PT-16-1902 Miami Shores Village
Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax:(305)756-8972 BY;
INSPECTION LINE PHONE NUMBER:(305)7624949
FBC 20M
BUILDING Master Permit No.Y'r� + 1(0
PERMIT APPLICATION Sub Permit No.
BUILDING ELECTRIC ROOFING ❑ REVISION EXTENSION RENEWAL
❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP
amCONTRACTOR DRAWINGS
JOB ADDRESS: S9_7 a cI - j
City: Miami Shores County Miami Dade zip: 33 f
Foilo/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): SPT L6101 il(yq S . LL Phone#;�19^7 L 3-2913
Address: l yW I Bhc) I .A :P-, # I LI oO
City: M I 0.TM1 s 'I State: EL— Zip: 3 3 J 3
Tenant/Lessee Name: Phone#•
Email:
CONTRACTOR:Company Name: Phone#:
Address: blow
City: State: Zip:
Qualifier Name: Phone#•
State Certification or Registration#: Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ,•�❑ Demolition
Description of Work: _ r C,0�0,4 LI<j_ -
Specify color qf color thru tile:
Submittal Fee$ Permit Fee$ CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
j
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.
E e, ',
Signature --- 'F
Sign
OWNER
OWNER or AGENT CONTRACTOR
The foregoing Instrument
was acknowledged before me this The foregoing Instrument was acknowledged before me this
day of 11 r .20 .by day of 20_____,by
;00
-2-0 &-2who Is personally known to who is personally known to
me or who has produced as me or who has produced as
Identification and who did take an oat . identification and who did take an oath.
NOTARY PUB NOTARY PUBLIC:
Sign: Sign:
Print: Print:
Seal: Seal:
JESSE WALTERS
Notary,,QQPublic-State of Florida
s�>W60,M*0aeion'67111���a ****«««*******«*****«****«*««****««*****************«****
ij eft
IIIH
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
UNANIMOUS WRITTEN CONSENT ACTION OI+'THE 11IKINURS
Olt
IPI HOLDINGS LLC
Ilhl HOLDINGS,LLC ('be "C0mpany").a Dclawate limited lialnlity company. filed its Certificate of
Formation on July IB . 2014- Pursuant to the audk)lity contained in the Delaware Limited Liability
Company Act(the"Act-).the mwnbers(the"MCmbad")of the Company do hereby tate the following
actitms and adopt the Following resolutions by written rvnsent in lieu of meeting:
CERTIFICATE OF FORMATION
RESOLVED.that the Certificate of Formation of the Company that was;filed with the Secretary of State
of tate Sung of ix-lawgre on July 18&.3011.true and correct copy of which is attached hereto as Exhibit
A.in hereby approved by the Members and that said certificate of Fortmation be filed by the,Managers of
the Company among the pprnwnam records of the Company.
MANAGERS
RESOLVED, that Stewart James Cumcrom and Nicholas FmrWI are named as the Managers of dee,
Company. and they hereby accept their appointmcyus to such office and hereby agree to serve as
Managers of the Company until their successors are duly elected and qualified or until the earlier of their
deatk resignation.relisoment.disqualification or removal from office.
FISCAL,YEAR
RWROLVED.that the Company adopts a discal year ending December 31 for financial and tux repotting
purpongc
BANKING AUTHORIZATION
RESOLVED.that The Managers are hereby authorized and empowered for and on behalf of the Company
to designate in writing such banks,trust companies or other fiamcfal institutions as depositories for the
funds of the Company to be carried in an account or accounts as styled by the Mannpls in their
discretion:and such depository is authorized and requested to accept. honor and pay. without further
inquiry and until written notice of the revocation of such authority grained Is received by it.all clacks.
drafts and other orders for the payment or withdrawal of such fumhs of the Company. Inclutifng any
instruments payable orendorsed to the order of the Company by lite Managers:and be it further
RESOLVED,that Manngas are hereby authorized to execute and cgnify any resolutions n*wd by any
depository.and such resolutions will he included in this Consent as if duly considered and adopted by
said hin aggrs.
ORGANIZATIONAL EXPENSES
RESOLVED, that the Managers are hereby authorized to pay all fees and expenses related to the
organization of the Company.
QUALIFICATION IN FOREIGN JURISDICTIONS
RE.SAI-VED,that for the purpose of authoriving the Company to transact business in any state.territory
or dependent*,of die United States or any foreign country in which it is necessary or expedient &►r the
Company to transact business,the Managers are hermby authorized to appoint and substitute all necessary
agents or attorneys fix service of process.to designate and change the location of all necessary statutory
offices and to execute,acknowledge.deliver and rile all necessary cw1ftcutes.Imports,powers of atomey
and osier I"- utunts as may he rquired by the laic;of such state.territory.dependency or country to
suthcxiye the Company to troll act business therein and. whenever It is expedient rior the Company to
cease tuning business therein and to withdraw therefrom, to revoke any appointruent or agent or
attorney for service of prcxess.and to execute. acknowledge.deliver and file vuch cartificates. raports.
revocation of appnirtment or surrender of authority that may be necessary to terminate the authority of
the Canrnwty to tmuslct budnem in any such Marc.territory.dependency or country.
IRS FILINGS
RESOLVED, that the Managers of the Company. are aadu►rized in such capacity. for as longs as is
nom",ssaty.to execute on behalf of the Company the Application for the Federal Identification Nunther
(forth W with the Internal Reverme Service.
FURTHER ACTION
RESOLV1;D,that the Managers am hereby authorized to execute.acknowledgle.deliver and file such
other documents and to take such further actions as It may deem necestory or appropriate to effect the
intent and accomplish the purposes of the preceding resolutions.
-- .171 wCotxsont,Actiw4%slgnedtlti4i- �gof 201 4;to be efftive wogag
MEMBER(S)SIGNATURES:
IPI 1ANAGEMENT LLP.
By: Q.W-�
Name:
Title: N4 Ata*
IN A GEME�'T,IN
By:
Stewart Jaynes Cameron.President
IPI Holdings,LLC
1441 Brickell Ave#1400
Miami, FL 33131
Statement of Authority of the Managers of IPI Holdings,LLC
On my oath and under penalty of perjury,I swear that Stewart Cameron and Nicholas Farrell are the
duly appointed Managers of IPI Holdings,LLC,a Delaware Limited Liability Company. I certify that we
have not been removed as Managers and have the authority to act for and bind IPI Holdings,LLC in
business transactions for which this affidavit is given as affirmation of their authority
A
- ""�A Q---
Signature
Name
Sworn and subscribed before me the undersigned authority,on 20_Z$_.
otary Public
No"PuM SMI
yY A�M Fadfel d P
Wdft
M`�„ 0 EL 01
897497
Miami Shores Village
�- Building Department JUL os Zoe
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795-2204 Fax(305)756-8972 ]BY:
INSPECTION LINE PHONE NUMBER:(305)7624949
FBC 201q
PAINT (waster Permit No. fr to- 1q02)
PERMIT APPLICATIONSub Permit No.
!OB ADDRESS:
X91 �j
City: Miami Shores County: Miami Dade Zia: is 1 31Z
Folio/Parcel#: 11 ?I Z O b , i!i 20c J Is the Building Historically Designated:Yes NO
OWNER:Name(Fee Simple Titleholder): 1 , , I Phone#-L71b 7zoaii 1
Address: i P �'TV
City: b"�� .,� State: Zip•
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: Phone#: `1 5
Address: !UICS V
qty: State: Zip: tt11 /
Qualifier Name: Phone#: -t�-1 �C7i� 07
State Certification or Registration#-U,_'S�a 7 �®I Certificate of Competency#:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Description of Work:
Application is hereby made to obtain a permit to do the work and insta ations as indicated. 1 certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction In
this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL,PLUMBING,SIGNS,WELLS,POOLS,FURNACES,BOILERS,
HEATERS,TANKS,AIR CONDITIONERS,ETC.....
"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$250,the applicant must promise In good faith that a
copy of the notice of commencement and construction lien law brochure will be deUvered to the person whose property is subject to attachment Also,a cerWed
copy of the recorded notice of commencement must be posted at the job site for the}irst inspection which occurs seven(7)days after the building permit Is issued.
In the absence of such posted notice,the inspection will not be approved and an Inspection fee will be charged.
Permit Fee$ CCF Fee$ Notary$
Technology Fee$ Tmining/Education Fee$ Double Fee$
TOTAL FEE NOW DUE$
PAINT COLOR APPROVAL AND AGREEMENT
All elements on the site must be listed and indicate the color to be painted
DIRECTIONS: Please circle corresponding number to appropriate color sample.
Walls: 1 2 3 4
�� Attach color sample with name and number
Fascia: 1 3 4
Drip edge: 1 2 3 4 1. SW 7064 236-C7
Soffit: 1 2 3 4 Passive
Flower Bins: 1 2 3 4
Shutters: 1 2 3 4
Awnings: 1 2 3 4 2s7-C7
2. SW 7006
Chimney: 1 2 3 4 Extra White
Doors&4a#nss: 1 2 3 4
Garage Doors: 1 2 3 4
Railings: 1 2 3 4
3.
Fences: 1 2 3 4
All Brick: 1 2 3 4
Stucco Bands: 1 2 3 4
Other Stucco
Feature: 1 2 3 4 4•
Accessory Bldg: 1 2 3 4
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable4aWs regul'atigg c nstWuction and zoning.
L �
Signature Signature 0�e"4
OWNER or AGENT CONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of 20 by S�day of y 20 ��/ by
�' ` «,�,who is personally known to �N� ,r� k"�ho is personally known�u O
me or who has produced !,� "I'�` as me or who has produced ED G (1SS -(os3•f�0' as
identification and who did take an oath. ✓ identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print:
J fC ��r
Print:
SISL WOO
Seal: Seal: a
ell JESSE WALTERS ebc�o APPROVED BY: ' • otary Public-State of Florida •• bdx Novz
ssW�:•My Comm. Expires Sep 23 2
de Official
P Commission#EE 837922 ��q Wb30H O" O``'
% �y/111181111111% 0\ Historic Preservation Board
Property Search Application- Miami-Dade County Page 1 of 1
OFFICE OF THE PROPERTY APPRAISER
Summary Report
Generated On : 7/7/2016
Property Information
Folio: 11-3206-014-1040
R
Property Address:
597 NE 93 ST
Miami Shores,FL 33138-2843 :
Owner IPI HOLDINGS LLC
3411 SILVERSIDE RD RODNEY --
Mailing Address BUILDING 104
WILMINGTON,DE 19810 USA
Primary Zone 1000 SGL FAMILY-2101-2300 SQ
0101 RESIDENTIAL-SINGLE
Primary Land Use
FAMILY: 1 UNIT
Beds/Baths/Half 3/2/0
Floors 1
Living Units 1
Actual Area 2,622 Sq.Ft `
s..
Living Area 1,994 Sq.Ft
Adjusted Area 2,607 Sq.Ft Taxable Value Information
Lot Size 12,341.76 Sq.Ft 2016 2015 2014
Year Built 1940 County
Exemption Value $0 $0 $0
Assessment Information Taxable Value $463,243 $475,386 $434,313
Year 2016 2015 2014 School Board
Land Value $308,823 $296,198 $259,295 Exemption Value $0 $0 $0
Building Value $139,012 $166,736 $162,402 Taxable Value $463,243 $475,386 $434,313
XF Value $15,408 $12,452 $12,616 City
Market Value $463,243 $475,386 $434,313 Exemption Value $0 $0 $0
Assessed Value $463,243 $475,386 $434,313 Taxable Value $463,243 $475,386 $434,313
Regional
Benefits Information Exemption Value $0 $0 $0
Benefit Type 2016 2015 2014 Taxable Value $463,243 $475,386; $434,313
Note:Not all benefits are applicable to all Taxable Values(i.e.County,
School Board,City,Regional). Sales Information
Short Legal Description Sale Previous Price Page OR Book-
Qualification Description
6 53 42 10/05/2015 $470,000 29811-4813 Qual by exam of deed
MIAMI SHORES SEC 2 PB 10-37
LOT 23 BLK 56 05/06/2013 $303,100 28646-1989 Financial inst or"In Lieu of
LOT SIZE 96.420 X 128
Forclosure"stated
COC 25151-2628 10 2006 1 10/01/2006 $850,000 25151-2628 Sales which are qualified
06/01/2005 $660,000 23577-4225 Sales which are qualified
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
Version:
http://www.miamidade.gov/propertysearch/ 7/7/2016
UNANIMOUS WRITTEN CONSENT ACTION OF THE MEMBERS
OF
fill HOLDINGS LLC
IPI HOLDINGS,LI.0 (the "Company"). a Defawam limited liability company. filed its Certificate of
Formation on July le. 2011. Pursuant to the authority contained in the Delaware Limited Liability
Company Act(the"Act").the members(the"Members!*)of the Company do hereby take the following
actions and adopt the following resolutions by written consent in lieu M'a meeting:
CERTIFICATE OF FORNIATION
RESOLVED.that the Certificate of Formation of the Company that was filed with the Secretary of State
of the State of f>w:hau.=on July 18'".2014.true and cornet copy of which is attached herein as Exhibit
A.is hereby approved by the Members and that said Certificate of Formation be filed by die Managers of
the Company among the permanent mcords of the Company.
SIANAGERS
RESOLVED, that Stewart James Cumcron and Nicholas Farrell are named as the Managers of the
Company. and they hereby accept their appointments to such office and hereby agrec to serve as
Managers or the Company until their successors are duly elected and qualified or until the earlier of their
death.resignation.retim ent.disqualification or removal from office.
FISCAL,YEAR
RESOLVED.that the Company adopts u fiscal year ending December 31 for financial and tux reporting
Parpoes.
BANKING AUTHORIZATION
RESOLVED,that the Managers are hereby authorized and empowered for and on Ixsl►alf of the Company
to designate in writing such hanks, trust companies or other fitrancial institutions as depositories for tle
funds of the Company to he carried in an account or accounts as styled by the Managers in their
discretion: aro)such depository is authorized and requested to accept. honor and pay. without further
inquiry and until written notice of the revocation of such authority granted is received by it.all checks.
drafts and other orders for the payment or withdrawal of such funds of the Company, including any
instruments payable or endorsed to the order of the Company by the Managers:and he it further
RESOLVED,that Managers am hereby authorized to execute and certify any resolutions required by any
depository.and such resolutions will be included in this Consent as if duly considered and adopted by
.said Managers.
ORGANIZATIONAL EXPENSES
RESOLVED, that the Managers are hereby authorized to pay all fees and expenses related to the
organization of the Company.
QUALIFICATION IN FOREIGN JURISDICTIONS
RESOLVED.that for the purpose of authorizing the Company to transact business,in any state.territory
or dependency of tie United Sates or any foreign country in which it is necessary or expedient for the
Company to transact business.the Managers are hereby authorized to appoint and substitute all nwe%wry
agent.%or attorneys for service of process.to designate and change the location of all necessary statutory
afficcc and to execute.acknowledge.deliver and file all necessary certificates.reports,powers of attorney
and other instruments as may be required by the laws of such state.territory.dependency or country to
authorize the Company to transact business therein and, whenever it is expedient for the Company to
cease tmnsaeting business therein and to withdraw therefrom, to revoke any appointment or agent or
attorney ror service of pnxvss.and to execute, acknowledge.deliver and rule awh certificates, reports.
revocation of appointment or surrender of authority that may be necessary to terminate the authority of
the Company to transact business in any such state,territory.dependency or country.
IRS FILINGS
RMSOLVED, that the Managers or the Company, are authorized in such capacity. for as long as is
ri=ssary. to execute on behalf of the Company the Application for the Federal Identification Number
(form SSd)with the Internal Revenue Service.
FURTHER ACTION
RESOLVED, that the Munagers are hereby authorized to execute,acknowledge. deli,.vr and file such
other documents and to take such further actions as it may deem necessary or appropriate to effect the
Intent and aceamPlislt tie purposes of the preceding resolutions.
-------Thi1 Co;mnt•Actk*4s si thiw
l�� -2nithy'ofSqmember-2Qld;ta-be-efl$rtfve'nc'o't''Jtt1p'1'A*.-MTa:---
MEMBER(S)SIGNATURES:
IPI AiANAGEMENT LLP.
By: C,—� -
Name:
IPI l< GEME1'T,IN
By:
Stewart James Cameron.President
IPI Holdings,LLC
1441 Brickell Ave#1400
Miami, FL 33131
Statement of Authority of the Managers of IPI Holdings,LLC
On my oath and under penalty of perjury, I swear that Stewart Cameron and Nicholas Farrell are the
duly appointed Managers of IPI Holdings,LLC,a Delaware Limited Liability Company. I certify that we
have not been removed as Managers and have the authority to act for and bind IPI Holdings,LLC in
business transactions for which this affidavit is given as affirmation of their authority
— ��J—Q—,—
Signature
&%WrV .-+r l,P►�E2on.B
Name
Sworn and subscribed before me the undersigned authority,on 20 /S
tary Public
n.
sYNo"Public SO
M °�Fbdda
RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
��CGC1513799
The GENERAL CONTRACTOR
Named beiow IS CERTIFIED
Under the provisions of Chapter 489 FS.
expiration date: AUG 31,2016
LAURSEN,OLE H
EUROPEAN RENOVATIO.NUAAITED.CORP4351 N.E. 15 TER
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FORT LAUDERDALEwEt.33334 j
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ISSUED: .08127/2014 DISPLAY AS REQUIRED BY LAW SEQ# L1408270003588
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tri-ode County, _State of
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cQR CERTIFICATE OF LIABILITY INSURANCE DAo5,3ono16
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOUR 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 PRS,AND THE CERTIFICATE HOLDER.
IMPORTANT:it the Certificate herder is an ADDITIONAL INSURED,the policy(les)must be endorsed.It SUBROGATION 19 WANED,su*d to
the terms and eorKNdOrc of"policy,certain poBeles may requirsart andarsenwit A statement on INis eartifieate does not corder rWft to the
corifficeft holder In Neu of such endoreement(s).
PRCIOUC R
ORR&ASSOCIATES INSURANCE SERVICES =LOW 858-2W-O992 886-96M47
3083 ROSECRANS PL STE 208 .cont
INSURIM)AFFORDMICOMthGEtDafc r
SAN DIEGO CA 921104822 A: Proferred ColNradom Ins Cc RRG LLC 12497
INSUMS) 9
EUROPEAN RENOVATION UNLUTED INSURER C:
EUROPEAN RENOVATION UNLUTED o:
4331 NE 15TH TER E:
OAKLAND PARK FL 33334.3823 NEM
p.
COVERAGES CERTIFICATE REVISION
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOIWITHSTANDING ANY REOU4REMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUME14T WITH RESPECT TO WHICH THIS
CERTIFICATE WAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLJCIES.LIMITS SHOV01 MAY HAVE BEEN REDID BY PAID CLAM
MR LIR TYPE OPMTB
ADMINIAM COMMERCIAL GOI RAL LIAMUTY EACH OCCURRENCE S 1,000,000
CLAVAS4AADE ®OCCUR S 50,000
MED EV ore -S 5,000
A PCIC5026-PCA560577 02/26/2018 02/28/2017 PERSON&aAovwngy $ 1,000,000
G'EWL AGGREGATE LWT APPLIES PER GMRAL AGGREGATE S 1,000,000
POLICY� a LOC PRODUCTS-COWqQP AGG S 1,000,000
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Evil of Coverae
license#CGC 1513799
CERTIFICATE HOLDER TION
hftrrd Shores Bung Dept
10050 NE 2nd Ave SHOtnu ANY OF TW ASM PODS BE CANS MORE
THE EXPIRATONI DATE THEREOF, NOTICE 1111LL 0E VOLIVERED IN
Miarrr»Shy,FL 33138 ACCORDA14CE VOM IM POLdCY PROVISO.
0 4958-M4 At'ORD CONIORATI10i.AN ftft mooriet
ACORD 26(2014M) Tfw ACORD name and logo ars registerW marks of ACOS
Jun. 30. 2016. 4:47PM No. 5575 P. 5
.TEFF ATWATER
CWEF FINANCIAL OFFICER STATI:OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
'*CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW 4'
CONSTRUCTION INDUSTRY EXEMPTION
This ceftilles chat the Individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 4/6/2015 EXPIRATION DATE: 4!5!2017
PERSON: LAURSEN OLE H
FEIN: 203786287
13USINESS NAME AND ADDRESS:
EUROPEAN RENOVATIONS UNLIMITED CORP
GREAT DANE CONSTRUCTION
4361 NE 15TH TERRACE
FORT LAUDERDALE • t. 33334
SCOPES OF BUSINESS OR TRADE:
LICENSED GENERAL
CONTRACTOR
Pursuant to Chapter 440.08(14),F.S.,an officer of a aupora0on who elects exemption from this chapter by Ming a•certificate of eleclion under this asolion
may not recovar bano tM1 or compensa0on under this ohapw,Pursuant to Chepter 440.08(12),P.S..CadfOoates of dad n to be exempt...apphq only
within the scope of the business or trade bled an The notice or ehe008 to be worto.Pursuant to Chapter 440.08(U3 F.S,Notices of etecttat to be
exempt and cah6ricates Of election to be exempt shell be subjeal to revocalfm If,at any lime WW the filing of the notice or the Issuance of the v er0fioate,
the parson named on urs no**or certificate no longer masta the requlrementa of this section for issuance or a cartMoete.The department shall revoke a
DFS-F2-OWCG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08.13 QUESTIONS?(850)413-1909
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Miami Shores Village
Building Department
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 cov=ge 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,parttime employees or subcontractors.
BY SIG,7 OW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONT
Signature: '
Owner
State of Florida
County of Miami Dade
Lr
The foregoing was acknowledge before me this /�7 day of �J U ,20L
By P tg/C� v�t�y Dui who is personally known to me or has produced
C C -L. as identification.
Notary:
Y°�e'•., JESSE WALTERS
°. •`�
SEAL. , . _ Notary Public-State of Florida
3,' 'Q My Comm.Expires Sep 23,2016
Commission#EE 837922
Great Dane Construction
License # 1513799
4351 NE 15th terrace
Fort Lauderdale FL 33334
954 860 6707
Date: .' L®
State: pOP—►JOA
County of: -gJMPAY.)0
Before me this day personally appeared &-6 IA!:o ZcS N
who, being duly sworn, deposes and says:
That he or she will be the only person working on the project located
at: (4 13 PE q%'M
)M► A rn i 5 BM S
Sworn to (or affirmed) and subscribed before me this qday of
x_,20 1U , by
.��. •� �223,��``.11Z
aJ
m
�4�3 * Personally known , k4�t
• `
OR Produced Identification
Type of Identification Produced_