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MC-12-1823 1 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-239936 Permit Number: MC-10-12-1823 Scheduled Inspection Date: July 27, 2015 Permit Type: Mechanical - Residential Inspector: Perez,JanPierre Inspection Type: Final Owner: CENOz, EFREN Work Classification: Addition/Alteration Job Address:51 NW 110 Street Miami Shores, FL 33168-4318 Phone Number 305/751-5274 Parcel Number 1121360030600 Project: <NONE> Contractor: JOMANI INDUSTRIES INC Phone: (786)229-5862 Building Department Comments MECHANICAL WORK FOR INT. REMODEL Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-179327. missing dryer vent and ref lock cap replace louver door to little return area Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. July 27,2015 For Inspections please call: (305)762-4949 Page 28 of 30 k( SfL* U0 ve. e-01 JJ,/ �-- tA Miami Shores Village g Building Department artment rBy � ��10050 N.E.2nd Avenue,Miami Shores,Florida 33138 OcT 2c114Tel: (305)795.2204 Fax: (305)756.8972 i INSPECTION'S PHONE NUMBER:(305)762.4949 - FBC 20 BUILDING Permit No.14'c—/a 1 9 P-3 PERMIT APPLICATION Master Permit No. Permit Type: MECHANICAL / ��— JOB ADDRESS: ,.5Z- AL of ZZ/� ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: OWNER:Name(Fee Simple Titleholder): d?!5 2EA1 6!5AIJ Z- Phone#:7S,:� V2-7- Address: -Address• .5-0-5-5 Al 1.rf S City: _-]1 it 222Z State:-rl- Zip: /- TenanvLessee Name: Phone#: Email: CONTRAC OR:Company Name: om lyul C Phone#: Address: -7 r State: Qualifier Name: 1 �JL' Phone#: State Certification or Registration#: � ��'-c'a(;, Certificate of Competency#: Contact Phone#: �p � � '� Email Address: ® �f /�� I e Z, Cf DESIGNER:Architect/Engineer: Phone Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration �Kew ORepair/Replace ❑Demolition Description of Work: Submittal Fee Permit Fee$ �fCCF$ �� CO/CC$ Scanning Fee$ C Radon Fee$ d 153 DBPR$ Sr (S Bond$i Notary$ .CQ Training/Education Fee$ Z Technology Fee$ AQ �-4 , P) n Double Fee$ ( y Structural Review$ — 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 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 subject to atAwhment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which oc en (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be app r a a rein ection fee will be charged. Signature Signature Owner or ent Contractor II The foregoing instrument was acknowledged before me this 4iO The foregoing instrument was acknowledged before me this l day of 20 by 6f-r"T b— 7 z, day of�L J r ,20 a,by f�t— 19 C-4(ZAr who is personally known to me or who has produced who is personally known to me or whofro uced'A-)t" P `EL DL- As identification and who did take an oath. as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: �' Sign: ��sIwiu'o) dn AdVION Print: IPrint: Ltim CHERYLLANDRADE v My Commission Expire' My Commission Expires: ° 'sMY COMMISSION 4 EE 843924 4/ 'EXPIRES:October 15,2016 S U'�i, / 8� e� ftded Thru Notary Pulft UndmWraeB 1111 aYeY9ntnt•9lrskaR+trdeat•otrrkeY9edr�i•sYvY4e&dntroY4i•4nYeYak•lnYdntriniretr9r&dnkVe3ede9:dnt�+riraF9eskirdr9esYrkdr9e�rlPdcskakvYirdedr'r9Yskir4nY�&aYde9iaYYaYFr4r4nYY+nYd•qtr•&•+'idFskt•+rdr4rdnYettYak4:�•9Ytr APPROVED BY �� Plans Examiner Zomig Structural Review Clerk (Revised 3/12)2012XRevised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY LBT 5499249 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES JOMANI INDUSTRIES INC RENEWAL SEPTEMBER 30, 2014 1000 NW 147 ST 5739371 Must be displayed at place of business MIAMI, FL 33168 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED JOMANI INDUSTRIES INC 196 SPEC MECHANICAL BY TAX COLLECTOR CONTRACTOR 75.00 09/12/2013 Worker(s) 1 CAC57236 0228-13-001552 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 holders qualifications,to do business.Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 6a-276. For more information,visit www miamidad ov/texcollector MIAMFDADEt; �9 N ,,,, ,,,,,rn Miami shores Village Building 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: I. 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, o�y 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 Contractor Print Name: Print Name: Signature: == Signature: /1V State of F da) State 4 r1onda-) County of Miami-Dade) S� County of Miami-Dade) Sworn to and u�scribed before me this �� *� Sworn to and subscribed before me sliis`a®• '�0 ��''� day of J 0 day of c�C�lam`: ,20O/ssi` By By (SEAL) (SEAL) Type of Identification produced Type of Identificationproduced._ PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDAIMPORTANT -- ---- ---- -- : Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation DEPARTMENT OF FINANCIAL SERVICES who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or DIVISION OF WORKERS'COMPENSATION CONSTRUCTION INDUSTRY EXEMPTION °°mom i0 compensation under this chapter. CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L Pursuant t0 Chapter 440.05(12),F.S.,Certificates of election to WORKERS'COMPENSATION LAW D be exempt...apply only within the scope of the business or trade EFFECTIVEDATE* 11N4/2012 EXPIRATION DATE: 11/14/2014 listed on the notice of election to be exempt. PERSON: AVILA JOSE FEIN: 760780305 IH Pursuant to Chapter 440.05(13),F.S.,Notices of election to be j E exempt and certificates of election to be exempt shall be BUSINESS NAME AND ADDRESS: 1 R subject to revocation if,at any time after the filing of the notice 1000 1NI INDUSTRIES INC E or the issuance of the certificate,the person named on the 000 N W 147 ST notice or certificate no longer meets the requirements of this MIAMI FL 33168 section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person named on the SCOPES OF BUSINESS OR TRADE: certificate to meet the requirements of this section. HEATING, VENTILATION, AIR-COND DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 s 07/17/2014 16:26 9549630586 EZ INSURANCE AGENCY PAGE 01101 DA7E Ur�f"R'w! AC RDS CERTIFICATE OF LIABILITY INSURANCE 07117/2014 pRp fcER Tmm CERTIFICATE 16 ISSUED As A MATTER OF INFORmik'now EZ INSURANCE AGENCY, INC. ONLY AND CONFERS NO PJGHTS UPON THE CERTIFICATE 6230 PEMBROKE RD, STE 3 ALTER TITHIS CV91tAGE A1`Fo ow sy THE Fb biya sELl�°IVR. MIRAMAR, FL 33023 954-963.0M INSUMM AFFORDING COVERAGE i NAIC0 INsuR� -- -— R�suRERa F€DEPATED NATIONAL INSURANCE ' 10790 JO)MANI INDUSTRIES INCA 1000 NW 147 ST o � MIAMI,FL 33188 MSURER0. RMURER F— COVERAGES TME POLICIES OF INSURANCE LISTED BELOW"AVE BEEN ISSUED TO THE INSURED NAMED A84YE FOR THE POLICY PERIOD INDICATE0.NOTWrTHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 46ttel)OR MAY PERTAIN.THIF INSURANCE AFFORDED BY YHE POLICIES DESCRIBED IieRE:IN 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS.AND CONDITIONS OF SUCH POL:CiES.AGGREGATE UMrr$SHOWN MAY HAVE SM REDUCED BY PAID CLAIMS. MRA 1 VO�kR'NIIYBER 148 POLICr Lfuns I :ONNERAL LIABN.Irf EACH OCCURRENCE 1,000,000 { �k C4MRA IALGENERALLWBILITY f I ORENdSESfEbaagereazaal s 100• 000 110M �►+ L, GL-0000022953-00 'I uw&w1014 08/26/2015 `LIED c «�_ I S 5,000 i? I Pi511SONAL s ADV tWURY is 1,000 000 OP�ERALApGREOATE 'E 1.000,000 ' IGEWLAWREC-ATELIMrrAMESPER- f 4 4Pi200DUM-C40MMORAGO S 1.000.000 X ,POLICYI PRO. i7l Loc !AuroiaaalLE U&II&M c�OMeINEO>3t LIMIT S ANYAU=O f i (Eaaccidant) i 1 ALL axe Alrf08 ! E eCoP �+ }RY s SCHEMEDALMOS WRED AVOS ! @pb1LY rNJIJRY 1 tM4Y avEDAUTOS j E IPoracmartt s PROPERTY sDAMAN -- *AAAAwu4131uTY j AUTO ONLY-EAA=OENT a t ANY AUTOI J ! OTHER THAN OAACC S j E AL110 QNLY AGG S j �FSCGE8S1U51BRELLA•LNBN.l1Y 1I EACHO=MRENCE E ODOUR `CLAIM$MADE ! 'ACL'-RELATE _ i S DEDUCTIBLE l S ti RMNTION S I S WORKERS C01001SATM A AND EMPLOYERS'LIABUITY SR ANY rt%OPstiffT PAR—,NP 0mcunvE t B.L EACH A=DENT 3 OFACEWE NER rmcwDloT IrFa+.U In NH) i S.L r ASE-EA EMPLQYE 5 I ifyiS de9giD3 u(IQW 3PEL�IiLPR Ddow ELDISEASE•pOFicy Llmrr S QTHLIt )) I I DF3CRIPn011 oP oPi�RAnQM.R►LOCA71alITLf veI¢a.f5rmtou�OerSADORD 9Y@IDOR9�iT1SPEgAL.PROYIS10I4Y LIC#CACO67236 CERTIFICATEHOLDER CANCELLATION SNOULDANYOF9thABOVgDescf POUCMBeCANCMJ"IBOonsTNEWWVATM MIAMI SHORES VILLAGE OATS WWW.TM MMDIBURER ww.El4MVOR TO VA DAYS wtsrrTr�at MIMN€2ND AVE Non=yomw ►TENoIo®RNUUM,oTMU�,BUTFAlt�T000sO10060 sxALL aroW No 09LIGA7M OR LVW LffV OF ANY FMW IIPON THE AVSURP^TIS AGMTS OR MUMI SHORES, FL 33138 ATPA$- REPWrMTATWE ACORD 25(2008107) 0 IsIlIII-20DOACORD CORPORATION. All righft reserved. The ACORD name and logo are rnglslemd marks of ACORD ACORDs provided by Forms Boss,www.FotmsBws.c om;(0 Impressive Publishing 800-2084977 STATE OF FLORIDA DEPARTNIEtIT OF BUSINESS AND PROFESSIONAL. REGULATION CONSTRUC--ION INDUSTRY LICENSING BOARD {850}4$7-1395 1940 NORT�TALLAHASS =EQNRC)FE 3233 9-0783 AVILA, JOSE S 1000 NW NRIE 140 THTST EET MIAMI FL'3168 Congratulations! With this IiC9ns' you become one of the nearly one million Ftorioians licensed by the Department of Business and STATE OF FLORIDA professional Regulation. our prc iessicnals and businesses range DEPARTMENT QF BUSINESS AND from architects to yacht brokers,��om boxers to barbeque restaurants, PROFfF,§§ 'R ULATION and they keep Florida s economy strong. pg/22/2014 CAC057236 Every day we work to improve th:way we do business in order to serve you better For informatior about our services.please log onto CERTIFIED Al www.myftoridalieennd the reggut loons se.com. Ti ere you can find more information .,�, •' .,.' ...; about our divisions athat impact you, subscribe AVILA,JOSE to department newsletters andNe ern more about the Department's JOM.ANi INDU Our mission at the Department i::License Efficiently,Regulate Fairly We constantly strive to serve yot better so that you can serve your IS CER-FRIED unser tre orovis+ona of Ch.469 FS customers. Thank you for doing business in Flonda• E, .,asb cs;b AUG 3' 2016 L140922000'531 and congratulations on your new license' DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY STATE OF FLORIDA I.1EPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CAC057236 The CLASS AAIB CONDITi()NTNG CONTRACTO.E3 Narnec oeiow IS CERTIFIEC Under the provisions of Chal der 489 FS. Expiration date: AUG 31, 2016 AVILA,JOSE S JCMANI ?NDUSTRIE 51 1000 NW 147TH STj:EE MIAMI > rico+ AV nC pFt�IIiPCt� Gttif t piA! Fns �anao�nnnua+ IVIIAM�M[DAWDMIAMI-DADE COUNTY - STATE OF FLORIDA N/A October 14,2014 MImm AMaDAD LOCAL BUSINESS TAX RENEWAL 5499249 2014 -2015 APPLICATION RECEIPT 5739371 STATE#CAC57236 DBA/BUSINESS NAME: BUS.COMMENCEMENT DATE:02/01/2005 JOMANI INDUSTRIES INC SEC TYPE OF BUSINESS BUSINESS LOCATION: MECHS SPEC MECHANICAL CONTRACTOR 1000 NW 147 ST 1 MIAMI,FL 33168 OWNER/CORP. APPLICATION DETAILS JOMANI INDUSTRIES INC FEE AMOUNT PHONE# 786-229-5862 Receipt Fee 30.00 UMSA Fee 30.00 1000 NW 147 ST Beacon Council Fee 15.00 MIAMI,FL 33168 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: 238990 Doing Business without a License Penalty 0.00 Late Penalty 7.50 Collection Cost 0.00 NSF Fee 0.00 Prior Years Due 0.00 Amount Recently Paid - 82.50 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 14,2014 STATE OF FLORIDA LOCAL BUSINESS TAX RENEWAL 1 STATE#CAC57236 AC57II RECEIPT: 2014 -2015 APPLICATION I II III(I II 5499249 I II ISI I I II II I III BUSINESS LOCATION: 1000 NW 147 ST MIAMI,FL 33168 BUS.COMMENCEMENT DATE:02/01/2005 SEC TYPE OF BUSINESS OWNER/CORP. MECHS SPEC MECHANICAL CONTRACTOR JOMANI INDUSTRIES 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. I SWEAR THAT THE INFORMATION IS TRUE AND CORRECT. JOMANI INDUSTRIES INC JOSE AVILA PRES ST SIGNATURE REQUIRED SEE INSTRUCTIONS ABOVE 1000 NW 147 MIAMI,FL ST Please pay only one amount The amounts due after Sept 30th Include penalties per FS 205.053. if Paid By Oct 31,2014 Nov 30,2014 Dec 31,2014 Jan 31,2015 Please Pay $0.00 $0.00 $0.00 $0.00 7000000000000000000000005739371201500000007500000000000002 000 • Miami Shores Village �l Tc-- Building Department 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 � 0000� INSPECTION'S PHONE NUMBER:(305)762.4949 BY:oo_ _ BUILDING Permit No. PERMIT APPLICATION Master Permit No. — FBC 20 Permit Type: MECHANICAL OWNER:Name/(Fee Simple Titleholder): Phone#: Address: / (� b City: State: Zip: Tenant/Lessee Name: Phone#: Email: JOB ADDRESS: 'RANI? r S '4A®✓e. City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes /1�']O�; Flood Zone: CONTRACTOR:Company Name:- �, �� °'� Phone#: = Address: k)ce,) / S 7- City: �d:2/ L a State: Zip: Qualifier Name: 6) :S( ) : ( Phone#: = State Certification or Registration#:�°� � Certificate of Competency#: Contact Phone#: & �G � ' ress: DESIGNER:Architect/Engineer Phone#: L900W Value of Work for this ermit:$ `""''Squai0Lltiejr Footgge;of ork: Type of Work: OAddress DAlteration 5i'('3 h 's®Nenv, +,+ 7tfiReplace ODemolition Description of Work: 22 0 xx�xx��x��xx�xxxx�x��xxx��xx�x:x�x�xx�:x�Feesxx� x��xxn��xxmx�x��x�x��x��x+xxxx�x��x�x Submittal Fee$ Permit Fee$ �" CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$ Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ c 0l) W 7 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 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 pennit with an estimated value exceeding $2500, the applicant►nust 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 ' section which occurs seven (7) days after the building pennit is issued. In thebsence of such posted notice, the inspection will n e a reinspection fee will be charged. Signature Signature L"ll Owner or gen T Contractor The foregoing instrument was acknowledged before me this 01 The for ing ins ment s ackno ledged befor mes day of DGk�,(oe�20 L,by Frrcn genas day of 207,by who is personally known to me or who has produced who is pers ally knowppn��t a or who has produced 06h d4 � As identifica' 4d' fic/c/ ation and who did take an oath. ,,pI too p, 6ER k C.OWEGA NOTARY PUBLIC: ''` '�H Nom►Pok-State 6 1mi T RY PUBLIC: • My COM.Enpkes Sep 27,2016 r Commissi n 0 EE 205166 Sign: ) �y �c Ip�0iMsspAtl�tiosM. n; TY1G1 a• �� 9 Print: ''P"' r Public State of Florida Print' v ` M Comm.Expires e My Commission Expires: -)41201(o P My Co e :Commission# EE 128810 Bonded Through National Notary AsW x«��=x �x</x� x� ��x=x+xx�=x�x�_=x=<��=x=t=��:=x=x�=x��=x=x=x=x�=x�=xx=x=x�x==x��x==x=x�xe<=xx=x=x=k=x�=x�=x� APPROVED BY v /1 -7 /dans xE aminer Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) 10-14-2010 ALEX SINK 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 certifies that the individual listed below has elected to be exempt from Flori orkers' Compensation law. EFFECTIVE DATE: 10/14/2010 EXPIRATION DAT 10/13/2012 PERSON: AVILA JOSE FEIN: 760780305 BUSINESS NAME AND ADDRESS: UOMANI INDUSTRIES INC 1000 NW 147TH ST MIAMI FL 33168 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED AC CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 0504), 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 440.0502), 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 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 person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-160 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09-06 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O 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 & D chapter. EFFECTIVE: 10/14/2010 EXPIRATION DATE: 10/13/2012 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be of "'r E exempt.. apply only within the scope of the business or trade listed on �r o o E the notice of election to be exempt. R � -0,< C- tiChapter to Cha ter 440.05(13), F.S., Notices of election to be exemptt ^+ o ri rn or 3 0 o ry y - to be exempt shall be subject to revocation n o 3Zm �� r r-r H~ a o m n "0 3 "` nr the issuance of the A —r t7 �' Rt (m7'-ti `-'o-� ry p� 3 '']a r.. n n r r f,.. 1^nner meets o aH� aW zo W r— otiA " c oC,rr�CD rn C:C6 23 -or �m r� c, H� R >>oti n y� Zen A rN 73 �y T �rSr stn rC12 �+ Z' T! H r, X --ram H r tHn n m ,U co frt �?rD n ' �' N iu 3 b» H X ,�., '~rj r� C7 y o C, .� � �j --C H x u a V ��H �p Z ac rzn w�> +c v> o� � � v"C:) x a t3 , co 9 rn c cx� y o vNi � Q) N n, -m _.g rr7 " 4 „ o a ,gym n o- 3 cn r� to rJ j ID C z o b cnm v riz� , 60� m ?co z CJ X co ' K3 `7 O T C).`may. r- >� ff3 co �u7.' N Z o m DWC-252 L'tn ill o 0 o x STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH ��awe TALLAHASSEEMONROE STRFLT32399-0783 AVILA, JOSE S JOMANI INDUSTRIES INC 1000 NW 147TH STREET MIAMI FL 33168 JSTATE OF FLORIDA AC# 6 3 4 16 L Congratulations! With this license you become one of the nearly one million II DEPARTMENT OF BUS Ir rSu A Floridians licensed by the Department of Business and Professional Regulation. + PROFESSIONAL ;REGULATION j Our professionals and businesses range from architects to yacht brokers,from boxers to barbeque restaurants, and they keep Florida's economy strong. ! ;• CAC057236 09/07%12 127015207 Every day we work to improve the way we do business in order to serve you better. ! ! For information about our services,please log onto www.myfloridalleense.com. CERTIFIED= ATR CONE) CONTR There you can find more information about our divisions and the regulations that AVILA, JOSE S- ! impact you,subscribe to department newsletters and learn more about the JOMANI INDUSTRIES INC Department's initiatives. i 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 new license! ( I$ cERTIFISD unser the provisions of ch.489 Fs i I Expiration date: AUG 31, 2014 L12090702758 j G DETACH HERE kC# 6346161 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEW L12090702758 j .. LICENSE NBR j ! 09 07 2012 127015207 CAC057236 i The CLASS A AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED ; Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 AVILA, JOSE S JOMANI INDUSTRIES INC 1000 NW 147TH STREET i MIAMI FL 33168 i RICK SCOTT KEN LAWSON GOVERNOR SECRETARY DISPLAY AS REQUIRED BY LAW Oct. 4. 2012 2:33PM FLORIDA BANKERS INSURANCE No. 9220 P. 1/1 CERTIFICATE OF LIABILITY INSURANCE F 10fE( 1�2 Din •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 pollcypes)must be endorsed fi SUBROGATION IS WANED,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 o certificate holder In lieu of such endorsemengs4 PRODUCER CONTACT MARTA ALONSO Florida Bankers InstNrarce PFAX HONE Ed): (305)266-6493- AfC Nol: (305)262-0679 7278 SW 8 Street ADDRESS: manta@floridabankersinsurance.com Miami,FL 33144 PRODUCER CUSTOMER ID Phone (305)266-6493 Fax (305)262-0679 INSURER(S)AFFORDING COVERAGE NAIC s INSURED INSURERA: FEDERATED NATIONAL INSURANCE COMPAN JOMANI INDUSTRIES INC INSURER 13: 801 Brickell Bay Dr L-7 INSURER C: MIAMI,FL 33131- INSURER D: (321)746-2615 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 ANYCONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EAP L TYPE OF INSURANCE INSR yyyp POLICY NUMBER MMIDD (MMfDONYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,000.00 TO u COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100•000•00 ❑ ❑ A CLAIMS-MADE ® N OCCUR GL-0504008534 12242011 12242012 00 MED EXP(Any one person) $ 5.000.00 ElPERSONAL&ADV INJURY $ 5QO,000.00 ❑ GENERAL AGGREGATE $ 500,000.00 GEN'_AGGREGATE LIMIT APPLIES PER: I PRODUCTS-OOMPIOP AGG $ 500,000.00 © POLICY ❑ PERCOT ❑ LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ ALL OWNED AUTOS BODILY IWURf(Per accident) $ ❑ SCHEDULED AUTOS ❑ HIRED AUTOS PROPERTY DAMAGE $ r(Peraccident) ❑ NON-OWNED AUTOS $ ❑ $ ❑ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAR ❑ CLAIMS-MADE AGGREGATE $ ❑ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATIONWC STATU OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOWPARTNEWEXECUTIVE NIA E.L EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatoryln NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe unde DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,K more space Is required) 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 DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2 AVE MIAMI SHORES,FL 33138 AUTHOR®REPRESENrATwE ®1988-2009 ACORD CORPORATION. All tights reserved. ACORD 25(2009109)QF The ACORD name and logo are registered marks of ACORD 2012-10-04 14:52 5614719826 Paaina 111