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RC-14-2640 (3). ra 01 Miami Shores Village I c Tv L Building Department L ;D4C4 4 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 �1 . Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20� BUILDING Master Permit No..-R Q_j - 9-04-0 PERMIT APPLICATION Sub Permit No. 12?,BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP jj CONTRACTOR DRAWINGS JOB ADDRESS: t a Z 'N� O T Com: Miami Shores County: Miami Dade Zip: Folio/Parcel#: l 1 ?,13G n t o oo kc) Is the Building Historically Designated:Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): O 0 _T�v LLC Phone#: Address: P 0 W1, LIE�035k3 k-'_RY 12-s iSCf,�I`l City:. �LS ' Q QW State: _T O_OQ lb n Zip: 3 I y(2s Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Phone#: Address: oS� IASI) t?2-0y City: t4 IJ1-c State: CY3 Zip: '331 &Z Qualifier Name: 0 lc�O c �-- --T- �'- Phone#: -2&6 333 92-48 State Certification or RegistLation#:CC= /S l a3 J "3 Certificate of Competency#: DESIGNER:Architect/Engineer: V nkA \QAA� Phone#: L�?)Cz> 80ass ss Address: S Co Z no City: H C 0 tic Stater L Zip:33 ( U y °Sap y/+ Value of Work for this Permit:$ �.�o�(`Z!`1 � Square/Linear Footage of Work: �1.6�1 4 c5 T e of Work: ❑ Addition Alteration yp � ❑ New Repair/Replace El Demolition Description of Work: Specify color thru tile: P fY color of Submittal Fee ° W Permit Fee 0 °(� CCF 8-V CO CC $�'0 s s3 / sem°CM Scanning Fee$ J to -Ob Radon Fee$ (0 ° 7 5 DBjP-R$ 10° 35 Notary$ S. Technology Fee$ I V°IfV Training/Education Fee$ �I Double Fee$ Structural Reviews$ Lo Bond$ 57 TOTAL FEE NOW DUE $ 1-3 (:) (Revised02/24/2014) n �1 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. 1 certify that no work or installation has II work will be performed to meet the standards of all laws regulating commenced prior to the issuance of a permit and that a p g g 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 livered to the person promise in good faith that a copy of the notice of commencement and construction lien law brochure will be de p whoseroPe►'IY is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site P 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 rei ection fee will be charged. Signature Signatur OW GENT CT R The foregoing instrument was ac edged before me this The foregoin ent was ackno dged efore a this —�— day of alp6e2 ,20 1 Li ,by day of 20 A • by e_ who is personally known to C who is personally known to p y me or who has produced N�A as me or who has produced , lt as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Print: A e= n ADRIAIN/A KAflAABE n ary Public State of Flow Seal �'� • , Se a Joanna M Feliciano ='s �': MY COMMISSION#EE136658 Hca no�9 Mycomm* FF 082783 EXPIRES October 09,2015 ExAires 01/12/20�8 (407 39&0133 Floriclalloteryowyloa,com PTI ; APPROVED BY Plans Examiner l Zoning Avk� 1) Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CGC1519353 ISSUED'" 08103/2014 CERTIFIED GENERAL CONTRACTOR G OMEZ,CARLOS E LANDA ENTERPRISES CORP IS CERTIFIED under the provisions of Ch.488 FS ExPrgLaidate=AUG 12016" n L1408030003489 N i L!C f. Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY LBT -.,/ 6616701 BUSINESS NAMEMOCATION RECEIPT NO. EXPIRES LANQA ENTERPRISES CORP RENEWAL SEPTEMBER 30, 2015 857 NW 122 AVE 6887195 must tre iispiayed at piace of business MIAMI FL 33182 Pursuant to County Code Chapter 6A-Art.9&10 OWNER SEC.TYPE BU NESS 196 GENERIBU1 ING CQNTRAGTOR PAYMENT RECEIVED ,_;NDA ENTERPRISES CORP BY TAX COLLECTOR Worker(s) 1 CGC1512669` X75.00 08/21/2014 CHECK21-14- 052676 This Local Business Ta Receipt only confirms payment of the Local Business Tax. The Receipt is not a license. permit,or a certificadaoithe holder"squalifications,to do business. Holder muni comply with any governmental or nongovernmentalreittiatory laws and requirements which apply to the business. The RECEIPT N4.above must be displayed on all commercial vehicles—Miami-Dade Code Sec 8a-276. For som kdo mation,visit INwm4Wida4e g ugglteetor ° ' ` ' `� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 11 126114 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. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT MIRIAM First Insurance Group PHONE (305)221_7878 FAX LM.No. AIC No• (305)554-7090 10967 SW 40 St -RWL miriammesa@aol.com Miami,FL 33165 INSURERS AFFORDING COVERAGE NAIC S Phone 305)221-7878 Fax 305)5547090 INSURER A: REPUBLIC—VANGUARD INSURANCE COMPANY INSURED INSURER B: LANDAENTERPRISES CORP INSURER C: 857 NW 122 Ave INSURER D: Miami,FL 33182- 305 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. ILTR TYPE OF INSURANCE ADD UB POLICY NUMBER MMMILDIDNYYYY MMMILDDI ICY EXP uMlrs GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000.00 Q COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 100 000.00 PREMISES a occurrence $ A ❑ ❑ CLAIMS-MADE E] OCCUR Y 01/26/2014 01/26/2015 OCCUR PGL006229-14 MED EXP(Any one person $ 5,000.00 ❑ PERSONAL 8 ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000.00 ❑ POLICY ❑ PRO-SER ❑ LOC $ AUTOMOBILE LIABILITY INGLE LIMB a axi ent ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AALLLrOOWNED ❑ SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPER AMAGE $ ❑ HIRED AUTOS ❑ AUTOS Per acci� ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATIONElWC STATU- El OTH- AND EMPLOYERS'LIABILITY Y I NLIMS ANY ROPj1A ETORARTNE PRIEMBER IEXECU71VE NIA E.L.EACH ACCIDENT $ IC,(Mandatory in NH) ❑ E.L.DISEASE-EA EMPLOYE $ If g;describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) GENERAL CONTRACTOR LIABILITY Q00116wS A CERTIFICATE HOLDER CELLATION 1 zAHOULD ANY OF THE ABOVE DESCRIBED PO IES BE CANCELLED BEFORE MIAMI SHORES VILLAGE ^� THE EXPIRATION DATE THEREOF NOTICE VOLL E DELIVERED IN ACCORDANCE WITH THE POLICY R S BUILDING DEPARTMENT 10050 NE 2ND AVENUE, AUTHORIZED REPRESENTATIVE MIAMI SHORES FLORIDA 33138 ©1988-2010 ACORblciw N. All rights reserved. ACORD 25(2010105)QF The ACORD name and ogo r egistered marks of ACORD r' JEFF ATWATER STATE OF FLORIDA CLEF 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 cerdfm that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 2/15/2013 EXPIRATION DATE: 2/1512015 PERSON: GOMEZ CARLOS FEIN: 271031945 BUSINESS NAME AND ADDRESS: LANDA ENTERPRISES CORP 857 NW 122 AVE MIAMI FL 33182 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exernption from this chapter by ffift a certificate of election under this section may not recover bene8ta or cocnpensetion under this chapter.Pc suM to Chapter 440 05(12).F.S.,Cerdftdes of election to be exernpf...apply only within the score of the bis or trade meted at the notice of election to be exernpL Pursuant to Chaps 440.05(13),F.S.,Nolloes of election to be exempt and owncates of election to be exwnpt shall be subject to n K.at any tim atter the ftg of the notice or the issuance of the Vie. the person named on the notice or certificate no larger meets the requkernents of this section for Issuance of a certificate.The departm ft shah revoke a DFS-F24DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)413-1609 Ar n Mi Mi Shores village Building Department �pR1pA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305)756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company. Therefore,you may be personally liable for the worker compensation injuries 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 �p ��t Contractor Print Name ww'C Tr.�.LC- .SIX 'iFT 1 Print Name 1Z. S '6. •Z Signature: Signature- 01 11 1 rh 0009 State of Florida) State o orida) 0 ;p o County of Miami-Dade) County of - ade) 9 a Sworn to and subscri — Sworn to d subs be ore o A N day of •WO"163 RIANA KAMBE day of 20 �--COMMISSION#EE136658ByAA015 BFlorMeNotery$eryft coin (SEAL) (SEAL) Type of Identification produced &&j2A21k rn T -ratification produced M� MIAMI-DADE COUNTY-STATE OF FLORIDA N/A October 15,2015 LOCAL BUSINESS TAX RENEWAL 6616701 2015 -2016 APPLICATION RECEIPT:6887195 STATE 0 CGC1512669 DBA/BUSINESS NAME: BUS.COMMENCEMENT DATE:04/01/2010 LANDA ENTERPRISES CORP SEC TYPE OF BUSINESS BUSINESS LOCATION: BLDG1 GENERAL BUILDING CONTRACTOR 857 NW 122 AVE 1 MIAMI,FL 33182 OWNERICORP. APPLICATION DETAILS LANDA ENTERPRISES CORP FEE AMOUNT PHONE 111786-333-5248 Receipt Fee 30.00 UMSA Fee 30.00 857 NW 122 AVE Beacon Council Fee 15.00 MIAMI,FL 33182 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 NAICS CODE: 2389 Transfer Fee 0.00 Doing Business without a License Penalty 0.00 Late Penalty 0.00 Collection Cost 0.00 NSF Fee 0.00 Prior Years Due 0.00 Amount Recently Paid TOTAL AMOUNT DUE: 0.00 ................................................................................................................................................................................................................................................................................................................. If no longer in business,please notify us In writing. To pay online go to wmmmiamidade.aov/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- i DETACH HERE AND RETURN THIS PORTION WITH YOUR PAYMENT j WA October 15,2015 STATE OF FLORIDA LOCAL BUSINESS TAX nmmppppA mmmn fl RENEWAL 2015 -2016 APPLICATION UU���I�II�I����UUI�IUU�IIII���WI�II RECEIE# 1 STATE 6616701 IIIIWI III �I BUSINESS LOCATION: u 857 NW 122 AVE MIAMI,FL 33182 BUS.COMMENCEMENT DATE:04/01/2010 SEC TYPE OF BUSINESS OWNERICORP. BLDG1 GENERAL BUILDING CONTRACTOR LANDA ENTERPRISES CORP 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 SMEAR THAT THE INFORMATION IS TRUE AND CORRECT. LANDA ENTERPRISES CORP 857 NW 122 AVE MIAMI,FL 33182 SIGNATURE REQUIRED SEE INSTRUCTIONS ABOVE Please pay only one amount.The amounts due after Sept 30th include penalties per FS 205.053. NReceived By Oct 31,2015 Nov 30,2015 Dec 31,2015 Jan 31,2016 Please pay $0.00 $0.00 $0.00 $0.00 7000000000000000000000006887195201600000007500000000000002 May. 21. 2015 1 :48PM THE FIRST INS. GROUP CORP No. 0852 P. 1 ` = � CERTIFICATE OF LIABILITY INSURANCE 1 DATEO5/21°"YYY' S121/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CI_RTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: K the certificate hoider is an ADDITIONAL INSUPAD,the pollcypes)must be endorsed. IT SUBROGATION 18 WAIVED,subJed to the terms and COntlitiorta or the pOiltyI certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder In 119U of such endorsement(s), PRODUCER ONT MIRIAM First Insurance Group P of (306)221.7878 N (305)654701X1 10987 SW 40$t pp'� mirlammesettol.com Miami,FL 33165 IN s APPORDWG COVERAGE NAICS PhOne 221-7878 Fox )554-7090INSURER A. UNITED SPECIALTY INSURANCE COM INSURED LANDAENTEINSURER BRPRISES CORP INSURER 5: 867 NW 122 Ave INSURER D: Miami,FL 33182- 305 INAIRER E: COVERAGE$ INSURER P CERTIFICATE NUMBER: REVISION NUMBED; THIS 18 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 tS SUBJECT TO ALL THQ TERMS, EXCLUSIONS AND OONDRIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INN TYPE OF INSURANCE AVD BR ROL�y����FF PO INS POLICY NUMBER M LOP - MOM IIMIT9 GENERAL LIABILrry oEAC OCCURRENCe 1,000,000,00 ® COMMERCIAL GENERAL LIABILITY PREM a nco S 100,000.00 A C3 (] CIAIMgMADE C] OCCUR 689759 MEOIXP Yom person g 5,000.00 ❑ Y Y 01/26/2075 01/26/201 t3 PERSONAL&ADV INJURY S 1,000,000,00 Q GENERAL AGGREGATE s 2,000,000.00 GEN L AGCIREGATE LIMIT APPLIES PER: ❑ POLICY ❑ 1;& ❑ LOC CTS PRODU .COMPIOP AGG $ 2,000,000.00 AUTOMOBILE LIABILITY MBlra®� GLF LIMITs t ❑ ANY AUTO BODILY INJURY(Per pereon) s ❑ �AtlTos�l� ❑ A�����r� ULED ❑ BODILY INJURY(Per aAolden s HIRED AUTOS •"N OWNED ❑ AUTOS PROP n AMA S El ❑ UMBRELLA UAB ❑O=)R $ El EXCESS UA8EACH OCCURRENCE s ❑c�..AtM3-MADE AOciREcaTe $ ❑ Om RETENTION WORKERS COMPENSATION $ AND EMPLOYERS'UABILJTY Y r N ❑WC STATU 711. ANY PROPRI��77ORlA OFFICERIMEMSER EXCLU 0? N 1 A E.L.EACH ACCIDENT $ (Mandatory In NH) tf W OF OPERA7tONs belowEEl LDISEASE•EA EMPLOYE S E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OP OPERgTIONS!LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Ia requtrod) GENERAL CONTRACTOR LIABILITY LIC CGC1519M �'gOV-ANCeA9, A g1NG�197' CERTIFICATE HOLDER ADD© 1 �4 CANCELLATION 3C5a�1�$ MIAMI SHORES VILLAGE SHOULD ANY Op THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 10060 NE 2ND AVENUE, AUTHORIZED REPRESENTAT1ve MIAMI SHORES FLORIDA 33138 ,.^^� ! . id ACORD 26(2010105)OF ®1033.2010 ACORD CORPORATION. AN rights reserved. The ACORD name and logo are registered marks of ACORD a 02-10-2015 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 02/15/2015 EXPIRATION DATE: 02114/2017 PERSON: GOMEZ CARLOS FEIN: 271031945 BUSINESS NAME AND ADDRESS: LPMA ENTERPRISES CORP 857 NM 122 AVE MIAMI FL 33182 SCOPES OF BUSINESS OR TRADE: 1- LICENSED GENERAL CONTRACTOR IMPORTANT- Pursuant to Chapter 440 . 05(141 F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election ander this apt section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate as 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) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCUU.SERVICES F DWISION OF WORKERS COMPENSATION 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 FLORIDAL under this section may not recover benefits or compensation under this WORKERS COMPENSATION LAW 9 D chapter. EFFECTIVE: 02/15/2015 EXPIRATION DATE. 02/14/2017 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exem .. 1 only within the scope of the business or trade listed on PERSON: CARLOS GOME2 E PL SPY Y � FEIN: 271031845 the notice of election to be exempt R BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt LANDA ENTERPRISES CORP and certificates of election to be exempt shall be subject to revocation 857 NW 122 AVE if, at any time after the filing of the notice or the issuance of the MIAMI, FL 33182 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 SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this 1- LICENSED GENERAL CONTRACTOR section. QUESTIONS? (850) 413-1609 CUT HERE II • Carry bottom portion on the job, keep upper portion for your records. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 Miami Shores Village 10050 N.E.2nd Avenue NW "a Miami Shores,FL 33138-00001 t � Phone: (305)79-r-2204 Expiration: 11/2912015 t Project Address Parcel Number Applicant 102 NW 108 Street 1121360100010 DOUBLE TT LLC Miami Shores, FL 33168-4313 Block: Lot: Owner Information Address Phone Cell DOUBLE TT LLC P.O.BOX 90393 KEY BISCAYNE FL 33149- P.O.BOX 90393 KEY BISCAYNE FL 33149- Contractor(s) Phone Cell Phone $ 23,000.00 Valuation: LANDA ENTERPRISES CORP (786)333-5248 Total Sq Feet: 416.21 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final PE Certification Date Denied: Drywall Type of Construction:REPLACE WINDOWS,KITCHEN AN Occupancy:Single Family Miscellaneous Stories: Exterior: Window Door Attachment Front Setback: Rear Setback: Tie Beam Left Setback: Right Setback: Final Bedrooms: Bathrooms: Framing Plans Submitted:Yes Certificate Status: Insulation Certificate Date: Additional Info: Truss Insp Columns Bond Retum: Classification:Residential Foundation Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Window and Door Buck CCF $13.80 Fill Cells Columns CO/CC Fee $50.00 Invoice# RC-12-14-53770 Wire Lathe DBPR Fee $10.35 06/02/2015 Check#:1268 $948.50 $50.00 Review Electrical DCA Fee $10.35 12/04/2014 Credit Card $50.00 $0.00 Review Planning Education Surcharge $4.60 Review Planning Notary Fee $5.00 Review Planning Permit Fee $690.00 1 Review Planning Plan Review Fee(Engineer) $160.00 Review Building Scanning Fee $36.00 Review Building Technology Fee $18.40 Review Building Total: $998.50 Review Building Review Mechanical Review Plumbing Review Plumbing F.Termite Letter F.Elevation Certificate Review Structural Declaration of Use June 02,2015 Authorized 3 na re: r / Applicant / Contractor / Agent Date Buil ' ment opy June 02,2015 2