Loading...
BPP-14-2373 1 • ' Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 inspection Number: INSP-230829 Permit Number: BPP-10-14-2373 Inspection Date: May 04, 2015 Permit Type: Pools/Whirlpools/Hot Tubs Inspector: Dacquisto, David Inspection Type: Survey Final Owner: PATINO, BIBIANA Work Classification: New Job Address:95 NW 95 Street Miami Shores, FL 33150- Phone Number (786)252-1343 Parcel Number 1131010330540 Project: <NONE> Contractor: ROSMEL POOL INC Phone: (305)592-7900 Building Department Comments NEW POOL Infractio Passed Comments INSPECTOR COMMENTS False C� Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-230825. POOL NOT AS II��II SHOWN ON APPROVED PLANS. MINIMUM SETBACK BETWEEN SIDE PLOT LINE AND POOL WATERS Failed EDGE IS 12.5 FEET Correction Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid. For Inspections please call: (305)762-4949 May 04,2015 Page 1 of 1 I ABREVIATION OF AW APPLIED) AAN-.mat auOnDNo un P!&-=,.mmw i F.I.P. .024M 5 ALLEY cammosmuw 61L-IIeaT mm PA-PAI'W a•VAVM W 12.0 ,F2$ HOUSE PICTURE LOCATION MAP , P�:�a. P.PNapIRIr TNR \ 30.00' no cap)EAST—WEST 81.30' (MR) (no cap) 0..m II1170TaR01QRR6 ; C=L-AMNII re RX-PAQ W vIRITNer l�::. l0 IID --..aNwiae YNTL IaL�eRr RML Limft lotD h* FAUM U �8j •9 V C.B.S. o In a-IIIIIRIA am 00 Wall �c F�.i 2b' earl-UMIM i.ma�Oi►aY R. F71NUA0N�' aD/N=AJ GIRL NRLL am ry M Y 12.50' "' 15 14 13 12 ML I OLW X°R re'wr UWo A>a in 0.75' Tiled ti; ►R/p FO WJL AD Imo iu firer IIIaI PIP[ 3 O " rV.-wuo RAI PR SAK Ar NMW Q rA-wuo II= DIY-alar I.P..tae ME SRL- rn c 3') IIW-QQ-IIrAa� w mPvaAUT a a. .- MIL. VJS Uu.FAV>r01' no C.B.S. O o�c � = (. ue SLP. M „�J„.... WOII I O v 1 18 19 IID.IIm m Nlws 2.5' 17.0' �c 5' C.B.S. 3 SURVEYOR'S LEGEND OF ANY APPLIED) .. ......... :.16 2 \ 21.2' / pp Wall �� 2a' .... O1 i 0 (� n s a r Z BOUNDARY LINE ® CATCH BASIN ::'� Utility ^10.0' .. "I'� s 'i$ El IBM) 0 MANHOLE •.:::•:. �+::.: 15.0 12.50 w �a srRucruRE BLDG ..:.... •� 'r;::::� / \ 15.0 •� a r ¢ — w .:a...,c 2 :AFD:::..to . ; N.W. 95th ST. CONCRETE Tuoal wau o.E ovERHlao RECT. o� MM :�.�:::... \ / v METAL FENCE � POWER POLE Q a•':N C]•: • WOODEN FENCE -0- ........ LIGHT POLE C ; :: p1 Car Port N Terrace`c� Rc,'o O z '++' to �, • `' FI r ADN Lo ® CHAIN LINK FENCE //L�� HANDICAP SPACE .. . .............. ....... Z C'. :.• ::ZO. / \ �- _-- WOOD DECK/DOCK w :. 13.20 10.10 • 0 ASPHALTED AREAS HANDICAP SPACE -— I- t.. O. 38.x• Y 0 CONCRETE - EASEMENTLWE / 'l 1 STY. C.B.S. tai ®BRICKS OR PAVERS y WATER VALVE Q d m ` ®ROOFED AREAS tV TY-CABLE BOX RESIDENCE ��� ® WATER(EDGE OF WATER) AM wAT�M QER � � JOB SPECIFIC SURVEYOR NOTES: t: O r ••••• •••••• .. D., NO. 95 THE PROPERTY DESCRIBED ON THIS SURVEY DOES NOT LIE WITHIN A SPECIAL HAZARD AREA AS DEFINED By THE FEDERAL EMERGENCY MANAGEMENT AGENCY:THE PRWERTY LIES WITHIN A • L 0 O ++ •• FLOOD ZONE'x°OF THE FLOOD INSURANCE RATE MAP IDENTIFIED AS COMMUNITY PANEL No. 120652-302L.WITH AN EFFECTIVE DATE OF SEPT.11,2009. BASE&90D F.NEVA"ON OF • ••• • o Highest F.F. Elev. 13.13 .-.� cn J N/A(NGVD) .. �• • • 'M o_ I Lowest F.F. Bev. 12.65 °'� O m o I ..... .. •••••• •;• •; �x LAND AREA OF 5U8JECr PROPERTY: 11,626 SF(+/-) . • • •• p 14.00 - J; ;n (� IV ®ELEVATIONS ARE BASED ON THE NATIONAL GEODETIC VERTICAL DATUM(NGVD)OF 1929,AS PER MIAMI-RADE COUNTY BENCH MARK Na NIA,WITH AN ELEVATION OF N A FEET. sees • see• O (9 Z O LTiI@_C�_ O Z q ® BEARINGS SHOWN HEREON ARE 64SID ON AN ASSUME MERIDIAN OF NORTH-SOUTH.,BEING THE RECORDED BEARING FOR THE CENTERLINE OF N.W 1st AVE,AS SHOWNl7• 10 AT ••••• o•�,••• 1q t0° ° ° ° ° 1t) QO ._,.., PAGE 39 OF THE PUBLIC RECORD OF MIAMI-DARE COUNTY FLORIDA to 18.60 OD IID 16.60• ••••n Una ••••• :.... 20.00 6.5 p z ® ® ..�..� ..:. ....:. ,O to I" a M ® < GENERAL SURVEYOR NOTES: •o •• • N •' . F.I.P. •C• r' ^ -0 M M THE SHOWN LEGAL DESCRIPTION USED TO PERFORM THIS BOUNDARY SURVEY WAS PROVIDED BY THE CLIENT. 000000 • • •:•..... Q o 7 ® • • e R •• )e•• • .•• (n0 cap) . J J z 0 SURVEY IS BASED ON RECORDED INFORMATION PROVIDED BY CLIENT.NO SPECIFIC SEARCH OF THE PUBLIC RECORD HAS BEEN MADE BY OUR OFFICE • • •••••• • II ppp 3 UNLESS OTHERWISE NOTED,AN EXAMINATION OF THE ABSTRACT OF TITLE WAS NOT DONE BY THE SIGNING SURVEYOR TO DETERMINE WHICH INSTRUMENTS,IF ANY ARE tfwwz SHE SUBJECT PROM •••••• c a g ::Asph.rivewz W THIS SURVEY IS EXCLUSIVELY FOR THE USE OF THE PARTIES TO WHOM IT WAS CERTIFIED. •• • •••••T j • W ® •'. �l m PURSUANT TO RULE 61G17-6 OF THE FLORIDA ADMDRSTRATIVE CODE THE E%PECTED USE OF LAND IS SUBURBAN,THE MINIMUM RELATIVE DISTANCE ACCURACY FOR THIS TYPE OF SURVEY IS L FOOT IN 7,500 •.p.......................... :: :•':: ..�•:. FEET.THE ACCURACY OBTAINED BY MEASUREMENT AND CALCULATIONS OF CLOSED GEOMETRIC FIGURES WAS FOUND TO EXCEED THIS REQUIREMENT. fLV F.I.P. Z -I THERE ARE NO VIABLE,ABOVE GROUND ENCROACHMENTS(a)BY THE IMPROVEMENTS OF THE SUEJECT PROPERTY UPON ADJOINING PROPERTIES,STREETS OR ALLEYS,OR(b)BY THE IMPROVEMENTS OF THE (� ••• R-=25.00' •- '.: 1/2-0 = < ADJOINING PROPERTIES,STREETS OR ALLEYS UPON THE SUBJECT PROPERTY OTHER THAN THOSE SHOWN ON THIS BOUNDARY SURVEY. N Planter �6. :: (no cap) � D A=39.27' �!,1 r M THERE ARE NO VISIBLE EASEMENTS OR RIGHT-OF-WAY OF WHICH THE UNDERSIGNED HAS BEEN ADVISED OTHER THAN THOSE SHOWN ON THIS SURVEY. A-96-00-00 EAST—WEST 56.30' M&R ':5# Std@ arc �I CD THE MAP OF SURVEY IS INTENDED TO BE DISPLAYED AT THE SHOWN GRAPHIC SCALE IN ENGLISH UNITS OF MEASUREMENT.IN SOME CASES GRAPHIC REPRESENTATION HAVE BEEN DWMRATED TO MORE f. j •'.'• > O CLEARLY ILLUSTRATE A PARTICULAR AREA WHERE DIMENSIONS SHALL HAVE PREFERENCE OVER GRAPHIC LOCATION. -71 :,,• 15' P/W O .7 j THE ELEVATIONS(IF ANY)OF WELL-IDENTIFIED FEATURES AS DEPICTED ON THIS SURVEY AND MAP WERE MEASURED TO AN ESTIMATED VERTICAL POSITIONAL ACCURACY OF VA FOOT FOR NATURAL GROUND O Z (- .� SURFACES AND yip FOOT FOR HARDSCAPE SURFACES,INCLUDING PAVEMENT,CURBS,SIDEWALKS AND OTHER MANMADE STRUCTURES. fed :$ : : C m '•15.•'•' •'17.0'" THE SURVEYOR MAKES No REPRESENTATION AS TO OwNERSrBP,P055ESSION OR OOCUPATION OF THE SUBJECT PROPERTY BY ANY ENTITY OR INDIVIDUAL • •: ....................... ANY FEMA FLOOD ZONE INFORMATION PROVIDED ON THIS SURVEY IS FOR INFORMATIONAL PURPOSE ONLY AND IT WAS OBTAINED AT WW W.FE MAODM. ..:. ••:..•:•:.:..•. :•. :'.:..::..... •f i .2 C & Gutter IF YOU ARE READING THIS BOUNDARY SURVEY IN AN ELECTRONIC FORMAT,THE INFORMATION CONTAINED ON THIS DOCUMENT"IS ONLY VALID IF THIS DOCUMENT IS ELECTRONICALLY SIGNED AS SPECIFIED �. IN CHAPTER 51-17.062 OF THE FLORIDA ADMINISTRATIVE THE CODE.IF THIS DOCUMENT IS IN PAPER FORMAT,IT IS NOT VALID WITHOUT THE SIGNATURE AND ORIGINAL RAISED SEAL OF THE PROFESSIONAL .. :........................ ..................... . .:�:::::............. rut ^/�-M� .�•• �/ � ^✓ ` LAND SURVEYOR AND MAPPER OF RECORD. . ........... . .. ............. ............ .....::::: .:: ::::::::::::: :i� . Asphalt Pavement ' �• ::�0. :. ::::::::...' ............................... ................. ENCROACHMENTS AND OTHER POINTS OF INTEREST: ;;;;; , ..... 80 TOTAL CERTIFIED TO.• i( .. :• ,tr -THERE ARE NO VISIBLE ENCROACHMENT OF THE SUBJECT'PROPERTY �•,y.. ;, PU BUC R W MON McERLEAN -THE SUBJECT PROPERTY IS WITHIN A FLOOD ZONE X(SEE NOTE 1) / -THERE ARE NOT PLATTED UTIL EASEMENT ON THE SUBJECT PROPERTY I HEREBY CERTIFY THAT THE ATTACHED SKETCH OF'BOUNDARY SURVEY'AND THE SURVEY MAP REEILTiNO THEIWRO M OF THE ABOVE DEAD P'RMERTY L4 A N.W. 5th STREET ET TRUE AND col:RECT CITATION OF A FIELD SURVEY MADE UNDER MY DURECiI°N AND MEEiS THE INTENT OF THE APPLICABLE PROVOONS OF THE°MIMMUM .............. ......................... ............... .......................... .............. ......................... „ ............... ARDS FOR LAND SURVEYING IN THE STATE OF FLORIDAr PURSUANT TO RULE 8J-17 OF THE FLORIDA ADMNSTRATIVE ODDS AND ITS.Ii/PL.E]mVl® LANK CHAPTER 472.027, OF THE FLORIDA STATUTES. ................................................... LEGAL DESCRIPTION:IPTION: SITE ADDRESS: 95 N.W. 95th AVE., MIAMI SHORES, FL. 33150 American Services Of Miami, Corp. # LOT 16 AND THE WEST 1/2 OF LOT 17,BLOCK 131,OF MIAMI SHORES JOB NUMBER: 13-819 Consulting Engineers . Planners . Surveyors SECTION No.6 ACCORDING TO THE PLAT THEREOF AS RECORDED IN PLAT DATE OF SURVEY JUNE 12. 2013 0 Ed?Ptno a BOOK 10 AT PAGE 39,OF THE PUBLIC RECORDS OF MIAMI-DADE COUNTY, RASED DATE DECEMBER 5. 2013/ JANUARY 16. 2015449 9370 S.W. 72nd Street, Suite A-102 P 0. VEYORR FLORIDA Miami, Florida, 33173 FOLIO NUMBER: 11-3101-033-0540 LB 6683 PH: (305) 598-5101 FAX (305) 598-8627IDNoY 771 suR A ASOMIAMLCOM . NOT VALID WITHOUT THE SIGNATURE AND RAISED SEAL OF A FLORIDA LICENSED SURVEYOR AND MAPPER DATE UM NOT VALID WITHOUT THE SIGNATURE AND RAISED SEAL OF A FLORIDA LICENSED SURVEYOR AND MAPPER ' Miami Shores VillageTIE,0,- Building Department OC--2 8 2614 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 2010 BUILDING Master Permit No — `22203 PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL F-]PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP p,-� CONTRACTOR DRAWINGS JOB ADDRESS: clS NyJ q ST t4 1 I�iG 1 City: Miami Shores County: Miami Dade Zip: S"D Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:���yy OWNER: Name(Fee Simple Titleholder): �) AA A TAT)rJ0 Phone#:-1%b d-!Ul�,46 Address: 9's- rqW qU4 STJZ-1� y, City: �1/`awl stw) eEs State: 'f - Zip: )-s® Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: V-�OS Pcld Inc. Phone#: -SqZ--1q00 Address: C)i45 Lj ,�(® S°t. �,jz� SLA City: -U)exel f State: V11 Zip: Qualifier Name: V Ly-e—(, Phone#: State Certification or Registration#: 1 45(d,KOY Certificate of Competency#: DESIGNER:Architect/Engineer: 2 j'(, &, 4 Iu 0 Phone#: 3 Address: �C,y� u) 9A)oji City: Wil, 'D,m_i' Stater /. Zip: Value of Work for this Permit:$ I'M-2. f� Square/Linear Footage of Work: CI'L,-44. Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Description of Work: Oe'o 777 x Specify color of color thru tile: Submittal Fee$ 0 l J Permit Fee$ CCF$ ey CO/CC$ Scanning Fee$ Radon Fee$ - �� DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 0...�� (Revised02/24/2014) 4 � 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 9 94 OWNER or AGENT CONTRACTOR The foregoing instrumei was acknowledged before me this The foregoing instrument was acknowledged before me this day( 20 14� ,by _ �day of ( oxr ,20 B�t ,by �ew"'� ruwho is personally known toJa 2L,< < —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: Sign: Sign: Print: Print: a MERCEDES 8.ESPOM Seal: ' ; MY COMMISSION#FF 120M Seal: EXPIRES:June 16,2018 ;,Pi, MARC03 A MARTINEZ Bonded nw Undem m r , ;.r r MY COMMISSION#FF 008989 •, EXPIRES:May 15,2017 C e1 kkJf APPROVED BY Plans Examiner d Zoning Structural Review Clerk (Revised02/24/2014) RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARDr CPC 1456804 , The COMMERCIAL POOL/SPA CONTRACTOR : f Named below IS CERTIFIED ' Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2616 1° NMI Z� VARELA, MIRTHA ROSMEL POOLS INC ITE 8045 NW 36 STREET,SU 540 MIAMI FL 33166 ISSUED: 09/02/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1409020001833 I 00asos Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL -,DO NOT PAY 6333306 111-L B Tj BUSINESS NAME/LOCATION RECEIPT NO_ EXPIRES ROSMEL POOLS INC RENEWAL ' SEPTEMBER 30,;2015 8045 NW 36 ST 540 6600.176 Must bq displayed,at place of business _DORAL FL X316 Pursuant to County Cuda Chapter BA—Art.B'&10 OWNER SEC.TYPE OF BUSINESS ROSMEL POOLS INC 196 SPECIALTY PLUMBING CONTRACTOR PAYMENT R Worker(s)kBf(9} i CPCI$5680$ 8Y TAX COLLECTOR $45.00 07/29/2014 CHECK21-14-037755 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license. permit or a certification of the holder's qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 6a-276. For more information,visit m88w;mlamidade goyAaxcolloclor moo/t4I llDlq 11:jn JU02261525 CITING PAGE 05/23 CERTIFICATE OF LIABILITY INSURANCE `' ""` i., TwsISSU79D XSA JIT80R Aamrcr coxv ONLY AND SM NO RIQMTS THE C 0 XZ" MAAre= ST +60VXWN' 213 ALTER THE COVERA©E CORM NOT O � FZ 33145 -22$-1?33 INSURERS AFFOWM COVERAW Roomm POOL", 1'NQ. COZONT ZKOMWX CGRP Y .. INSIrRSR s: f.)t 8045 Xw 36 8'T., 9== $40 �UR6RC: FL 33166 odum o: u�eldl& 4OR :THE,PDL OF I NCB LWER BELOW I4AVC BEEN MUED TO THE IN.SUAEO NAA M ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHST t O 4i@FT.TERN OR CONDi4"M OF ANY CONTRACT OR OTHER OOCUMETNY WITH RESPECT TO WWJ4 THO CERTIFICATE MAY BE IMEWOR THE INSURANCE AFFORDED BY THE POUCIE$OESCRISED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSKM AND CONDITIONS OF S A4GREtiATE LIMIT$SHOWN MAY HAVE SN RBDUCEO BY PAID CLAIMS. � EE IYPi W RRIIRIu+Qt PO{ICY F�NY16� Lam »' LA2wr ccoAmucc $1,000,0 4 3 u"LI Y oAMA.4itMra�sn) t 104 00' "• eLAreew�os acxuR L�sooxn roa.o.�+l s 5 0 OZ402623P 06/20!14 06/?0/Z? fBRSONAL$.AWS RM si aa0 VO OQLEJNLA�tE(1pTi :1 40Q o TEUWTAP e9PE7e PwowcTs• �o.Aoo s1 000,00 Po►sw Loc UABUTY s ALL AUM t 2CHWAMAUM Iojo "MAU= saosrwunrr TOM t t AQ01 UANUTY AUPO ONLY•EAACCROM $ ANr AUTO OTHIM THAN to AM i ALTO CKY: ,GO $ • . VADLny LCHOCCURRENCE t OCCUA 0 cwls wm AOORlOATE S • ' .F s REllJYi4t► $ t . dr�oiecwoavo+a+►noeuaro .f' tu�lrY EL EACH ACCOM s e L RmUsz•EA EIEI'L "F s c.L o •P'CLlDY wa► s ADOW 4TH SY PAW 311 C'OAVXACTOR T E. 'A TC ADpTN1MAL Llrr= CANC19LLATWN $M*UW ANY Of TM AWN OWED POLtCM OQ OAN6LkW WOR[TM!E>waAt* e M1= 8'AOR.84' VI&M=.-B=WZI7Q DPT DAMN TMLst W TW.rosWio 00AN WU WDUVO TO eup, �"vs 10000 RR 2HD AVZ mn=TO TA CCTe mxm mma TO"a LETT,WN PAs m To to so swAU • mum 050"8, FL 33138 w. s Nb GOUCAWM w NY WANUTY OP AKM UKW THE 0001k ft AMUM 011 e: 8•Ar$305-7d8-8572 ` a i " �'"(YAM GiWIHU/4VilfVl{illtVii in, JEFF ATWATER •+keg""s 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: 3/21/2014 EXPIRATION DATE: 3/20/2016 PERSON: VARELA MIRTHA FEIN: 203013092 BUSINESS NAME AND ADDRESS: ROSMEL P01"3LS INC ROS^-"EL Piv OLS&OUTDOOR 8045 NW 36TH ST STE 540 DORAL FL 33166 SCOPES OF C!!SINESS OR TRADE: LICEf'SED f")01- CONT RAC T'J!--, .40.05(14),F.S..an officer of a corporation who elects exemption from this chapter by tiling a certificate of election under this section may not recnvpc txererh 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 tiadelisted 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:,eels 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 cn W; 7ertificate to meet the requirements of this section. DFS-F2-D',N'C-2.'.CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?($50)413-1609 .,,. nmi" Miami shores V Building Department A 10050 N.E.2nd Avenue �OR1D Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if- 1. f: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 ( � Contrac r Print Name: � Print Name:& �4 Signature: Signature: Pe`9 State of Florida) State of Florida) County of Miami-Dade) County of Miami-Dade) Sworn to and subscribed before me this 2 5 Sworn to and subscribed before me this day of day of 20F - BJL q4 r oyek s a MAR N B .. ,P;y,� Wiff roez By '" 1h Al y _ #FF 0(18989 ry Pub' nderite ndemurs (SE (SEAL) 'R�" Type of Identffication producbd Type of Identificationproduced