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PL-15-2993 .- - .. ac zg 61 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-254357 Permit Number: PL-12-15-2993 Scheduled Inspection Date: March 14,2016 Permit Type: Plumbing- Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: DEVELOPEMENT LLC,OORT Work Classification: Addition/Alteration 0 Nuccc Job Address:326 NE 92 Street Miami Shores,FL 33138- Phone Number (305)842-8745 Parcel Number 1132060136470 Project: <NONE> Contractor. ALADDIN PLUMBING&CONSTRUCTION CORP Phone: (305)758-6246 Building Department Comments DISCONNECTING PLUMBING AND RECONNECT Infractio Passed Comments PLUMBING FOR INTERIOR RENOVATION. INSPECTOR COMMENTS False Inspector Comments Passed Dq CREATED AS REINSPECTION FOR INSP-248586. no access 3pm Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-Inspection fee is paid I March 14,2016 For Inspections please call: (305)762-4949 Page 28 of 40 Mar, 7, 2016 12:24PM �/�/` �/ �-- No. 9227 P. 1 ' CERTIFICATE OF LIABILITY INSURANCE °A' 02102ND`16 • �� - _ o2ro DIVYYY) THIS CERTIFICATE 1$ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$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 PRODUCLR,AND THE CERTIFICATE HOLDER. IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED,the pollcy(IeS)mustbe endorsed. It SU13ROGATION 13 WAIVED,subject to the terms and conditions of the policy,certain policies may require an andoreemant, A statement?h this certificate does not confer rights to the cartifioate holder in lieu of auth andorsamont(e). PRODUCER YANET PADRON Almer Insurance Servloss,Ina. 3 E333�789 _ I��05.Z._._3- 533-0926 2331 N.W.27th Ave. RyanetpsdronDt,*aol.com Miami,FL 33142 INSURE AFFORDING COVERAGE NAIC0 Phone (305)833.3781 Fax 303 633.0928 INSURBRAI SCOTTDALE INSURANCE COMPANY - INSURED INSURERS: ALADDIN PLUMBING&CONSTRUCTION CORP. INSUMM01 660 NW 121 St INsu D: _ Miami,FL 33168- (306)788-6174 INSURER E — _,•• r ....--.-�___ COVERAGES CERTIFICATE NUMBER: INSURER F 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 REQUIRIO ENT,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 CLAms. I sR TYPE OP INSURANCE A°D HR pICY Ex PO41��_�—. .t{Y!M�..( ?!91IR _ LIMITS GENERAL LIAeIL1TY II EACH OCCURRE CE 1,000,000.00 ® CommaRciALGENERAL LIABILITY D E 0 S 100,000.00 ❑ [3OLAJM84MDE ❑1/ OCCUR OPS1240648 MED EXP Anrta Ort $ 5,000.00 A ❑ 02/01/2018 02/01/2017 PERSONAL&AM INJURY s 1,000,000.00 ❑ • i GENERAL AGGREGATE S 2,000,000.00 GeNn.AGGIIea'rELIMIT APPLIES Pea PRODUCTS-COMPIOPAGO a 1,000,000.00__ ❑ POLICY ❑ Prp ❑ LOC S AUTOMOBILE LIABILITY CMB DINGLE T a ❑ ANYAUTO BODILY INJURY(Per person) S ALL OWNED 8CHQDULP.D ❑ AUTOS ❑ AUTOS BODILY INJURY(Per anddaM S NON-OWNED ❑ HIRED AUTOS ❑ AUT OG I i. PEl RROP E El ❑ UMBRELLAUA13 ❑OCCUR —---.............- S.,... _._ • .,6ACH QAC REN E ~`� EXCESS LIAR C1 CLAIMS-MADE :' . AGGREGATE S DED 13 RETENTIONS _ _ $ WORKERS COMPENSAEMTION ❑- AT_ a AND EMPLOYERS'INABILITY YIN ANY PROPRIEMRtPAFtTNERFEXECUTNE E.L.EACH ACCIDENT 46 $ OFFlC6WMSMBEREXCLUDED? ❑NIA IlAendIn NH) E.L.DISEASE-EA EMPLOYEES If Yyee8a dee&ft under DH8�RIPTION OF OP 3 below _- E.L.DISEASE-POLICY LIMIT a DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Scfiadul%If Mora upwo is mqulrad) PERSONAL AND COMMERCIAL PLUMBING I!1 LICENSE NUMaER,CFCO26527 I I ' .1t , Is; CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE CRIBED POLICIES BE CANCELLED B£FORE MIAMI SHORES VILLAGE HALL THE EXPIRATION DATE THE F OTICE WILL BE DELIVERED IN 10050 Northeast 2nd Avenue ACCORDANCE WITH THE P C ROVISIONS. MIAMI SHORES,FL 33138 AUTHOR¢eb RES fax(305)-758-8972 ®1 6 040 ACORD CORPORATION. All rights reserved. ACORD 26(2010!06)OF The A D rmme and logo are registered marks of ACORD G «- 2g4 r TL- is - 7�3 „�. Miami Shores Village d 10050 N.E.2nd Avenue NE � Miami Shores,FL 33138-0000 Phone: (305)795-22044g ;,. y Expiration: 0610412016" Project Address Parcel Number Applicant 326 NE 92 Street 1132060136470 Miami Shores, FL 33138- Block: Lot:” INTER-TEN LLC Owner Information Address Phone Cell INTER-TEN LLC 6187 NW 167 Street (305)842-8745 HIALEAH FL 33015- 6187 NW 167 Street HIALEAH FL 33015- Contractor(s) Phone Cell Phone Valuation: $ 200.00 ALADDIN PLUMBING&CONSTRUCTI (305)758-6246 Total Sq Feet: 0 Type of Work:DISCONNECTING PLUMBING AND RECONNEC Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Retum: Final Classification:Residential Scanning:1 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $0.60 Invoice# PL-12-15-57907 DBPR Fee $2.25 12/07/2015 Credit Card $109.10 $50.00 DCA Fee $2.25 Education Surcharge $0.20 12/01/2015 Cash $50.00 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $0.80 Total: $159.10 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: Icertify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. F or I authorize the above-named contractor to do the work stated. December 07,2015 Authorized gnature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 07,2015 1 � t Miami Shores Village � Building Department DEC 01 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION UNE PHONE NUMBER:(30S)762-4949 FBC 20N BUILDING Master Permit No. Fm_IS-o��Oc1 PERMIT APPLICATION Sub Permit No. FL IS-a99,3 ❑BUILDING ❑ELECTRIC ❑ ROOFING [j REVISION ❑EXTENSION ❑RENEWAL .PLUMBING F-1MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF ❑CANCELLATION (] SHOP 77�F ��{{ �} n CONTRACTOR DRAWINGS /� JOB ADDRESS: �//a /" l; 7 O� .5✓'"' � City: Miami Shores County: Miami Dade Zip: 33 l.? Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER Name(Fee Simple Titleholder)L o—L scs v, i--w 0 i 1 N4CV+k&,, I I C. Phone#: Address: V-1 �, City: 1 k a<,,u"I State: Zip: Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name:� ��//(J ���/�/ D /V Phone#:3©S ��� Z46 Address: City: A-ZfState: Zip: wo Qualifier Name: E=j- Phone#: State Certification or Registration#: L•-�''~ Certificate of Competency#: DESIGNER:Architect/Engineer. Phone#: –2— Address: City: State: Zip: Value of Work for this Permit:$ 7ib 0. 06 Square/Unear Footage of Work: Type of Work: ❑ Addition 14 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: l4 CY1i� V s C Specify color of color thm We: Submittal Fee Permit Fee$ sU y CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$i0 (Re,iseaoz/ia/Zoia) Goading Company's Name(if applicable) Bonding Company's Address qty 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 Hen 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 Signatu NER r AGENT CONTRACTOR The forego!VsZtrument was acknowledged before me this The foregoing instrument was acknowledged before me this SO day of OC-' lez- 20 ( 5 •by ;;26 day of 0 C'/7— .20 by who is personally known to 0 CST Sens ,is personally known to me or who has produced AJ O.17t as me or who has produced v/ as Identification and who did to an oath. Identification d who did take an oath. d'`:�'•`: - LEg1.EYNIGUtrS. NOTARY P C: * * WC=ffM1FFMM NOTARY PUB • ss�'y'� l9N S:J=9,2019 : Jose Lu6'891 o $�aoa`*! Boa�lAroBu�llN�ty8a11�! MY�MASSWFF914315 Sign: Sign: 6xphesON31/2019 Print, V. Print: 70i Seal: a�'"." VARIMS Seal: s « MYC0MfdI.R81 #FF2= AM �oEXPIRESJa9,2019 640** APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r CFN:20150610705 BOOK 29786 PAGE 815 IN WITNESS WHERM first party has WSW and sealed these present the dale set Rdb above. Signed,sealed and delivered in the prestarice op U.S.Book NA,Successor Trustee to Biutk of Amcriciy NA. Successor in Interest to LaSalle Bank NA,as Tnotco,on Behalforthe Rattlers of the Washington Mutual Mort8iigc ]� Pass-Tluvugh Certificates.WMALT Series 2006-AR9 -/off'/.S` W i fly.s sigitntarc I'ririt I : utters, C01*01 of er Truces Venders nden.DM GM*W Officer Select ortdutia Servicing Ina !'roti icitn n Attorney-in-fad 3815 SW Temple Street.Salt Lake City,UT 84 114 Witness stwe (Corporal •8 I'dw witness name ��•••• � � n State of Utah (booty or Salt Luke % t'HP l'URE(iOING INSTRUMI:N7'tyns ncknowlet(ged imrore ine this . day of f!i^5L.54 _ OTAA 201 S.by Julee MVlettM,6;c.Control 0MW ofS-feet Portfolio Servicing,Inc.,arc Aflunicy-ill-Fact for U.S.Bank NA,Successor Trustee to Bank of Atncrhx,NA,Successor in Interest to LaSalle Bank NA,as Tritstee,on 16niror the Hnitierb of file Wasiiington Mutual Morig;tp Pass through Certificates,WMALT Series 2006-AR9, who is personally known to the or who has producer) valid driver's license as iderdification. -�� 'p Notary Public Tworspencer Print Notary Nmim My Cotninission Exptres. I 1/-/Z.oI Notary Sea! TREVOR SPENCER Notary Misr Store of Utah MY Commission E*rm on: November 07,2018 Comm Number:680187 01:1.0•!yxciw wtsrattty JXVd-CuTmac 1rioc 2 ore CFN:201 W610705 BOOK 29786 PAGE 814 DATE:09/22/2015 12:06.47 PM DEED DOC 2,712.00 HARVEY RUVIN,CLERK OF COURT,MWDADE CTY Prepared by and Roturm to: Genesis Title Company Danielle Acosta 1140 Kyle Wood I ane 8tandon.Florida 35311.4931 Our File Number:0215192 For official Hse by Ckr ',s oiliee only STATE-OF WAR ) SPECIAL WAIUtANTY DEED COUNTY OF SAL•1'LAKE ) (Cuiporate Sclier) ) THIS INDLINITURE,made this IR j day of A4My&#_ .2015,beiweom U.S.Bank NA, Su"v=r Tnwn to Baht of America,NA,strecossor in i Lasalla Bmuk NA,us TnoWe,ort Behalf of de lioidersof the Woshatgton Mutual Mortgage Paas-Thtowlt cem icmcs,WMALT Sories 2006-AR9,a notionai bw*ing ammiaiion organized and wdslhtg under the laws of due United States of America,whose malling address is:381 S Soudtwest TerMIc Street,Suit take City,Utah $4114. party of tie first part and Inter-Ten LLC,a Florida Limited Liability Company,whow mailing address is:6187 NW 167th St STEH9.Hialeah,FL 33015,party/panles of the second part, )I I NE6SETFL Firm parly.rut:urd in considcnuion of the sum of TEN WI.I.ARS(l;10.00) and outer valuabic considerations.recegx twhereuf is in:reby acknowledged,does hereby grant.bargain,soil,aliens,remises,releases,txntveys and confirms unto second Parry/parties,hisAter/their Itcirs ural assigrsc tin;following described property,to wit in she Cotuuy of Mlams-Dade.State of Florida. Lot 10 and Ute west 112 oi•Lot 9,in Block 48.AMENDED PIAT OF MAIMi SHORE'S, SECTION ONK,according to the plat thereof as recorded in Plat Hook 10,Page 70,of the Public.Records ofMiatni-Dade County,Florida Parcel ID: 11-3246-013-6470 Subject,honrever,to all Covenants,conditions,restrictions.re ervasium limitations,casements and to nil applicable zoning ordinances and/or resu ictions and prohibitions imposed by goveminwsl authorities,if any. TOGETHER with all the tenements,herediteatents and appurtemmca thereto belonging or in anywise appertaining. TO HAW AND TO HOLD the sane in fee simple forever. AND lite parry ofthe first part hereby covenants with said party otfdte second pan.that it Is IawNUy seized orsadd land in fee simple dint it Ins good right and Iawiltd authority to sell and convey said land;tint It hereby fully warrants Ute title to sold land and will defend the same against slue lawful claims of ail persons cleaning by through or under the party of the first pan. UF.FI)-Stwud Warraay Iked-Ctxtnaate nage t art STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MENESES, ORESTES FELICITO ALADDIN PLUMBING&CONSTRUCTION CORP 660 NW 121 ST STREET NORTH MIAMI FL 33168 Congratulations! With this license you become one of the nearly one minion Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPARTMENT.:OF BUSINESS AND and they keep Florida's economy strong. PROFES§10NA IGULATION Every day we work to improve the way we do business in order to CFCO26527 U 10/01/2014 serve you better. For iriformation about our services,please log onto 9 www.myfloridaliceFoo.com. There you can find more information CERTIFIED PLUWr". "00S. BAR about our divisions and the regulations that impact you,subscribe �.1 to department newsletters and learn more about the Departments MENESES,ORW initiatives. ALADDIN PLUi0k4,*5`,- w! NCO Our mission at the Department is:License Effic lentiy,Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the-provisions of Ch.488 FS. and congratulations on your new license! aura;nuc 31,are L14100100025M DETACH HERE Rlr,"C0-rT,--G-OVERNOR-` - - - Y STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFCOM27 The PLUMBING CONTRACTOR `. Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31,2016 - =, o, ;o MENESES, ORESTES FELICI f ALADDIN PLUMBING&bdA&RUCTtON CORP 1 4595NJEFFERSON AYIT � " MIAMI BEACH ` . 140e • e ISSUED: 1 Oro1/2014 DISPLAY AS REQUIRED BY LAW SEQ# L141W10002588 locallTm Ra a Miami—Dade County, State of Ftoria —THIS IS NOTA BILL — 00 NOT PAY 7161612 1\ILBTI/ SUWVHSS N"En OCAT ON &= Recaurr NO. EXPIRES ALADDIN PLUMBING&CON)TRuerloN 6 g MAL SEPTEMBER 30, 2416 674 NW 112 ST 7438488 Must be displayed at place of business' MIAMI FL 33168 Pursuant to County Code Chapter SA-Art.9&10 OWNER SEC.TYPE OR BUSINESS RECEIIIED ALADDIN PLUMBING&CONSTRUCTION~LUMBING COMPACTOR, BY TA NTx� �LLECTOR C/O ORESTES F MENESES FRES CF0026527 Ta w0dwr(s) 1 $825010/13/2015 CREDITCARD-16-001727 TMa Lgoef-Basiaesa;ar I�eipt� oaf�#�1 Tax.Tire RecaipZ is�t a , � :aft ara�rerHHeatbraafft11 s otodp Nsbbxr my 2 ry t�rV ,apply�tbab T6sREI:M N&SbM M"1 &ph*W on all MMMONVOMOWS— Cele Sec Sa-278. For�►ebdioa.rit - ACMDr CERTIFICATE OF LIABILITY INSURANCE DAA 11�4f15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS filo MGM UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND ORA�.7�i THE COVERAGE AFFORDED BY THE POLICIES BELOK THS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING WSURER(g).AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. BAPORTANT: N the cedWstaft holder Is an ADDITIONAL DU WJA the pollay0m)must be emtoesad.Lf SUBROGATION IS WAIVED.StibiOdto th$Wmwtdcondt0matthopok7.cwtdnpoMwmityroWroanondonmoft A statemeid on thla cemicate does not comer rWft to the certi[leato holder In Beu of such mWorsernerA4 PRS YANET PADRON Akw Irmrwm Sa%ioM Iter 6333781 Not mum 2WI N.W.27t1t Ave. 1®wL=n Mistid.FL 33142 ° Phone 633-SM Fax M 633.0826 a: SCOTTOALE MUROANCE COaBPAWY INSURED ALADDIN PLUMBING&CONSTRUCTION CORP. 680 NW 121$t Mini,FL 331M PM 7W4174 F• F• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.HOTINITHSTANDIN3 ANY REIT.TERM OR CONDITION tom'ANY CONTRACT'OR OTHER DOCUMENT WITH RESPECT TOVi HIGH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCWSIONS AND CONDITIONS OF SUCH POLICIES.Lfr'rs SHAWN MAY HAVE BEEN REDUCED•BY PAID CLAMS. TYPE OF I POLICY N LIMITS Q9NERAL UamurY s 1000 00WOD ® COMMERCIAL GMERAL UABILtrY $ 100,000.0D A ❑ ❑ ty.alaISMAW W1 CPS1940548 MEDEXP ae s 8,000.00 02'1015 0ua1►zme 7L PERSONAL&ADVINARY S 1.000. OD.00 ❑ GENWtAL AGGREGATE s 000 oDD.00 GOMAGGRECATELIWAPPMPM PRODUCTS-COMPXPAW S 110M.W0.0D ❑ MACY ❑ M ❑ Loc $ AUTOMOBILE LIABILITYC] ANY AUTO RiN Lei BODILY wJRy war;Beeonl 8 ❑ ALL OWNED S AUTO ❑ SCHEDULED .YNAIRY(Peraask ❑ HIREDAUTOS ❑ s S ❑ UMBRELLA Lw8 ❑CC= EACH OCCURRe4CE S 13 Mom Lm AGGREGATE S 11 ow E] mmmms S VIORI(ERSOOMPENSATION 0VifCST AND EMPLOYEWLIABILITY YIN ANY PROPRIET'ORJP�A� IYE NIA '• E.L.EACH ACt�FJdT $ ❑ Et..DWEASE-EAI LOYE S KTIONS b0aw E.L.DISEASE.POLICY LNYgT S DESCRIPTION OF OPERATIONSIWCATIM (A Ch ACORD 101,AdMOW ReMeft SCbKkftIf simespace to requftdl PERSONAL AND COMMERCIAL PLUMBING CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE ABED POLICIES BE CANCEIJUM BEFORE MIAMI SHORES VILLAGE HALL THE TION DATE Tom,NOTA WML 13E DELIVERED IN WITH IM POUCY 1 ODS 2nd Avenue, MIAMI SHORES,FL 33138 AUTMORIZEDREIntESENFATME ®1888 10 TION. AI d"reserved. ACORD ZS{Z016105)OFThe FORD mW logo we registered nmtfks of ACORD i, i• .MFF ATMTEIt CHIEF FVL4XCL L OFFICER STATE OF FLORIDA DEPARTMENT OF FIAT.SERVICES X11 OF WORKERS'COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORA WORKERS't ATKSN LAW" CONS71RUCTION OWUSTRY EXEMPTION Tt4s=NOS VW to kWM&W lNed bebw has egad m be mmmpt ftm Fbrkta Workers'Cion low EFFECTIVE DATE« 2117/2015 EXPIRATION DATE: 218/2017 PEROW. MENESES ORESTES F FEIN: 850918482 BUSINESS NAIL AND ASS: ALADDIN PLUMBING&CONSTRUCTION LLC 874 NW 112 STREET MIAMI FL 33188 SCOPES OF BUSHWAS OR TRADE: LICENSED PLUMBING PLUMBING NOC AND CONTRACTOR DRIVERS P<p=W to Cfwtor 440.x(14},F.S.,an olft w of a ampomoat vdm eMft aamtVft hn thb►art ow by Sbg a awe of ebtclrt underthbt seat nW not reaor+w bertha oraalip liffmt undwthb ab#s.Puttwd to Chsow 440A%lA F.S., afeb oda►to be amnWt...W*only w tthaswwofdwbudn9=orftde@*donthe muclefebeftnimbeaemr1tfM=wdto(hapta44DAR14F.&,Nobnofebolonfabe mmmPt and OOMOO sof ebto0on to ba amain dM be aL*d th wiocabon If,at ww than actor the MM ofthe raHoe orthe bmmmcfftowdftaft. the Person rmmed on tha rtofioe oroerVl=W no W lilldwmqukwnwftofvft,l aort for momm of a m iffi l ads.The cbI ranee a DF8*2 Dwr,252 CERTIFICATE OF FLECTION TO BE EXEMPT REIASED 08-13 QUESTIONS?(WW13-1IW ALADDIN PLUMBING 6 &COWRUMON,INC. G6O NW 121st Street North Miami,Florida 33168 (805)7586246 Date• oZ / .� I' State of_ ��IJRd County of Before me this day personally appeared i— /Y}td A1+e5�'S a/ 31 PS who,being duty sworn,deposes and says: That he or she will be the only person working on the project located at: 3 2 Gn A1I--� !1 a s Sworn to(or affirmed)and subscribed before me this date of_ 6Z 20 Eby Personally know---!:::/- Of Produced ldentification Type Identification Produced Print,Ty or Stamp Name of Notary CD AAD ) Notary Public stets of Florida Jose Luis Saladin F; -= My Commission FF$14315 EW3112019 OR1E,s Iun nm Miami shores Village Building Department �tpR�pA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Aa4 (� �'" p' E�'�! Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption 77 T . r 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. f1. 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: wn r State of Flori County of Miami-Dade The foregoing was acknowledge before me this day of ,20 t� . By t—Q`kz SGgt e ` who isersonally lc�igxn to me or has produced IJ as identification. Notary: *°sem';' yh+ gS1�t FFi 2 * * S:�upea�2019 SEAL: gaT►mti