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CC-15-3093 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-249719 PermitNumber: CC-12-15-3093 Scheduled Inspection Date: December 22,2015 Permit Type: Commercial Construction Inspector: Rodriguez,Jorge Inspection Type: Final Owner: , Work Classification: Alteration Job Address:10275 NE 2 Avenue Miami Shores, FL 33138-2343 Phone Number (305)753-6006 Parcel Number 1132060134900 Project: <NONE> Contractor: ALPINE ENGINEERING AND DEVELOPMENT CORP Phone: (305)699-2332 Building Department Comments SEALCOAT&STRIPING Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-249652. not ready Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid December 21,2015 For Inspections please call: (305)762-4949 Page 31 of 33 Pe -3{ 93 �S'T tMiami Shores Village Fpm t Type Cotion 10050 N.E.2nd Avenue NE It4%rkJass; a#icier ill eration Miami Shores,FL 33138-0000 PBrmitstahts.AI�I�Rt�E3C�; Phone: (305)795-2204 1� t1$ Expiration: 06/15/2016 Project Address Parcel Number Applicant 10275 NE 2 Avenue 1132060134900 Miami Shores, FL 33138-2343 Block: Lot: AGM DEVELOPMENT 1 LLC Owner Information Address Phone Cell AGM DEVELOPMENT 1 LLC P O BOX 490915 (305)753-6006 KEY BISCAYNE FL 33149- P O BOX 490915 KEY BISCAYNE FL 33149- Contractor(s) Phone Cell Phone Valuation: $ 2,800.00 ALPINE ENGINEERING AND DEVELOI (305)699-2332 Total Sq Feet: 20000 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Window Door Attachment Date Denied: Tie Beam Type of Construction: Occupancy Load: Slab Stories: Exterior: Termite Letter Front Setback: Rear Setback: Framing Left Setback: Right Setback: Store Front Attachment Plans Submitted: Certification Status: Insulation Certification Date: Additional Info: Drywall Screw Bond Return: Classification:Commercial Window and Door Buck Scannin :3 Ceiling Grid Fill Cells Columns Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Final PE Certification CCF $1.80 Review Electrical DBPR FeeInvoice# CC-12-15-58046 Review Planning $2.25 12/18/2015 Credit Card $ 118.30 $50.00 DCA Fee $2,25 Review Building Education Surcharge $0.60 12/15/2015 Credit Card $50.00 $0.00 Review Building Permit Fee $150.00 Review Plumbing Scanning Fee $9.00 Review Structural Technology Fee $2.40 Review Mechanical Total: $168.30 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 certify that all the foregoing information is accurateAand that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-nanyj= o tract do the work stated. December 18, 2015 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 18,2015 1 Miami Shores Village l� Building Department DEC 15 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 'y: INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201q BUILDING Master Permit No. 0—e C —met PE MIT APPLICATION sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 10 2-7 Nt Z City: Miami Shores County: Miami Dade Zip: �My Folio/Parcel#: 1(-32--®f?-013- ggoo Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): AI , !,L Phone#: 305-'1.53 Address: P-6 ^ � * "l f®�(S City: State: zip:. 3� T i Tenant/Lessee Name: bw U k-L' `- ko 4 Phone#: Email: A o CONTRACTOR:Company Name:. If d'� Eq,®� t e e � 9l�/ � Phone#: jr %1 S 3-;�- Address: 1 ( 3� pp•�� tyState: Zip: I Ci l Qualifier Name: V-e4 Phone#: State Certification or Registration M �i (�-7—�)—I Certificate of Competency#: DESIGNER:Architect/Engineer: z Phone#: Address: City: State: Zip: Value of Work for this Permit:$ oo `O u Square/Linear Footage of Work: o,o o o 5-F Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: (�04b o re+ �tg�i Specify color of color thru tile: Submittal Fee$ Permit Fee$ 1 d `� CCF$ ^ 9 0 CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ n Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ ° c � (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 v`C Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 1 day of � �/Iu"�?� ,20 ( � ,by �� day of l`�c. l 20 ,by who is personally knaow�to_ ew4110 A-WIt L 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: S. Sign: J Print: �y UL MAN JIVANI print: d� `` ���6°0, U MAN JIVANI 4 ma4- 5t-1- �Seal: _ .• My Comm:Expires May 29,2016 Seal: ?' • My Comm.Expires May 29,2016 Commission#EE 203163 =; Commission#EE 203163 "0 g ry ' pBonded Through National Notary Assn. Bonded Through National Nota Assn. ******x��r*�e**�srrs•rrs�� f�*�*�+r*r7rs>�rrrr•��ss**�s*+r*�***�*w****r�r*rare*��rr***err**rr�r+r�r*s*.r*yrs****�*****�x**r*r APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application- Miami-Dade County Page 1 of 1 `4OF THE PROPERTY APPRAISER0, Summary Report Generated On:11/30/2015 Property Information Folio: 11-3206-013-4900 10275 NE2AVE �� Property Address: , Miami Shores,FL 33138-2343 m. � . Y Owner AGM DEVELOPMENT 1 LLC PO BOX 490915 Mailing Address A E KEY BISCAYNE,FL 33149 USA Primary Zone 0900 SGL FAMILY-1901-2100 SQ r 7144 RELIGIOUS-EXEMPT: Primary Land Use RELIGIOUS Beds I Baths I Half 0/2/0 Floors Living Units 0 � t �raic -; Z • ' , wz Actual Area Sq.Ft � � x� Living Area Sq.Ft Adjusted Area 4,833 Sq.Ft Taxable Value Information Lot Size 30,940 Sq.Ft 2015 2014 2013 Year Built 1967 County Assessment Information Exemption Value $0 $0 $590,595 Year 2015 2014 2013 Taxable Value 1 $647,252 $588,411 $0 Land Value $743,512 $403,172 $403,172 School Board Building Value $169,377 $166,070 $169,035 Exemption Value $0 $0 $591,718 XF Value $18,827 $19,169 $19,511 Taxable Value $931,716 $588,411 $0 city Market Value $931,716 $588,411 $591,718 Assessed Value $647,252 $588,411 $590,595 Exemption Value $0 $0 $590,595 Taxable Value 1 $647,252 $588,411 $0 Benefits Information Regional Benefit Type 2015 2014 2013 Exemption Value $0 $0 $590,595 Non-Homestead Assessment Taxable Value $647,252 $588,411 $0 Cap Reduction $284,464 $1,123 Religious Exemption $590,595 Sales Information Note:Not all benefits are applicable to all Taxable Values(i.e.County, Previous Price OR Book- Qualification Description School Board,City,Regional). Sale Page 03/04/2013 $517,600 28535-4902 Financial inst or"In Lieu of Short Legal Description Forclosure"stated MIAMI SHORES SEC 1 AMD PB 10-70 07/01/1998 1$380,000118198-0369 1 Sales which are qualified LOTS 10 THRU 14 BLK 36 LOT SIZE 238.000 X 130 OR 18198-0369 0798 1 The Office of the Property Appraiser is continually editing and updating the tax roll.This website may not reflect the most current information on record.The Property Appraiser and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at http://www.miamidade.govriinfo/disclaimer.asp Version: http://www.rniamidade.gov/propertysearch/ 11/30/2015 Detail by Entity Name Page 1 of 2 w Detail ntl Name Florida Limited Liability Company AGM DEVELOPMENT I, LLC Filing Information Document Number L12000036399 FEI/EIN Number APPLIED FOR Date Filed 03/14/2012 Effective Date 03/14/2012 State FL Status ACTIVE Principal Address 135 POST AVENUE #1J WESTBURY, NY 11590 Mailing Address 135 POST AVENUE #1J WESTBURY, NY 11590 Registered Agent Name&Address MURAI WALD BIONDO & MORENO, P.A. 1200 PONCE DE LEON BOULEVARD CORAL GABLES, FL 33134 Authorized Person(s) Detail Name &Address Title MGRM AGM DEVELOPMENT HOLDING, LLC 135 POST AVENUE#1J WESTBURY, NY 11590 AnnualRe orts Report Year Filed Date 2013 03/26/2013 2014 04/20/2014 2015 04/30/2015 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 12/9/2015 Detail by Entity Name Page 2 of 2 Document Images 04/30/2015--ANNUAL REPORT View image in PDF format 04/20/2014 --ANNUAL REPORT View image in PDF for 03/26/2013--ANNUAL REPORT View image in PDF for 03/1412012 -- Florida Limited Liability View image in PDF format Copyright ri(tit and Privacy:"ofrie5 Stant of Flo C1a,IJeparw,,.ne r,r ya'a http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 12/9/2015 Detail by Entity Name Page 1 of 2 s r Detail by Entity Name Florida Limited Liability Company AGM DEVELOPMENT HOLDING, LLC Filing Information Document Number L12000036009 FEI/EIN Number APPLIED FOR Date Filed 03/14/2012 Effective Date 03/14/2012 State FL Status ACTIVE Principal :address 135 POST AVENUE #1J WESTBURY, NY 11590 Mailing Address 135 POST AVENUE #1j WESTBURY, NY 11590 RqR:!stered Agent Name &Address MURAI WALD BIONDO & MORENO, P.A. 1200 PONCE DE LEON BOULEVARD CORAL GABLES, FL 33134 Authorized Person(s) Detail Name&Address Title MGRM MERCHANT, IBRAHIM 135 PCST AVENUE, #1J WESTBURY, NY 11590 AnnualReports Report Year Filed Date 2013 03/26/2013 2014 04/20/2014 2015 04/30/2015 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 12/9/2015 Detail by Entity Name Page 2 of 2 Document Images 04/30/2015--ANNUAL REPORT View image in PDF for 04/20/2014--ANNUAL REPORT View image in PDF for 03/26/2013--ANNUAL REPORT View image in PDF for 03/14,2012 -- Florida Limited Liability View image in PDF format Co vrwttt Li'n Privacy:'oo,,ws Slate of Flo,!da,Departm,,.M of Stat,,, http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 12/9/2015 RICK SCOTT,GOVERNOR .�_ _ _._._.KEN LAWSON,SECRETARY STATE OF-F-:C R4DA WPAARTMN�.�!� StMAIESS AN©PROFESSIONAL I GU!ATION 4- Trot-, ° # TY FJFCA ATi ej M31,- v; ``- ^"'" - 'e' �.. M" °� tea."� max.; �`�..�., �- d'°�,s.-�"" c J le •� .r r �o��Jam' d s •7� � �b �2 '�, �� � xj �*. ..�" a+ i".'^-n � '� ISSUED: 04/02/2015 DISPLAY AS REQUIRED BY LAW SEQ# L1504020001248 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CUC 1225216 ISSUED: 04/02/2015 CERT UNDERGROUND&EXCAV CNTR HERNANDEZ, EDUARDO ORLANDO ALPINE ENGINEERING AND DEVELOPMENT IS CERTIFIED under the provisions of Ch.489 FS. Expiration date AUG 31,2016 L1504020001248 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 7180343 �LBT 13USINESS NAME/LOCATION RECEIPT NO. EXPIRES ALPINE ENGINEERING AND RENEWAL SEPTEMBER 30, 2016 DEVELOPMENT CORP 7460702 Must be displayed at place of business 8921 SW 140 ST Pursuant to County Code MIAMI, FL 33176 Chapter 8A-Art.9&10 OWNER SEC. T'E'E OF BUSINESS ALPINE ENGINEERING& PAYMENT RECEIVED 19 GENERAL I�L;iir�ING BY TAX COLLECTOR DEVELOPMENT CORP �"' NRACTOR Cin Fnl IARnn HFRNANnF7 75.00 09/15/2015 Worker(s) 1 C 0237-15-000603 This Local Business Tax Receipt only ca.-Am— paTmeg3t,};I; Local Business Tax.The Receipt is not a license, permit,or a certification of the holder's w bnnsipcss.Holder must comply with any govermnmatsl or nongovernmental regulatory laws and requlrems which apple to the business. The RECEIPT NO.above roast be displayed on all commercial vehicles-Miami-Dade Code Sac Ba-278 HIAMN ADM For more inkwmation,visit wdvrv.oniamidade gav/taxcagectar Scanned by CamScanner TE ASR CERTIFICATE OF LIABILITY INSURANCE DA y11/2D0D15 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). PRODUCERM ; Ail Ravelo South Florida Assurance LLC PHoroe (754)400-7109 FAx AIC No 62006 NW 167th Street a MAa ail nmravel mail.com INSURER(S)AFFORDING COVERAGE NAIC d Miami FL 33014 INSURERA: UNITED SPECIALTY INS CO 12537 INSURED INSURER B Alpine Engineering and Development Corp. INSURER C: 8921 SW 140th St. -INSURER D, INSURER E: Miami FL 33176 INSURERF: 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 DRESS 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, LTR TYPE OF INSURANCE POLICY NUMBER POLICY F MIDD P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS MADE a OCCURPREMISES Eaoccurrence) $ 100,000 MED EXP(Any one person) S 5,000 A X 864103 12/02/2015 12/02/2016 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY[ ]JECT F7 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY BI D SINGLLIM $ Ea a�idem ANY AUTO BODILY INJURY(Per person)ALL $ OWNED AUTOS BODILY INJURY(Per accident) $ RTY H $ HIRED AUTOS AUTOS NON-OWNED (PaPROt accident) AGE $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAJMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER H- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L;DISEASE-EA EMPLOYE $ IfYes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be alt chad If more space Is required) Certified Underground Utility and Excavation Contractor-CUC1225216 Certified General Contractor- CGC1516217 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Village of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Miami Shores,FL 33138 AUTHORIZED REPRESEN E Allyn Ravelo O"Ae C WORAVION.All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD we 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: 3/4/2015 EXPIRATION DATE: 3/3/2017 PERSON: HERNANDEZ EDUARDO 0 FEIN: 471286925 BUSINESS NAME AND ADDRESS: ALPINE ENGINEERING AND DEVELOP,ENT CORP 8921 SW 140 ST PALMETTO BAY FL 33176 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONCRETE WORK CARPENTRY CONTRACTOR INCIDENTAL TO TH INSTALLATION OF CA 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 440.06(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 H,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 QUESTIONS?(850)413-1609 3, G v" Miamishores Village Building Department �LpR{pA 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 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-rime 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 and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of ,20 Vs . By X1 ` who is personally known to me or has produced as identification. A Notary: SULEMAN JIVANI yp Notary Public-State of Florida SEAL: ' My Comm.Expires May 29,2016 5•. Commission#EE 203163 %o.F°`�` Bonded Through National Notary Assn. Alpine Engineering Date: December 11, 2015 State of Notary Public State or Florida Michael F Areces My Canmission FF 062794 County of ora Expires 10/1412017 Before me this day personally appeared Eduardo Hernandez who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 10275 N E 2nd Ave. Sworn to (or affirmed) and subscribed before me this io"ilday of Disc iefv�—t .20(�' by Personally know Or Produced I.D. Type of I.D. Produced