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MC-14-1936Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-223832 Scheduled Inspection Date: November 26, 2014 Inspector: Perez, JanPierre Owner: , Job Address: 515 NW 111 Street Miami Shores, FL 33168-3331 Project: <NONE> Permit Number: MC -9-14-1936 Permit Type: Mechanical - Commercial Inspection Type: Final Work Classification: A/C Replacement Phone Number (202)772-4076 Parcel Number 3021360210710 Contractor: AMORES QUALITY PLUMBING INC Phone: (786)222-6711 Building Department Comments CHANGE OUT HVAC 3 TONS Infractio Passed Comments INSPECTOR COMMENTS False <T- t ( l Passed Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. Inspector Comments CREATED AS REINSPECTION FOR INSP-219081. November 25, 2014 For Inspections please call: (305)762-4949 Page 24 of 48 BUILDING PERMIT APPLICATION 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: (305) 762-4949 I�iov� yo . I FBC 20 U yy Master Permit No. 1. Sub Permit No. ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP i ,, 11 N CONTRACTOR DRAWINGS JOB ADDRESS: .5 1 5 u ' � City: Miami Shores County: Miami Dade Zip: " ' 6p Folio/Parcel#: I I a 13C in 10—+10 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 0%1- J6('*d►CM-Je, Phone#: Address.l��r City State: P►Q zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: %�i'l �(��.�Gl,�I r� m1c.Phone#: Address: �Q JLO 12(� ' City: Qualifier Name: :El- Zip: B3 7� State Certification or Registration #: C M C ) a 1 '5 Certificate of Competency #: _ DESIGNER: Architect/Engineer: Phone#: Address City: State: Zip: Value of Work for this Permit: $ A c® 0 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Permit Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) 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 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 notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this 3 day of t 20 _ by v 7, who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: �tb'- �60' as Signature CONTRACTOR The foregoing instrument was acknowledged before me this day of1JO Q 20 , by 4rmyLLA- who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: WV i 6 e!� Seal: NOTARY PUBLIC Seal: NOTARY PUBLIC STATE OF FLORIDA STATE OF FLORIDA Coma# EE12MI CX=m#EE1=M �z.iirea 1 15 b APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) irsswca,Jam gum pemtt cn��q*ftgoft bWneMkMdernWcQ�*wflh -- —: — . I i , &A 'cam wNchap*tothe VmF6*#) NO tlThorehybrtt II" o 96 tQ LLI I fwjD rl II" IS CERTIFIED under the Pr0vi$1045 Of Ch.469 FS. E1 raficndi* AUG31.2US k. �® CERTIFICATE OF LIABILITY INSURANCE DA09/(IIBIUDDIYY) 04/14 PRODUCER Florkla Bankers Insurance 7278 SW 8 Street Miami, FL 33144 Phone (305)266-6493 Fax (305)262-0679 MIAMI SHORES VILLAGE BLDG DEPT THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE BELOW. INSURERS AFFORDING COVERAGE MAIC # INSURED Amores Quality Plumbing Inc. 10440 SW 170 ST MIAMI, FL 33157 MIAMI SHORES, FL 33138 INSURER A. FEDERATED NATIONAL COMPANY INSURER B: INSURER C. INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OF MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADDS MR TYPE OF INSURANCE POLICY NUMBER DATE BAY DATE T�1 NMO/ LIMITS A ❑ GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS MADE R] OCCUR ❑ ❑ GEML AGGREGATE LIMIT APPLIES PER. ® POLICY ❑ PROJECT ❑ LOC GL-05040101&3-00 07/26/14 07/26/15 EACH OCCURRENCE 1,000,000.00 ANM0 PREMISES (Ea REN S 100,0M.00 MED EXP {Any one person) 5,000.00 PERSONAL & ADV INJURY 1,000,000.00 GENERAL AGGREGATE 2,000,000.00 PRODUCTS - COMP/OP AGG 2,OW,OW,00 B ❑ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS ❑ COMBINED SINGLE LIMIT (Es ecdde" BODILY INJURY BODILY INJURY (Per accident) PROPERTY DAMAGE (PeraoddeM C ❑ GARAGE W18RM ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG D EXCESSIUMEIRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE E WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yea, describe wxIer SPECIAL PROVISIONS below ❑ T&Wes ❑ TH E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT F OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFIED MECHANICAL CONTRACTOR 1249813 CERTIFICATE HOLDER CANCELLATION ACORD 26 (2001108) QF © ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL MIAMI SHORES VILLAGE BLDG DEPT 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2nd AVE THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI SHORES, FL 33138 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE BBAai.bnp ACORD 26 (2001108) QF © ACORD CORPORATION 1988 PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE r---- — — — — --- ..__ _..--------..... ..-. IMPORTANT j STATE OF FLORIDA I Pursuant to Chapter 440.0504). F.S., an o4ksar of a corporation DEPARTMENT OF FINANCIAL SERVICES who efts exemption from this chapter by ffting a certificate of ' DIVISION OF WORKERS' COMPENSATION I •® F election under this section may not recover benaf is or CONSTRUCTION INDUSTRY EXEMPTION i ip corrnaensetian underthIs chapte�. 1 CRIM BATE OF ELECnaN To BE EXEW T Fete FLORmA I L Pursuant to Chapter 440.05(12), F.S., Certificates of election to WORKEW COMPENSATMN LAW D be exempt., appy only within the scope of the business or trade I EFFECTIVE DATE: lMN2013 EXPRATtoN DATE: treaaots listed on the notice of election to be exempt. i OMM: AMORM ANGEL A IH FEDI: swssena E Pursuant to Chapter 440.05(13). F.S., Notices of election to be exempt and ceWcates of election to be exempt shall be BUSINESS NAME AND ADDRESS: R subject to revocation if, at any time after ft fMM of the notice ' AMORES QUALITY PLUMBING INCE or the issuance of the certificate, the person named on ft i AMORES QUALITY CONSTRUCTION I notice or certtiirate no longer meals, the requhemema of this section for Issuance or a certificate. The department shall revoke 10440 SW 170 ST � I a certificate ffi any time for fe8ure of the person named on the I MIAMI FL 33167 ceftfficate to meet the requirements of thIs section. SCOPES OF BUSINESS OR TRA LICENSED GENERAL PLUMBING NOC AND HEATING, VENTILATION, bONTRACTOR DRIVERS AIR-COND DFS-F2-DWC-282 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 i 4 CitiMortgage June 6, 2014 Letter of Authorization RE: 515 NW I I I St. Miami, FL 33168 To Whom It May Concern: Citi www CdbT lgage.com Ptease accept this tetter as authorization for Domestic Renovations to pup permits and complete repairs for the above referenced property, as they are sub -contractors with our preservation vendor, Safeguard Properties. LLC. Thank You; Marie Sig er Assistant Vice President ® 2011 CiliMortgage. Inc. citiMortgage. Inc does business as Citicorp Mortgage in lei CibMortgage. Inc. is an equal housing lender Cpi. Arc Design. and Cid arul Arc Design are registered semis marks of c4group lnc. 'Calls are randomly monitored and recorded for quay assurance. Mortgage is a debt colleaor ard any Intomsation obtained will be used for that purpose. s or estic nc. Subcontractor Agreement Property Address: 515 NW 111 Street Miami Fl. 33168 Folio# 1121360210710 This subcontractor agreement is made between Amores Quality Plumbing, "Subcontractor," and Domestic Renovators, Inc., "Contractor." The agreement covers work to be done and sets expectations regarding that work. Violations of this agreement may lead to legal consequences. This agreement guarantees the Subcontractor a payment of $2,000 for the work to be done. In cases of additional labor, the Subcontractor will be granted additional pay and will have the right to negotiate the amount. The total amount due will be paid upon completion of the work, with a deposit of $1,000 in place before the work is begun. The work to be performed by Subcontractor is limited in nature. It covers exactly and precisely the following duties: Remove and Replace HVAC, 3 ton. Materials for this work will be provided by Amores Quality Plumbing and have been considered in the pay rate listed above. The Subcontractor will be responsible for providing labor and managing the project as stated above. It is understood that the work will be started on 8/27/2014 and will be completed by 9/10/2014. If unforeseen circumstances prevent the safe and effective completion of the work, extensions will be discussed but are not guaranteed. If delays are not remedied within 30 days, the Contractor will have the right to withhold payment, unless the delays are caused by forces within the control of the General Contractor. The work performed will be of a certain standard in order to be considered acceptable. These standards are explicitly outlined in the description of the project provided to the Subcontractor, but generally include before, during and after photos of all work. If legal disputes arise, the case must be arbitrated by an independent entity qualified for this position. The fees for arbitration will be paid by the party deemed in the wrong, and all charges will be voluntarily submitted once arbitration is complete. By signing this agreement, both the Subcontractor and the Contractor are agreeing to all terms above. 08/27/2014 08/27/2014 10763 NW 23rd Street Miami Fl. 33172 Phone (305) 639-2020 AlF t Mariane(a Negrete A=unt omestic Renovators .Inc. ©(305)639-2020 ©(766)925-6886 ®Marfaneltapdomest crenovatDmcom QQ facebook coM mesticRenovators ©twitter am V DomesticRenovat Q www.domestlaenovAws cam Qv 10763 fdW 23 St Miam6 FL 33172 • Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): City: Miami Shores Village C ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES F] NO E]ARHI Sheet Attached: YES MO ❑ Contract Attached: YES 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: Phone: M U-101/ State Certificate or Regist i Certificate of Competency No. Signature Date ? l4 gnature) (Revised02/24/2014) UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER Ci AHU or PKG. UNIT MODEL # G. COND. UNIT MODEL# KW HEAT NOM TONS AHU CU PKG 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3)VOLTS AHU CU PKG PKG UNIT / / PKG UNIT EER/SEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4"CONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: Phone: M U-101/ State Certificate or Regist i Certificate of Competency No. Signature Date ? l4 gnature) (Revised02/24/2014) Des ig nstar Load Calculation Results are intended for use with Rheem heating and cooling systems i:h a New Dogtoo *' Con fon.'y Information SHR .......... ................... ..._._...................................... 75 ................................_....................._..._........................ Number of residents ............................................... .._._........................ ................. ......._............................ .... ............ ,. 2 ............................................... Ceiling height ..................................................................... ..................... _...................... ...................... ,................................ 9 _........... ..................................................... ............................ ................................. Wall U -value R -value . ............ .............. ............................................... ... ............ .......__.......,.................. .............................................. ............................ _...... ................... ........................... ......... .......... 0.091 11 Floor U -value R -value ........ ........... --............. ........................ ............................-...... ............ .................... .........................................................._ .................................... ................... _..-............... ........... .............._........ ....................... ........... ........... . 0.2 ( 5 Ceiling U -value I R -value .......... .-................................................._............................._.............._......................................_...__..........................................................._......_.._..................................................................................... ................ 0.0531 19 Window U -value .. ............. ................................_......................................................................._........._....................................................................._.................................................._................................_........... . 0.5 Window SHGF .............. ........................... ..................................... 0.85 ......._...:.................. -.......... ................ ........._............................... Moisture grains ........................ ................. ........................ .................._..... .........,.......................................... ..................... ................ ...... 58 _............_.........................................- _.......................................... Duct loss % ............................................................................................................................:.................... ..................._....I".., .............. ....................... .................. ....................... ... 10 _................ ................................ Duct gain % ................................ ............. _.......................................... ,............... ............................. .,.... .......... 10 ................ ................... ............................. ..........................._._............. Cooling infiltraction (ACH) _ .......... ............................... .......................... ......... ............... --- .......... ..... _....... .. ...................... ............................................................,..... 0.6 ............... ..........._.............................................. ........... ............................................ Heating infiltration (ACH) ....... ............... ..................... ........_.................................... ......................................................... .._:...:. 0.8 _........................................................................ ....................................... ............ ........................................................... Winter ventilation ................... ....................................... ._,..,.............._............................,................................ ...................... 0 ..................................... ................................. ........... ........................._........................ Summer ventilation ...................................... ...... _....... .................._........._............................. ............ .................. ...... 0 Relative humidity Moisture difference 50% f Indoor Heating:......._......_Cooling _. ......................................................._......................................................................................................... Indoor temperature (°F) 70 75 .... .................. ...................... .:................................:............................ ......... ........._,...................:_,.................................,...........:.............:..._.........,....................:...:..............,..._....:........,.................... Design temperature differenceff) 20 15 Heating Loads Area Btuh% of load Wall 2040 15.2 ................. ........................................ _................... Floor ............ ...... 3436 _....... ......_........_............... .... 25.5 Ceiling 1446 10.7 ._................................__.......,..............._..__..........._..........._..........._ Windows 1960 14.6 Infiltration 3349 24.9 __................................................................. ......_........................._............................--- System Efficiency Loss .... 1223 _................. ............................ 9.1 ............ ............--- ...................... .............. ......... Total: ...................... .............................................. ._...................... .............. ........... .... 13454 ............... .............. ........................... ._ ......... .................................... . Heating Loads 13,454 BTU/hr Floor Infiltratior ISystem Efficiency Loss ng Windows Cooling • . • AreaBtuh % of load Wall .................. 1530 5.7 ...................... .................... ................_................... Ceiling _.... .............. .................. 2892 _....... .......................... _..._ ..._ 10.7 Windows ....._......................................._............................._...._...................._........_..........................................__ 10747 39.8 Sensible Infiltration 1884 7 Latent Infiltration 4503 16.7 System Efficiency Gain 2156 8 Internal 2400 8.9 Sensible People Load .................... 460 1.7 ---- ......................................... ..................... ......._.................... Latent People Load ............... 460 _............................. ......_...... 1.7 Total: 27031 Windows Sensible People Load r _ Latent People Load ble Infiltration System Efficiency Internal Ade nate Ex osure QiversitgA GraphAED 15000 10000 5000 0 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm Hourly Loads — Average System equipment selection will be made using the following derived values. Glass (E) .._........................................................_................................._............................................................_...................._.......................................__.............__........_................._..........................._....................................... 99 sq. ft. Glass (S) ..................... ........... ............................. ............. ....................................... ........................................... _...... 14 sq. ft. _....................................:_.:.............................................:............:.........:..........._............................. Glass (N) .. .................... .._................. ............................ ....................... ..................................................... 14 sq. ft. ...................................................... Glass (W) ... .......... ... --- :...................... ... ................................... ..........._................. .......................................... .._...................................... _............................................................ ................:.................. .................... 69 sq. ft. ............. ._.......................................... ............................... ..................................... Summer Outdoor ...... 90°F ......_.........................................................................................................................................................................................................._..........................................................................:....................................... Summer Wet Bulb 77°F ................. ............................. .............................. ............................................... .... Summer Indoor _..................................................................................................................................................................................................................................._.................................................................................................................... .................... .............. ............... ._........................ ............_............................:.:.....................................- 75°F Summer Design Grains 50% _ .. ................. ............................ --- .......................... ...................................._...........................,..:......................... Winter Outdoor ............................. ........_,...................._........... ................... ..........,..:................. ......:........ .......... ...... 50°F _.................. ................................................................................................ Winter Indoor _ ..........._........................... _........ ............. _.......................... .................... .................. ................... 70°F .............. ........................ ............. .................................................. ......._...._._..._....................... Sensible Cooling .......................... .................... ..................:......._.....,:.......................................................... _...................... _...... ..................................... ..................... ......._......_........................ ........... 22,069 Btuh ............. ..:....:...............................:............... Latent Cooling .................. ._.......................................... ........_...:........................... _...................._......................_....._.......................... 4,963 Btuh ..................._.......................... ............ ........................................................ Required Cooling Airflow ..................... ............ .................. ............. _......._.................................................. ................ ............................. .......... 1,003 CFM .......................................................................................... Sensible Heating ...................................................._............................................................. ................ ............................._.....,......................................................................................................... 13,454 Btuh _,...................................._.........__.........._......._................._.................................._................................. Required Heating Airflow ......................... ........_................ ..._....................... ................ ................................... .._................. 175 CFM ............... ................. ............_.._.........,.... .... .......................... ............................................ .......:.. All calculations are based upon approved hvac industry .......... standards and procedures, and comply with all local, state and federal code requirements. All computed results are Estimates. Product provided by Energy Design Systems and Idea Tree Miami shores Village 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 iniuries of any_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: � etN Signature: State of Florida ) County of Miami -Dade) �,1 Sworn to and subscribed before me 's N(V day of , 20. Contractor Print Name: Signature: State of Florida ) County of Miami -Dade ) Sworn to and subs ribed day of % WILSON KANGByot STATE OF FLORIDATi of before me this 000 20 114. NOTARY PuI3LIC F X�,:;t - iv -4-7015