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DS-16-11 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-255724 Permit Number: DS-1-16-11 Scheduled Inspection Date:April 04,2016 Permit Type: Driveways/Sidewalks/Slabs Inspector. Rodriguez,Jorge Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address:2 NW 108 Street Miami Shores, FL 33168- Phone Number (305)773-3101 Parcel Number 1121360110090 Project: <NONE> Contractor. CAP PROPERTIES LLC Phone: (305)773-3101 Building Department Comments REPLACE CONCRETE AND ASPHALT DRIVEWAY BY Infractio Passed Comments OLD MIAMI BRICK. INSPECTOR COMMENTS False TO CLOSE PERMIT#DS14695 Inspector Comments Passed CREATED AS REINSPECTION FOR INSP-255569. CREATED AS REINSPECTION FOR INSP-254938. CREATED AS REINSPECTION FOR INSP-250384. No permit on site ❑ PERMIT WILL BE INSIDE OF THE MAIL Failed X Replace sod or landscape 30&77&3101 Correction Needed 03-24-2016 Asphalt driveway need to be properly compacte The a It has grass growing through it. Se Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid April 01,2016 For Inspections please call: (305)762.4949 Page 19 of 35 3 Miami Shores Village ,?rr 10050 N.E.2nd Avenue NW 3 Miami Shores,FL 33138-0000 Phone: (305)795-2204 Expiration: 08/17/2016 Project Address Parcel Number Applicant 2 NW 108 Street 1121360110090 CAP REALTY LC Miami Shores, FL 33168- Block: Lot: Owner Information Address Phone Cell CAP REALTY LC 12000 BISCAYNE Boulevard (305)773-3101 MIAMI FL 33182- 12000 BISCAYNE Boulevard MIAMI FL 33182- Contractor(s) Phone Cell Phone Valuation: $ 3,400.00 CAP PROPERTIES LLC (305)773-3101 Total Sq Feet: 2500 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:REPLACE CONCRETE AND ASPHALT DR Additional Info: Review Planning Bond Retum: Classification:Residential Review Building Scanning:3 Fees Due ]$24716 Pay Date Pay Type Amt Paid Amt Due CCF Invoice# DS-1-16-58228 DBPR Fee 02/19/2016 Credit Card $247.16 $0.00 DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: 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;et y age , servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOONG a SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accuat all rkwitl be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contra e rk tated. February 19,2016 Authorized Signature:Owner / Applicant / Contractor g n ate Building Department Copy February 19,2016 1 Miami Shores Village ,- l L1 l BuildingDepartment p J o s 2096 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FB C 01T . BUILDING Master Permit No*-1;1S PERMIT APPLICATION Sub Permit No.' _ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ORENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP �pp CONTRACTOR DRAWINGS JOB ADDRESS: 2 /4 1A) 1 OO City: Miami Shores County: Miami Dade Zip: -313 1 lot Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):& eo,` L G Phone#: 0S*—; 'i --%'-O Address: ,�Z1-ate �- l& ' City: , _ ` l ayw State: y Zip: 3?;1 9 Z Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Pcblq&r -o Phone#:asais-- '"3`o, Address: 12.0 OO UiSLlll/he tid *- '7011 City: t!A► (A WV 1 <1 State: �L' Zip: y:3l 21 Qualifier Name: XOI. tr V1 CAp-Oz L41 Phone#: (,, State Certification or Registration#: L CG s- g(p s3 Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ �' uare Linear Foota a of Work: �®�- .� S4 / g Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: N ar- '�� Ll e 17--� � 1 W �`r' CON ��� (�� `17E f� r � Lt•a — v 'PI �7`° "•..Iry e T1F Specify color'6jtolor•: tiru tile; Submittal Fe o�S itta a Permit Fee $ cZ CCF CO Scanning Fee$ r CO Radon Fee$ 7?,El DBPR$ � Notary$ 7� Technology Fee$ Z� - �ZO Training/Education Fee$ �'/� Double Fee$ Structural Reviews$ Bond$ � /� i TOTAL FEE NOW DUE$ e2`t a r (Revised02/24/2014) Bonding Company's Name(if applicable) Bonding Company's Address * 4. 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 dpplicant must promise in good f?ith thgt 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 , 100011�01WNER or AGENT CONTRACTOR' The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of'/�►�G�wi(aLr ,20J by ,/ day of�.e��V/1�OG� ,20 ,by ]� i!i/ Ac V J t l� ,who' ersonally know o ✓i4-r rao D.[ V�L6 w rsonally known t //m__a or who has produced as me or who has produced as identification and who did take an oath. identification and wWdidtaan oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: Print: �+ Seal: NOTARY P'UBLIC Seal: NOTARY PUBLIC STATE OF FLOMM STATE OF FLO RM Cmm#FF900118 s.. Can"FF9W t 19 Expires 7/15/2019 !BY APPROVEPlans Examiner Zoning Structural Review Clerk (RevisedO2/24/2014) Property Search Application - Miami-Dade County Page 1 of 1 _' TY APPRAISER IE ay THE PR" ,:: m Summary Report Generated On : 1/6/2016 Property Information Folio: 11-2136-011-0090 Property Address: 2 NW 108 ST Miami Shores, FL 33168-4311 Owner CAP REALTY LC ® . Mailing Address 12000 BISCAYNE BLVD#704 MIAMI, FL 33182 USA Primary Zone 0800 SGL FAMILY-1701-1900 SQ Primary Land Use 0101 RESIDENTIAL-SINGLE FAMILY: 1 UNIT Beds/Baths I Half 4/2/0 Floors 1 Living Units 1 Actual Area Sq.Ft Living Area Sq.Ft Adjusted Area 1,717 Sq.Ft Taxable Value Information Lot Size 9,194.25 Sq.Ft 2015 2014 2013 Year Built 1952 County Assessment Information Exemption Value $0 $0 $99,082 Year 2015 2014 2013 Taxable Value $274,297 $206,289 $0 Land Value $165,565 $99,043 $45,826 School Board Building Value $107,658 $106,158 $117,199 Exemption Value $0 $0 $25,500 XF Value $1,074 $1,088 $1,102 Taxable Value $274,297 $206,289 $73,582 Market Value $274,297 $206,289 $164,127 City Assessed Value $274,297 $206,289 $99 082 Exemption Value $0 $0 $50,500 Taxable Value $274,297 $206,289 $48,582 Benefits Information Regional Benefit Type 2015 2014 2013 Exemption Value $0 $0 $50,500 Save Our Homes Cap Assessment Reduction $65,045 Taxable Value $274,297 $206,289 $48,582 Homestead Exemption $25,000 Second Homestead Exemption $23,582 Sales Information Senior Homestead Exemption $50,000 Previous Sale Price OR Book-Page Qualification Description 02/20/2014 $280,000 29045-1963 Qual by exam of deed Civilian Disability Exemption $50�0 Note: Not all benefits are applicable to all Taxable Values(i.e.County, 05/07/2013 $222,500 28629-4267 Qual by exam of deed School Board,City, Regional). 08/01/1988 $70,000 13779-857 Sales which are qualified Short Legal Description 36 52 41 PB 52-33 DUNNINGS MIAMI SHORES EXT NO 7 LOT 1 BLK 211 LOT SIZE 74.750 X 123 OR 13779-857 0888 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.gov/info/disclaimer.asp '/" i http://www.miamidade.gov/propertysearch/ 1/6/2016 Detail by Entity Name Page 1 of 2 Detail by Entity Name Florida Limited Liability Company CAP REALTY LC Filing Information Document Number L06000089951 FEI/EIN Number 20-5550248 Date Filed 09/13/2006 Effective Date 09/13/2006 State FL Status ACTIVE Principal Address 12000 Biscayne blvd suite 704 miami, FL 33181 Changed: 04/13/2013 Mailing Address 12000 Biscayne blvd suite 704 miami, FL 33181 Changed: 04/13/2013 Registered Agent Name & Address CAPDEVIELLE, XAVIER 12000 Biscayne blvd suite 704 miami, FL 33181 Address Changed: 04/13/2013 Authorized Person(s) Detail Name &Address Title MGR CAPDEVIELLE, XAVIER 12000 Biscayne blvd suite 704 miami, FL 33181 http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 1/6/2016 Detail by Entity Name Page 2 of 2 Annual Reports I Report Year Filed Date 2013 04/13/2013 2014 01/24/2014 2015 03/05/2015 Document Images 03/05/2015—ANNUAL REPORT view image in PDF format 01/24/2014—ANNUAL REPORT View image in PDF format 04/13/2013—ANNUAL REPORT View image in PDF format 04/26/2012--ANNUAL REPORT View image in PDF format 04/08/2011 —ANNUAL REPORT View image in PDF format 03/19/2010—ANNUAL REPORT View image in PDF for—m—a-F—­1 04/25/2009—ANNUAL REPORT View image in PDF format 04/21/2008—ANNUAL REPORT View image in PDF format 04/04/2007 ANNUAL REPORT View image in PDF format 09/13/2006 Florida Limited LiabilityViewimage in PDF format---] ............ CoUvright Oc and Privacy Policies State of Florida,Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 1/6/2016 12000 Biscayne Blvd 704 Miami,FL 33181 j CAP Properties LLC. Phone:(305)777-1888 Fax:(30586-9191 E-Mail:Xavier@capgroupmiami.com January 29,2016 City of Miami Shores Building and Zoning Department 10050 NE 2°a Ave Miami Shores FL,33168 State of Florida County of Dade Dear Building Official: Before me this day personally appeared Xavier Capdeville who being duly sworn,deposes and says: That he will be the only person working on the project located at:2 NW 108th Street Miami Shores Fl,33168 Sw to and subscribed before me this--- --day o -------- ®-----I----------------------2016 ,by Personally known Or Produced Identification Type of identification Produced Print,Type or Stamp Name o4No4 AftMoboft WrARYPUBM STATE OF FLORIDA Caertri#F,�ppg� 8H3J�18 s� Miami shores Village noggin Building Department "fie n e�y� 10050 N.E.2nd Avenue �IOR'NA Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner - Workers' Com ensation 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 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 A day of-f�cl" ,201,� . ByY,424L%� who i ersonally kno me or has produced 4,id ntifica' n. Notary: SEAL: Owl STATE:OF FLORIDA . Conry*FYOUM EXphvs 8111 19 Miami Shor es Village �_��111111111111111111111111111111111111111111111 Brisp�� a Building ep e t 2016RO1033e`8 10050 N.E.2nd Avenue OR BK 29968 R'3 682 ( Pss) ' .� RECORDED 02/19/2016 0?:17:35 Rok Miami Shores, Florida 33138 HARVEY RUVINr CLERK OF COURT Tel: (305) 795.2204 MIAMI-DADE COUNTY? FLORIDA Fax: (305) 756.8972 STAW 0FfLORKNk,COUM of oWN Pio HEREBY CERTIFY that this is a true copy of the J~ ci[QK mgrnal filed in thip office on day of Q� A COVENANT OF CONSTR CTIQN WITHIN RIGHT OF AY FEB 2016 , A© zo Whereas, (owner) G ate �.L \ -C.. mITNESS my hand and Official Seal. 3 UVIW,CLE of Qrcw and rm�o Wit ' hereinafter referred to as the owner 6f the following descri ed O.C. property (address): Legal Description: Lot Block Subdivision Folio# A Q- -O Requests permission to install (describe work): Witt•— in the public right of way of(address) IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said items within public right of way including restoration of street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from any and all liability, which may rise by virtue of permitting the installation of these items within the public right of way. 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village (or his fully authorized representative Signature Owner or Agent State of Florida County of Miami Dade he foregoing instrument was acknowledged before me this !� day oa%k000- , 20 jj�_, by �•l L, . w i onall kn n to me or who has produced !sLidentifi t n. NOTARY UBLI Sign: �Vl Alicia Maria or& Print: SEAWTMYPUauc STATE of Fl.ownA *E*hm F.FM42 8/13MO19 i Is ib- cl CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 02/22/16 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. ff SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONAN'MEET Abby Torres Great Florida Insurance-Pinecrest PH NE , (305)256-0616 M NO: (786)522-1889 12745 S.Dixie Highway ADDRE-MAIL Abby@legacy3insurance.com Miami,FL 33156 INSURER(S)AFFORDING COVERAGE NAIC# Phone (305)256-0616 Fax (786)522-1889 INSURERA: International Insurance Company of Hannover SE INSURED INSURER B: CAP Properties LLC INSURER C: 12000 Biscayne Blvd. #704 INSURER D: Miami,FL 33181 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE ADD UBR POLICY NUMBER MMMIDDPOLIDY EFF MMIUDDI EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 © ENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000.00 A ❑ ❑ CLAIMS-MADE Q OCCUR© N N 02/26/2016 02/20 IG06A011369-00 MED EXP(Any one person $ 5,000.00$1,000 Deductible /2017 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 ❑ JFCT PRO- 0 LOC $ AUTOMOBILE LIABILITYacct ant aal D INGLE LIMIT ❑ ANY AUTO BODILY INJURY(Per person) $ ElAALOOSWNED ❑ SSCHEESDULED BODILY INJURY(Per accident) $ F-1 HIREDAUTOS ❑ AUT SWNED PP�08ER�nDAMAGE $ ❑ ❑ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAS ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑WC S IT 1:1ED AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) ElE.L.DISEASE-EA EMPLOYE $ If yyes describe under DESdRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMrr $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) General Contractor Roofing operations performed directly by the insured and/or the Insured's direct employees is prohibited. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Bldg Dept THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores,FL 33138 AUTHORIZED REPRESENTATIVE ©1888-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)QF The ACORD name and logo are registered marks of ACORD f ' CERTIFICATE OF LIABILITY INSURANCE 2/23/Date2016 Producer: Plymouth Insurance Agency This Certificate Is issued as a matter of information only and confers no 2739 U.S. Highway 19 N. rights upon the certificate Holder. This Certificate does not amend,extend Holiday, FL 34691 or alter the coverage afforded by the policies below. (727)938-5562 1 Insurers Affording Coverage MAIC# Insured: South East Personnel Leasing, Inc. &Subsidiaries insurer A: Lion Insurance Company 11075 2739 U.S. Highway 19 N. Insurers: Holiday, FL 34691 Insurer c: Insurer D: Insurer E: Coverages 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 contact or other document with respect to which this certificate may be issued or may pertain,the Insurance afforded by the policies described herein is subject to all the terms,exclusions,and conditions of such policies.Aggregate limits shown may have been reduced by paid claims. INSR ADDL Policy Effective Policy Expiration Limits LTR INSRD Type of Insurance Policy Number Date Date (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence $ Commercial General Liability Damage to rented premises(EA Claims Made 1:1 Occur occurrence) $ Mad Exp Personal Adv Injury General aggregate limit applies per: General Aggregate Policy ❑Projed ❑ LOC Products-Comp/Op Agg AUTOMOBILE LIABILITY Combined Single Urrdt Arty (EA Accident) $ Auto Bodily Injury All Owned Autos (Per Person) Scheduled Autos Hired Autos Bodily Injury (Per Accident) Non Owned Autos Property Damage (Per Accident) EXCESSIUMBRELLA LIABILITY Each Occurrence Occur ❑Claims Made Aggregate Deductible A Workers Compensation and WC 71949 01/01/2016 01/01/2017 x we Stew- OTH- Employers'Liability I tory Limits I ER Any proprietor/partner/executive officer/member E.L.Each Accident $1,=,Otm excluded? NO E.L.Disease-Ea Employee $1.000.000 If Yes,describe under special provisions below. E.L.Disease-Policy Limits $1.000,000 Other Lion Insurance Company is A.M.Best Company rated A-(Excellent). AMB#12616 Descriptions of Operations/LocaUons/Vehicies/Exclusions added by Endorsement(Speeial Provisions: Client ID: 92-70-075 Coverage only applies to active employee(s)of South East Personnel Leasing,Inc&Subsidiaries that are leased to the following"Client Company": CAP Properties LLC Coverage only applies to injuries incurred by South East Personnel Leasing,Inc.&Subsidiaries active employee(s),while working in:Fl— Coverage LCoverage does not apply to statutory employee(s)or independent contractor(s)of the Client Company or any other entity. A list of the active employee(s)leased to the Client Company can be obtained by faxing a request to(727)937-2138 or by calling(727)938-5562. Project Name: ISSUE 02-23-16(PH) Begrin Date 2/3/2016 CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES Should any of the above described policies be cancelled before the expiration date thereof,the Issuing Insurer will endeavor to mail 30 days written notes to to certificate holder named to to left,but failure to BUILDING DEPARTMENT do so shall Impose no obligation or liability of any kind upon the insurer,Its agents or representatives. 10050 NE 2ND AVENUE MIAMI SHORES, FL 33138 1 ' i t i, JEFF ATWATER �'}�• a 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: 3/4/2016 EXPIRATION DATE: 3/4/2018 A PERSON: CAPDEVIELLE XAVIER O FEIN: 320433052 i BUSINESS NAME AND ADDRESS: CAP PROPERTIES LLC I' 12000 BISCAYNE BOULEVARD NORTH MIAMI FL 33181 6 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR .fi Punauennt to Clungter 440.05(14).F.S..an officer ale ooryaa5on who clads ezempiian Gan On W-y�Ler bbyy filing a cerblicale of n under#n sectionmay net teaovor benOfits a comporeon wider a0tlft dmpter.Rnuant to ChePW440.05(12).F.S..Ca5/ketoa of ebcftn tD be exempt...apply only ewift xempt a amps,of the busWam oft olaL1ma fotrade listed on Ore rftw of n to be exempt.Pursuant to ChaCp�r440.05(13),F.S..Names of etedion to be �' 0ne persan named on Ore ndice a certifx no lsim8 Do sublW to ravonxNon H,at any time atter One fi5ng of dm troika or Ore Issuance of the cmtiReata, Doge meeffi the r�utrements of Irws section for nssuarroe of a ceedcale.The department sha8 rawoke a DFS•F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413.1609 f i I i i• F i. E ( 6 ) t f t i ( E t 063592 " Local Business Tax Receipt Miami—Dade County, State of Florida THIS IS NOTA BILL - DO NOT PAY 7167392 BUSINESS NAME/LOCATION CAP PROPERTIES LLC RECEIPT No. EXPIRES 12000 BISCAYNE BLVD 704 RENEWAL SEPTEMBER 30, 2016 MIAMI FL 33181 7 $927 Must be displayed at place of business Pursuant to County Code Chapter 8A-Art.9&1 o OWNER SEC.TYPE OF BUSINESS CAP PROPERTIES LLC C/O XAVIER 196 GENERAL BUILDING CONTRACTOR PAYMENT RECEIVED CAPDEVIELLE CGC1508653 BY TAX COLLECTOR Worker(s) 1 $75.00 08/06/2015 CREDITCARD-15-039970 This Local Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt Permit or a certification of the hohfer's qqualificatlone,to do blmin�s Holder spud curnplyIs not a license, or nomgovemmental regulatory laws amd requirements which apply to the basisess any governmental The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dada Code Son fia Z76. For more information,visit famMmiamidad gy Yh a gio 5