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PL-14-1553 d J, Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-242305 Permit Number: PL-7-14-1553 Scheduled Inspection Date: September 01, 2015 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: RIVERO, MANUEL Work Classification: Addition/Alteration Job Address:1286 NE 95 Street Miami Shores, FL 33138- Phone Number (305)762-7851 Parcel Number 1132060144050 Project: <NONE> Contractor: UNIVERSAL PLUMBING CORP Phone: (305)887-3131 Building Department Comments KITCHEN RENOVATION Infractio Passed comments INSPECTOR COMMENTS False nspector Comments Passed CREATED AS REINSPECTION FOR INSP-242013. gas stove shall be E�/ connected and a drop test shall be provided for final Failed Correction Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. August 31,2015 For Inspections please call: (305)762-4949 Page 28 of 37 Miami Shores Village cI� I� Building Department �Y JUL 17 2014 • 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fax: (305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 FBC 20 le BUILDING Permit No. ?/ �Y PERMIT APPLICATION Master Permit No. 0� 1�cy Permit Type: PLUMBING JOB ADDRESS: (O ICS �i City: Miami Shores County: Miami Dade Zi f2 Y Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: ° OWNER:Name(Fee Simple Titleholder): � Phone#: Address: iZ l��i. /�� City: `� ��4l� `��i'/ State: TV Zip: Tenant/Les ee Narne: Phone#: •Email: I •,p CONTRACTOR:Company Name:_6 1 (��iG Z�✓ �U�fiLbi`�'!� �t t(� Phone#: Addres • City: - ��di G� State: Zip: ��� Qualifier Name: Phone#:T� �/ State Certification or Registration#��/�V.Z hflU f Certificate of Competency#- Contact Phone# ' mail A ess: DESIGNER: chitect/Bngineer: one#: % 05 Value of Work for this Permit: Square/Linear Footage of Work: Type of Work: OAddress Iteration ONew a epi l� tion�� Descriu n of Work: `4 -�(Cm�L.' ,._ Ott r x��xxu�xxx�®®u+x��x�x�:xx�x�����x������� 5 Submittal Fee$ 'W Permit Fee$ Z2 CCF$ CO/CC$3. Scanning Fee$ � �� Radon Fee$ ��` � DBPR$� Bond$ *Notary$ ttE3 -CQ Training/Education Fee$0- 4Q) Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ 9 CIP Q _ 10 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 a 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 ELECTRICAL WORK,PLUMBING,SIGNS, WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 subjec o tachmen. lso, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspectio hic occurs sev n (7),days after the building permit is issued. In the absence of such posted notice, the inspection will not b a nd a rei ec ' n fee will be charged. Signature Signature Owner=acknowle ent nn Contractor The foregoing instrument wasdged before me this/ The oregom- instrument was acknowledged before me this day of .20) ,by day of (/�6 ,20 ,by who is sonally known to me r who has produced who is personally known to me or who has produced s i en ca o ho did take an oath. as identif, d who did take an oath. .4, NOTARY PUBLIC: NOTARY P C: r '�, LOURDES MAR!IN My COMMISSION al FPQQ@1@7 '`�O°",'�;�� EXPIRES April 19,2017 Sign: gn: a "ee-oras GPM Prin. �; Joanna M e ciano t: � y es My Co s1 irr8g of o�/1�2o1a y Commission Expires: APPROVED BY `f Plans Examiner Zoning Structural Review Clerk (Revised3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Page 1 of 1 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certi ies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 5/9/2013 EXPIRATION DATE: 5/9/2015 PERSON: GARCIA MICHEL FEIN: 264039076 BUSINESS NAME AND ADDRESS: UNIVERSAL PLUMBING CORP 141 E 60 ST HIALEAH FL 33013 SCOPES OF BUSINESS OR TRADE: PLUMBING NOC AND DRIVERS Pdrsvard to Chaptor 4x0.05(141.F:n•urnWer��r[haC�r Pursoani to Chapter°OS(72�F.S�Certlliwtm of eledio°nto�beteezempaLl.�aPPtY��Y��ihe s�Pe not recover beneflla or ComPenneM _ of the btrehtees or Vada fisted an Ne mtiee of electlon to be exempt Pursuant to Chapter x411.05(13).F.S.Notices of election to ba exempt and wdi8cetes ceeNficete no longer meets b raQ�irkemen�opt tn�naealon forVtsaeence of a�eNO°ela.The depathrtmentNs shetl revvkeacerttdeafe etpaM lhre for tature of Noce or person trertted on the ceNifcate to meet Ne requhementa of this sec0on. DFS-F2-DWC•252 CERTIFICATE OF ELECTION TO 8E EXEMPT REVISED 07-12 QUESTIONS?(650)413-1609 • 5/�or)n11 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CMC1250146 a, The MECHANICAL CONTRACTOR Named below IS CERTIFIED WE Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 Nit 0 GARCIA, MICHEL UNIVERSAL PLUMBING, CORP 141 E 60 ST HIALEAH FL 33013 0 � ISSUED: 08/31/2014 DISPLAY AS REQUIRED BY LAW SEO# L1408310005801 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD `r CFC14284214 a The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 GARCIA, MICHEL 0 0 UNIVERSAL PLUMBING, CORP 141 E 60 ST ; HIALEAH FL 33013 ISSUED: 08/31/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408310003913 2 4 Miami Shores Village oC Building Department g p JUL 17 2014 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 BY:!a_�_ �� INSPECTION'S PHONE NUMBER:(305)762.4949 61 FBC 2016 BUILDING Permit No. PERMIT APPLICATION Master Permit No. Permit Type: BUILDING ROOFING JOB ADDRESS: 7— �& V 6? iS- City: Miami Shores 1 County: Miami Dade Zip: ^� Folio/Parcel#: 0 Is the Building Historically Designated:Yes NO Flood Zone: If OWNER:Nameee Simple Titleholder): � `PU " ` f� ' � P ) Phone#: Address: �• �- 11 City: L i o t-\\ � D � State: 4l D Kg. �q Tenantdxssee Name: Phone#: Email: ' CONTRACTOR:Company Name. � �� �� I Phone#: Address: qe, o® E City: Lot State: Zin:: Qualifier Name: �y r Phone# State Certification or Registration#: 161 ? Certificate of competency#: Contact Phone#: Email Address: y� DESIGNER:Architect/Engineer: �C xPhone#:_ o—cc ° Value of Work for this Permit:$ 1 01®m m-- Square/Linear Footage of Work: Type of Work: OAddition Iteration ONew ORepair/Repl De Oli/Ition Des c 'ption of Work: A Color thru tile: Submittal Fee$-!EEO ' Permit Fee$ 1 h 4 CCF$s 00 CO/CC$ Scanning Fee 0 2,,0D Radon Fee$ D-1,C,30 DBPR$ 20 ED Bond' Notary$_ Training/Education Fee$ e Technology Fee$ `) Double Fee$ Structural Review$ 1 TOTAL FEE NOW DUE$ ` 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 6 secured for ELECTRICAL WORK,PLUMBING,SIGNS, WELLS,POOLS,FURNACES,BOILERS,HEATERS,TANKS and 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 t be posted at the job site for the fir t inspection which o s ven (7) days after the building permit is issued. I the abs ce of such posted notice, the inspectio will not be app d a einspection fee will be charged. Signat Signature Own r or Agent Contractor The fore o' g instrument was ac owledged befo me this The foregoing instrument was acknowledged before me this-4 day of ,20 by 4 day of 2011,by_"C-I L-• fire,� , j h s p�on y o�wpn to me or who has produced who,is personally ,Io/ g,r h c ., 'y "`A's i fication and who did take an oath. �Y 1*r4 UV Fkate an� u is � �a - at �ii a NOTARY PUBLIC: NOTARY My mm. xpires May 2015 =" Co s Ion#EE 25 Bonded h A tary Assn. Sign:XUtIA, Sign: Print: Print: I;-A My Commission Exp' s: *� * WMIAIISSIEMM �# My Commission Expires: �„� ��, �-0 l& EXPIRES:FeM"%,2017 �f4 'OFP�OQ��v BonWThruBWONftySakes �ksisikds�asiaekskik�H=+kgasRHa�a�k�k�rk��IasksIada�a�Ha=ksksksk �kI=kpik sksksIa=kda�k�ktk=ksk�skskslssk=k�k���k=kskskHagasksIasIa:k�Iaak�k�k�k�k�ksksk�kHasksIs�sksk�ksIaskXaek:k�a�k�k=k��H�k+k�k:ksksksk��8aeksI:sk APPROVED BY Plans Examiner Zoning A vi-�11 4 I Structural Review Clerk (Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) DEPARTMENT OF PLANNING ARID ZONING4 •a CERT NO: 2011080442 MSEC. 4 TWP: 54 RNG.. 40 PROCESS NO: U2011014560 �NFOLIO: 3040040540001 ZONE: RU FEE: $23. 78 ' MAILING ADDRESS/CONTACT PERSON: CORP NAME/D/B/A AND ADDRESS: p�f VERSATILE STRUCTURE INC VERSATILE STRUCTURE INC ' k: 20 NW 87 AVE VERSATILE STRUCTURE INC MIAMI, FL 33172— xINy W 87 AVE ; BUSINESS USE: HOME OFF n „ €r r USE SPECIFICS: HOME OFF 1 .., CONDITIONS: NO COMM VEi- 'g MFRS i �' s, � � g LEGAL DESCRIPTION: PARK' CONDO '1%,, � FONT LEAD � Kfl 5 r flDATE OF CU ISSUANCE: 10/1 13 WRENEWOf � THIS CERTIFICATE M U S ' B E -,-,p O S � REMISES. -THIS CERTIFICATE OF T I hiE AS STATED BELOW PROVIDED THERE BUSINESS NAME OR OWNE RSH I P. ALSO, THERE ,. NS OR ADDITIONS TO THE APPROVED USE. ALL CH z f RE ISSUANCE OF A INEW CERTIFICATE OF USE. '' w THIS CERTIFICATE EXPIRE$$ THIS CERTIFICATE OF USE DOES r3 LICANT FROM COMPLIANCE WITH ANY FEDERAL, STATE, OR LOCAL3OU ARE ALSO REQUIRED TQ k3, ALLOW ZONING INSPECTIONS AT ANY RE TIME BY REPRESENTATIVES OF3 THE DEPARTMENT. FOR MORE INFORMATION, PLEASE CONTACT THE ZONING PERMIT 3 SECTION AT (788) 315-2888. IN ADDITION TO THE ZONING PERMIT SECTION, APPLICANT MUST ALSO CONTACT THE BUILDING DEPARTMENT AT (788) 315-2100 ; FOR OCCUPANCY REQUIREMENTS AND LOCAL BUSINESS TAX RECEIPT AT , (305) 270-4949. k 10/15/2013 13: 10 YDENIS 281310150031 TCPM937C CENTRAL 23. 78 � x RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CGC151 m The GENERAL CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,20016 PEREZ, JOEL L VERSATILE STRUCTURE;tNC,..n` 20 NW 87 AVE#A21,8 SF , MIAMI >=L 381'7"2' - ISSUED: 05/07/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1405070000979 Local Business Tax Receipt Miami—Dade County, State of Florida -7MS S NOTA BLL-00 NOT PAY 6801980 LBT BLUIMM NAAMAOCAMM MMEtPT Am. EXPIRES VownLE*ST CCI MINC RENEWAL 20M11►87AVEA218 7075MSEPTEMBER 30, 2014 MIAMI.R. 33172 Must be displayed at place of business Pursuant to County Code Chapter 6A-Art.9&10 OF BU GS V�1.ESRJaURE1NC �.TYPE GENERALBIJUDING PAYANENT RECEIVED CD M BY TAX COLLEECrOR WOWS) 1 CGC1518777 82 50 1 W 1:12013 02214 4-ON249 This LOW®akess Tau Reseipt edy ceaf w palwat of the Lecal Ovdam Tau.The RuWpt b fret a Rcease. perslt, of a cedWeadva of the kddaig q§awCad@M to de baiuss.noun tam Cespff wiY a"yevetaseatal or aaysv*nmteulal teplat"lamesaed re dMusa e vAkh apply ft go ice. The REWT H&sieve test be dbphq"on A Cesser9iat uNdes-Mad-Dade Cede See 6&416. Fir sew irfonaaties.vi�t I ' MU1MFDiAD MIAMI-DADE COUNTY -STATE OF FLORIDA N/A October 08,2014 LOCAL BUSINESS TAX RENEWAL 6801980 2014 -2015 APPLICATION RECEIPT:7075658 STATE#CGC1518777 DBA/BUSINESS NAME: BUS.COMMENCEMENT DATE:04/01/2011 VERSATILE STRUCTURE INC SEC TYPE OF BUSINESS BUSINESS LOCATION: BLDG1 GENERAL BUILDING CONTRACTOR 20 NW 87 AVE A218 1 MIAMI,FL 33172 OWNERICORP. APPLICATION DETAILS VERSATILE STRUCTURE INC FEE AMOUNT PHONE# 305-970-4777 Receipt Fee 30.00 UMSA Fee 30.00 20 NW 87 AVE#A218 Beacon Council Fee 15.00 MIAMI,FL 33172 Bingo Permit Fee 0.00 Nightclub Permit Fee 0.00 Multi-Municipal Contractor Fee 0.00 Restricted Contractor Fee 0.00 Library Fee 0.00 Transfer Fee 0.00 NAICS CODE: 2389 Doing Business without a License Penalty 0.00 Late Penalty 0.00 Collection Cost 0.00 NSF Fee 0.00 Prior Years Due 0.00 Amount Recently Paid - 75.00 TOTAL AMOUNT DUE: 0.00 If no longer in business,please notify us in writing. To pay online go to www.miamidade.gov/taxcollector Review and correct the information shown on this application. To pay by mail, make check payable to: Miami-Dade County Tax Collector A 25%penalty will be assessed to anyone found operating Business Tax without a paid local business tax, in addition to any other 200 NW 2nd Avenue penalty provided by law or ordinance(Sec 8A-176(2)). Miami FL 33128 To pay in person go to: A Certificate of Use and/or City Business Tax 200 NW 2nd Avenue Receipt may also be required. (305)270.4949,fax(305)372-6368 A service fee of not less than$25.00 up to a minimum of 5% will be charged for all returned checks. t RETAIN FOR YOUR RECORDS t ................................................................................................................................................................................................................................................................................................................. MIAMI-DADE COUNTY- DETACH HERE AND RETURN THIS PORTION WITH YOUR PAYMENT + N/A October 08,2014 STATE OF FLORIDA LOCAL BUSINESS TAX RENEWAL RECEIPT' 2014 -2015 APPLICATION II I II I IIIIII VIII Illll�lall IDII C5658 G 6801980 II��I I I I U I II II II� I I u' lul lul STATE ##CGC1518777 BUSINESS LOCATION: 20 NW 87 AVE A218 MIAMI,FL 33172 BUS.COMMENCEMENT DATE:04/01/2011 SEC TYPE OF BUSINESS OWNER/CORP. BLDG1 GENERAL BUILDING CONTRACTOR VERSATILE STRUCTURE INC 1 APPLICATION IS HEREBY MADE FOR A LOCAL BUSINESS TAX RECEIPT OR PERMIT FOR THE BUSINESS PROFESSION OR OCCUPATION DESCRIBED HEREON.I HAVE BEEN INFORMED OF ALL ZONING RESTRICTIONS IMPOSED ON THIS RECEIPT. 1 SWEAR THAT THE INFORMATION IS TRUE AND CORRECT. VERSATILE STRUCTURE INC JOEL L PEREZ PRIES AVEASIGNATURE REQUIRED SEE INSTRUCTIONS ABOVE 20 NW 87 #A218 MIAMI,FL E Please pay only one amount The amounts due after Sept 30th Include penalties per FS 205.053. ffReceived By Oct 31,2014 Nov 30,2014 Dec 31,2014 Jan 31,2015 Please Pay $0.00 $0.00 $0.00 $0.00 7000000000000000000000007075658201500000007500000000000005 CERTIFICATE F DATE(MM/DD/YYYY) ® LIABILITY INSURANCE os/23/14 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: K 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 Ileu of such endorsement(s). PRODUCER CONTNAME ACT MARTA M ALONSO Florida Bankers Insurance PHONE (305)266-6493 FAX 2 2- 305 No: 0679 ) 6 7278 SW 8 Street L marts@fioridabankersinsurance.com Miami,FL 33144 INSURERS AFFORDING COVERAGE NAIC d Phone (305)266-6493 Fax (305)262-0679 INSURER A: FEDERATED NATIONAL INSURED INSURER B: VERSATILE STRUCTURE INC INSURER C: 20 NW 87 AVE STE.A-218 INSURER 0: MIAMI,FL 33172 (305)970-4777 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 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILNSTRR TYPE OF INSURANCE ADD U yr4p POLICY NUMBER POLICY EFF MMMPOLICY/EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 © COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100,000.00 PREMISE Ea occurrence) $ A ❑ ❑ CLAIMS-MADE © OCCUR N GL-0504011336-00 10!1912013 10/19/2014 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 © POLICY ❑ PRO ❑ LOC $ AUTOMOBILE LIABILITY COaxid% tSINGLE LIMIT ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AUTOWNED ❑ AUULED TOSBODILY INJURY(Per accident) $ ❑ HIRED AUTOS ❑ AUTOS P(iOPERTY DAMAGE $ rar accident ❑ p $ ❑ UMBRELLA LIAB ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ El DED El RETENTION $ WORKERS COMPENSATION W C STATU OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) ❑ E.L DISEASE-EA EMPLOYE $ If yyes describe under DESGtRIPTION OF OPERATIONS below E,L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) CGC 1518777 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,FLORIDA 33138 117188.bmp @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF 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: 217/2014 EXPIRATION DATE: 2/7/2016 PERSON: PEREZ JOEL FEIN: 260287062 BUSINESS NAME AND ADDRESS: VERSATILE STRUCTURE INC 20 NW 87 AVE#A218 MIAMI FL 33172 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR-PROJECT CONTRACTOR MANAGER,CO Pursuant to Chapter 440.0.5(14),F.S.,an officer er of a corporation who elects exempfion from this chapter by filing a cervicale 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 Hated 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 fie.The deparhnent shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(80413-1608 O a A soon Miami shoresVillage wilding Department �ORiDA 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-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 iniuries 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 C retractor t Name: \d Print Name: Ff, �- Si oY gnature:% ` * * W MWISSION f EE EXPIRES:Febmwq 15,2017 S orida) 01.0110 kM7h8WgdNokry$vvWate of Floriae2 County of Miami-Dade) / County of Miami-Dade} Swo bscri ed before s [ Sworn to an su cribed before me this o ,20 day of ,20 . By a�CP�Y P (SEAL) i�? a° Nor lic-State orida s a 1 Type of Identffication oduced ° ,N, frhdH °'oP,;� ° Bonded Through National Notary ssn. 0Was STATE OF FLORIDA DEP OF BUSINESS PROFESSIONAL RETI®N HOARD OF ARCHITECTURE & INTERIOR DESIGN 1940 NORTH NONROE STREET (850) 487-1395 TALLAHASSEE FL 32399-0783 PYLE, ARTHUR G 1016 NE 114TH ST MAKI ISL 331616734 �r!gm [ With this[[cartes you one of the nearly one mi#r t STATE OF ? ? Z ridians ficensed by the DOPartITISM Of Business and Professional RegulaVon. MWAMEM OF SWINE= Am Our Professionals and businesses range from architects to yacht brokers,from PROFESSI , L REGMATION boxers to barbeque restaurants,and they keep Florida's economy Wrong. `< j Every day we worts to improve the�y we� in order to serve you AR0007174 120258130 ftmration about our log onto www.myfloddelicense.com.co . r °W There you can find more Information about our divisions an the regulations that ME, impact you, to and team more about the is initiatives. Our mission at the Department is:License Efficiently,Regulate Fairly.We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida,and congratulations on your now license[ I zs L1CM88D pravasl ms o: ds.481 FS. Nupisatiw date, FZB 29, 2015 L12123101090 ---.-------_ DETACH HERE 0 STATE OF FLORIDA D$P�AR H F P1 ' D I TIO SE L3.2123101090CRUSE p R 01-15 .213ILaOl2A258I30 AR004717 ,-he ARCHITECT beow Iffi LICENSED aider the provi®ims of Cha ter'. xpiratioaa date. FEB 28, 2015 _ 10168NE 114 ST MIAKI 9'L 3316ji 03', x " i RI= SCOTT i e2"