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EL-15-321 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-228206 Permit Number: EL-2-15-321 Scheduled Inspection Date: August 20, 2015 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: BREEN,JAMES & MAR Work Classification: Addition/Alteration Job Address: 1481 NE 104 Street Miami Shores, FL 33138-2663 Phone Number (786)617-3500 Parcel Number 1122320320090 Project: <NONE> J Contractor: APA ELECTRIC INC Phone: (305)225-8964 Building Department Comments UPDATE TO CODE KITCHEN POWER SYSTEM. (ADD 4 ISPEC Passed Comments INSPECTOR NEW GFCI OUTLET, REPLACE 4 OLD GFCI OUT TOR COMMENTS False OUTLETS AND SMALL APPLIANCES OUTLETS 4 NEW RECESSED. Inspector Comme PassedE! Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. August 19, 2015 For Inspections please call: (305)762-4949 Page 4 of 41 zf ' rmrf�tt0. L-2' �s °nts o, Miami Shores Village f mitrypt �e IC lI l estl! 1 10050 N.E.2nd Avenue NE Wb*V,1aWkatr t Addltiort/Alter all Miami Shores,FL 33138-0000 Phone: (305)795-2204 � fiLOR�DP. "� tssueCtat Expiration: 09l2712015 Project Address Parcel Number Applicant 1481 NE 104 Street 1122320320090 Miami Shores, FL 33138-2663 Block: Lot: JAMES&MAR BREEN Owner Information Address Phone Cell JAMES&MAR BREEN 1481 NE 104 Street (786)617-3500 MIAMI SHORES FL 33138- 1481 NE 104 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone APA ELECTRIC INC 305 225-8964 ( Valuation: $ 1,500.00 ( ) (786)256-9093 Total Sq Feet: 0 Type of Work:UPDATE TO CODE KITCHEN POWER SYSTEM Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Meter Box Alteration Relocation Fire Alarm Service Change Underground W.W. Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee Invoice# EL-2-15-54490 $2.25 02/13/2015 Credit Card $50.00 $ 116.70 DCA Fee $2.25 Education Surcharge $0.40 03/31/2015 Credit Card $ 116.70 $0.00 Permit Fee-Additions/Alterations $150.00 Scanning Fee $9.00 Technology Fee $1.60 Total: $166.70 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I cepqy that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction n zonV/, h more, I authorize the above-named contractor to do the work stated. - March 31, 2015 Author ignature:Owner / Applicant / Contractor / Agent Date Building Department Copy March 31,2015 1 Miami Shores Village C Building Department FEB2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY; INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 (Q BUILDING Master Permit No. 1/ 7 PERMIT APPLICATION sub Permit No. E7L-1'.5 —32.1 BUILDING 2 ELECTRIC ROOFING REVISION EXTENSION RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1q91 A-1 E /0/-/ S/ City: Miami Shores County: Miami Dade Zip: -33139 Folio/Parcel#: // - 2 2 32- -03 2 -00 90 Is the Building Historically Designated:Yes NO—)< Occupancy Type: ReSId Load: Construction Type: C,6_5 Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):,T6 M P_S 92-eL A_, Phone#: 7 e6 -6717 "3S DLA' Address: /q 9 / U Z- /O L/ .S T City: 1-4 /.4 Mi S-4,0 S State: PL Zip: 33 /3 Lq Tenant/Lessee Name: Phone#: Email: ICA,M 1Y S f✓- a"e-e adni CONTRACTOR:Company Name: )(7J06 Phone#: 3CSS --3O Z-$ 76 ly Address: /4�5,-?/ 5 LtJ .5-Z L IV City: A-I 11 A4/ nn State• �',G Zip: Qualifier Name: ��/LG e iZoe v,_ Phone#: 796 - ZS 6 -9093 State Certification or Registration#: ,f-_(7_ f 3 d 6-5-190 6 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ `-47M_00 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New IBJ Repair/Replace ❑ Demolition Description of Work: /,a o%-tP_ re C�o d e- /��fa- �.v "w-2&2 S /S7k x4 _ r SMD G' 00-TL✓T I YL--VLOCz `� OLO (,'PCX OUTS I/�v-�0 S K Wh L �! f L<{PN,1-C. S O U-rLt- S �l �.)C11.� �1 EZC:5 5 Lk l Specify color of color thru tile: Submittal Fee$ ED . co Permit Fee$ /g CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ I I � (Revised02/24/2014) ' r 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 appro ed and a inspection fee will be charged. Signature Signature 77 OWNER or AGENT ON OR The for /ngnstrument was acknowledged before me this The foregoing instrument was acknowledged before me this �r- day of F�fq rt atA121,20 l 5— by day of �- Sa 4,rJJ fL/ ,20 by t .Lru� One e-4-1 ,who is personally known to who is personally known to me or who has produced F-i7LQ 6S O'�5 3 S as a or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: I �f 6, R Q--u Sign: Print: ` Print: DIEVA RICODIEVA RICO Seal: Seal: ''t :•!+ MY COMMMIONSEES279MMY XP�MION it EE827008 EXPIRES August 19,2oi8 ;tt.'• August 10.2014 ta0��a�Ai�ii� ppll�►lop,� (407)39"153 mco.aam ssssrssssssssssrssssrrssss 'i'Fri'ss�ssssssrsssssssssssssssssssrsssssssssssssssrssssrsssrrssss ssssssssssss 2a;I,s- APPROVED BY4i /) '>o Plans Examiner Zoning Structural Review Clerk (RevisedO2/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ROQUE, JORGE DE JESUS APA ELECTRIC INC 16531 SW 52ND LN MIAMI FL 33185 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 STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to EC13005806 ISSUED: 07/02/2014 serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information CERTIFIED ELECTRICAL CONTRACTOR about our divisions and the regulations that impact you,subscribe ROQUE,JORGE DE JESUS to department newsletters and learn more about the Department's APA ELECTRIC INC 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, IS CERTIFIED under the provisions of Ch.489 FS. and congratulations on your new license! Expiration date: AUG 31,2016 L1407020001430 DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD EC13005806 The ELECTRICAL CONTRACTOR A Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 ROQUE, JORGE DE JESUS. APA ELECTRIC INC 16531 SW 52ND LN MIAMI FL 33185 M9 Mn1V n4 A MIQDI AV AC DCnI IIDCr1 RV I AIA/ CF(1 iii 1 1An7ngnnn1d3n Fo find out about business and economic opportunities for Florida veteran business enterprise~ as well as Florida`s small minority and women-owned businesses,please contact or%isit the Department of Management Service's Office of Supplier Diversity at: �`'"> llttp•//wwt,�t,,dinc.ini,lorida.cnrn/other prOZrains/nffce of supplier diversity osd Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT ABILL-DO NOT PAY LBT) 5795662 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES APA ELECTRIC INC RENEWAL SEPTEMBER 30, 2015 16531 SW 52 LA 6043210 Must be displayed at place of business MIAMI,FL 33185 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED APA ELECTRIC INC 196 ELECTRICAL BY TAX COLLECTOR CONTRACTOR 75.00 09/23/2014 Worker(s) 1 EC13005806 0221-14-005166 This Local Business Tax Retxipl only confirms payment of the Local Business Tax.The Receipt is nota license, permit,ora certification of the holders qualifications to do business.Holder must comply with anygovernmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec 88-276. MIAW For more information,visit wwwmismidade.aut 9collector ACCM& CERTIFICATE OF LIABILITY INSURANCE ATE 2/06//YYYY) 02/06/15 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(les)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 CONTACT NAME: YANET PADRON Almar Insurance Services, Inc. (A/C"No Ext) (305)633-3781 AA/C No) (305)-633-0926 2331 N.W.27th Ave. E-MAIL yanetpadron0l aol.com DRESS- � Miami, FL 33142 INSURERS AFFORDING COVERAGE NAIC# Phone (305)633-3781 Fax (305)633-0926 INSURER A: ASCENDANT UNDERWRITERS LLC INSURED INSURER B_ APA Electric Inc INSURER C: 16531 SW 52 Lane INSURER D: miami, FL 33185- (305)225-8964 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 0_F SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR - - — -- — LTR TYPE OF INSURANCE POLICY EFF POLICY EXP POLICY NUMBER _ (MMID-DA(YYYLIMITSS GENERAL LIABILITY -- -7 EACH OCCURRENCE $ 1,000,000.00 �/❑ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence $ 100,000.00 A ❑ ❑ CLAIMS-MADE d❑ OCCUR Y GL-36158 10/05/2014 10/05/2015 MED EXP(Any one person) $ 5,000_00 _ - ❑ ____ ___ PERSONAL&ADV INJURY $ 1,000,000.00 GENERAL GREGATE $ 1,000,000.00 G❑EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTSGCOMP/OP AGG $ 1,000_000.00 El POLICY ❑ PRO-JECI ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ❑ ANY AUTO BODILY INJURY(Per person) ' $ ALL❑ AUTOS AUTOS OWNED ❑ SCHEDULED -- --- -- BODILY INJURY(Per accident) $ NON-OWNED F-1HIRED AUTOS PROPERTY DAMAGE ❑ AUTOS Per accident) $ -- ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB _❑CLAIMS-MADE AGGREGATE $ I $DED RETENTION$ _ -_ ; WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY Y/N ❑ TORY LIMITS ❑ E ...... ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under _DESCRIPTION OF OPERATIONS below —� - E.L.DISEASE-POLICY LIMIT $ — LL— 1 -- DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ELECTRICAL WORKS ADDITIONAL INSURED:SAM ASH FLORIDA MEGASTONE,LLC AND SAM ASH MUSIC CORPORATION 278 DUFFY AVE HICKSVILLE, NY 11801 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE IBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE BLDG DEPT THE EXPIRATION DATE THE O OTICE WILL BE DELIVERED IN ACCORDANCE WITH TH I PROVISIONS. 10050 NE 2 AVE MIAMI SHORES, FL 33138 - -- - — AUTHORIZED REPRE T ©1 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)QF a ORES name and logo are registered marks of ACORD 2/11/2015 Report Viewer 1— j 100% --i .� Afi• k ai .TEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION ••CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERSCOMPENSATION LAW•' CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 2/10/2015 EXPIRATION DATE: 2/9/2017 PERSON: GARCIA ENRIQUE FEIN: 204577742 BUSINESS NAME AND ADDRESS: APA ELECTRIC INC 16531 SW 52ND LN MIAMI FL 33185 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pm yrrawt b Chmow 40•[16(14).F.S.,an dkw d a oarpmatm who delle auwnFGmtam$A dwkv by O ft a emtkob dabftan w%W M secgm W fr soopedfbcrompwomWtr4wtftbAkme NdWmte�ddactlm bbeownp Wwru db WW 40r�06(13) Nckn ddecfnbbbe erwnPtardOWWICBWofdec$mtobebAdptSWbeahjedbrewaOmIf.atmy6"MAWN Oft Of rMOW arri WftmcedCneorUCW ft pww rbmed on to ndke a co"cab nofaW mode to re4Nemws d*a aedlfon for bwance of a o"kaea The depwbnere rhd nyckea DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)4131809 i httm://apps8.fldfs.com/crreportviewer/reportViewer.mpx?data=kdvpginc9D703gH6TER69P1FWIZ%2fSz5bXKYfBxkrokeESoPVylv4NPOPN42XeirDRGXVW... 1/2 4/212014 ReportViewer 1 1 100° JEFF AMMER CHIEF FINMICIAL 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 This certifies that the individual listed below has elected to be exemptirom Florida Workers'Compensation law. EFFECTIVE DATE: 4/19/2014 EXPIRATION DATE: 4/18/2016 PERSON: ROQUE JORGE D FEIN: 204577742 BUSINESS NAME AND ADDRESS: j APA ELECTRIC INC 16531 SW 52 LN MIAMI FL 33185 SCOPES OF BUSINESS OR TRADE:- LICENSED RADE:LICENSED ELECTRICAL CONTRACTOR Pursuant to ChspW 440.06(14).F.S.,an officerof a corpar6am vft elecis aoerroon from he chapter byliling a certlllcate of election under this sectlon may }t{ not recover benefits or convensabon under this chapter.pursuant to Chapter 440.05(12),F.S.,Certificates of election to be mmpt..,applymlyvAtNn the scope of the business or trade listed on the noticed election to be emrpL Pursuant to Chapoar 440.05(131.F.S.,Nud of election to be menet and cat kates d election to be eenpt shall be subied to remation if,at anytime after tiro filing of notice er IAe Issuance d the certificate,the person reared on the notice or cersficate ro larger rreeFs the requirements d this section for issuance d a certificate The depertne t shall rade a certificate at arrysrna for fallure d the per.eared on tie ratificele to neat the requlrerne is of this section DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07.12 QUESTIONS?(850)413-1609 I I s s i i https://apps8.fldfs.conYcrreporNewer/reportViewer.aspx?data=NJ"iric9D7Q3gH6TER6ePlKMZa/a2fSz5bXKYfB*elaeESoPVylvr NPOPN42XeirDRGXVWI:H... 1/2 2/11/2015 Report Viewer 1 - 100% ------------ tiKt z 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 This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 2/10/2015 EXPIRATION DATE: 2/9/2017 PERSON: ROQUE JORGE E FEIN: 204577742 BUSINESS NAME AND ADDRESS: A P A ELECTRIC INC 16531 SW 52ND LN MIAMI FL 33185 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR Pursuar4 to Chapter 440.05(14),F.S.,an officer d a corporation who elects exemption from this chapter by filing a certificale d electlm u cler this secbm may not recover benefits a comp oq antler this dWW.Pusuwt b Ctepter 440.05(12),F.S.,Cw llfiewAs d elecbm to be exempt..apply or'ty wifian lie scoped the dsiress or trade listed m the nodee d ele0on b bo exempt Pursxsnt b Chapter 440.05(13),F.S.,Ndices d election b be exempt and certificates of dectlm to be exempt shall be subject b rewxatim if,at any lime after the filing d fie notice a the issuance d the certificate, the person named m the notice a certificate no longer meds ge rextutrements of this section for Issuance of e certificate.The department shell revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 https://apps8.fldfs.com/crreportviewer/reportV ewer.aspx?data=kdvpginc9D7Q3gH6TER6ePl KMZ%2fSz5bXKYfBxkrekeESoPVylv4N POPN42XeirDRGXVW... 1/2 Miami s village move- 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 7�F,IoridarequiresWorkers' Compensation insurance coverage under Chapter 440 of the FloridaStatutes. Fla. Stat. § 440.05 aowprate 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 11.. .,'' ii► `he constriction industry may elect to be exempt if: I. The officer owns at least 10 perccnt c, Ole stock of the corporation,or in the case of an LLC,a statement attesting to the nii-nimum 10 percent ownership; 2. The officer is listed as an officer of ilie 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 p. any person allowed to work under this permit. Please check with your rsonally liable for the worker compensation iniuries of 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 (� Contractor Print Name: ✓11 �✓ �"? Print Name: �O Signature: Signature: State of Flo da) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and subscribed before me this IJ Sworn to and subscribed before me this .5 day of 1-12 62u L tiY ,20 I S� . day of T--p&L..,.4 I,20 ` S (SEAL) ' ' ' (SEAL) Type of IdType of Id Poo,,` EItPtRE3 August 19,2018 EXAIRES Auguw 1 g.2018 •oz)a991oOJ s (�07)3W-015Y -- %A&N �iM aaRm We are the Owners , of APA Electric Inc. a corporation organized and existing under the laws of the Florida, with its principal office located at 16531 SW 52nd Ln, Miami FL 33185 , and for whose behalf I make this affidavit. We, Jorge E Roque, Jorge D Roque and Enrique Garcia are the only workers in the above company (Job: 1481 NE 104 St, Miami Shores FL 33138)and have a Certificate of Exemption for WORKER COMPENSATION-CONSTRUCTION INDUSTRY EXEMPTION under the laws of the State of Florida. ToCCL,0Q�x gWXZ 2po Sig e sa 2L-� F'Li$ '2200 LtZLt- 5O-31- l Ag a ' e e�9_ ztl" ,1.)'�IQJC' Ci'� LGIW X025 - Loc) - S-Z..Z.1-O Signature SWORN to and subscribed before me,this V3 day on(-* 20\S- 0 0\5'0 NOTARY PUBLIC. DIEVA RICO �' a? MY COMMISSION#EES279961 M Commission Expires: ARES Aqu.t 19,2016 Y p c•o�i�io,so . ...... . . . .... ...... .... . ..... ...... . . ..... .. .. .. .. ...... REGI V L . . • . . . . ...... FEB 2015 • . . ...... BY: AdoX? A113 A $ ( e_ T 0OJOTI, Gr_ Iv, lE i AOU SN10KE/GAhb0i4 y1ul'dCJ1;lr1Lr ANY AND ALL CLOTH AND RUBBER �± INSULATED CONDUCTORS TO BE REPLACED, ••• •••••• '••••• ***GeeNO • • POINT ALONG CUUNiU C", , ; �t � � ray,;,; •••• .. PRECISE DIMENSIONS INC. T see** MIKE 305.409.3247 2 FEET FROM G.F. ('RQi s^Fl.U r;�t,Lrlra,;_r �': •: ,...;JAMES 849N PUT D/Vu RECEP I,aCLk III��UE` Lila . PLEASE BE AWARE_THAT ANY STRUCTURAL c CHANGES TAKE WILL THE MEASUREMENT ALI-FIXED AFPLLIANCES�� k'i;; � ,_N . . • HAS BEEN TAKEN WILL REQUIRE A REMEASURE • • /fit?? £'s�' P� �-?�, f • • ••• •••••• c • • • 1181: -- � •• • 30•- 1 D c :v 27;4" 44?' -48;. 19y' 51F. 16A 14" 31}" 74 H' I 3 • r 02NJEP�,. O 13612 p•o� 3DB30D 3OB3JD 0 RANGEI 3D033D m N F13i- u a w m _ _ I I r BpF,rJ38R 2�,DISHW 815R 824 133�2 1 r' W3036 38• 7 2 s" 4" 3 N - �, ..I u 4sy 2i 33" 33" i5j APPLIANCES NOTES: $9' 30 33• 3o Y " FRIDGE:89"H X 38^W X 30"D ----- ----tea"----- 1' �' STOVE:30"W -" HOOD:30"W PI FACE SEE SKETCHUP DRAWING FOR /`�✓ D1w:24"W Al f.IN DINING ROOM WHERE CUSTOMER �«. ,. w SINK:33"W HIA NT$CUSTOM CABINETS._.. w NO TILE UNDER CABINETS.. CUSTOMER �f WILL BE REPLACING TILE... w {{ NOT SURE WHAT APPLIANCES WALL BE USED..... "3 4 cn w w -� U U ICD ZD � i cr F— a_ I I c- D I r � r -1 U l` I w _ L, ca ? I— i JAN 2 1 215 All dimensions size designations 7r1 This is an original design and must Designed: 11/21/2014 given are subject to verification on ECq-4010GIES � not be released or copied unless Printed: 12/16/2014 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. I I JAMES BREEN official measurements All Drawing#: 1 i •••••• •••••• i V. I . c� _ .... .. .......... — l I I .......... i Note:This drawing is an artistic 2C� Designed: 11/21/2014 interpretation of the general c+aoiocies � ! appearance of the design. It is printed: 12/16/2014 not meant to be an exact rendition. JAMES BREEN official measurements All Drawing#: 1 I i 6666 • 6666 6666.. — - —118,3.. 6666.. 6600.. • 6666.. 2315n 3n ••... "it 6• 6666.• 16 50 4 1,12 _ � I •• 0 6666. 00.00. 2715n , �� .. .. + ..:. •6666 16 6666.. 4 4 465 O �t BEP491101 ..: 06 6 • W302012/� W1236 / 13612 MW.HOC p 0/1Z F0 rn 36REF1-2D1 Lo -N co 3424E 30-RANGEI% 3DB33D i 74,6 ' 12" 331 e, „ 1313ir / 116 r —88,'-6" —16 g'" All dimensions_size designations This is an original design and must Designed: 11/21/2014 given are subject to verification on 2O �c Es J not be released or co ied unless job site and adjustment to fit job p Printed: 12/16/2014 conditions. applicable fee has been paid or job order placed. JAMES BREEN official measurements EI 1 Drawing#: 1 i ,. � .. � � | ! / °° � °°°°°° :°°°°° ° � °~°*°° ° =°°= ~ ° °°°°°° �°° °° %°°°°: � =°° 00 °° =°°° =:°°: °°�° 00:00000 °° ° � °°°°= ° ° :09:0: ° � ° ° ° ° °°°°:° ~ ° �=°°° | °°°° � ~ �°°°° ° � | �°° ° ° �°° i | | / ! � | | | � / ! � � | | � | ' i �-.L J]------- � | / Note:This drawing is an artistic Designed 1 1/21/2014 interpretation of the general 20 appearance of the design.It is not meant to be an exact rendition. N official measurements Drawing#: I � ! i i I I ---163"— - - ....oo_ I' 30" • � ' 33" 30" .... _ • . 69"- 0 0 .. . . ... ...... M W3036 W3336 W3036 ti LO j � I r•v 1._.._.... 00 i I � " B B30-2 B24 B15R 24.DISHW SB33 BCFD36R M ; i 30" 24 x`-15" 2I 1 — 3 --36�� ' 82" -- -- -- I —28 2 ----52 2 , i i I I ' I i i I All dimensions_size designations �� This is an original design and must Designed: 11/21/2014 given are subject to verification on E'"� E not be released or copied unless job site and adjustment to fit job p Printed: 12/16/2014 conditions. applicable fee has been paid or job i order placed. JAMES BREEN official measurements EI 1 Drawing#: I i t • fi • • •••••• • •• I i i .......... ---------- i Note:This:daing is an artistic interpretatithe general Designed: 11/21/2014 appearancee design. It is `��O40GIES Printed: 12/16/2014 not meant tan exact rendition. JAMES BRF_EN official measurements All Drawing#: 1 i 98-41-" - -- I ----i ----- 1 r r •••. 0000•• • 0000.• � • 3 if -481 " 000:0. 0000.. 3 a • , 0000 4�� ,-----•__:�--�. 0000.• • • • • •• 0000. 00:04: • •.. 0000. - - •• _ 000000 MIT �EP40 01 � I ! 1N Ln :IN SIN CO - 36REF1-2D1 SIN A ti./ 0) _I N CO M It BCFD36R B B12R M -36"- n 1 2" rr 48"----------- �� 2 q 74 4 rr - -24"-/ All dimensions_size designations 20 This is an original design and must given are subject to verification on b b Designed: 116/201 14 job site and adjustment to fit job e:avoioeies"� not is released or copied unless Printed: 12/16/2014 conditions. applicable fee has been paid or job order placed. i i JAMES BREEN official measurements GI 1 Drawing 9: