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PL-16-2410 R Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone: (305)795-2204 Fax:(305)7564972 Inspection Number: INSP-266277 Permit Number: PL-8-16-2410 Scheduled Inspection Date: September 19,2016 Permit Type: Plumbing - Residential Inspector. Hernandez, Rafael Inspection Type: Final Owner. WYBROW,JOHN S JACQUELINE Work Classification: Gas Job Address:1000 NE 96 Street Miami Shores,FL Phone Number (786)651-7979 Parcel Number 1132060143560 Project <NONE> Contractor. RUIZ PLUMBING INDUSTRIES INC. Phone.(617)755.6875 Building Department Comments InfractlINSTALL GAS WATER HEATER CPVC WATER SERVICE, ommerns INSTALL GAS LINE TO RANGE AND GAS LINE TO INNSPECSPEC TOR COMMENTS False BARBEQUE. Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection a Fee No Additional Inspections can be scheduled until re-inspection fee is paid. Miami Shores Village Perrnit NO. PL-8-1 6-2410 4+ 10050 N.E.2nd Avenue NE rm ' Permit Type.Plumbing-Residential Miami Shores, FL 33138-0000 Work Classlllcation.Gab Phone: (305)795-22010 Permit Status:APPROVED liens Date:9/1/2016 F Expiration: 02/2$/21017 Pro)ect Address 1000 NE 96 Street Parcel Number Applicant Miami Shores, FL 1932060143560 Block: Lot: JOHN&JACQUELINE WYBROd1'? Owner Information Address JOHN&JACQUELINE WYBROWPhone cell 1000 NE 96 Street MIAMI SHORES FL 33138- (786)651-7979 1000 NE 96 Street MIAMI SHORES FL 33138- Contractor(sj Phone RUIZ PLUMBING INDUSTRIES INC. Cell Phone (617)755-6875 Valuation: $ 2,200.00 Total Sq Feet: 50 Type of Work:INSTALL GAS WATER HEATER CPVC WATER Type of Piping: Available Inspections: Additional Info.INSTALL GAS WATER HEATER CPVC WATER - ' pInspection Type: Bond Return: 0 Final 14 Classification:Residential Press Test Scanning:3 b, a Review Plumbing FNotayF Due Amount Pay Date Pay Type Amt Paid Amt Due ee $1.80 Invoice# PL-8-16-61145 e 52.25 $225 09/01/2016 Credit Card S 123.30 $50.00 n Surcharge 0 812 912 0 1 6 Credit Card ee $0.60 S 50.00 $0.00 ee S5.00 $1500o Fee S900 gy Fee52A0 $173.30 4ppllcant Copy For Inspections, Call(305) 762-4949 or Log on at https://bidg.miamishoresvilla e.com! Requests must be received by 3 pm for following day inspections. cap/. OTICE: In addition to the requirements of this permit, there may be AND THERE MAY BE ADDITIONAL PERMITS REQUIRED FROM OT dditional restrictions applicable to this property that may be found in GOVERNMENTAL ENTITIES SUCH AS WATER Is public records of this county. HER DISTRICTS,STATE AGENCIES,OR FEDERAL AGENCIES.MANAGEMENT eptember—01—,20 — — _ �_ 2 AM, 9 IUN (,k) -f TIM 4-- tiI I I o Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-267186 Permit Number: PL-8-16-2410 Scheduled Inspection Date: September 14, 2016 Permit Type: Plumbing - Residential Inspector: Hernandez,Rafael Owner: WYBROW,JOHN&JACQUELINE Inspection Type: Gas pressure Test Job Address:1000 NE 96 Street Work Classification: Gas Miami Shores, FL Phone Number (786)651-7979 Project: <NONE> Parcel Number 1132060143560 Contractor: RUIZ PLUMBING INDUSTRIES INC. Phone: (617)755-6875 Building Department Comments INSTALL GAS WATER HEATER CPVC WATER SERVICE, Infractio Passed comments INSTALL GAS LINE TO RANGE AND GAS LINE TO INSPECTOR COMMENTS False BARBEQUE. Inspector Comments Passed Failed ❑ ;^ Correction I Needed / Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. ptember 13,2016 For Inspections please call: (305)762-4949 Page 32 of 44 Rik Pkmft Ruiz Plumbing Industries, Inc. C.F.C. 1427881 5648 Arthur Street Hollywood, FL 33021 (954)430-7211 Office/(954)324-8306 Fax Email: Office@ruizplumbing.net Website:www.Ruizplumbing.net GAS LINE PRESSURE TEST VERIFICATION FORM •All newly installed or altered fuel gas supply lines are required to be tested in accordance with the provisions of Section 406 of the 2003 International Fuel Gas Code. The test pressure shall be not less than 1.5 times the proposed maximum working pressure but not less than 2psig, irrespective of design pressure. When test pressure exceeds 125 psig, the test pressure shall not exceed a value that produces a hoop stress in the piping,greater than 50 percent of the specified minimum yield strength of the pipe. The test duration shall be not less than 10 minutes. • Tests shall be made after all piping installations have been completed.A Final Occupancy Certificate shall not be issued until the test has been observed by the Building Inspector,or this form has been returned to the Miami Shores Village Building Department. Address:1000 NE 96"'street Owner. David King and or Cynthia Herbst Testing Person: Jose Ruiz Testing Company.,Ruiz Plumbing Industries, inc. Testing(Check one) X Company or Person Adaress:5648 Arthur Street Hollywood Florida 33021. Phone 954-430-7211 Test Pressure: 2psig Duration Minutes 15 Minutes Test Date 09/14/2016 • Test Pressure Not Less Than 2 Lbs. • Test Duration Not Less Than 10 Minutes. "My signature indicates that 1 am qualified to perform the required testing procedures and verify that all fuel gas lines after the meter, have been tested in accordance with the requirements of the 2003 International Fuel Gas Code;and the testing requirements have been successfully completed;and no perceptible drop i ressure was observed for the required specified time;and the lines e fr e from leaks, to the best owl knowledge." CL,i Gn Signa rlo ZXTest4erm it Holder or Authorized Representative bate i (Check at least one) ' A o \° ID• £ F Miami Shores Village P1d) ��, 10050 N.E.2nd Avenue NE v £ ` Miami Shores,FL 33138-0000 Phone: (305)795-2204 y°> 'xt1RTFY'' �H 11 tiatee'811120gfi Expiration: 02/28/2017 Project Address Parcel Number Applicant 1000 NE 96 Street 1132060143560 Miami Shores, FL Block: Lot: JOHN&JACQUELINE WYBROA Owner Information Address Phone Cell JOHN&JACQUELINE WYBROW 1000 NE 96 Street (786)651-7979 MIAMI SHORES FL 33138- 1000 NE 96 Street MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone Valuation: $ 2,200.00 RUIZ PLUMBING INDUSTRIES INC (617)755-6875 _. ...w..... _.,_...._ m._.. . :.._ _...,,...r_. _ Total Sq Feet: 50 Type of Work:INSTALL GAS WATER HEATER CPVC WATER Available Inspections: Type of Piping: Inspection Type: Additional Info:INSTALL GAS WATER HEATER CPVC WATER Final Bond Retum: Press Test Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.80 DBPR Fee Invoice# PL-8-16-61145 $2.25 09/01/2016 Credit Card $ 123.30 $50.00 DCA Fee $2.25 Education Surcharge $0.60 08/29/2016 Credit Card $50.00 $0.00 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $2.40 Total: $173.30 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 employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS 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. Futh rmore,I authorize the above-named contractor to do the work stated. September 01, 2016 Authorized Signature:Ow er / Applicant / Contractor / Agent Date Building Department Copy September 01,2016 1 C F. r Miami Shores Village ,TXnFD AUG 2 9 2016 ` Building Department �".�_,__ 10050 N.E.2nd Avenue,Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 201q PL6o -2.(I10 BUILDING Master Permit No. PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: �()(��6 S� City: Miami Shores County: Miami Dade Zip: -3-3/3 e Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder)�� r Q �_ -Fu- T���� Phone#:1�/�]'�✓�,i r(��S'7�' Address:_ loon m >^ Q f �-�-- City: &6LWj _5"@3-_S State: rbc r k 00a_ Zip: 331,3� Tenant/Lessee Name: (( Phone#: Email: V�&0 , C&'\ CONTRACTOR:Company Name: t ✓ Phone#: ES"S�-T39 ' 72 s Address: qv "_' UX City: State: Zip:. Qualifier Name: Phone#:T F w 5 d 72 State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$ ek) Square/Linear Footage of Work: Type of Work: ❑ Addition :1 Alteratioon/ �❑/ New Repair/Replace ❑ Demolition Description of Work: { 5«/ (�„�-3' �/ —hfC S � ��j',L •� fJ� e� Specify color of color thru tile: C� Submittal Fee$ ” Permit Fee$ �e CCF$ yl�_ CO/CC$ Scanning Fee$ Radon Fee$ ?S DBPR$ ' • ��J Notary$ Technology Fee$ ® Training/Education Fee$ Double Fee$ 1 Structural Reviews$ Bond$ 0 TOTAL FEE NOW DUE$ J23. 3 (Revised02/24/2014) � R 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 issue in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. 4-7- Signature " Signa OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before/me this day of 4(1(2d 20 by }day of S 20 by 1�C�YiC� 1�i+rnG4 ,who is personally known to 5QSV- R - who is personally known to me or who has produced as me or who has produced -T)rid'ey U CIMS as 1-k,.-. (0-7-01- 2()1g identification and who did take an ath. identification and who did tak NOTARY P NOTARY P ELIC: Sign: UA-c Sign: Print: �ri'f` `® Print: Y n Seal: YANADYkiuo MY COMMISSION FF 214431 Seal: Q�= EXPIRES:March 25,2019 s iS^"� YA IS ON F PRIEr214031 Bonded Thru Notary Public Undan yrs s+. :+: MY COMM '= EXPIRES:March 25,2D19 max, o; �'''•• c�� n ad Thry Notary Public Urelerurcldere eR ek ek%e ek ek ek eg eg ek ek ek#eta*ek ek ek*ek ek ek ek ek ek ek ek ek�a ek ek>ia ek ek ek ek ek ek eta ek ek ek*ek ek****#ek eta ek ek ek ek ek ek*****%eek ek& e��• ' eta eta ek e[a>K*ek ea ek eF APPROVED BY �' l Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r ' STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 RUIZ,JOSE A RUIZ PLUMBING INDUSTRIES INC 5648 AUTHOR STREET HOLLYWOOD FL 33021 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 "' STATE OF FLORIDA from architects to yacht brokers,from boxers to barleque DEPARTMENT OF BUSINESS AND restaurants,and they keep Florida's economy strong. - ' PROFESSIONAL REGULATION Every day we work to improve the way we do business in order CFC1427081 tSSUED: 05116/2016 to serve you better. For information about our services,please Iaagg onto www.myfforidalicenme.com. There you can find more CERTIFIED PLUMBING CONTRACTOR information about our divisions and the regulations that impact RUIZ,JOSE A - you,subscribe to department newsletters and learn more about RUIZ PLUMBING INDUSTRIES SIC the Department's initiatives, Our mission at the Department is.License Efficiently,Regulate Fairly.We constantly strive to serve you letter so that you can serve your Customers. Thank you for doing business in Florida. IS CERTIFIED under the provisions of Ch.489 FS and congratulations on your new license! EWrat+on date AUG31 2018 060616 o 769 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD CFC1427081 The PLUMBING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS Expiration date: AUG 31,2018 rMl LMJ RUIZ,JOSE A RUIZ PLUMBING INDUSTRIES INC 5648 AUTHOR STREET HOLLYWOOD FL 33021 i. BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2016 THROUGH SEPTEMBER 30,2017 .1 Receipt#' 6DBA: UIZ PLUMBING I�DUS:R"ES INC PLUMSING/LWN SPRNXL/C R Business Name: Business YRe: (PLUABING CONTRACTOR) Owner Name:JosE a Ruiz Business Opened:o4/19/2010 Business Location:5648 AUTHOR s_ State/County/Cert(Reg:CFC1427081 HOLLYWOOD Exemption Code: Business Phone:3 C 5-627-3 5 6 7 Rooms Seats Employees Machines Professionals For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 a.00 -..00 0.00 0.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for:he privilege of doing business within Broward County and is non-regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has Changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. t Mailing Address: JOSE A RUIZ Receipt #048-15-00006961 5648 AUTHOR ST Paid 07/12/2016 27.00 HOLLYWOOD, FL 33021 2016 - 2017 r%r%^1aJa r%n #%P%o rae"ae 1 ^0%a r r►r 4w1&4r0%0% 4aYso • DATE(MM/DD/YYYY) .at 't CERTIFICATE OF LIABILITY INSURANCE 8/25/2016 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 SOUTH FLORIDA CASUALTY PHONEW. 561 533-6144 FAX (561)533-6170 415 North 4th StreetE-MAILaine s cins.ne Lantana, FL 33462 INSURERS AFFORDING COVERAGE NAIC# INSURERA, Scottsdale Insurance Company 39217 INSURED Ruiz Plumbing Industries, Inc. INSURER B: 5648 Arthur Street INSURER C: Hollywood, FL 33021 INSURER D: (954) 430-7211 Office INSURER INSURER 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. INSR LTR TYPE OF INSURANCE PO I Y U B POLICY EFF POLI Y EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1 00O 000 X COMMERCIAL GENERAL LIABILITY $ 100,000 CLAIMS-MADE ®OCCUR MED EXP An one rson $ 5,000 A CPS2347043 12/10/1512/10/16 PERSONAL&ADV INJURY 1,000,000 GENERAL AGGREGATE $ 2,000,000 iN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 2,000,000 POLICY M PRO- MO $ AUTOMOBILE LIABILITY COMBINED SINGL LIMIT ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS UMBRELLA LAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYERS'LIABILITY yy�/�Ny ANY PROPRIETOR/PARTNER/EXECUTIVE ^ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? U N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If es,describe under pLIMIT DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additlonai Remarks Schedule,H more space is required) Plumbing Services CANCELLATIONCERTIFICATE HOWER Miami Shores Village Building Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g P THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami SHores, FL 33138 AUTHORIZED REPRESENTAT ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD JEPP A'TWATER CHIEF FINANCIAL OFFICER 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 individual listed below has elected to me exempt from Florida Workers'Compensation law EFFECTIVE DATE: 31302016 EXPIRATION DATE: 3/30/2018 PERSON: RUIZ JOSE A FEIN: 271516180 BUSINESS NAME AND ADDRESS: RUIZ PLUMBING INDUSTRIES INC 5648 ARTHUR STREET HOLLYWOOD FL 33021 SCOPES OF BUSINESS OR TRADE: CERTIFIED PLUMBING PLUMBING NOC AND CONTRACTOR DRIVERS PLMAnt t0 Cnapler 440.0$(14),F S„an offt0er of a=peraLor wno e!0a6 exGfnrbcr f:o r tnz[napier t v filmy a cevicam of&emon uncer me 6ecbOr'- rnay not recover berefrts or Compensation weer t.ta Chapter PlyI�Znt to C-Site'44",x-;12; FS Certificates of eieCtfln to pe exempt apply only wrthtn bte sG%*of Vie busrress or trade listed on the notce of eim on to oe exerr m=6r6uan:to Chapter cot;05(:3).F S,Wroee of e e Ion:p W -..exemOOM ce"cateS of®lection t0 he exempt ere.1 be eubMw to revo=cn rf at or;*.r-&a`tar vxi eery of tr+a narce or the r tame of the„pt.f,rata. the person meta on the nonce or cenrficate ro onge,meets the fegw.rernents o'in.a aeG-..,wr nor ssuanoe of a ce"5!.cate 'ne tlepettmen;Statravoxe a DFS-F2-0WC-292 CERTIFICATE OF ELECTION TO aF EXEMPT REVISED 3B.13 QUESTIONS?(SW)413.1808 Ruiz PllmM" - -Mem'-t.'nlm Ittdl ries ItL Ruiz Plumbing Industries,Inc. C.F.C. 1427081 5648 Arthur Street Hollywood, FL 33021 (954)430-7211 Office/(954)324-8306 Fax Email:Office@ruizplumbing.net Website:www.Ruizplumbing.net Date: State of Florida County of Dade Before me this day personally appeared lose A Ruiz who,being duly sworn, deposes and say.- That ay.That he or she will be the only person working on the project located at:1000 NE 96st Miami Shores Florida. n Sworn to(or armed)and subscribed before me this G 1 day of�� ,20j by S� �`I`ITO Nl a uk Personally Know Or Produce Identification Type of Identification Produced _L2-P-A\�e- C�C�J5-k NTD LL1, Print, Type or Stamp of Notary h!nra,Y:Public State of Florida Sind;@ A;vaiez s , o ti"y Commission FF 156750 Expires 09/03/2018 MiamishoresVillage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305)756.8972 Notice to owner— Workers, Com ensation Insurance Exemption Florida Law requires Workers' Compensation insurancecoverage under Chapter 440 of the Florida Statutes. Fla..Stat. § 440.Q5 allows corporate officers in the construction industry to exempt Of from this requirement for any construction project prior to obtaining a building permit. pursuant to the Florida Division of Workers'Compensation Employer pacts Brochure: An employer in the construction industry who employs one or more part-time or full-time members employees,including the owner,must obtain workers' compensation coverage. Corporate officers ex empt if: of a limited liability company (LLC) in the construction industry may elect to be ex I. 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 s permit under this day labor,part-time employees workers'compensation exemption and has acknowledge that he or she will not use 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 req workers'compensation insurance coverage from the contractor's ire verification of company for day labor,Part-lime employees subcontractors. CONT'ENT'S. require BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS Signature: Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this 3 I S+day o f 6t g l��S 20_1E. By Davi 8 who is personally known tome or has produced ri Y i as identification. Notary: SEAT: , J'd;r,, YANADYPRIErO MY COMMISSION#FF 214031 EXPIRES;March 25,2019 �• ���� � c� �I AUG 2 9 206 Lo c4 BY: • ;' '! t,1 7C)(;��^,if'I ",�dCl_ ^Ji IA[ L_t-I IN 1IAL 7 •••••• • •• •••••• to PAJ•••• r 0