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EL-15-1500 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 6 Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-261698 Permit Number: EL-6-15-1500 Scheduled Inspection Date: July 11,2016 Permit Type: Electrical- Residential Inspector: Devaney, Michael Inspection Type: Final Owner: WICHMANN,ANGELA KELSEY Work Classification: Addition/Alteration Job Address:1399 NE 104 Street Miami Shores, FL Phone Number (954)444-2156 Project: <NONE> Parcel Number 1122320320040 Contractor: FAIRBAIRN ELECTRIC LLC Phone: (305)753-2550 Building Department Comments KITCHEN AND BATH REMODEL AND ADDITION OF 1/2 infraction Passed comments BATH WITHIN FOOTAGE INSPECTOR COMMENTS False Inspector Comments Passed ��/� CREATED AS REINSPECTION FOR INSP-237139. Add arc fault I I protection and smoke/carbon monoxide detectors. Label panel correctly and put breaker locks in the off position for range, oven and micro wave. Failed ❑ Move counter recentacle up. Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. July 08,2016 For Inspections please call: (305)762-4949 Page 19 of 45 x x ar s o, Miami Shores Village ` �u P~r"&N 10050 N.E.2nd Avenue NE Miami Shores,FL 33138-0000 Phone: (305)795-2204 1 20 Expiration: 05/2016 Project Address Parcel Number Applicant 1399 NE 104 Street 1122320320040 Miami Shores, FL Block: Lot: ANGELA KELSEY WICHMANN Owner Information Address Phone Cell ANGELA KELSEY WICHMANN 1399 N.E. 104 ST. (954)444-2156 MIAMI SHORES FL 33138 Contractor(s) Phone Cell Phone Valuation: $ 8,448.00 FAIRBAIRN ELECTRIC LLC (305)753-2550 Total Sq Feet: 00 Type of Work:KITCHEN AND BATH REMODEL AND ADDITI Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Scanning:3 Meter Box Alteration Relocation Fire Alarm Service Change Review Electrical Underground W.W. Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $5.40 DBPR Fee Invoice# EL-6-75-56020 x.44 12/08/2015 Check#:3052 $328.28 $0.00 DCA Fee $4.44 Education Surcharge $1.80 Permit Fee-Additions/Alterations $298.00 Scanning Fee $9.00 Technology Fee $7.20 Total: $328.28 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFID T: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and VW uthermore,I authorize the above-named contractor to do the work stated. December 08, 2015 Authorize nature:Owner / Applicant / Contractor / Agent Date Building Department Copy December 08,2015 1 01/25/2016 12:15PM 3052851042 FAIRBAIRN ELECTRIC PAGE 01/02 FAIRS-1 OP ID:GM �•.-� CERTIFICATE OF LIABILITY INSURANCE DATE(MMMWyrM [jELOW- HIS CERTIFICATE I8 SUED AS A IYL4TTER OF 16 INFOR(Y►q't•1pN ONLY AND CONFERS NO RlQtilS UPON THE CERTIFICATE HOf.DER0`110812OTHIS ERTI�CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, l:7(TEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ITHI$ CERTIFICATE OF INSURANCE f>OFJ; NOT CONSTITUTE A CONTRAC BETWEEN THE ISSUING INSURER{8), AUTHORtZI:D EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDElZ,PORTANT: Ii the Certificate bolder is an ADDITIONAL INSURED,the poliaypes)mug be endorsed_ If SUUKVVATION IS WAIVED.subject to the terns and conditions of the policy,certain policies may require an endOrSernent. A state Certificate hokier in lieu of such endorseln nt&, manE on this ceetiFrCats does not confer rights to the PRODucsR Glottal Risk Ls? NAME., !vette Jimenez $859 Blue 33 us Dr Suite 101 PLLONs E�:345-455-7250 A BAINEriiDGE No..305-455-7251 E =Mail lolmlRiskLLC.cont IN$U $)AFFORDfN$COVERAGE NAIC�! ►+ airbaim lectric ILC ZYMURERAMStiOnwide Ins Co of America 264 53 P O Box 330856 INSURER 0: Miami,FL 33333 I NSUPjM INSURER D INSURERS: COVERAGESInsuRER P CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE uSTED BELOW HAVE BEEN 155UED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD !INDICATED. NOTtMTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY _ CERTIFICATE MAY Be ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TH ES DESCRIBED REIEN WTH Is EC ALL THETERMSTHIS . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE RMN REDUCED BY PAID CLAIMS, LTR TM OF INSURANCE A X COMMERCIAL GEN POLICY EF MLi DCY um"LU►r3tLrtY PMMY NUMBER CLAIMS~S �I°�LZ{�.i864361374 EACH OCCURRENCE E 1,�y0 lij01!09/2016 61/08/2017 PRI Mu$P� ooamenoe $ 100100 MED EXP A^S'we porson) $ 6,00 GW1.AGOMOATE umrrAPPLIES PER. PERSONA!.&AOV INJURY S 1,0110.00 X POUCy El Et�`T F-1 LOC GENEWW.AGOREGATE s 2,000,0 OTHER: PRODUCTS.CONP/OpAGS $ 2A1i0,0 AUTONOPME LIABILITY $ BINED SW GI LIMIT ANY AUTO se �� A TOS ED 0HEDULED BODILY WJURY(Per pe►ew) S HIRED AUTOSBODILY DUJRY(Per eowdenn $ AUTOS PROPERTyAMA E $ IN UMBRELLA LIAR OCCUR s EXQEN UAs CLAIMS MADE EACH OCCURRENCE g DED RETENTION S A00REGATEAND g S VAMUTY Y/N OFFICERIME 9�EXCLUDED? �E [�N/A STA ER - I(E X41 NH) FINIA EACH A001bew g DESCRIPTION OPOPERATI{ S �, ELaiWAGr-EA EMPLOY $ &L DISEASE.POLICY LtMfr g DESCRIPTION OF DPEWlT10HS/LOCAYIcm/VIEN CL.Es(ACORD 101.A*=*-I RSMAft SoRetmte,M4y bo dashed irM" State of Florida Electrical Cont AcOng Licenser S£C0000912 CERTIFICATE HOLD CANCELLATION MIAMJA Miami Shores village $HOULD ANY OF THE ON DDA7E�TtoF�NOT1c WILPOLICES L 8EDEp M 10060 North mt 2nd Avenue RDANCE W M THE pOLICy PROVISION$ MISMI Shores,FL 33138 p REr'LiESENTA7IVE ACORD 28(2014141) ®19i�-x.'014 ACORl7 CORPORATION. All Ljights The ACORb name and logo are registered marks of ACOR D reserved. 01/25/2016 12:15PM 3052851042 FAIRBAIRN ELECTRIC PAGE 02/02 b6 JEFF ATWATER CHIEF FINAK%UL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION "CERTIFICA'T'E OF ELECTION TO Ele EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW"* CONSTRUCTION INDUSTRY 1=XEMPTION This DeMes that the individual listed below has eleded to be eXempt ffam Florida Workers'Compenwoon low. EFFECTIVE DATE: 1/24/2016 EXPIRATION DATE: 1/23/2018 PERSON: FAIRBAIRN BRUCE FEIN: 203252609 J BUSINESS NAME AND ADDRESS: FAIRBAIRN ELECTRIC LLC PO BOX 330858 MIAMI FL 33233 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL CONTRACTOR matt to Chapter 4to.o$(14),F.B..an otfiQrmay of a oorporeaon wh elect exam fn from tbl8 chapter by filing 8 cafl6cate of kwon undar this sercdon M!rot taco l)e of etfts si ttsation unser ,this dmpt�u.P_ursuaot to Chanbr 44046(92),F.8-.Cel is elac ionto be ememp2„apply eu+iy— vridrin the snipe of ffie business or trade dated on fhe nafte of efecden to be exempt pursuttrrt to Chapter 440.06(13),F.S,NoddCs of etectlon to be ft"Vt end cm0c afas or efagt�to be exempt aftad be eubleet to revooadon if,et anytime aft 'r the tiNnp of the notice or the fsauarof or the the Person named on the t►odoe or np m the lGQuiterrrenffi d thfa st cdon for issuance of a cudrtmm.Ite depwmrent 04 eke a DF3•F2-DWC-252 CZRTIFICATE OF ELECTION TO BE E)(EMPT REVISED Mfg QUESTIONS?(850)413-1608 D , Miami Shores Village C �,T P,ID Building Department JUN IS 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 8X: � �- Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20!® BUILDING Master Permit Nozf/-Jr— f 11V9 PERMIT APPLICATION Sub Permit No/, 15-- /,5z ❑BUILDING ,ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [] MECHANICAL ❑PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS' t-:?,FzfQ "5—= R CATz, '<z2Et!ST City Miami Shores County Miami Dade Zip: — Folio/Parcel#: 0D4 0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: — ruc AmqA Gv chi OWNER:Name(Fee Simple Titleholder): � � � l Phone#: �; I VS1,a/S Address: City:Wl 1.4 VA, State: Tenant/Lessee Name: Phone#: Email: �r,I� ' _ CONTRACTOR:Company Name: VA ( 1� .� C-� ?A =1 �. hone#: Address: PC) City: State: 1t' Zip: � - �— Qualifier Name: �RUC1 ���R-641� )J Phone#: 30S State Certification or Registration#: �"�(2-0 o o!? --- Certificate of Competency#: DESIGNER:Architect/Engineer:-J 4® AP-4115 J Phone#: Address: Q5 N W A®� '( �� City:' '�—� �tate: Zip: Value of Work for this Permit:$- `'t Square/Linear Footage of Work: i-Type.otWork:—/❑ Addition Alteration Q ElNew ElRepair/Replace ❑ Demolition Description of Work: K I 1 CP-c7moL-, I Liles Specify color of color thru tile: Submittal Fee$ Permit Fee$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ �- (Revisedo2/24/2014) 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. 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 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. ZI/ Signature Signature WNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 020 U;,by _day of Q Y\,P-- .20 .by 9 SCvn .who is personally kno toCV CP_ ai rig rn ,who is personally known to m.,e or who has produced as me or who has produced V-L Oci �-S "nse.. as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PU Sign: Sign: Print: awL � Print: QJAQL Seal: Seal: ►'" JEENA NELSON , , JUDYEBARR 1v1Y COMMISSION#FF033M s WCUOMMOEEW180 ° �C3` EXPIRES:Septwdw 1S,2017 EXPM&-,)M 29,2016 a ls' APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) OR IM Miami shores Village `z 01 Building Department ��OR1D� 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES,FL 33138 Certificate must specify the description of operations or contractor license number. ........................................................................................... BUSINESS NAME: BUSINESS ADDRESS: Iy eOX 30 &SC=> CITY M 7�G�1 STATE�� ZIP �213S Ic BUSINESS PHONE: � � `7S3'2-S50 FAX NUMBER( ) CELL PHONE�) QUALIFIER'S NAME:��1 ��� QUALIFIER'S LIC NUMBER: E:-- G d0 0 0 9 ( Z IMPORTANT STATE OF FLORIDA `S Pursuant to Chapter 440 05(141 F S.an officer of a Corporation who DEPARTMENT OF FINANCIAL SERVICES h ,1 elects exemption from this chapter by filing a certificate of election under DIVISION OF WORKERS' COMPENSATION a this section may not recover benefits or compensation under this chapter CONSTRUCTION INDUSTRY EXEMPTION O Pursuant to Chapter 440.05112).F.S_Certificates of election to be exempt apply only within the scope of the business or trade listed on CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L the notice of election to be exempt. WORKERS'COMPENSATION LAW D EFFECTIVE DATE: 1r242014ExPIRAnoN DATE: 1 24-_015 Pursuant to Chapter 440.05(13).F.S..Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if. PERSON: FAIRBAIRN Aauc=_ H at any time after the filing of the notice or the Issuance of the certificate. FEIN: 20325260' E the person named on the notice or certificate no longer meets the R requirements of this section for issuance of a certificate The department BUSINESS NAME AND ADDRESS: shall revoke a certificate at any time for failure of the person named on FAIRBAIRN ELECTRIC LLC E the certificate to meet the requirements of this section PO BOX 330856 MIAMI FL 33233 SCOPES OF BUSINESS OR LICENSED ELECTRICAL CONTRACTOR Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 5702668 b BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES W FAIRBAIRN ELECTRIC LLC RENEWAL SEPTEMBER 30 2015 w 1227 SW 3 AVE 406 594788 #. W Must be displayed at lace of business MIAMI, FL 33130p a Pursuant to County Code q Chapter 8A Ix -Art.9&10 to it U -m OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED r � FAIRBAIRN ELECTRIC LLC 196 ELECTRICAL BY TAX COLLECTOR CONTRACTOR 45.00 09'1120'= ` Worker(s) 1 EC0000912 CRED'TCARD 036595 s ' This Local Business Tax Receipt only codrms payment of the Local Business Tax.The Receipt is not a license. permit,or a certification of the holder's qualifications,to do business.Holder must comply with anygovernmernal 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-276. IA ADE For more information,visit www.miamidade.gpvrtaxcollector ^?T1it� RICK SCOTT, COVE KEN LAWSON. SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION " s ELECTRICAL CONTRACTORS LICENSING BOARD _. EC000091Z The ELECTRICAL CONTRACTOR :„ Named below IS CERTIFIED Sri Under the provisions of Chapter 489 FS. Expiration date: AUG 31. 2016 FAIRBAIRN, BRUCE J I FAIRBAIRN ELECTRIC LLC 1227 SW 3 AVE #406 MIAMI FL 33129 ' Y. I FAIRB-1 OP ID: DM CERTIFICATE OF LIABILITY INSURANCE FDA051281201 1t7 05/28/2015 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 Neu of such endorsement(s). PRODUCER Global Risk LLC NAME: Daniel Martinez 5959 Blue Lagoon Dr Suite 101 PHONE o �:305-455-7250 N,I.305-455-7251 Miami FL 33126 -MAIL GAYLY A BAINBRIDGE ADDRESS:Mail@GlobaiRiskLLC.com INSURER(S) AFFORDING COVERAGE MAIC# INSURER A:Nationwide Ins Co of America 25453 INSURED Fairbaim Electric LLC INSURER B: P O Box 330856 INSURER c Miami,FL 33233 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY) thIM1001YYYY11 LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE rx]OCCUR ACP5964351374 01/09/2015 01/09/2016 PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000, GERL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000, POLICY PRO- HJECT LOC PRODUCTS-COMP/OP AGG $ 2,000, OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PRO AUTOS aEkl DAMAGE $ $ UMBRELLA LUU3 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PE - AND EMPLOYERS'LIABILITY Y/N STATUTEI OR ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? El NIA E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ N yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) State of Florida Electrical Contracting License#EC0000912 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department WITH TH THE POLICY PROVISIONS. 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores, FL 33138 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD , Miami shores Village Building Department tOR1DA 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption 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 SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: JV Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this day of � ,20 . By f—!'�'lG 0,1 (4 who is personally known to me or has produced as identification. "0 1 ,•.r" �a',% REATHA L BORN SEAL: .a°. „`<•; Notary Public-State of Florida ;.; •= my Comm.Expires Feb 4,2016 '.V Commission#EE 137477 °;;; Bonded Throug a onal Notary ASS 06/14/2015 Fairbairn Electric LLC Bruce Fairbairn PO Box 330856 Miami, Florida 33233 305 753 2550 tel 305 2851042 fax Fairbairn912@gmail.com EC0000912 State of Florida County of Miami Dade Before me this day appeared Bruce Fairbairn who, being being duly sworn, deposes and says: That he or she will be the only person working on the project located at: 1399 NE 100 Street Miami Shores, FL 33138 Personally know Or Produced Identification Type of Identification Produced V-L- r!1 C. Prin p;or Name of Notary JEENA NELSON MY COMMISSION#FF053790 w EXPIRES:September 15,2017