DEMO-15-148 Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
I
Inspection Number: INSP-240596 Permit Number: DEMO-1-15-148
Scheduled Inspection Date: August 04, 2015 Permit Type: Demolition
Inspector: Rodriguez,Jorge
Inspection Type: Final
Owner: MARIANA JULIA LIVORS, FABIANO Work Classification: Building
" "IIDA A!`-1 III AD
Job Address:9935 NE 13 Avenue
Miami Shores, FL 33138-2634
Phone Number
Parcel Number 1132050090470
Project: <NONE>
Contractor: FITCH BUILDERS LLC Phone: (754)234-0064
Building Department Comments
DEMO 3 BATHS, KITCHEN AND INTERIOR WALLS ISPEC Passed Comments
INNSPEC
ACCORDING TO PLANS. TOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-239766. CREATED AS
REINSPECTION FOR INSP-226920. GARAGE DOOR WILL BE OPEN
PERMIT WILL BE INSIDE
No access
Failed
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
August 03, 2015 For Inspections please call: (305)762-4949 Page 36 of 37
i
JCD ARCHITECT, INC A.A. #26001 560
1385 CORAL WAY SU #407 TEL.#(305)285-4343
MIAMI, FL 33 145 FAX#(305)285-4330
July 31, 2015
Village Of Miami Shores Bldg Dpt.
10050 NE 2nd Avenue
Miami Shores Fl
Address: 9935 NE 13 Avenue, Miami Shores Fl
Owner: Fabian Silveira
Permit#1-15-148
CERTIFICATE
The undersigned Juan C David, Architect of record for the above mentioned property certifies
that the existing interior partitions frame shall be remain in order to support the existing roof
structure
thanks for your understanding in this matter
.t :r
tall Davi
AR#'
FULL ARCHITECTURAL SERVICES ed RESIDENTIAL CZ COMMERCIAL cz CUSTOM DESIGN cue LEED CERTIFICATION
J UAN C DAV I D Q JC DARC H Ff ECT.C OM
011
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-227985 Permit Number: DEMO-2-15-293
Scheduled Inspection Date: June 12, 2015 Permit Type: Demolition
Inspector: Devaney, Michael Inspection Type: Final
Owner: MARIANA JULIA LIVORE, FABIANO Work Classification: Electric
en vcion nr_1 m no
Job Address:9935 NE 13 Avenue
Miami Shores, FL 33138-2634 Phone Number
Parcel Number 1132050090470
Project: <NONE>
Contractor: GENESIS ELECTRIC, INC Phone: (754)638-1564
Building Department Comments
DEMO EXISTING ELECTRIC TO PREPARE FOR NEW Infractio Passed Comments
WORK. DISCONNECT POWER TO HOUSE. INSPECTOR COMMENTS False
Inspector Comments
Passed El evl i l
Failed e�v6�' �
c.
Correction
-
Needed ❑
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
June 11, 2015 For Inspections please call: (305)762-4949 Page 2 of 26
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-228213 Permit Number: DEMO-2-15-322
Scheduled Inspection Date: June 16, 2015 Permit Type: Demolition
Inspector: Diaz, Osvaldo
Inspection Type: Final
Owner: MARIANA JULIA LIVORE, FABIANO Work Classification: Plumbing
0" 1510A Af-1111 AC
Job Address:9935 NE 13 Avenue
Miami Shores, FL 33138-2634
Phone Number
Parcel Number 1132050090470
Project: <NONE>
Contractor: WOLFE & BOBS PLUMBING Phone: (954)981-1496
Building Department Comments
DISCONNECT WATER TO HOUSE. LEAVE 1 EXTERIOR Infractio Passed Comments
HOUSE BIB ACTION FOR WATER SOURCE. INSPECTOR COMMENTS False
Inspector Comments
Passed
Q�
Failed
Correction ❑ � � �
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
June 15, 2015 For Inspections please call: (305)762-4949 Page 6 of 31
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-229939 Permit Number: DEMO-3-15-533
Scheduled Inspection Date: July 20, 2015 Permit Type: Demolition
Inspector: Perez,JanPierre
Inspection Type: Final
Owner: MARIANA JULIA LIVORE, FABIANO Work Classification: Mechanical
en IMIDn nr_1 iu no
Job Address:9935 NE 13 Avenue
Miami Shores, FL 33138-2634 Phone Number
Parcel Number 1132050090470
Project: <NONE>
Contractor: AMERICAN HVAC-R SERVICES Phone: (954)779-5042
Building Department Comments
demo duct work+ air handler condensors. Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed
Failed
Correction ❑
Needed
Re-Inspection
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
July 17,2015 For Inspections please call: (305)762-4949 Page 5 of 35
gttORES Miami Shores Village
10050 N.E.2nd Avenue NE E
Miami Shores,FL 33138-0000
e� .mom Phone: (305)795-22042 w
r.
Expiration: 09/07/2015
Project Address Parcel Number Applicant
9935 NE 13 Avenue 1132050090470
FABIANO SILVEIRA AGUILAR M
Miami Shores, FL 33138-2634 Block: Lot:
Owner Information Address Phone Cell
° FABIANO SILVEIRA AGUILAR MARIANA 9935 NE 13 Avenue
--- MIAMI SHORES FL 33138-2634
9935 NE 13 Avenue
MIAMI SHORES FL 33138-2634
Contractor(s) Phone Cell Phone Valuation: $ 3,000.00
FITCH BUILDERS LLC (754)234-0064 Total Sq Feet: 1500
Type of Demo:Building Available Inspections:
Additional Info:DEMO 3 BATHS,KITCHEN AND INTERIOR Inspection Type:
Classification:Residential Final
Scanning:3 Review Electrical
Review Electrical
Review Electrical
Review Planning
Review Planning
Review Building
Review Building
Review Mechanical
Review Plumbing
Review Plumbing
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Review Structural
CCF $1.80
Invoice# DEMO-1-15-54221
DBPR Fee $2.00 01/21/2015 Cash $50.00 $ 147.80
DCA Fee $2.00
Education Surcharge $0.60 03/11/2015 Credit Card $ 147.80 $0.00
Permit Fee $100.00
Plan Review Fee(Engineer) $80.00
Scanning Fee $9.00
Technology Fee $2.40
Total: $197.80
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS, DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is ac ate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore, I authorize the above-n d con actor to do the work stated.
March 11, 2015
Authorized Signature:Owner / Applicant / C ntr ctor / Agent Date
Building Department Copy
March 11,2015 1
Miami Shores Village cE f
JAN
Building 015
g Department
10050 N.E.2nd Avenue, Miami Shores,Florida 33138 LY:
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC``2AA (0 1110 0
BUILDING Master Permit No D . 16-- ) H 0
PERMIT APPLICATION Sub Permit No.
BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: ,�" ! � ��//i7 / SA-'0 12-6-7S
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: /F'�lood Zone: BFE: FFE:
OWNER: Name Fee Simple Titleholder): F85 /
�840 S/CA(A4 I'El I L AP Phone#: Jr / 13( 03
Address: d'O BatUtAN 67-
City:
TCity: -08P 4R A <- State: FL Zip: 3
Tenant/Lessee Name: Phone#:
Email: FAfiiitaj SiLyeiRA A�jiLAR.6, 6�MA& ,CQ.A
CONTRACTOR:Company Name: C// b2az,� Phone#:2 S2%" 2-'—,
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration#: C 1�D 6 O 7—9.F— Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: , City: State: Zip:
Value of Work for this Permit:$ 4*6d Square/Linear Footage of Work: O�
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace Demolition
Description of Work:
Specify color of color thru tile:
Submittal Fee$EO+CD Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ ]�'
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address _
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for 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 fo_�� _,� " Signature
OWNER or AGENT 11 —0 CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 1, by day of _ U� ) 20 ' by
ftp 1ye11� V who is personally known toy I N ` T (2)4 who is person1alllyy known to
me or o has produced � as me or who has produced EL.DOW2 LACc� as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC-
S i g n:
UBLIC:Sign: Ql�Gh�"Y Sign:
Print: �I� 1 \ 1�'` l.�S 1 VA Pri40 nt:
Notary Pu is a
Seal: p�P�.. Seal: $ SindiaAlvarez
CARMEN ESTHER JUSINO 6 My Commiasf0 FF 156750
MY COMMISSION#FF046931 omk ExPIroa 0 910 312 01 6
iN1'. Via;
OF FV EXPIRES August 19,2017
Itoi**** UnaVo,;4 e is*COM*** ********************************************************************
a
APPROVED BY Plans Examiner Zoning
�J
Structural Review Clerk
(Revised02/24/2014)
STATE OF FLORIDA
741 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD 850 487-1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
FITCH, JOHN W
FITCH BUILDERS LLC
6711 NW 22 TERRACE
FORT LAUDERDALE FL 33309
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 4; STATE OF FLORIDA
from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND
and they keep Florida's economy strong. PROFE4$10 GULATION
Every day we work to improve the way we do business in order to CGC060298
09/07/2014
serve serve you better. For information about our services, please log onto
www.myfloridalicense.com. There you can find more information CERTIFIED G' 13NR '
about our divisions and the regulations that impact you, subscribe
to department newsletters and learn more about the Department's
FITCH, JOHNA "t
initiatives. i FITCH BUILDIi G
Our mission at the Department is: License Efficiently, Regulate Fairly.
We constantly strive to serve you better so that you can serve your " j
customers. Thank you for doing business in Florida, Is CERTIFIED under the prfdvisions of Ch.4e9 Fs.
and congratulations on your new license! Expiration date; AUG 31,2016 L1409070003095
DETACH HERE
RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
CGC060298
The GENERAL CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS. ,
Expiration date: AUG 31, 2016
,
w
FITCH, JOHN W ,: .
FITCH BUILDERS LLC . .
-3561-NE 13 AVE
FT LAUDERDALE . " 3334'
'
ISSUED: 09/07/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1409070003095
BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT
115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000
VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015
DBA:
Business Name: FITCH BUILDERS LLC Receipt#:180-9023
Business Type:
CONTRACTOR (GENERAL
yp CONTRACTOR)
Owner Name:JOHN WILSON FITCH
Business Location: 6711 NW 22 TER Business Opened:02/23/2006
FT LAUDERDALE
State/County/Cert/Reg:CGC 0 6 02 9 8 Business Phone: 754-234-0064 Exemption Code:
Rooms Seats Employees Machines
Professionals
1
For Vending Business Only
Number of Machines: VendingT
Tax Amount Transfer Fee Type:
NSF Fee Penalty Prior Years Collection Cost Total Paid
27.00 0.00 0.00 2.70
0.00 0.00 29.70
THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS
THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is
non-regulatory in nature. You must meet all County and/or Municipality planning
WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when
the business is sold, business name has changed or you have moved the
business location.This receipt does not indicate that the business is legal or that
it is in compliance with State or local laws and regulations.
Mailing Address:
JOHN WILSON FITCH
6711 NW 22 TER Receipt #30B-14-00000078
FORT LAUDERDALE, FL 33309 Paid 10/09/2014 29.70
2014 - 2015
^-1T
Certificate Page 1 of 2
s
Submit Request Bottom of Form Help Service Menu
CERTIFICATE OF LIABILITY INSURANCE Original Issue Date:
1/21/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT
CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR
PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS
WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
CONTACT
Producer
NAME:
Construction Pros Insurance LLC PHONE: FAX:
PO Box 186 (A/C, No, Ext): 800 685 0027 (A/C, No):
12054 Curley Street EMAIL
San Antonio, FL 33576 ADDRESS: office@constructionprosins.com
PRODUCER
Insured CUSTOMER ID: FITCBUI-01
Fitch Builders LLC INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:Accident Insurance Company Inc 11573
6711 NW 22 Terrace INSURER B:
INSURER C:
Fort Lauderdale FL 33309 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1755734527 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED
NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR
CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN
REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY j Policy EFF Policy EXP
TYPE OF INSURANCE LIMITS
LTR INSR WVD NUMBER (MM/DD/YYYY) (MM/DD/YYYY)
A GENERAL LIABILITY CPP 1/21/2015 1/21/2016 Each Occurrence 1,000,000
X Com Gen Liab 0017773-0 Damage to Rented
Premises(Ea 100,000
Claims Made Occurrence)
X Occurrence Med Exp(any one 5,000
person)
Personal&Adv 1,000,000
Injury
Gen Agg Lmt Applies Per General Aggregate 2,000,000
Policy Products- 2 000,000
Comp/OP Agg
Project
Location
AUTOMOBILE LIABILITY Combined Single Limit
Any Auto (Ea accident)
All Owned Autos Bodily Injury
(Per person)
Scheduled Autos Bodily Injury
Hired Autos (Per accident)
Property Damage
Non-Owned Autos (Per accident)
EXCESS LIABILITY Each Occurrence
Umbrella Liab Occurrence Aggregate
https://wd02.i-csr.net/active/A25-2010-05.asp?CertKey=1755734527&CertTemplateKey=... 1/21/2015
Certificate . Page 2 of 2
Excess Liab Claims Made
Deductible
Retention
WORKERS N/A WC
COMPENSATION AND ota u- Other
ry
EMPLOYERS' LIABILITY Limits
Any Proprietor/Partner/Executive E.L.Each Accident
Officer/Member Excluded?
(Mandatory in NH) EmployeeyEa
se
If yes,describe under
DESCRIPTION OF E.L.Disease Ea Policy
Limit
OPERATIONS below
OTHER
DESCRIPTION OF OPERATION S/LOCATIONSNEHICLES
Qualifying Individual: John W Fitch-CGC060298
Please review named insured's policies referenced in this document for complete list of all applicable coverage's, limits,
endorsements, exclusions, deductibles, and their respective terms and conditions they contain.
CERTIFICATE HOLDER CANCELLATION
miami shores village
10050 N.E. 2nd Ave SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
miami shores, FL 33138
Ed Collins
Top of Form
https:Hwd02.i-csr.net/active/A25-2010-05.asp?CertKey=1755734527&CertTemplateKey=... 1/21/2015
1
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
`CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW''
CONSTRUCTION INDUSTRY EXEMPTION
^is ceftfes that Ne I^drv-dual listed Delos has a ected tc Ce exempt foam F!ofda',Aicrkel Com. uinsa:cr,lax.
EFFECTIVE DATE: `011 T201.1 EXPIRATION DATE: 1'311M oi6
PERSON: FITCH JCHN A
FEIN: 2432 '-'15
BUSINESS NAME AND ADDRESS:
FITCH BUILDERS LLC
$711 N'Af 22 TERRACE
FOR'LAA DERDkE FL 333
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL
LCNTRA'C'CR
Tat_x r?GT'?f fr fe166 N.:CCe^ rW f,+ier SK:f �`d&.a"T 8 SL:35 f.$.r2* � f� ? L°bfCUp;f?}
A 're;'"�Yire:i3m;-y:'33E:mx?,?,":dce:foemrw�exeiT:.PJt artt.,'I' 5.: 5?.`. �.tiCY�6oTe.e�:f
?XA1"{:if.Xr:14�:3L6:"�JE:kt t fi eXery vi9 6'.Buie«^.ints'i f f,31 n",fl$3Rer x'?�`^:f Te m°.;r n i6fiLrce:!T+i'x"'.'G9'•e:.
T2'P'.Ce 7 2[".-k.3'.e M 1-;r Tea%i fv 66Lr4-ti_ermz f T-f ieAina.f1 sm T.O(-2 i
:`_+....EST':F,CA'E w,F c_eC-,0N TO a---EQM RMSEC.-.1 _5,IC`iv
5N°R
evil ,,,,,� Miami shores Village
Building Department
�ORID� 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. 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 z Contractor
Print Name: - Print Name: b�� `�'
OT
Signature: S' Signature:
State of Florida) State of Florida)
County of Miami-Dade) County of Miami-Dade)
Sworn to and subscribed before me this 3 Sworn to and subscribed before mg this L 1
day of j_ �--4pWdr96W
day of � 1 w Q!� 20By 4Notary Public State of Florida
R SINO My Commission FF 166750(SEAL) (SEAL) oEq� Expires 09/03/2016T e of Ida ORType of Identification pro uce
'v -oa`= EXP
(407)398A153 FloridallotaryService.com
FITCH BUILDERS LLC
6711 NW 22 TERRACE
Fort Lauderdale, FI 33309
CGC060298
3/11/2015
State of�L��
County of
Before me this day personally appeared:JbJ.A(,) U)%LC--0N to who, being duly
sworn, deposes and says:
I John Fitch as qualifier for Fitch Builders LLC hereby state that no person from my company will work on
the project at 9935 NE 13 AVE, Miami Shores Village, under Demo permit 15-148
Sworn to (or affirmed)and subscribed before me this I j day
of 2015, by J()PtJ wl LWO TM�'
Personally know ( '
Or produced identification
Type of identification produced �vJ
Print,Type or Stamp Name of Notary
ge;
Notary Public State of Florida
Sindle Alvarez
MY
AACommlaelon FF 158750
Expins 0910312018