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DS-16-1857 i � 16- l �s� ,r (w Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax: (305)7564972 Inspection Number: INSP-262483 Permit Number: DS-7-16-1867 Scheduled Inspection Date:August 03,2016 Permit Type: Driveways/Sidewalks/Slabs Inspector: Mesa,Michel Inspection Type: Final Owner: ALVAREZ,MARIALI Work Classification: New Job Address:825 NE 91 Terrace Miami Shores, FL 33138- Phone Number (786)374-9810 Parcel Number 1132060050250 Project: <NONE> Contractor: PREMIER CONSTRUCTION AND PAVERS Phone: (954)441-4224 Building Department Comments NEW PAVER DRIVEWAY Inftectio Passed omments INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid 4� August 02,2016 For Inspections please call:(305)762-4949 Page 9 of 29 NOTICE OF COMMENCEMENT ��! A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TiME OF FiRST INSPECTION C-F I,$ 2 1316 R I a 3 6 6 4 2 3 OR BK 30124 P3 4375 (IPss) PERMIT NO. TAX FOLIO NO. RECORDED 116/2:37/21116 11.319:04 HARVEY RUVIHr CLERK OF COURT STATE OF FLORIDA: flIAMI-DADE COUHTYP FLORIDA COUNTY OF MIAMI-DADE: V►TE OF A DIC1110I1 r CW Lx%" �►v Garr °. f fY geb• of Vie THE UNDERSIGNED hereby gives notice that improvements will be made �C property,and in accordance with Chapter 713,Florida Statutes,the fol 211 V�I l i Is provided in this Notice of Commencement. INifIf1.S sa1►1 �°r � _�eG ••art�•�� Z Space above reserved for use of recording office 1.Legal description of property and street/address: 114m 2.Description of improvement: 01 AW ZAIP0,k4l 3.Owner(s)name and address: 24' Voaees Interest In property: Name and address of fee simple titleholder: 4.Contractor's name,address and pho a number ah b Slit s �d✓c 3 O 5.Surety.(Payment bond required by owner from contractor,if any) Name,address and phone number Amount of bond$ 6. Lender's name and address: 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7.,Florida Statutes, Name, address and phone number 8. In addition to himself,Owners designates the following person(s)to receive a copy of the Lienor's Notice as provided in Section 713.13(i)(b),Florida Statutes. Name,address and phone number: 9. Expiration date of this Notice of Commencement: (the expiration date Is 1 year from the date of recording unless a different date is specified) WARNING TO OWNER:ANY PAYMENTS MADE BYTHE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I,SECTION 713.13. FLORIDA STATUTES,AND CAN RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY.A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION.IF YOU INTEND TO OBTAIN FINANCING,CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. Signature(s)of Own r(s)oit Owner s)'Authorized Officer/Director/Partner/Manager Prepared By Gtr tQtt _ Prepared By �/S 6toi Print Name X .yfetl, tJC�(�L- Print Name Title/Office 0wA16/2- Title/Office 1010M, ZA& (� STATE OF FLORIDA COUNTY OF MIAMI-DADE The foregoingtrume was knowledged before me this day of �l•U?G �l/+ By /�rl a �rC7.1 vidually,or IJas for LIS Personally known,or ❑produced the following type of Identification: Signature of Notary Public: Print Name: (SEAL) "1°fee, SANDY ROMERO VERIFICATION PURSUANT TO SECTION 92.525.FLORIDA STATUTES 3. : Notary Public-State of Florida Under penalties of perjury, I declare that I have read the foregoing and , moo,; Commission FF 915708 that the facts stated In it are true,to the best of my knowledge and belief. '•';FOFF��(;� My Comm.Expires Sep 7,2019 Signature(s)of Owner(s)or O (s)'s Authorized Officer/Director/Partner/Manager who signed above: Byv &n_& By 12301-52 PAGE 8112 Date:7/21/16 s COMMERC9AL KtMIEK RESIDENTIAL State of Florida CONSTRUCTION AND PAVERS, INC. County of Dade Before me this day personally appeared Michelle Lyman who, being duly sworn,deposes and says: f That he or she will be the only person working on the project located at: 825 NE 911 Ter Miami Shores, FL. Sworn to and subscribed before me this 20th day ofJuly by Mi elle Lyman _7 Personally known Notary signature 5� Marthaa Estr da COMMOM f FF19W i9VRMs:,may+29,2019 www.AAAosNOTAnr.coa Office 954-441-4224 a Fax 954-693.4703 Email: premierenterprisegroup@yahoo.com Premier Enterprise Group of South Florida Inc Building Contractor . Licensed & Insured CBC 1256001 A � g Miami Shores Village pet) l� D�it#t1 ,� Ild abs 10050 N.E.2nd Avenue NE t Miami Shores,FL 33138-0000 APPR Phone: (305)795-2204 `'; " a hate:71211201j� Expiration: 01/17/2017 Project Address Parcel Number Applicant 825 NE 91 Terrace 1132060050250 MARIALI ALVAREZ Miami Shores, FL 33138- Block: Lot: Owner Information Address Phone Cell MARIALI ALVAREZ 825 NE 91 Terrace (786)374-9810 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 7,500.00 PREMIER CONSTRUCTION AND PAVE (954)441-4224 Total Sq Feet: 1300 Approved:In Review Available Inspections: Comments: Inspection Type: Date Approved::In Review Final Date Denied: Foundation Type of Work:NEW PAVER DRIVEWAY Additional Info: Review Planning Bond Return: Classification:Residential Review Building Scanning:3 Review Building Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 Invoice# DS-7-16-60441 CCF $4.60 07/05/2016 Check#:2880 $50.00 $626.30 DBPR Fee $2.25 DCA Fee $2.25 07/21/2016 Check#:2917 $626.30 $0.00 Education Surcharge $1.60 Bond#:3158 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $6.40 Total: $676.30 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 employed. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVI :. certify that le for going info ti n is accurate and that all work will be done in compliance with all applicable laws regulating construction and zor)in re, au'1 tho ze the above ed contractor-to do the work stated. July 21, 2016 Authorized Signature:Owner cant / Contractor / Agent Date Building Department Copy July 21,2016 1 Miami Shores Village _ A;�-� Building Department I JUL 0 6 2016 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 rJ- INSPECTION LINE PHONE NUMBER:(30S)762-4949 - FBC 201 BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP ,J -/ CONTRACTOR DRAWINGS JOB ADDRESS: DzJr i x�r L� 9/ S�' �'� City: Miami Shores Countv: Miami Dade Zia: 23 13'? Folio/Parcel#:_ h - 217- C= - (N Is the Building Historically Designated:Yes NO ✓ Occupancy Type: Load: Construction Type: Flood Zone: BFE: ® FFE: qr� OWNER: Name(Fee Sim le Titleholder): / r/GI �(visa 2 Phone#: � D _ 3-7q- /d (6 Address: UZ� fl -ce- 1 /I T Zi Zip: City: /fl �f'l10r, State: Tenant/Lessee Name: Phone#: Email: / �1 CONTRACTOR:Company Name: l�Pb �D v+s�r,,c f /pct va ; 5 Phone#: SY- 47 t -5800 Address: 7le?od Su) fb�L City: AState: /CL Zip: 333,�U Qualifier Name: Phone#: State Certification or Registration#: G Z s O Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: tate: Zip: r Value of Work for this Permit:$ 7iJd Squqre/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New r . '- ❑ Repair/Replace ❑ Demolition Des c pftgmgf�N k ✓ ,r. i l3� r Specify color of 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$ 56® W TOTAL FEE NOW DUE$ 12-0 . 30 (Revised02/24/2014) (0 26 e 30 A 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. Si g g naturet� �� Si nature —;fe�� OW E or AGE T CO TRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this d y of 20 by 2-3 // day of ��C. ,20 1-61- ,by r YY V�r� who is ersonally kn ci "y on who i personally kno to me or who has produced as me or who has produced as identification and w �, � �lg;an oath. identification and wh .dicl,tXp,pn oath. �11AA �.% SANDY ROMERO o.H SANDY ROMERO NOTARY PUB _'?� �,°,�= Notary Public-State of Florida NOTARY LIC 2 Notary Public•State of Florida �.� Commission# FF 915708 N. Commission # FF 917,208 0 �F� �r My Comm.Expires Sep 7,2019 •'.',�ovF.�.•� My Comm.Expires Sep 7,2019 "8L �auua Sign: Sign: Print: .0 D Print: O Seal: Seal: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Property Search Application - Miami-Dade County Page 1 of 1 OFFICE OF THE PROPERTY APPRAISER Summary Report Generated On:7/5/2016 Property Information Folio: 11-3206-005-0250 Property Address: 825 NE 91 TER Y t. Miami Shores,FL 33138-3217 Owner MARIALI ALVAREZ ROHENA JAVIER O SALGADO 855 NE 91 TERM * Mailing Address MIAMI SHORES, FL 33138 USA 3� Primary Zone 0900 SGL FAMILY-1901-2100 SQ , Primary Land Use 0101 RESIDENTIAL-SINGLE FAMILY: 1 UNIT ;f Beds/Baths I Half 3/2/0 ` t Floors 1 Living Units 1 . Actual Area 2,223 Sq.Ft `° Living Area 1,871 Sq.Ft Adjusted Area 1,945 Sq.Ft Taxable Value Information Lot Size 14,000 Sq.Ft2016, 2015 2014 Year Built 1954 County Exemption Value $0 $0 $0 Assessment Information Taxable Value i $341,7091 $310,6451 $282,405 Year 2016 20151 2014 School Board Land Value $308,430 $210,105 $195,615 Exemption Value $0 $0 $0 347, Building Value $135,372 $135,372 $131,871 Taxable Value _ $445,832 $ 125 $329,158 XF Value $2,030 $1,648 $1,672 City Market Value $445,832 $347,125 $329,158 Exemption Value $0 $0 $0 Assessed Value $341,709 $310,645. $282,405 Taxable Value $341,709 $310,6451 $282,405 Regional Benefits Information Exemption Value $0 $0 $0 _............._._.__._._._......... Benefit Type 20161 2015 2014 Taxable Value $341,709 $310,645 $282,405 __.._ Non-Homestead Assessment Cap Reduction $104,123 $36,480 $46,753 Sales Information Note: Not all benefits are applicable to all Taxable Values(i.e.County, Previous Price OR Book- Qualification Description School Board,City, Regional). Sale Page 05/06/2016 $480,000 30070- Qual b exam of deed Short Legal Description 2823 y GOLDEN GATE PARK ADDN PB 6-130 27079- LOTS 18&19 BLK 2 11/06/2009 $340,000 4806 Qual by exam of deed LOT SIZE IRREGULAR ___.___.._.__. ._ _ - �....._____._ __ _____...__..__........_........ OR 21346-4110 04 2003 6 04/01/2003 $285,000 21346- Other disqualified 4110 01/01/2002 $0 20327- Sales which are disqualified as a result 4058 of examination of the deed 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/ 7/5/2016 CERTIFICATE OF LIABILITY INSURA_NCE DA TE 04/28/16) PRODUCER Accurate THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 8300 West Flagler Suite 114 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Miami,FL 33144 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone(305)226-8727 Fax (305)226-8767 INSURERS AFFORDING COVERAGE NAIC# INSURED Premier Enterprise Group of South Florida Inc.DBA INSURER A: United Specialty Insurance Co. Premier Construction and Pavers INSURER B: 4200 SW 141 Street INSURER C: INSURER D: Davie,FL 33330 INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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,EXC USIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION L INSRD DATE MM/DD DATE MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE 1,000,000 Q COMMERCIAL GENERAL LIABILITY S111003B19158 10/07/15 10/07/16 PR SES EGE TO RENTEDu encs 100,000 ❑© CLAIMS MADE ❑ OCCUR MED EXP(Any one person) 5,000 A ❑ PERSONAL&ADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRO UCTS-COMP/OP AGG 1,000,000 ❑ POLICY ❑PROJECT ❑ LOC AUTOMOBILE LIABILITY COM INED SINGLE LIMIT ❑ ANYAUTO (Ea a cadent) ❑ ALL OWNED AUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per erson) ❑ HIRED AUTOS BODI�Y INJURY ❑ NON OWNED AUTOS (Peraccident) ❑ PRO ERTY DAMAGE (Per ccident) GARAGE LIABILITY AUTC i ONLY-EA ACCIDENT ❑ ❑ ANY AUTO OTH R THAN EA ACC ❑ AUTC 1 ONLY: AGG EXCESSIUMBRELLA LIABILITY EAC OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGG EGATE I ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ❑ WC STATU- ❑ OTH- TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT OTHER DESCRIPT10N OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CBC1256001 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CA BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WIL TO MAIL Miami Shores Village Building Department 30 DAYS WRITTEN NOTICE TO THE CERTIFIC L ED TO 10050 NE 2ND AVE THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE ' G O LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR R P E E Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE Lucia Estrella ACORD 25(2301/08)OF ©ACOR CORPORATION 1988 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: 1/28/2016 EXPIRATION DATE: 1/27/2018 PERSON: LYMAN MICHELLE FEIN: 205516821 BUSINESS NAME AND ADDRESS: PREMIER ENTERPRISE GROUP OF SOUTH FLORIDA INC PREMIER CONSTRUCTION AND PAVERS 4200 SW 141 AVE DAVIE FL 33330 SCOPES OF BUSINESS OR TRADE: LICENSED BUILDING CONTRACTOR Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects examption from this chapter by filing a certificate of election under this 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 Pursuard 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 cartificate no longer meets the requirements of this section for issuance of a certificate.The department shallii revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)113-1609 S��193 �1 Miami Shores Village 'SINE Building Department `h- „��� 1b050 N.E.2nd Avenue R1�A Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 SURVEY AFFIDAVIT STATE OF(FLORIDA) COUNTY OF(DADE) The undersigned Affiant, � 7� �� ,does hereby attest that (Property owner) The attached survey, performed by I. SA 10a W ve olf l (Name of surveyor's company) For address: g2� /� �� ��fL f�'/lA/�,• 1O✓�I Performed on l Zd 01� (date of survey) is an accurate representation of the existing conditions and locations of all structures on the property as of this date. The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to remove or obtain permits for any structures which now may exist on the property which are not permitted or which may violate zoning or building code regulations. The Affiant further understands that the existence-of any such structures may affect final inspections as applicable to this or other permits. Furth Aff rit say h nau ht. u ( �� �k� 2b Property Own'r ignature Property Owner Print Name SWORN TO AND SUBSCRIBED before me this Z3 day of Affiant is rsonall ri to me, produced as ntification. Ell- SANDY ROMERO otary Public-State of Florida N tary Commission#FF 915706 y Comm.Expires Sep 7,2019 Revised(6/25/12)Revised on 5/2212009/Revised on 6/12/09 OR Ilk Miami Shores Village Building Department CFN 2CI16RO386:338 10050 N.E.2nd Avenue OR BK 30137 Ps 3726 (1P9s) RECORDED 1-1'17z'AV20 1.6 Miami Shores, Florida 33138 Hf`tR.VE*f RUWI�? CLERK OF �':!DUR T 0 _:O1JHTY,- FLA� 'Cin' Tel: (305) 795.2204 Fax: (305) 756.8972 COVENANT OF CONTS? ,�RUFION WITHIN RIGHT OF WAY U/i P Whereas, (owner) /&.P &W_VL_ hereinafter referred to as the owner of the following described property (address): Legal Description: Lot Block Subdivision Folio # Requests permission to install (describe work):_4/ Aw Within the public r* - ight of way of (address) SZ� /VC MIAMI 6k 9s 3505 IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows: 1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to make repairs or maintain said items within public right of way including restoration of street by reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall constitute a lien against the above described property until paid. 2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County harmless from any and all liability, which may rise by virtue of permitting the installation of these items within the public right of way. 3. The Owner does hereby agree to remove or relocate their facilities at their own expense, within 60 days notice by the Village to do so. Failure to comply with this notice will result in the Village causing the item(s) to be removed and a lien being placed on the property and/or assessed against the Owner for all costs incurred in the removal and disposal of the item(s). 4. The undersigned further agrees that these conditions shall be deemed a covenant running with the land and shall remain in full force and effect and be binding on the undersigned, their heirs and assigns, until such time as this obligations has be canceled by an affidavit filed in the Public Records of Dade County, Florida by the, ?A,jgWF6(% Miami Shores Village (or his fully authorized representative). 1 Y#w NTY OF DADE vnfft Signaturek- ­V V Owner or Agent of &W C"caft aftwi C ERI State of Florida 14' County of Miami Dade ff 722(X Th fore poing, instrument was acknowl efore me this 713 day of 20 by 41e ; eforeme _/4a/)' Who is 1 rsonally to me or who has pr)duced a tlenf icati NOTARY PUBLIC: -is-I", Sign: SANDY ROMERO Notary Public-state of Florida Print: S Commission#FF 915706 My Comm.Expires Sep 1 2019 1 NoSREs Git � Miami shores Village IRWIN oil ""'1" BuildingDepartment 050 N.E.2nd Avenue �LORIDP' 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 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 o work on your project. In these circumstances,Miami Shores Village does not require verification of workers' compensatio s ance c rage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING B U OWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: / Owner State of Florida County of Miami-Dade J '''''))'' The foregoing was ac owledge before me this / 9 day of c/u By 610/� 1 � who is ersonally known me or has prod ced as identification. Notary: SEAL: Martha Estrada .i • = COMMISSION / FF1940 s EXPIRES:January 29,2019 www.AARONNOTARY.COM Page 1 of 1 Aw , v JUL 05 2016 ;. P c 0 'pli , Ws -� l3 % a *11 TV UQ ft N��"� at �j REVIEW REQUIRED + � rids Health Miami-Dade County O.S.T.D.S.&Vyqll Progra Ap ication NO: �� K3 Sig tur ? ► f Cn H SEs'22 'Ik8 S .. awZ06�y APS'tl E'3r L 4 �fl1:'^ .. FRI �hcr s Village � fS BY DATE I�har t 1..7, DEPT --- J OF PT "CT CO CCP;IPLIFTICE V'VfTt-IFEDERAL IIII S AND REGULATIONS file:///C:/Users/jsalgado/AppDafAocal(Microsoft/Windows/I emporary%20Int7t%20F... 5/11/2016