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EL-14-2350 Miami Shores Village C � '_. lF Building Department �c� � � zo�� 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 !- '', �a INSPECTION LINE PHONE NUMBER:(305)762-4949 - FBC 20 4� BUILDING Master Permit NOD PERMIT APPLICATION Sub Permit No. 'EL, � -f ❑BUILDING N ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP ( ` }— CONTRACTOR DRAWINGS JOB ADDRESS: logo Iv E Com: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: (FIFE: OWNER: Name(Fee Simple Titleholder): V"-' � Phone#: G S Address: City: Awl State: Zip: Tenant/Lessee Name: Phone#: Email: V. 1 e 5,t% p E= 6) f/ w _ uo i'y) CONTRACTOR:Company Name: PhonelW � Address:���I S. {A, o» 1011. ��_ City: � A State: Zip: 3?i Q32___ Qualifier Name: ���� ►+R(i�L_� Phone#:at, 'yiL)L State Certification or Registration#:F-- F��� Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ '. U Square/Linear Footage of Work: 1� Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee$ Permit Fee$ CCF$ �� CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ e Notary$ Technology Fee$ � _Training/Education Fee$ Double Fee$ Structural Reviews$ 0 Bond$ TOTAL FEE NOW DUE$ B (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 Signature OWNER or AGENT NTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of Dc� el)Q ' ,2 A by 10 day of (�������_ .20 by who is o „4 M •gyp} ,who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PU ,,,,,y J0SE MIGUELDE LA CRUZ ..z MY COMMISSION#FF 016797 EXPIRES:May 12,2017 Sig n: eorWedrhmNo" ublicwmerwrimrs t: Print: & Seal: � ,PLY°Oe�� Notary public State of Florida Seal: Joanna M Feliciano My Commission FF 082753 �occ�o� Expires 01/12/2018 APPROVED BY i✓ 2 'r— Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) i fl i Q &'. Construo�n 7reQ— BUSINESS CERTIFICATE OF COMPETENCY 00001 X4837 iPARDIME ELECTRIC INC � D.B.A.: SMI OLEY JACKSON e Is certified_under the provisions of Chapter 10 of MienV-Dade County VALID FOR CONTRACTING UIVTIL 09/30/2015 oe 'IN Local Business Tax Receipt Miami-Dade County, State of Florida —THIS IS NOT A BILL—DO NOT PAY LBT 1208347 BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES PARDIME ELECTRIC INC RENEWAL SEPTEMBER 30, 2015 24525 SW 127 AVE 1208347 Must be displayed at place of business MIAMI,FL 33032 Pursuant to County code Chapter SA—Art.9&10 • C.TYPE OF BUSINESS OWNER PAYMENT RECEIVED PARDINIE ELECTRIC INC 196 ELECTRICAL BY TAX COLLECrOlt CONTRACTOR 82.50 10012014 Worker(s) 1 000014837 022345-000034 This local BasmessTax Receipt only ooatimm paymentolibe Local BashmaTax.The Receiptis nota Raeaw, permit ora cetligicstion otffie bolder s guaIIBcations.to do business.11914611 mast comply WM aay 99ve11meuml or aengoverameaml mgalalory laws and regaimmeslswhM applyt9 the bowness. The RECEWr b0.above a=be displepd on a8 commemial vebicles—M de Code Sec 89-276. For mom mlormatioa.viwtty W4jN idadeuavttaxc9Rector Municipal Contractor's Tax Receipt Miami—Dade County, State of Florida TNSIS NOTA TILL-DO MOT PAY MC CC NO:000014837 BUSINESSNAME/LOCATION RECERarNO_ EXPIRES PARDIME ELECTRIC INC yea►Busillmm SEPTEMBER 30, 2015 24625 SUN 127 AVE 7456=4 MIAMI,FL 33032 Must be displayed at plaee of 6usinass Pursuant to County Code Chapter BA-Art.9&10 OVVNER • TYPE OF BUSINESS PAYMENT RECEIVED PARDUE ELECTRIC INC ELECTRICAL CO\1TRACTOR BY TAX COLLECTOR 200.00 10/02/2014 0229-15-000044 _ Tyr non Taformadoa.vb twww.mkmMado govftxcallector OCT/17/2014/FRI 10: 23 AM FAX No, P, 001/001 LP A °ATE`MI'/201a '' CERTIFICATE OF LIABILITY INSURANCE xo/1 72ol THIS CERTIFICATE !S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS -- F CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVE=LY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUM-ER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(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 certtficato holder in lieu of such sndorsement(s). PRODUCER NAME: AnisleY ZZ Simon International Insurance Center, Inc. PHONE (305>279.5446 FAX 7Q90 SW 117 Avenue E-MAI112 E4�L Arc No•(305)279-4045 Suite 209 DRESS: Mialhi FI' 33183 wSUAER(S AFFORDING COVERAGE NAIc n INSURED t1N Nationwide Insurance Com an ,Pardime Electric Inc. 24625 SW 127TH AVE 140mes teal >:Z 33032 INSURER E: INSURER 0: COVERAGES CERTIFICATE NUMBER_CL14 91000710 THIS IS TO CN NUMBER; ERTIFY THAT THE POLICIE=S OF INSURANCE'LISTED BELOW HAVE 88EN ISSUED TO YHE INSURED ENAMED A50VE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM 09 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 A L SUB LTR TYPE OF INSURANCE s POLICY NUMBER p�I upD UCY EXP Gi=N>=RAL LL4BI13TY LIMITS X COMMEROwL GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 A CL41MS-MAbE Q OCCUR CPGLZO5925204235 /13/2014 /13/2015 PR MI ' ^ urrence 5 100,CCO MED FxP(Any one person) $ 1,000 _ PERSONAL&ADV INJURY $ 11000,000 GEN•LA13GREGATELINIIYAPPLIESPER: GFNERALAGGREGATE S 2,000,000 X POLICY PRO- 40C PRODUCTS-COMP/OPAGG 3 2,000,00JECT AUTOMOBILE LIABILITY $ ANY AUTO COMB�I,. nt INGLE LIMIT ALLOw)vE0 SCHEDULED 80DILYINJURY(Perpereon) $ AUTOS AUTOS NON-OWNED BODILY INJURY(Per accident) 5 HIRED P.UTOS AUTOS Red DAMAGE Per $ UMBRELLA LAB EXCESS LULe OCCUR CLAIMS4AAAD9 EACH OCCURRENCE ---- DEQ RETENTION$ AGGR50ATE g WORKERS CbmPENsAT)ON $ AND EMPLOYERS'LIABILITY WC STATU• y ANY PROPRIETORIPARTNER/EXECUTIV£ YIN❑ OFROER/MEMEER EXOWDED7 N/A GDEN7 (Mandatory in NM E.L.EACH ACS Dyea,d�Iunder B.L.DISFAS9_EA EMPLOYE $ DESCRIPTIONO14 OF OPERATIONS trelp�v E.L DISPAS9.POLICY LIMIT S beSCRIPTION OF OPERA'nONB r LOCAMNS/VEHICLES(Attach ACORD 7di,Addi anar Remarks gehedvle,If mores acR I= Electrical Contractor P ►ec(u)red1 Electrical Construction CERTIFICATE HOLDER CANCELLATION � rTHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BSFORp E EXPIRATION DATE THEREOF, N0710E WILL I DEL)VER1=D 1N MiaaLi Shores Village CORDANCE WITH THE pOUCY PROVISIONS,13uilding Department 10050 N$ 2nd Avenue ORLZEp Rr✓pResENTATIVE Miami Shares, FL 33138 9dwrard Cabassa/cR ACORD 25(x040/05} --,�, IN3n25 r�n�nnRl nt ThP Of 11R11 nnrnp and Innn Bra�wiia*s.►wrl�'�.88-2010 t: ,ACORD CORPORATION. All rights reserved. ADP 10/23/2014 11 : 28 : 53 AM PAGE 2/002 Fax Server AC Ro " CERTIFICATE OF LIABILITY INSURANCE °°-M(IMMUDIr" 10/23/2014 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: f the certificate holder Is an ADDITIONAL INSUR D,t o policy les must be endorsed. f SUBROGATION IS W'AlVffD—, 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 NAn1E Automatic Data Processing Insurance Agency,Inc. No: 1 Adp Boulevard ADDRESS` Roseland,NJ 07068 INSURER(S)AFFORIMGCOVERAGE MC# INSURER A: NorGUARD Insurance Company 31470 INSURM PARDIME ELECTRIC INC INSURER B: DBA:Pardime Electric Inc INSURER C: 24625 SW 127th Ave INSURERD: Homestead,FL 33032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 276777 REVISION NUMBER: THIS IS TO CERTIFY THATTHE 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.UTATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NLMIMER UMrrS RgAL GENERAL UABIUTY EACH OOCU RENCE $ C LAW-3-MADE [—]OCCUR PRBWSES E==, $ MED EXP(Ary one person) $ PERSONAL a ADV INJURY $ GENLAOGRECATE P UpM�I T.'APPUES PER: GBsIERALAMREGATE $ ucy F1 Mor � LCA PRODUCES-Ca%F/OP ACG $ OTFER $ AUTOMOBILELIABILITY ac d $ AWAUTO BMILYINJURY(Pe Wsm) $ ALLOVNVED SCHEDULED Alms MVIED BODILY INJURY(Per acddera) $ wT DAuros ALTOSg n $ lJ1VBRFl�e LJAB (X7(dAi EACH OCCURF4=NCE $ IXCESS LIAR CLAIMS�NADE AMF ELATE $ DEDRETEM70N $ WORIUM CONPETSA LION X AND EMFL.OYERS'LIABILITY Y/N A APROPRIETOR/PARTNER/IXECLFIVE ANY;;= EXCLUDED? N/A N PAWC557658 08/06/2014 10/31/2014 ELEACHAO-EA $ 100,000 I1yes desorEe un-Jar EL DISEASE-EA BVIPLOY $ 100,000 DE9C`31PTION OFOPEFATIONS hPJannr EL DISEASE-POLICY umrr I $ 500,000 DESCRFTM OF OPERATIONS/LOCATIONS/VEHCLES(ACORD 101,Additlorml Remarks Schedule,ffW be eMdied ff more space Is required) Contractor License:er0009013 a d CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 N.e.2nd Ave Miami Shores,FL 33138 AUTHORZ®REPRESEWAT1VE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ADP 11/26/2014 2 : 28 : 31 PM PAGE 2/002 Fax Server ACORL7® CERTIFICATE OF LIABILITY INSURANCE °A 111/26//26/2001414 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. M O T : If the certificate ho er is an A D I D,the po Icy les must be endorsed. If SUBROGATION A , 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 NAM Automatic Data Processing Insurance Agency,Inc. No: 1 Adp Boulevard ADDREss: Roseland,NJ 07068 INSURER(S)AFFORDNG COVERAGE Me# INSURER A: NorGUARD Insurance Company 31470 INSURED INSURER B: PARDIME ELECTRIC INC INSURER C: 24625 SW 127th Ave Homestead,FL 33032 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 286196 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERMOR CONDITION OF ANY CONTRACTOR 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, E)(CLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMER UNRS COMMERCIALGENERALUABIUTY EACH OCCURRENCE $ CLAACNIADE OCCUR PREMISES EaowmenceI $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENLAGGREGATE LIMTTAPPLIES PER: GENERALAGGREG4TE $ POLICY❑P&Qr F-1 UJC PRODUCTS-CCtNP/OP AGG $ OTHER $ AUTOMMLE UABIUTY $ aca ANYAUTO BODILY INJURY(Per person) $ ALLOMED AUTOS AUTOS BODILY INJURY(Per acddert) $ HIRED AUTOS NON-OW� gam $ $ �'LIAB OCCUR EACH OOCURRENCE $ EXCESS LIAR CLAING-MADE AGGREGATE $ DED I I RETENTION $ V ORKERS CONPBJSATION X A AND EMPLOYERS UABIUTY YIN ANY PROPRIETOR/PARTNEWEXECI.MVE EL EACH ACCIDENT $ 100,000 A QFF�ICERM EXCLUDED? � N/A N PAWC557658 08/06/2014 08/06/2015 1�"yy�eess"��"' . EL DISEASE-EAEMPUJ $ 100,000 DEStiRI OFOPERATIONS below EL DISEASE-POLICY UMTT $ 500,000 DESCRPTTON OF OPERATIONS!LOCATIONS/VE IMES(ACORD 101,AdcHarval Remarks Schedule,maybe attached B more space Isrequlred) Electrical Construction and electrical Contractors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave. Miami Shores,FL 33138 AUIHORREDREPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �. Miami Shores Village ' - 'p S ON 14 2894 LA Building Department �I I 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 „ (�. Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 �Id FBC 2000 BUIL I N G Master Permit No. PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: 9 OWNER:Name(Fee Simple Titleholder):\6hone#: 10lR�� Address: City: State: Zip: Tenant/Lessee Name: Phone#: V Email: • IP_XCQJe��, °fY1�,john CONTRACTOR:Company Name: 7—qtj r.- 'R�_ Phone#: �S 210,' ,Address: ® 7" /9'A_ City: C9A-A 9_1K-0 state•. ;a-Lj/Z-r-6 gyp: 3 0 G f' Qualifier Name: Phone#: State Certification or Registration#: �;C 00 S__q22 Certificate of Competency M DESIGNER:Architect/Engineer: Phone#: Address: City State Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: 2_0 0 S t /fr Type of Work: ❑ Addition ❑ Alteration }�New EDRepair/Replace F-1Demolition Description of Work: �_k \ �' Specify color of color thru tile: Submittal Fee$ SCC/ Permit Fee$ - CCF$ CO/CC$ Qj_ Scanning Fee$. / -! _Radon Fee$_(� DBPR$ (0 Notary$-S.. 0 Technology Fee$ _ Training/Education fee$ CIC) Double Fee$ Structural Reviews$ _ Bond$ TOTAL FEE NOW DUE'$ I (RevisedO2/24/2014) 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_ Tip 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien low brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. &At s Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this --day of �� /°` ,20= =— by day of D c,J ,20 /V ,by r� o is sonall i k n toe Q k e- ) ,who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Si tint: Print: }io. a 1. 000 pee, Notary Public State ol`-lonoa Seal: _ ^ Joanna M Feliciano Seal: o My commission FF 082753 v y ,, DBORAH S.PU8fLL0 S? •uuy..I,. 9r Ov iti P Expires 01/12/2018 :t. `q•F-•r MY Doi USSION$FF 012935 EXPIRES:August 28,2017 Bonded Tina try Polo Un&rwrbm APPROVED BY Cr z,, ` Plans Examiner / ��I oning Structural Review Clerk J I T' (Revisedo2/24/2014) iRICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGCO05472 ti-r i The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 � • HENLEY, ZANE R r ZANE R HENLEY LLC 2840 N.E. 7TH AVENUE 'POMPANO BEACH FL 33064 ISSUED: 06/08/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1406080001394 f 4 SNORES n .... o0" Miami shoresVillage Building Department R1DA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption -tom. 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 injuries 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 Contractor Print Name: Print Name:'ZMj A_ c Signature: ®o Signature: Q1":. _Q . State of Florida) State of Florida) County of Miami-Dade) o `_°. County of Miami-Dade) Sworn to and subscribed before me this ° d Sworn to and subscribed before me this 9 o0a day of� ,° ,20� . j day of C9eJ61Jj t-&,,i ,20J�. By BCL V Fn (SEAL) cP- (SEAL) __ T e ication pro uce T e of Identification produced at lt lilt�I 12-03-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE O' 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: 01/20/2013 EXPIRATION DATE: 01/20/2015 PERSON: HENLEY ZANE R FEIN: 205409429 BUSINESS NAME AND ADDRESS: ZANE R HENLEY LLC 2840 NE 7TH AVENUE POMPANO BCH FL 33064 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . (35114), F.S., an officer of a corporation who elects exemption from this chapter by tiling 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 440.0503), 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 trained 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 tine person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 VVC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES va"aj<;;, F DIVISION OF WORKERS'COMPENSATION x�� O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA . -` L under this section may not recover benefits or compensation under this WORKERS'COMPENSATION LAW u "v D chapter. EFFECTIVE: 01/20/2013 EXPIRATION DATE: 01/20/2015 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be PERSON: ZANE R HENLEY H exempt... apply only within the scope of the business or trade listed on FEIN: 205409429 R the notice of election to be exempt. BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt ZANE R HENLEY LLC and certificates of election to be exempt shall be subject to revocation 2840 NE 7TH AVENUE if, at any time after the filing -of the notice or the issuance of the POMPANO BCH, FL 33064 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 1- LICENSED GENERAL CONTRACTOR section. QUESTIONS? (850) 413-1509 CUT HERE Carry bottom portion on the job, keep upper portion for your records. UVC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 :i: k REGISTRATION NO. pompano City of cImpla oBea-Ch beach Business Tax Receippt Florida's Warmest Welcome NEW RENEWAL-, OWNER BATE ISSUED c .q v ACCOUNT NO. REGISTRATION FEE "! BUSINESS NAME DELINQUENT CHG. r *-.! LOCATION TRANSFER FEE i F CCLASSIFICATIONLTOTAL AMOUNT PA +�d EFFECTIVE DATE EXPIRATION DATE QGTOBER 1 SEPTEMBER 30 BUSINESSES MUST CONSPICUOUSLY DISPLAY THIS I••: l.;i'i t r S '',1 s' f. i„` BUSINESS TAX RECEIPT TO PUBLIC VIEW AT BUSINESS LOCATION CONTRACTORS MUST MAINTAIN ON FILE CURRENT LICENSING AND INSURANCE NOTICE:A NEW APPLICATION MUST BE FILED IF THE BUSINESS NAME,OWNERSHIP OR ADDRESS IS CHANGED.THE ISSUANCE OF A BUSINESS TAX RECEIPT SHALL NOT BE DEEMED A WAIVER OF ANY PROVISION OF THE CITY CODE NOR SHALL THE ISSUANCE OF A BUSINESS TAX RECEIPT BE CONSTRUED TO BE A JUDGEMENT OF THE CITY "j°' AS TO THE COMPETENCE OF THE APPLICANT TO TRANSACT BUSINESS. 1 A CERTIFICATE OF LIABILITY INSURANCE 10/9/2014 4 ) 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 pollcy(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 Fannie Baez NAME: Jackson Insurance Agency PHONE . (305)824-3464 FAX No:(305)822-8535 (AIC No2075 West 76th St E-MAIL fbaez@jacksona enc com ADDR SS: g y INSURER(S)AFFORDING COVERAGE NAIC# Hialeah FL 33016 INSURERA.LlO ds Of London 524210 INSURED INSURER B: Zane R. Henley / Zane R. Henley Llc INSURERC: 2840 Ne 7th Avenue INSURER D: INSURER E: Pompano Beach FL 33064 INSURER F COVERAGES CERTIFICATE NUMBER:2014-2015 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 SUB POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGETX RENTED COMMERCIAL GENERAL LIABILITY PREM SESOEa occurrence $ 100,000 A CLAIMS-MADE F_x1 OCCUR GSNR-M 4/1/2014 4/1/2015 MED EXP(Any one person) $ 0 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY JECT F7 PRO LOC I I $ 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 HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE FN/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Job Description: General Contractor This certificate is solely for the use as " Evidence of Insurance" CERTIFICATE HOLDER CANCELLATION (305)756-8972 sandra@marineboatlifts.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 10050 NE 2 Avenue AUTHORIZED REPRESENTATIVE Miami Shores, , FL 33138 Ed Jackson/FANNIE ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgmnn�;i m Tho Arnpn namo 2nA Inn^pro ronieforori mmora^f Af`rion