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PL-16-1587 1� Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-260569 Permit Number: PL-6-16-1587 Scheduled Inspection Date: August 11,2016 Permit Type: Plumbing - Residential Inspector: Hernandez, Rafael Inspection Type: Final Owner: , Work Classification: Addition/Alteration Job Address:955 NE 98 Street Miami Shores, FL 33138- Phone Number (786)376-9160 Project: <NONE> Parcel Number 1132060143360 Contractor: AMERICA SEPTIC TANK CORP Phone: (305)281-5128 Building Department Comments REPAIR DRAINFIELD 300 SQFT Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed h r/) /Z3 Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid August 10,2016 For Inspections please call: (305)762-4949 Page 8 of 23 ►• DIVISION OF Environmental Health Florida Health AnMiumi-Dade County AQQ OSTDS/Well Division OG �►� 11805 SW 26th Street•Miami,FL 33175 p Inspector a Date_ �•� .�L Address_ I QSTDS#_O d c Comments: Signatur J -T�- L �� � SE� y Y -7i vk 64587`5 Miami Shores Village P 7j* , 10050 N.E.2nd Avenue NE � Wallen E v Miami Shores,FL 33138.0000 Phone: (305)795-2204 \ :I Expiration: 01114/2017 p Project Address Parcel Number Applicant 955 NE 98 Street 1132060143360 Miami Shores, FL 33138- Block: Lot: PRESTIGE PROP INVESTMENT, Owner Information Address Phone Cell PRESTIGE PROP INVESTMENT GRP 2933 SW 27 Terrace (786)376-9160 - MIAMI FL 33133- Contractor(s) Phone Cell Phone Valuation: $ 5,000.00 AMERICA SEPTIC TANK CORP (305)281-5128 ....., m .._.m. _.;,..._ _.,.... : w, ..,.......__... Total Sq Feet: 300 Type of Work:REPAIR DRAINFIELD 300 SQFT Available Inspections: Type of Piping: Inspection Type: Additional Info: Top Out Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Underground Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Contractors Bond $500.00 CCF Invoice# PL-6-16-60108 $3.00 06/08/2016 Credit Card $50.00 $621.50 DBPR Fee $2.25 DCA Fee $2.25 07/18/2016 Credit Card $621.50 $0.00 Education Surcharge $1.00 Bond#:3147 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $4.00 Total: $671.50 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all a fo egoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zbning.;Futh rmore,I thori a the above-named contractor to do the work stated. . 3 July 18, 2016 Authorl d Sign ure:Owner I` AWficant / Con rector / Agent Date Building Department Copy July 18,2016 1 Miami Shores Village z57T Building Department artment JUN 08 201 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 By: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20 � BUILDING Master Permit No. l S��— PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL MN PLUMBING ❑MECHANICAL PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 955 NE 98 ST. MIAMI SHORES FL. 33138 City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3206-014-3360 Is the Building Historically Designated:Yes No NO Occupancy Type: RESIDENCE Load: Construction Type: REPaR�� Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):PRESTIGE PROP INVESTMENT GRP INC Phone#: Address:2933 SW 27 TERR. COCONUT GROVE FL. 33133 City: COCONUT GROVE State: FL Zip: 33133 Tenant/Lessee Name: NONE Phone#: Email: CONTRACTOR:Company Name:AMERICA SEPTIC TANK CORP. Phone#: 305-281-5128 Address: 15362 SW 36 TERRACE City: MIAMI state: FL Zip: 33185 Qualifier Name: JOSE A. DE CASTRO Phone#: 305-5538243 State Certification or Registration#: SR0890135 Certificate of Competency#.. 178640 --------------------------------------DESIGNER:Architect Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$ 75 Civ C97 Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New Q Repair/Replace ❑ Demolition Description of Work: REPAIR DRAINFIELD. 300 SQ. FT. 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$ cZ;'1b0 ` TOTAL FEE NOW DUE$ l ( qO (Revised02/24/2014) �� �® Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature , OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this lZ day of 20 1,4 by day of 20 1,4 by who is personally known to Liar g,who is pars611'a Iy known as produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: . _ Sign: G�^^'� ten• C • Print: tel• Print: 1prr' •dam Seal: Seal: ALEXANDER R VIERA ALEXANDER R VIERA -� •c MY COMMISSION#EE222731 's~ •`= MY COMMISSION#EE222731 EXPIRES August 06 2016 *�*x**�** a' �' **�* I'> s��Itl��Ii111** *�*��**����*�*•e** pts�**�� ��*** (4MM4153 s APPROVED BY '�� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) % I " PERMIT :13-SC-1678446 w.E�vT'r-7 "tip rf Ride a;a�Ct9_?"( ? 's'• i:tee?3 r # APPLICATION #:AP1237061 STATE OF FLORIDA DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID: CONSTRUCTION PERMIT RECEIPT #: DOCUMENT #:PR1017108 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: (Prestige Prop Investment Group Inc) PROPERTY ADDRESS: 955 NE 98 St Miami, FL 33138 IAT: 3,4 BLOCK: 80 SUBDIVISION: Miami Shores Sec 3 PROPERTY ID #: 11-3206-014-3360 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD existinq septic tank CAPACITY A [ ] GALLONS / GPD CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ 300 ] SQUARE FEET Bed configuration drainfiel SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH (x] BED [ ] N F LOCATION OF BENCHMARK: FFE 9.74'NGVD I ELEVATION OF PROPOSED SYSTEM SITE [ 18.40 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 38.48 ] [ INCHES FT ] [ABOVE BELOW BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 32.00 ] INCHES **THIS REPAIR PERMIT IS NOT FOR ANY ADDITIONS** O 1.-Existing 900 gal.septic tank,certified by Jose A. De Castro on 04/14/2016,to remain. T 2.-Install 300 sf of drainfield in bed configuration. H 3.-Install 12"of slightly limited soil at the bottom of the drainfield. 4.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench. E (Comments Continued on Page 2.) x SPECIFICATIONS BY: Jose A De Castro TITLE: Registered Septic Tank Contractor APPROVED BY: TITLE: Engineering Specialist II Dade CHD Erlande Omisca DATE ISSUED: 05/06/2016 EXPIRATION DATE: 08/04/2016 DH 4016, 08/09 (Obsoletes all previous editions which may not be usea�;f9c hl.Al. A; ° 9 f Incorporated: 64E-6.003, FAC [� 6 `A i°°' ° e O v 1.1.4 AP1237061 's:r 2@ k•r yes aree)is req1_6rw9 to pe."Om;a soil boring a :ace^' to J-3Ir�e;d excava::on at the time of firal Approval. tr+e FDOH 'nspector shall v.i(ness t e s3' n.oring ar„ oomp2,e the resu is to the onginai site evaluation submitted. A reinspection fee will be assessed it the contractor is not at the jobsite at the arranged time. DOCUMENT #: PR1017108 5.-Invert elevation of drainfield to be no less than 7.03'NGVD. 6.-Bottom of drainfield elevation to be no less than 6.53' NGVD. 7.-Water line within 10 ft of septic system to be Sch 40 PVC or sleeved in accordance with FAC Ch 64E-6.005(2)(b). The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow of 300 gpd. D C' - F STATE OF FLORIDA - DEPARTMENT OF DEALT H APPLICA i ION FOR ONSrrE SBUAGE DISPOSAL.SYSTEM CONSTRUCTION PERMIT Permi<Application Number -------_---'y :5 1----- -- - a-rc;'7TARTI1-StTEPLAN--------------------------- Scale: Each block re resents Q at and Ii inch=40 feet. 1 , v- A- CSP LL 6'Wood F. O i w V m o - v o m Asphalt o 9p0 50.00'i c^ --15.001--- -2-H-- o F -. a T.90' 22.50' 25.50' - r N eY S� a r . r_'_.�osp o _m 1.30 --- Q------- ---- ------ co 1LLN 9 CiST. R F l� 1 Q� �0 ^ (OJ IF O o co 0.60' c) 25.50' I> t j O ��( v, row o C7 x 2�6A � c as LU a so ,s I 5• o �; � � a 25.50' 3 a O ci 9�d oQ $h U I o 60 zo Jjjs I o �' �s 9`L• 128°11'4 ° I er Plat) a I 6 Notes_ el-9 n i 1 Yl2c d I?�/ P a l� C"T� e'' h� ,� CORO.Z �+ c. �► r C c ( �r z+ tM C� q �^(� r Slee Pian submfted by: -- Plan Approved - sig r:A roved ui to _ pp Daae County Health Department ALS.IGHA li6aES tt UST BE APPROVED BY THE COUWV HEALTH p3EpARTMENT DH 4015,10/96(R8p[aGM HRS-H r=oan 4016 which may be usen Page 2 of rt (Stack Number_ 5T44-0()2-4015-6) .a Detail Entity Florida Profit Corporation PRESTIGE PROPERTIES INVESTMENT GROUP INC. Filing Information Document Number P14000012409 FEI/EIN Number 47-1351113 Date Filed 02/07/2014 Effective Date 02/07/2014 State FL Status ACTIVE Last Event AMENDMENT AND NAME CHANGE Event Date Filed 06/18/2014 Event Effective Date NONE Principal Address 2933 SW 27 Terrace MIAMI, FL 33133 Changed: 09/11/2015 Mailing Address 2933 SW 27 Terrace MIAMI, FL 33133 Changed: 09/11/2015 Registered Agent Name & Address TAPIA, FERNANDO R 2933 SW 27 Terrace MIAMI, FL 33133 Address Changed: 09/11/2015 Officer/Director Detail Name &Address Title PRES TAPIA, FERNANDO R 2933 SW 27 Terrace MIAMI, FL 33133 Title VP MENGUAL, MILLY 1 2933 SW 27 Terrace MIAMI, FL 33133 Annual Reports Report Year Filed Date 2015 09/11/2015 2016 01/18/2016 Document Images 01/18/2016 --ANNUAL REPORT View image in PDF format 09/11/2015 --ANNUAL REPORT View image in PDF format 06/18/2014 -- Amendment and Name Change View image in PDF format 02/07/2014 -- Domestic Profit View image in PDF format ...i:'C'V"`L'-•' YiI t' -a;tti::t>''CI,>.c,.a Propeqy Search Application-Miami-Dade County Page 1 of 1 OFFICE OF T'HE PROPERTY APPRAISERL Summary Report Generated On:4/29/2016 Property Information y Folio: 11-3206-014-3360 Y Property Address: 955 NE 98 ST Miami Shores,FL 33138-2534 PRESTIGE PROP INVESTMENT '� w Owner f GRP INC M Mailing Address 2933 SW 27 TER COCONUT GROVE,FL 33133 USA Primary Zone 1100 SGL FAMILY-2301-2500 SQA Primary Land Use 0101 RESIDENTIAL-SINGLE FAMILY:1 UNIT Beds/Baths/Half 3/2/0 Floors 1 Living Units 1 Actual Area 2,940 Sq.Ft Living Area 2,103 Sq.Ft Adjusted Area 2,263 Sq.Ft Taxable Value Information Lot Size 10,760 Sq.Ft 2015 2014 2013 Year Built 1962 County Exemption Value $0 $0 $0 Assessment Information Taxable Value 1 $353,5801 $321,437 $292,216 Year 2015 2014 2013 School Board Land Value $219,504 $155,482 $124,386 Exemption Value $0 $0 $0 Building Value $165,380 $164,319 $165,613 Taxable Value 1 $387,058 $321,997 $292,216 XF Value $2,174 $2,196 $2,217 City Market Value $387,058 $321,997 $292,216 Exemption Value $0 $0 $0 Assessed Value $353,580 $321,437 $292,216 Taxable Value $353,580 $321,437 $292,216 Regional Benefits Information Exemption Value $0 $0 $0 Benefit Type 2015 2014 2013 Taxable Value $353,580 $321,437 $292,216 Non-Homestead Cap Assessment Reduction 1 $33,478 $560 Note:Not all benefits are applicable to all Taxable Values(i.e.County, Sales Information School Board,City,Regional). I Previous OR Book- Sale Price Page Qualification Description Short Legal Description 09/17/2015 $400,000 29800-1058 Qua[by exam of deed 5-6 53 42 05/12/2015 $195,000 29679-1746 Qua[by exam of deed MIAMI SHORES SEC 3 PB 10-37 01/02/2013 $100 29207-0277 Corrective,tax or QCD;min LOT 4&SWLY20FT OF LOT 3 BLK 80 consideration LOT SIZE SITE VALUE 07/01/2009 $100 26963-4170 Financial inst or"In Lieu of OR 20624-2519 08 2002 5 1 1 1 Forclosure"stated 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 hfp://www.miamidade.govfinfo/disclaimer.asp Version: http://www.miamidade.gov/propertysearch/ 4/29/2016 Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOTA BILL — DO NOT PAY \,_LBT �) 178640 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES AMERICA SEPTIC TANK CORP RENEWAL SEPTEMBER 30, 2016 15362 SW 36 TERR 178640 Must be displayed at place of business MIAMI FL 33185 Pursuant to County Code Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED AMERICA SEPTIC TANK CORP 196 SPECIALTY PLUMBING CONTRACTOR BY TAX COLLECTOR Worker(s) 10 SEP890027 $75.00 07/09/2015 CHECK21-15-083406 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit,or a certification of the holders qualifications,to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-176. For more information,visit www.miamidade.goy/taxcollector STATE OF FLORIDA < ` DEPARTMENT OF FINANCIAL SERVICES n { DIVISION OF WORKERS'COMPENSATION ! nk REGISTERED SEPTIC TANK CONTRACTOR CONSTRUCTION INDUSTRY EXEMPTION -- JOSE A. DE CASTRO �RTIFICMRIKERWCOFELE°TKI TO DE EIlEmFr Fliom FLORIDA 15362 SW 36 TERRACE • NORRERATE OF ENSA oN 13 W EFFECTNE DATE: Taariou EXPIRATION DATE: 7a7MI7 ¢ MIAMI, FL 33185- PERSON: DE CASTRO JOSE A 7y FEIN: 5 M7,. > AMERICA SEPTIC TANK CORP. BUSINESS NAME AND ADDRESS: _ _ AMERICA SEPTIC TANK CORP 15362 SW 36TH TERRACE SR0890135 Business Authorization: SA0890027 MIAMI FL 33185 SCOPES OF BUSINESS OR TRF AMERI12 OP ID: MARZ ,4coRO" CERTIFICATE OF LIABILITY INSURANCE FDATE(M05/09/209/20 6 16 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 endomement(s). PRODUCER CONTACT iSure Insurance Brokers NAME: Javier A.Fem3ndez 8700 W.Fla9ler St.,Suite 270 alc°No •305-223-2533 FAXAIL No):305-220-0765 Miami, 33174 E-MAILR Javier A..Fem>Ilndez SS:Certificates@iSureBrokers.com INSURER(S)AFFORDING COVERAGE MAIC# INSURERA:WeSCO Insurance Comp 25011 INSURED America Septic Tank,Corp. INSURER S: Jose A DeCastro 15362 SW 36 Ten• INSURER C: Miami,FL 33185 INSURER D: 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. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR WVD POLICY NUMBER MWDD MWDD A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,00 CLAIMS MADE XoccuR WPP1130021-02 01/19/2016 01/19/2017 PREMGE ToISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 500,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,00 POLICY❑JECOT- D LOC PRODUCTS-COMP/OP AGG $ 1,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Par aMZt UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? EIN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) SEPTIC TANK SYSTEMS, INSTALLATION,SERVICING OR REPAIR CERTIFICATE HOLDER CANCELLATION CITYMI1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Miami Shores ACCORDANCE WITH THE POLICY PROVISIONS. Fax:305-756-8972 10050 NE 2 Ave AUTHORIZED REPRESENTATIVE Miami,FL 33138 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ORES 5 Arc.193J s� Miami shores Village Building Department 10050 N.E.2nd Avenue �LORIUp' 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: 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 a permit under this workers'compensation exe'mption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances,Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING4BELOWANOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of Florida County of Miami-Dade The foregoing was acknowledge before me this I day of o ,20 . By_(��S�� Del 0?PV�l o is personally wn to me or has produced dentification. „��u KRISIA DEL PRADO NOtary: 3��• e``,': iSx ti:A . PkHQQ NOtB/y PUDIiC-state Ol�IOf� to rY a �i r. Aare of:ioripa CiOmmlSs�n#FF 981913 M Comm.Expim Jun 8.2M SEAL: 98�b 9 3 ���, �Ptic Tag lose A De Castro 15362 SW 36t'Terrace Miami, FI 33185 Telephone 305-281-5128 305-553-8243 e-mail:decastroadierl@gmaiLcom Date:06/27/16 State of:FLORIDA County of:MIAMI-DADE Before me this day personally appeared JOSE A De CASTRO who,being duly sworn,deposes and says: That he will be the only person working on the project located at; 955 NE 98 ST MIAMI SHORES,FL 33138 Sworn to for affirmed)and subscribed before me this 9 day of ..XJAC 20-L(O,by Sost A. De 'CAsmo Personally Known t.� OR Produced Identification Type of Identification Produced e . . SEAL _ ., ALEXANDER R VIERA -•. •+i MY COMMISSIONS EE22V31 EVIL E8 Alu0 N OS.2018 �eat53