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EL-13-619 (2) � Miami Shores Village �. (...r. M. Building Department JUN 05 2015 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20!b BUILDING Master Permit NOAef -3 _ Sd? PERMIT APPLICATION Sub Permit Nom/ ❑BUILDING ELECTRIC ❑ ROOFING ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKSCHANGE OF ❑CANCELLATION ❑ SHOP 'I CONTRALTO DRAWINGS JOB ADDRESS: I Z�5 N ' � . 9� -t'� �� City: Miami Shores County: Miami Dade zip: 33( 3s Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: -Z,C) S' 353 -C? 3 OWNER: Name(Fee Simple Titleholder):_ --7V C'T� C - S Phone#:30 �0 --'14nZ Address: 12� 1 Q. � �-t- . '1C4-L- . City: V 1, as - State: n I Zip; Tenant/Lessee Name: YQ / 4 Phone#:_ Email: CaA"S c • CONTRACTOR:Company Name: N'e4 �` PG t ^ Ila C Phone#: IdIlve Address: City: !k r Stat Zip; 33 / Z� Qgalifier Name: Phone#: Statg Certification or Registration#: noco Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ /Re lace Re air G, p p ❑ Demolition Description of Work: Specify color of color thru the (\ . Submittal Fee$ Permit Fee$ � �O CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ t _ TOTAL FEE NOW DUE$ j (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 'Signa OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20 /'� by day of 20 / J by Vcu�-\_C. 1c—� who is personally known to /S who is personally to me or who has produced O as me or who has produced ' as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: x Sign: #a Print: JOAll Print: +` WA FF11904g COMMISION#FFI19045 Seal; F` ,2018 Seal: EXPIRES MAY 4,2018 �0 398-01,93e.eom FloridallolaryServicecom ---- (407)398-0153 APPROVED BYS S�m� J`✓ Plans Examiner Zoning Structural Review Clerk (Ravisad02/24/2014) __ ♦SNORES Miami shores Village �sn. logger" Building Department NT I.�V� o`6 �v'res to 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. (,5e<) Owner's Name (Fee Simple Title Holder • t4CC0,`'C Phone#:iij Owner's Address: /G?/C/A � City: A4 - -4,( State : 09�t_ _ Zip Coder '1 Job Address (Of where work is being done): City: V*" Miami Shores State:—Florida Zip Code: Contractor's Company Name: AViO4 QAC Phone#: CiW p16/ Address: � 'S� Z7 /1,a,_ X City: /�'f '1"8'1 State: Zip Code: X? Qualifier's Name :4 11/7fe46 Lic. Number:,_' 0✓ 0 43YV,_ Architect/ Engineer of Record Name: Phone#: Address: City: State: Zip Code: Describe Work: hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. I the Id' Official and the Miami 5 es rmless of I invol e n Signature Si ner Agent Contractor or Architect >� The foregoing instrument was aknowledged before me ' The foregoing the was aknowledged before me thisTi3 day of MR!Dn 201'$,by LAKCO3Y(oS I rOSliit. this day of M � , 2A by Vo fi?4 Who is�ft _sonally known o me or who has produced who is personal Vknown to me or who has produced as indentification. as indentification. N YFF11904s Notary P b ; Nota qA 4,"18 Sign:Sign: Si g g Seal: Seal: r?QF,041F�E otary Publ�tate of Florida Dominguez y commission FF 120466x'irea 0510612018 Juan Carlos Acosta 128 NE 99th St. Miami Shores, Fl. 33138 Guy, Durrani Dudley(Primary, President) Architectural Service Inc. DBA Fl. License # EC13005061 (Certified Electrical Contractor) 8362 Pines Blvd. #179 667 S. Dixie Highway, W1 Pembroke Pines, Fl. 33024 Pompano Beach, 17133060 May 20, 2015 Re; Formal Electrical Contractor Termination Notice (New Master Suite Addition), Village of Miami Shores, Permit# RC 3-13-569 US Postal Service, Registered Certified Mail Number (# 7014 2120 0003 0441 5813) Mr. Guy, Durrani Dudley, Please be advised that this termination letter is being written subsequent to our telephone conversation at 1230 PM, on May 20, 2015. In that conversation,you stated that although you had been fully paid for the services rendered and further stated,that you had completed the electrical work per the plans submitted to the Village of Miami Shores, permit#RC 3-13-569, that your personal and business history and relationship with Mr. Yoshida, our previous general contractor,who had unfortunately been let go, precluded you from fully completing the job per the plans and signing the"As Built, Electric Revision Application"as required by The Village of Miami Shores. In addition,in that same conversation at 1230 PM on May 20, 2015, you were made aware of the Village of Miami Shores requirement,that the "As Built, Electric Revision Application",must be signed by yourself to actually complete the job and receive a final inspection on the electrical portion of the permit for which you were responsible for; however,you still refused to sign the form. Furthermore, even after a courtesy explanation, at your request, as to the nature of the termination of the business relationship with Mr. Yoshida, as well as the unfortunate and extenuating circumstances that lead to the termination of our relationship with Mr. Yoshida,you still refused to cooperate and sign the electrical revision application form or enter into a negotiated business fiduciary relationship with us. 1 of 2 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 Sender: Please print your name, address, and ZIP+4®in this box• iIIFIlIIiI},F�f�lllFlilllljilllFlltililtlli�F!!!#jli,Fffll�llFil i f I You give us no other alternative but to terminate the business relationship, implied or otherwise,that we may have with you, due to abandonment of an incomplete job site,and a refusal to sign the forms required by The Village of Miami Shores,which reflect the electrical changes to the original plans that you yourself initiated without our consent. As of the receipt of this certified letter (# 7014 2120 0003 04415813) your services as the electrical contractor on the above referenced permit have been officially terminated. Unfortunately, it is very disappointing to us,that you could not conduct yourself in a professional and efficient manor,as your Florida license requires you to do so. However,as stated previously,this letter serves,as your official notice that due to your own decision and the abandonment of the above reference permit and job site, your services as our electrical contractor are no longer needed. Furthermore, please keep in mind, that this termination notice does not in anyway preclude us from pursuing any, and all legal rights and remedies, which we are entitled to under Florida State laws and statures. Thank You Juan C.Acosta 2 of 2 S� Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-237054 Permit Number: EL-3-13-619 Inspection Date: June 26, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: ACOSTA,JUAN CARLOS Work Classification: Addition Job Address: 128 NE 99 Street Miami Shores, FL 33138- Phone Number Parcel Number 1132060132270 Project: <NONE> Contractor: AMENGUAL ELECTRIC INC Building Department Comments NEW ELECTRIC ON ADDITION Infractio Passed Comments INSPECTOR COMMENTS True Inspector Comments Passed I // I CREATED AS REINSPECTION FOR INSP-236978. Need low voltage first. Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 June 26, 2015 Page 1 of 1 Miami Shores Village : Building Department artment 2 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 LA INSPECTION'S PHONE NUMBER: (305)762.4949 FBC 20 tO BUILDING Permit No. PERMIT APPLICATION Master Permit Noz/ _ " ' Permit Type: Electrical (� n JOB ADDRESS: 1-2_,�f Ale' City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder): � Phone#: Address: /�l� �� /'-�1?9;; l 64_ 'I-'- City: S`io-� State: Zip: Tenant/Lessee Name: Phone#: Email: l_ , ,.i ,� L CONTRACTOR:Company Name: �Y1�1 ee-�)(W �1��1 ic- tCe+: Znc.. Phone#: Address: LA� V3 �fec+ City: ?OmpMQ 3COC h State: Zip: 33060 Qualifier Name: -DUV10n'( G�09 Phone#: c64` S(D$ �7t"{q(0 State Certification or Registration#: C Q 5901 Certificate of Competency#: Contact Phone#: Q 5L4'%f6--"ILiq fv Email Address: Offt,�eC+U(Q,I OCC+f i - @dmf I.('t7m DESIGNER: Architect/Engineer: Pone# Value of Work for this Permit: $ �0ov. Square/Linear Footage of Work. Type of Work: ❑Address ❑Alteratio/n C.1New ❑Repair/Replace . ❑Demolition Description of Work: 6 A- J%V55 ell Submittal Fee$ Permit Fee$ CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 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 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. Cabsen.-ef such posted notice, the inspection will t be appr Aved and a reinspection fee will be charged. Signature Signature Owner or Agent n� Contractor The foregoing jnstrumel►] vas acknowledged b ore me s 0 1 The foregoing instrument was acknowledged before me this o1y day of ► 20 , by day of - 20 ��,by cr(lflc /�O who is onally kn to me or who has produced who is personally known_to me or who has produced As identification and who did take an oath. as identification and who did take an oath. NOTAR PUBLIC: JANE ROSENBERG NOTARY PUBLIC: Y PVe♦ Notary Public-State of Florida _'•' :•E My Comm.Expires Mar 31,2016 g N Commission N EE 184297 Sign: Sign: •r one roug a lona Notary Asan. Print: Print: 5•` Q �J lQ IN PEIVA My Commission Expires: My Commission Expires: NOTARY PUBLICSTATE OF FLORID, Comm#EE067410 Im E 2/23/2015 �u iy APPROVED BY It ArvPlans Examiner Zoning Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) OR l� soon Miami shores Village Building Department ORiDp 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. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPT), D. 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 /'��� "`COMPLETE CONTRACTOR'S INFORMATION J- BUSINESS NAME: 6I 4ce- fVl o 1 fr U►Cep Inn. BUSINESS ADDRESS: 1q VY,- 14 ,-4cec4 CITY PCmo b STATE 'T::::L ZIP CODE 3,-K)b `1 BUSINESS PHONE: ( 95, 4 )_ spa I 3q4 FAX NUMBER( ) 590--X53 CELL PHONE ( a5�t) Se0'6---1'4Q(0 QUALIFIER'S NAME: L)JCOLIF l 0-,O' j QUALIFIER'S LIC NUMBER: EC i'�0050(o l E-MAIL ADDRESS (IF APPLICABLE): Or-ftt-�eo-+ji0jetQCkfl C a� Com Created on 3119109 BY MLDV/RV 3126109 MLDV STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET •�°�W TALLAHASSEE FL 32399-0783 GUY, DURRANI DUDLEY ARCHITECTURAL ELECTRIC SERVICE INC 2855 NW 210 TERRACE MIAMI GARDENS FL 33056 STATE OF FLORIDA AC# 6437601 Congratulations! With this license you become one of the nearly one million DEPT g :OF BUSINESS AND Floridians licensed by the Department of Business and Professional Regulation. PPA-- T SIONAL�.REGULAS, Our professionals and businesses range from architects to yacht brokers,from ` boxers to barbeque restaurants,and they keep Florida's economy strong. EC13005061 05/23/12 117055453 Every day we work to improve the way we do business in order to serve you better For information about our services,please log onto www.myfloridalicense.com. CERTIFIED ELECTRICAL CONTRACTOR There you can find more information about our divisions and the regulations that ' GUY, 'DT RRAIdI xjUDi,gg impact you,subscribe to department newsletters and learn more about the ARCHITECTURAL;-ELECTRIC SERVICE I 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! IS CERTIFIED nna®r the provisions of ch.4119 Fs . :Mc ration dnt-, AUG 31, 2014 L1265230.0697 DETACH HERE AC# (32 3 7 6 01 STATE OF FLORIDA DEPARTMENT OF BUSINESS. AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD SEQ#L12052300697 DATE BATCHNUMBER LICENSE'NBR -05 23 2012 117055453 EC13005061 The ELECTRICAL CONTRACTOR Named below IS CERTIFIED Under the provisions of -Chapter 489 FS. Expiration date: AUG 31, 2014 GUY, DURRANI DUDLEY ARCHITECTURAL ELECTRIC SERVICE INC 44 NE 1ST STREET POMPANO BEACH FL 33060 RICK SCOTT - GOVERNOR KEN LAWSON SECRETARY DISPLAY AS REQUIRED BYLAW BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT i. 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2013 THROUGH SEPTEMBER 30,2014 DBA: Receipt#:181-3271 Ii BUSIneSS Name;ARCHITECTURAL ELECTRIC SERVICE INC Business Type:ELECTRICAL/ALARMS/CONTRACTOR, (ELECTRICAL CONTRACTOR) I>{ k, i' Owner Name:GUY DURRANI Business Opened:o 1./13/2 0 0 8 i I<! Business Location:44 NE 1 ST State/Cou nty/Cert/Reg:EC 13 0 0 5 0 6 1 POMPANO BEACH Exemption Code: Ir Business Phone: 954-868-7496 "? Rooms Seats Employees Machines Professionals 2 f 1 1, For Vending Business Only i Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.000.00 0.00 0.00 27.00 l ,i I � r: THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS i"; 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 1 J, 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 f 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. I Mailing Address: {' ARCHITECTURAL ELECTRIC SERVICE INC Receipt #04A-12-00013585 44 NE 1 ST Paid 08/23/2013 27.00 j{ POMPANO BEACH, FL 33060 2013 - 2014 ARCHELI OP ID: FG CERTIFICATE OF LIABILITY INSURANCE DATE(MYYY) 09/005/15113 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). PRODUCER 800-742-1691 NAME:CONTACT Hallandale Branch NAME: Fredy Goyeneche Riemer Insurance Group 954-454-9552 AIC, o Ext):954-454-3145 ac No):954-454-1714 PO Box 250 E-MAIL Hallandale,FL 33008-0250 ADDRESS:fgoyeneche@riemerinsurance.com Stephen L Riemer INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Wilshire Insurance Company INSURED Architectural Electric Service INSURER B: Inc. 8362 Pines Blvd.Suite 179 INSURER C: Pembroke Pines,FL 33024 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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. lL7R ADDL R TYPE OF INSURANCE POLICY NUMBER MWDDY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CL00141249 09/13/13 09/13/14 PREMISES Ea occurrence $ 100,00 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITSI ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Miami Shores Village MIAMSH1 10050 N.E.2nd Avenue SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores, FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r 09-29-2011 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: 09/29/2011 EXPIRATION DATE 09/28/2013 PERSON: GUY DURRANI FEIN: 260697377 BUSINESS NAME AND ADDRESS: ARCHITECTURAL ELECTRIC SERVICE INC 44 NE IST STREET POMPANO BEACH FL 33060 SCOPES OF BUSINESS OR TRADE: 1- ELECTRICAL CONTRACTOR IMPDRTANT. Pursuant to Chapter 440 . 05114), 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 benefits or compensation under this chapter. Pursuant to Chapter 440.05(1Z), 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 440.051113), 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, we 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. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? 1850) 413-1605 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICESIMPORTANT DPASION OF WORKERS'COMPENSATIOFN Pursuant to Chapter 440.05{14). F.S, an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO 113E EXEMPT FROM FLORIDA L WORKERS'COMPENSATION LAW tinder this Section may not recover benefits or Compensation under this 9 D chapter. EFFECTIVE: 09/29/2011 EXPIRATION DATE: 09/28/2013 PERSON: DURRANI GUY H 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 FEIN: 260897377 E the notice of election to be exempt BUSINESS NAME AND ADDRESS: R ARCHITECTURAL ELECTRIC SERVICE INC E Pursuant to Chapter 440.05(13), F-S_, Notices of election to be exempt 44 NE ,ST STREET 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 POMPANO BEACH, FL 33oso 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 SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this I- ELECTRICAL CONTRACTOR Section. QUESTIONS? (850) 473-1609 CUT HERE Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Ul Q fl C*- coo�{�GC�O� :curDate><curTime>Work Comp Associates Inc.Elissa A Lucchese AC CERTIFICATE OF LIABILITY INSURANCE F01/06/2014 ATE(MM/DD/VVYV) 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). PRODUCER o°ME Michael D. Holleman WINE Work Comp Associates, Inc. i