ E f f ❑ UMBRELLA LIAR ❑ OGC !JA EXCESS LKS El CLAIMSMADE EACH OCU RRENCE S AGGREGATE0 f DEO El RETENTION $ S WORKERS COMPENSATION AND EMPLOYE7rRW LqIIABLITY Y I N OOFFRCERRIFAAEMBER'EXCLU°ED? (My�a m�nin udlet DESCRIF ION OF OPERATIONS below NIA V,iC A OTH LIMM E.LEACH ACCIDENr S E.L. DISEASE- EA EMPLOYE S E.L DISEASE - POLICY LIMrr f DESCRIPTION OF OPERATIONS I LOCATIONS I VMXXES (01110611 ACORD 101. Addiflaft Remeft SOM6111e. H more apace is required) GENERAL CONTRACTOR 01517602 GERTIrIUATE r1ULUEK CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 AVE MIAMI,FL 33138 ACORD 25 (2010106) OF SHOULD ANY OF THE ABOVE DESCRIBE=D POLICIES BE CANCELLED BEFORE THH EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOROW REPRESENTATIVE ($188B-2010 ACORD CORPORATION. jMjftMS reserved. The ACORD nma and logo are r*gh*MVftrb Of ACORD