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CC-15-167 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-245038 Permit Number: CC-1-15-167 Scheduled Inspection Date: October 07, 2015 Permit Type: Commercial Construction Inspector: Rodriguez,Jorge Inspection Type: Final Owner: CHURCH, ST ROSE OF LIMA CATHOLIC Work Classification: Alteration Job Address:415 NE 105 Street Miami Shores, FL Phone Number (305)758-0539 Parcel Number 1122310430010 Project: <NONE> Contractor: BAS ENGINEERING CONSTRUCTION INC Phone: (754)422-7160 Building Department Comments REMOVE EXISTING DAMAGE DRYWALL SUPPLY AND Infractio Passed Comments INSTALL NEW DRYWALL SUPPLY AND INSTALL OF INSPECTOR COMMENTS False NEW MARBLE TILE JOB ADDRESS 10500 N.E 5 AVE ST. ROSA LIMA CHURCH CONVENT Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. October 06,2015 For Inspections please call: (305)762-4949 Page 38 of 60 f WWII ,. \\ nr 'CCA4 5- 7 Pen t tis TM h� Miami Shores Village iEkI1 Ty 'Commercial Coristrucillon g� 10050 N.E.2nd Avenue NE , Ils�1C flprl lit;�tl�. a Miami Shores,FL 33138-0000 ` Phone: (305)795-2204 \ 'f, ' � h> A F�ORYDp' £ ..,. Expiration: 01127/2016 Project Address Parcel Number Applicant 415 NE 105 Street 1122310430010 Miami Shores, FL Block: Lot: ST ROSE OF LIMA CATHOLIC C Owner Information Address Phone Cell ST ROSE OF LIMA CATHOLIC CHURCH 9401 BISC BLVD (305)758-0539 MIAMI FL 33138-2970 Contractor(s) Phone Cell Phone Valuation: $ 15,000.00 BAS ENGINEERING CONSTRUCTION (754)422-7160 Total Sq Feet: 00 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Window Door Attachment Type of Construction:REMOVE EXISTING DAMAGE DRY Occupancy Load: Tie Beam Stories: Exterior: Slab Front Setback: Rear Setback: Termite Letter Left Setback: Right Setback: Framing Plans Submitted:Yes Certification Status: Store Front Attachment Certification Date: Additional Info: Insulation Bond Return: Classification:Commercial Drywall ScrewFill Cells Columns Scannin :4 Window and Door Buck Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Ceiling Grid CCF $9.00 Review Planning DBPR Fee $6.75 Invoice# CC-1-15-54245 Review Building DCA Fee $6.75 07/31/2015 Check#:2676 $449.50 $50.00 Review Building Education Surcharge $3.00 07/23/2015 Credit Card $50.00 $0.00 Review Building Permit Fee $450.00 Review Building Scanning Fee $12.00 Review Plumbing Technology Fee $12.00 Review Plumbing Total: $499.50 Review Plumbing Review Electrical Review Electrical Review Structural Review Mechanical 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 ns,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume re sibility for all ork done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLU ING,MECHANIC L, DOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: ify t fo g i ormation is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoni th ore, oriz he ove-named contractor to do the work stated. July 31, 2015 u r' ed Signature:Owner.,`/ Applicant / Contractor / Agent Date Buil ' g Department Copy July.-31, 2015 1 0S" Miami Shores Village \tae S Building Department SAN 2s Zo, J C� 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 A ,`� J ,��' � Tel: (305)795-2204 Fax:(305)756-8972 /INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 BUILDIN " 1Master Permit No. I M4 PERMIT APPLICATION Sub Permit No. P111 ILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION EfkNEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ®'SHOP �1 CONTRACTOR DRAWINGS JOB ADDRESS: ��� �© �C ���/i��G�it✓U� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 1 122Noq3 m� d Is the Building Historically Designated:Yes NO Occupancy Type Load: Construction Type:/� i( Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder)�70 ��� �Y��� (-�hone#: 3c�✓�r 7 J��J�� Address: City: i' —� State: /7::: Zip: l C� '5 Tenant/Lessee Name: rQ• ��'�® G./�'�-� ..aS'T�7�' Phone#:� � f 3 Email: CO/��-S s f' cap//c�/ • L'O CONTRACTOR:Company Name: AK %/7 f�2ST/c�T/ ne#: l ��� Z z --7/9D Address: . 2 .5 al . City: �i�7�,s���� //7� State: ;;Z� Zip:/-3-1? 02 Qualifier Name: /� /� ,/c��s Phone#: ! IVZZ a ?/60 State Certification or Registration#:/� / Certificate of Competency#: DESIGNER:Architect/Engineer: ee� AIM, IOA)Wl e-1A&#: r �,�6�� ✓� -dn�� Address: Z,!!�G9 3 �/� ��E City✓/ / ,W' State: ":;�Zip: —3302l Value of Work for this Permit:$ ,�c�. ��" C.-, Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition Description of Work:���/��� O,c�i�s7/.t�� 1� F !� -� zo'e '01 jV Specify color of color thru tile: Submittal Fee$ -!�Y) Permit Fee$ CCF$ CO/CC$ Scanning Fee$ 80on Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) I Bonding Company's Name(if applicable) t 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 sucfr- sted notice, the inspection will not be approved and a reinspection fee will be charged. Signature � Signature OWNER or AGENT -7CONTRACTOR 74 The foregoing instrument was acknowledged before me this The� foregoing instrument was acknowledged before me this JQW�� day of 2-3 20 /J' by ._-./Gil day of 03 20 �� , by 1 0 rU L who is personally known to �P_5 0 S 6 C1 S cA � who is personally known to me or who has produced__ lSn c1Jb 4 as me or who has produced 4 ro Yl as identification and who did take an oath. identification�nd who did take an oath. NOTARY-PUBIiIC: NOT BLIC: Sign* , i �Q. Q �/`�_, �. Sign: i Print: f; � ` � � 3Y �`� d/b Print: �� 1�� f 0 V i Seal: Seal: YESENIA MONTALVIJ ay.iYPi ° cI-ndaYESENIA MONTALVO Notary Public -State o� u My Comm. Expires Jun20 2017 rNotary Public-State of Florida FE 0299 2 MyCommEx fies Jun 0 7 tltAR *** *** **�'rommrssion* *F 09520'!a°;,;:',,'° Bon ed Thro gh National Notary ssn. Bonded Through National Notary Assn. APPROVED BY ( Plans Examiner o Structural Review Clerk (Revised02/24/2014) r SORBS 93 r on. 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 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. V OPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. ✓ COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: ( AS &V< AAC t NG CoN s ,cnoN . N� BUSINESS ADDRESS: M Sul IbyrN 4116vvE CITSTATE zip Vo2.-7 BUSINESS PHONE: (-35'Y ) q)2 - ?/&0 FAX NUMBER( ) CELL PHONE 22 '7/60 QUALIFIER'S N ME: }�N ��J3 QUALIFIER'S LIC NUMBER: CCC O 2- STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850)487-1395 9940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 BASABE,AARON A BAS ENGINEERING CONSTRUCTION INC 924 GREENWOOD ROAD WESTON FL 33327-1858 Congratutatiorra! VVith this license you become one of the nearly one mill on Flor Pians 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. PROFES It7",.REGULATION w Every day we work to improve the way we do business in order to CGCO62421 �' _',,-,,,12/21/2014 serve you better. For information about our services,please log onto www.myfloridaticerno.com. There you can find more information CERTIFIED Gl:lt{�4 ZON x about our divisions and theons that impact you,subscribe BASABE, x to department newsletters an seam more about the Departments initiatives. BAS ENGl INC Our mission at the D apartment is:License EffiaenNy,Regulate Fairly. We constant strive to serve you better so that you can serve your customers. ank you for doing business in Florida, IS CERTIFIED under the pravisiona of ch.48e Fs. and congratulations on your new licensel Er a on dee AUG 31,2018 LW2210002W3 DETACH HERE RICKSCOTT,GOV'ERNOR � �___.._�.._.._ _.......__�._._..._... .�_.___...._,..��_._._.�.- : E 1 A.RY ._ STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUC71ON INDUSTRY LICENSING BOARD CGCO6242t The GENERAL CONTRACTOR . �.` Named below IS CERTIFIED Under the provisions of Chapter-489 FS. Expiration date: AUG 31-,2018 BASABE,AARON A A.: BAS ENGINEERING CONSTRUCTION INC ' 172 SW 164TH AVENUE.— PEMBROKE PINES= VENUE. .PEMBROKE"PINES= . ��FL33027 �° STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL.REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 BASABE,AARON A BAS ENGINEERING CONSTRUCTION INC 924 GREENWOOD ROAD WESTON FL 33327-1858 __ _._ _. .... ._...... ...__ Congratulations! With this license you become one of the nearly _- one million Floridians licensed by the[3epartment 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. '' PROFf SSI `REGULATION Every day we work to improve the way we do business in order to CUC1223852 EIr? . 12/21/2014 serve you better. For information about our services,please log onto www.myfforidalicense.com. There you can find more information CERT UNDE'iGf IJ"0 EXGaw►V CNTR about our divisions and the regulations that impact you,subscribe BASABF,AARto }1 , initiatives department newsletters and team more about the Department's BAS ENGINEERING CON!TjW.,I ION INC 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! EXpi ation dsi.:AUG31,2016 L1412210002WT �I DETACH HERE KEN LAWSON,SECRETARYµ.. STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CUC1223862 The UNDERGROUND UTILITY&EXCAVATION CO Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31. 2018 Ml BASABE,AARON A Q BAS ENGINEERING CONUCTIC?N INC 172 SW 164TH AVENUE PEMBROKE PINES FL 33027 ■ i lssUl a. 12/21/2014 DISPLAY AS REQUIRED BY LAW SEQ# 1.102210002507 YIIpj.. _ S ��IFFrr &RROW 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,201S DBA.BAS ENGINEERING CONSTRUCTION INC Receipt#:GENERAL CONTRACTOR Business Name: Business Type: (CONSTRUCTION REMODELING Owner Name:AARON A BASABE/QUAL Business Opened:10/08/2014 Business Location: 172 SW 164 AVE Stete/County/Cert/Reg:CGC062421 PEMBROKE PINES Exemption Code: Business Phone:754-422-7160 Rooms seams Employees Machines Professionals 3 For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid r' 27.00 0.00 0.00 0.00 _ 0>00 0.00 27.00 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 f,r. 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: BAS ENGINEERING CONSTRUCTION INC Receipt #OIA-14-00000143 172 SW 164 AVE Paid 10/08/2014 27.00 PEMBROKE PINES, FL 33027 2014 _ 2015 Ae. k CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 01/23/15 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(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 CONTACT NAME: Univista Insurance Hialeah 49th St. PHc N . (305)362-7100 FAX No): (305)362-0303 1290 W 49th Street Unit A AD KESS: univista49st@univistainsurance.com Hialeah, FL 33012 INSURERS AFFORDING COVERAGE NAIC# Phone (305)362-7100 Fax (305)362-0303 INSURER A: ASCENDANT COMMERCIAL INSURANCE INSURED INSURER B: BAS ENGINEERING CONSTRUCTION INC INSURER C: 172 SW 164 AVE INSURER D: HOLLYWOOD, FL 33027 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. INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/VYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED 100,000.00 © COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A F-1N 01/22/2015 01/22/2016❑ CLAIMS-MADE © OCCUR GL-46815-0 MED EXP(Any one person) $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 RO ❑ POLICY ❑ JPE'T- ❑ LOC $ MBINED SINGLE LIMIT AUTOMOBILE LIABILITY (CO, Eaccident $ ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ❑ AUTOS $ F-] HIRED AUTOS ❑ NON-OWNED PPe�acClde^DAMAGE ❑ ❑ $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑C STATU IMITS ❑OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFIED GENERAL CONTRACTOR CGC062421 CERTIFIED UNDERGROUND&EXCAV CNTR CUC1223852 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES, FL 33138 NELSON HERNANDEZ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05)QF The ACORD name and logo are registered marks of ACORD 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: 1/15/2015 EXPIRATION DATE: 1/1412017 PERSON: BASABE JESUS A SR FEIN: 462836357 BUSINESS NAME AND ADDRESS: BAS ENGINEERING CONSTRUCTION INC 172 SW 164TH AVENUE PEMBROKE PINES FL 33027 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.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 the notice of election to be exempt.Pursuant to Chapter 440.05(13),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, 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 DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 OUESTiONS7{850)413-1609 StloR ns 9@19 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 ction Indus try to exempt themselves from this requirement for ancons y traction 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 nall does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore You may be ersoliable for the worker com enation injuries of anerson allowed to work under this ermit. Please check with your insurance carrier since most propertyinsurance policies D p O 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: r2 e-rx'rD Co,-C e S Print Name: Signature: �`iCG._. Signature:— ---------- State i ature:State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and subscribed before me this v�3 Sworn to and subscribed before me this a� �ot ,20 day of 20 ` By BY DIANA CENTENO DIANA CENIENO (SEAL) = •, Notary Public-State of Florida Type of Identi ;t o a >icgd Comm. Expires T e of I p 'p Cgfgm. xpires Mar 4, 2016 Commission#EE 175417 "i9jF X111 ,` \��``l i\ Bonded Through National Notary Assn. lllBonded Through National Notary Assn. Fi i' S Engineering Construction Inc 172 SW 164th Avenue Pembroke Pines, FL 33027 Phone: 754 422-7160. E-mail: jbmj63@yahoo.com { } J J �y January 26; 2015 State of Florida County of Broward Before me this day personally appeared Jesus Basabe who, being duly sworn, deposes and says he will not use day labor, part-time employees or subcontractors for your project at St. Rose of Lima Convent at 10500 NE 5th Avenue, Miami Shores, FL 33138 Sworn to and subscribed before me this 26th of January. 2015, by Jesus Basabe. • s Personally Know OR Produced Identification . YESENIA MONTALVO Type of Iden tjr ation Produced °� Notary Public-State of Florida . My Comm. Expires Jun 20,2017 "re Commission#FF 029952 opt= , i"OF F„� ..n Bonded Through National Notary Assn. I 'E e Print, Type or Stamp Name of Notary