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RC-16-636 Miami Shores Village ti 3� Building Department MAR 16 's 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY: r Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 SA14 FBC 20 I`--t �� BUILDING Master Permit No.gG 1 PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP n �t�A� CONTRACTOR DRAWINGS JOBADDRF.SS: 3 rS o �v I I &S City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Su� it--) ,f�C n • Phone#: Address: ` _�w I I 14' &V- City: /'u(i+�y S «S State: Zip: ^�` Tenant/Lessee Name: Phone#,%S LO _3 Email: CONTRACTOR:Company Name: WAIA / Phone#: Address: Cti (- City: KI'0,,%j Statte: ll el Zip:: 'f�` 3� Qualifier Name: �!(n % ic�'vti Phone#: }7 QS 7& q 0 r G State Certification or Registration#: 1 C "1 61c, Certificate of Competency#: DESIGNER:Architect/Engineer: J uC"A &% CZ— ,�,.AA Phone#:{{%` r� t j �p rq7 Address: �� ~� v�-' City: @��K4Mj State: F 1 Zip:_LSl r r Value of Work for this Permit:$ D Square/Linear Footage of Work: Type of Work: � Addltion ❑ Alteration 2<New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru We: Submittal Fee$ C� Permit Fee$ ( CCF$ CO/CC$ Scanning Fee$ '• Radon Fee$ 6Z� DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ a • Bond$ TOTAL FEE NOW DUE$ "t� ` -90 (Revised02/24/2014) p � Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING; SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature OWNER or AGENT CONTRACTOR The foregoing in rument was acknowledged before me this The foregoing instrument was acknowledged before me this day of mdl�w '20 1 (, .by 49 day of �+ � ,20 It .by u 0&- J who is personal)//y known to Q...r �e tX:✓% ,who is personally known to me or who has produced ice`&,D�!lWi "620- as me or who has produced tom.- V�iAwe,rs [�;ce�.ge as identification and who did take an oath. identification and who did take an oath. NOTARY P BLIC: NOTARY PUBLIC: Sign Sign. �. Print l.C_ Print: A6-z 6 Seal: ¢kA�� 7 ell Seal: �_ COMMISSION#FF22S731 ° Publiciofd Fla �- Commis�or�FF 1407 EXPIRES: Jury 1�7, 2019 wiNwAARONNOTARY.COM r APPROVED BY Plans Examiner Zoning Structural Review Clerk U. (Revised02/24/2014) sell mun Miami shores ilia e . Building Department �l®g 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 Notice to Owner - Workers' Compensation Insurance xem tion 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 CONT S. Signa Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this , �•- day of .VC ,20_L� BY ��i In DI( s��earl who is personally known to me or has produced "'ibv�� �ckt i GZrIfL as identification. ` �� 1� � ¢,�, UIrt#S$ell � No =$' x COMMISSION#FF22M731 5a� = EXPIRES: July 17, 2019 SEAL: ''� .' V wiV.AAR0%N01NVy,QOM GOLDIN Contractor Affidavit for Miami Shores Village 3/10/2016 State of Florida County of Miami Dade Before me this day personally appeared IZIwho,being duly sworn,deposes and says: That he or she will be the only person working on the project located at: W ll lS I. /A4C ; SL.a res Sworn to(or affirmed)and subscribed before me this: d day of .20 lir .by fv i Personally know Or Produced Identification V/ Type of identification4- .d" t, Print,Type or Stamp Name of Notary ALBXCASnU.0 fA Mot y Pdft Sbb of Raft Cone�iont FF 140708 My comm.son J*1%2018 Inspection Worksheet Miami Shores Village 1/ 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)756.8972 Inspection Number: INSP-256879 Permit Number: RC-3-16-636 Scheduled Inspection Date:April 15,2016 Permit Type: Residential Construction Inspector. Naranjo,Ismael Inspection Type• Final Owner: JULNOR JEAN,JOSEPHINESIMEON Work Classification: Solar Job Address:375 NW 111 Street Miami Shores,FL 33168-3303 Phone Number Parcel Number 1121360010760 Project <NONE> Contractor. GOLDIN SOLAR,LLC Phone: (305)469-9790 Building Department Comments SOLAR PHOTOVOLTAIC TIED TO GRID Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed lzr CREATED AS REINSPECTION FOR INSP-254469. Failed Correction � r-- Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid April 14,2016 For Inspections please call: (305)762-4949 Page 21 of 31 Miami Shores village 10050 N.E.2nd Avenue NW Miami Shores,FL 33138-0000 Phone: (305)795-2204 ` . `FAY Expiration: 212016 Project Address Parcel Number Applicant 376 NW 111 Street 1121360010760 Miami Shores, FL 33168-3303 Block: Lot: JOSEPHINESIMEON JULNOR JE Owner Information Address Phone Cell JOSEPHINESIMEON JULNOR JEAN 375 NW 111 Street MIAMI SHORES FL 33168-3303 Contractor(s) Phone Cell Phone Valuation: $ 5,000.00 GOLDIN SOLAR,LLC (305)469-979 Total Sq Feet: 0 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Solar Type of Construction:SOLAR PHOTOVOLTAIC TIED TO C Occupancy:Single Family Review Electrical Stories: Exterior Review Building Front Setback: Rear Setback: Review Structural Left Setback: Right Setback: Bedrooms: Bathrooms: Plans Submitted:Yes Certificate Status: Certificate Date: Additional Info: Bond Return: Classification:Residential Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.00 Invoice# RC-3-16.58974 DBPR Fee $2.25 DCA Fee $2.25 03/10/2016 Credit Card $50.00 $247.50 Education Surcharge $1,00 03125/2016 Credit Card $247.50 $0.00 Permit Fee $150.00 Pian Review Fee(Engineer) $120,00 Scanning Fee $15.00 Technology Fee $4.00 Total: $297.50 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: that all the foregoing information Is accurate and that all work will be done in compliance with all applicable laws regulating construction and N n eriaai above-named contractor to do the work stated. JL March 25,2016 Autho gn re:Owner / Applicant / Contractor / Agent ate Building Department Copy March 25,2016 1 ■•� GOLDSOL-01 JVELAZOUEZ AC`®Rl7" DATE rrrrl CERTIFICATE OF LIABILITY INSURANCE F8119/2015 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 ate holder Is an ADDITIONAL INSURED,the pol)cy(les)must be endorsed. M SUBROGATION IS WAIVED,subject to the terms and conditions of the Policy,certain policies may require an endorsement. A statement on this c wWk=W does not confer rights to the ow Mcate holder In lieu of suchPRODUCER CONTACT eredorsemere�s). NAI: 151 MSN lett Avennue�LLC PHONE •(561)226-7676 F me•(561)450.6617 Defray Beach,FL 33444 A I RM)AFFORDING COVERAGE NMC S INSUREIt A..Scottsdale Insurance Company 41297 INSURED Sia: Goldin Solar,Be c. Daren Goldin 3477 Percival Ave o Mland,FL 33133 INIKIRERE: NSF: 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. ADM POLICYEFF POLICY EXP em LTR TYPE OF POLICY Nth LAR S A X ComriERCIAL oEMERAL Lamm EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 0 OCCUR V14SM43 0911111A15 091111=6 pREM�EgitlffRowurrerge) $ 100,000 MED EXP(Any one person) $__ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLES PER: GENERAL.AGGREGATE $ 2,000,000 POLICY 0 JPEF'COT- F-1 Loc PRODUCTS-C OMLPIOPAGG $ 11000,000 Oma; DED 500 $ AUTOMOSM LlA9LLrY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SC BODILY INJIAIY(Per a $ AUTOS HIRED AUTOS PEITI rlL AMAGE $ $ UMBRELLA LIAO OCCUR EACH OCCURRED $ EXCESS LIAB S-MADE AGGREGATE $ oEo REII'ITION$ $ �^ wcouamcoxpEMTM AND I3114LOYERS'UABLI Y Y IN STATUTE ER ANY rOR1P�� ❑NIA E.L.EACH ACCIDENT $ (Y ry in NLI E.L.DISEASE-EA EMPLOYEE O $ under OF OPERATIONS bebw ELL DISEASE-POLICY LIMIT $ DESCRIPIMOIFOPERATIONSILOCAMNS/VEFHCi ES(ACS 101,AddWwW RettHece Schedu1%map be aftelood N more space Is te*dmM Solar Contractor License Number:CVC56M CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores BLDG DEPT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave. Miami Shores,FL,33138 AUTHORIZED rATNE 01988-2014 ACORD CORPORATION. All rights reserve& ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax:(305)756.8972 CONTRACTORS' REGISTRATION, IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A._COPY OF QUALIFIERS STATE LICENCES B.-COPY OF LOCAL BUSINESS TAX RECEIPT C.----COPY OF LIABILITY INSURANCE* D.-COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. _ COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTORS TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E, COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: E;-r0- r- LL r_ BUSINESS ADDRESS: 3 4 44 Of.re i JQ Avf-. CITY t�%AA�% STATE. 33t,33 BUSINESS PHONE: FAX NUMBER( . 06- CELL PHONE(-3 I '((Pq- 144 0 QUALIFIER'S NAME: ;>gCe-tA C-o keUVN QUALIFIER'S LIC NUMBER: C-ye- 5(o (0 57 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION �� sF CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 '':A�nw�z 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 GOLDIN. DAREN TAL GOLDIN SOLAR; LLC 2251 SW 27TH ST,APT 7 MIAMI FL 33133 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range =:j`y ._ STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants. f` DEPARTMENT OF BUSINESS AND and they keep Florida's economy strong. PROFESSIONAL REGULATION Every day we work to improve the way we do business in order to CVC56965 ISSUED: 12/21/2014 serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information CERTIFIED SOLAR CONTRACTOR about our divisions and the regulations that impact you, subscribe GOLDIN, DAREN TAL to department newsletters and learn more about the Department's GOLDIN SOLAR, LLC 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, IS CERTIFIED under the provisions or Ch 489 Fs. and congratulations on your new license! Expiraliondate AUG31.2016 1141221000083; DETACH HERE RICK SCOTT, GOVERNOR KEN LAWSUN, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CVC56965 The SOLAR CONTRACTOR Named below IS CERTIFIED Under tpe provisions of Chapter 489 FS- Expiration date: AUG 31, 2016 0 GOLDIN, DAREN TAL GOLDIN SOLAR, LLC y 2251 SW 27TH ST APT 7 MIAMI FL 33133 . 0 . . ISSUED: 12/21/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1412210000837 002027 - — Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY LBT 7180108 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES GOLDIN SOLAR LLC RENEWAL SEPTEMBER 30, 2016 3447 PERCIVAL AVE 74604448 Must be displayed at place of business MIAMI FL 33133 Pursuant to County Code Chapter SA—Art.9&10 OWNER SEC.TYPE OF BUSINESS GOLDIN SOLAR LLC 196 SPECIALTY PLUMBING CONTRACTOR PAYMENT RECEIVED C/O DAREN T GOLDIN MGR CVC56965 BY TAX COLLECTOR Worker(s) 1 549.50 10/19/2015 CREDITCARD-16-002202 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 Sa-276. For more information,visit www.miamidade.govftaxcollector •�"""'"} GOLDSOL-01 JVELAZQUEZ CERTIFICATE OF LIABILITY INSURANCE °A811912015 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: N the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. Ii 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 certificate holder in lieu of such endomement(s). PRODUCER CONTACT Research Underwriters LLC PHONE 151 NW let Avenue 561)226-7676 arc NO:(561)450$617 Delray Beach,FL 33444 ADD , INSU S AFFORDING COVERAGE MAIC# INSURER A:Scottsdale Insurance Company 41297 INSURED INSURER 8: Goldin Solar,III: INSURER C, Daren Goldin �� D 3477 Percival Ave Miami,FL 33133 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 NTH 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. LTR TYPE OF INSURANCE POLICY NUMBER POLId EFF Y tD� LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 145722-8 09/01/2015 09101=16 pREM18TEsENN 11517nce $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JEC LOC PRODUCTS-COMPiOPAGG $ 1,000,00 OTHER: DED 500 $ AUTOMOBILE LIABILITY COMBINED SIN E LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL AUTOS SIMNED SCHEDULED BODILY INJURY(Per accident) $ NON-OHIRED AUTOS AUTOSVNN6D Peer ao Rte) E $ UMBRELLA UAB L]OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSA71ON PER TH- AND EMPLOYERS*LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTiVEE.L.EACH ACCIDENT $ OFMCERIMEMBER EXCLUDED? N 1 A (MaandOM In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMiT $ DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached B nore apace M re*dmd) Solar Contractor License Number.CVC56965 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village BLDG DEPT THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave. Miami Shores,FL,33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD JEFF ATWATER CHMF FINANCIAL OFFIM 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 lndiMual Bated below has elected to be exempt from Flow Workers'Compensation law. EFFECTIVE DATE: 12292014 EXPIRATION DATE: 1212802016 PERSON: GOLDIN DAREN T FEIN: 465028211 BUSINESS NAME AND ADDRESS: GOLDIN SOLAR LLC 2251 SW 27TH ST.APT.7 MIAMI FL 33133 SCOPES OF BUSINESS OR TRADE: ELECTRICAL WIRING ROOFING-ALL KINDS WITHIN BUIL AND DRIVER Purauwd to Cheow 440.05(14)F.S.,an ordcer of a toorporalmn who ateft a onq*m tiara this by tag a e or umierthis aectlaot may net reoaver bene ar carmen under fids Pursuant faC.hepw 440.05(1 ,F.S.,Cam of ebcuon to be e'' p'..apply" wMMthe scope otthe buehress artrade etsd an the rrotkos at elecdm to be exempt.Puraumd to Chapter 440.05(13),F.S..Notkm at elBdion to be exetn1, smoomrafteafelecumtobe exempt dO be to reroco*m ffat any em after the titbg orft rxdice ar th tmrenoa attire oarf a, ttre person nerved on the rxdioe ar area no kx W meets the mpdreMft of ttds oectmn tar issuafuos at a tea.The d9pmb ft dW revoke a DFS-F2AW-2W CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609