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MC-15-2285 .., Miami Shores Village y;�e °�e �i>ltl l eald €tial ` 10050 N.E.2nd Avenue NW �Si� ditli + rlftri Miami Shores,FL 33138-0000 , �1 Q Phone: (305)795-2204 f Expiration: 03/26/201 Project Address Parcel Number Applicant 88 NW 111 Street 1121360030400 Miami Shores, FL 33138- Block: Lot: Trifecta Capital LLC Owner Information Address Phone Cell Trifecta Capital LLC 1504 BAY Road (954)465-3753 MIAMI BEACH FL 33139- 1504 BAY Road MIAMI BEACH FL 33139- Contractor(s) Phone Cell Phone Valuation: $ 4,800.00 SUNBAY AIR CONDITIONING AND HE (954)848-4121 (954)673-6920 __,.......... _...... ... _.... _ _._.._,,. _....._,...._ Total Sq Feet: 00 Tons: Available Inspections: Additional Info: Inspection Type: Classification:Residential Final Approved:In Review Rough Duct Comments: Date Approved::In Review Review Mechanical Date Denied: Type of Work:NEW A/C INSTALLATION Underground Scanning:3 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.00 Invoice# MC-9-15-57017 DBPR Fee $2.52 09/28/2015 Check#:1051 $ 190.04 $0.00 DCA Fee $2.52 Education Surcharge $1.00 Permit Fee $168.00 Scanning Fee $9.00 Technology Fee $4.00 Total: $190.04 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING, ICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certi at all the fore Ing in is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Fu ore,I authoriz the abov nam contractor to do the work stated. September 28, 2015 Authorized Signature: ne Applicant / ontractor / Agent Date Building Department Copy September 28,2015 1 Miami Shores Village C =TVED SEP Building Department 0 g 2015 10050 N.E.2nd Avenue,Miami Shores,Florida 3313E BY: Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 FBC 20PLI BUILDING Master Permit No.r PERMIT APPLICATION Sub Permit No.H C I s- zza BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION DRENEWAL ❑PLUMBING 01VIECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: S a &ky I I I , City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: I I - a13$-003'• z) Ova Is the Building Historically Designated:Yes NO& Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): r) 4, L.({. Phone#: 9i' Lf-V49--7-4-3 Address: 5() /c� Ion City: I.W State: Zip: ? Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: Yuh 14c, Phone#: s `,t"/ L"���1 L l Address: GZ City: P> a State: � (- Zip: / Qualifier Name: jz' Phone#: D State Certification or Registration#: j4 C_Q J'�Q Certificate of Competency#: DESIGNER:Architect/Engineer: Phone#: Address: City: State Zip: Value of Work for this Permit:$"00"' Square/Linear Footage of Work: Type of Work: ❑ Addition ❑,, //Alteration/ New ❑ Repair/Replace ❑ Demolition Description of Work: N2,,- Specify color of color thru tile: Submittal Fee$ Permit Fee$ CF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ 190 . 0 (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 inspecti which occu even (7) days after the building permit is issued. In the absence of such posted notice, the inspection will no :77 on 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 a day of S1;�7c--rrlibc—rL 20 tS by .1 day of Si--q Tem MEr2 20 4S �-by DJAIUItcL Cir-TL,rj who is personally known to tri 2C04A-et— who is personally known to me or who has 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: / Print: ELiwjP MF-0A,6,CLw- Print: FLA A N A t u i Seal: �.�"'�p�% Seal: Mod ELIANA MEDAGLIA rara oe�., �` �. ELIANA AAEDD132491 Notary Public-State of Florida Public•Sta �N• sem: Commission#fF 132491 C0J1W$8bn#F� APPROVED BY Is xa mer Zoning �A kJ -v--F- Structural Review Clerk (Revised02/24/2014) ,SN��cRiE,s Miami Shores Village Building Department �... null" 10050 N.E.2nd Avenue Miami Shores, Florida 33138 on:�•�� 0loRrop Tel: (305)795.2204 Fax:(305)756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC J S`SSA This form must accompany ALL air conditioning replacement permit applications. Each unit change-out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address(where the work is being done): 75 u f�✓ I I` n City: Miami Shores Village County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means:YES NO❑ ARHI Sheet Attached:YES�, NO ❑ Contract Attached:YES UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL# 5`I'4 I N/ COND.UNIT MODEL# 16 106,0 O KW HEAT AW _19 NOM TONS J AHU CU PKG 1)M.C.A AHU CQqj PKG AHU CU PKG 2)M.O.P AHU / CU 5D PKG AHU CU PKG 3)VOLTS AH jrCL1 G PKG UNIT / / PKG UNIT EER/SEER _167 YES NO REPLACING DUCTS 46S NO YES NO REPLACING THERMOSTAT NO YES NO NEW 4"CONCRETE SLAB ES NO YES NO NEW ROOF STAND YES io— YES NO NEW RETURN PLENUM BOX YES 1. Minimum Circuit Ampacity(Wire Size): 49 / 2. Maximum Overcurrent Protection (Fuse/Brea er Size): �S 3. Voltage of Circuit(208/240/480): o 4. Size Disconnecting Means: Contractor's Company Name: 4 (1 C- 12 Phone: State Certificate or Registratio!).M. Certificate of Competency No. Signature Date: (Qualifier's signature) (Revised02/24/2014) 6919 W Broward Blvd #160 SunBay Air Conditioning PLANTATION, FL 33317 (954)673-6920 Honest Work••• Fair Price kaz@sunbayac.com http://www.sunbayac.mm ESTIMATE ADDRESS SHIP TO ESTIMATE# 1013 Trifecta Capitol LLC Trifecta Capitol LLC DATE 09/03/2015 EXPIRATION DATE 09/03/2015 ACTIVITY AMOUNT Supply and install Goodman 5 ton 16 SEER system complete with new ACR copper, hurricane pad, thermostat, condensate drain Install all ductwork with supply outlets at cfm per print and pass through return air grilles. Ductwork will be installed in a"spider"manner not as a main trunk system. Proper cfm will be delivered to each supply outlet. Services:Air Cond 4,800.00 Above work will be completed per ASHRAE standards 60%down required before commencement of work TOTAL $4,800.00 Accepted Accepted Date (954)673-6920 r Ueftificate of Product Ratings AHRI Certified Reference Number: 5983791 Date: 9/3/2015 Product: Split System:Air-Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: GSX160601F* Indoor Unit Model Number:ARPT60D14A* Manufacturer: GOODMAN MANUFACTURING CO., LP. Trade/Brand name: GOODMAN; JANITROL;AMANA DISTINCTIONS; EVERREST; ONE HOUR AIR CONDITIONING AND HEATING; ENERGI AIR Region:All (AK,AL,AR,AZ, CA, CO, CT, DC, DE, FL,GA, HI, ID, IL, IA, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY,OH, OK,OR, PA, RI,SC, SD, TN, TX, UT,VA,VT,WA,WV,WI,WY, U.S.Territories) Region Note: Central air conditioners manufactured prior to January 1,2015,are eligible to be installed in all regions until June 30,2016. Beginning July 1,2016, central air conditioners can only be installed in region(s)for which they meet the regional efficiency requirement. Series name: GSX16 Manufacturer responsible for the rating of this system combination Is GOODMAN MANUFACTURING CO., LP. Rated as follows In accordance with AHRI Standard 210/240-2008 for Unitary Air-Conditioning and Air-Source Heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, independent,third party testing: Cooling Capacity(Btuh): 52500 EER Rating(Cooling): 12.00 SEER Rating (Cooling): 14.00 IEER Rating (Cooling): Ratings followed by an astensk(*)indicate a voluntary rerate of previously published data,unless accompanied with a WAS,which indicates an involuntary rerate. DISCLAIMER AHRI does not endorse the product(s)listed on this Certificate and makes no representations,warranties or guarantees as to,and assumes no responsibility for, the product(s)listed on this Certificate.AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s),or the unauthorized alteration of data listed on this Certificate.Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS This Certificate and Its contents are proprietary products of AHRI.This Certificate shall only be used for Individual,personal and confidential reference purposes.The contents of this Certificate may not,in whole or In part,be reproduced;copied;disseminated; entered Into a computer database;or otherwise utilized,in any form or manner or by any means,except for the user's individual, personal and confidential reference. AIR-CONDITIONING,HEATING, CERTIFICATE VERIFICATION &REFRIGERATION INSTITUTE The information for the model cited on this certificate can be verified at www.ahridirectory.org,click on"Verify Certificate"link we make life better- and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which is listed above,and the Certificate No.,which is listed at bottom right ©2014 Air-Conditioning, Heating,and Refrigeration Institute CERTIFICATE NO.: 130857819106878165 5�ORF xc. a3S r'I g... Miami Shores Village Building Department RiDp� 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. K COPY OF QUALIFIER'S STATE LICENCES B. K, 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: dr (. � BUSINESS ADDRESS: Coo l �5 No wa,U/1 ITY G TATE L ZIP S BUSINESS PHONE: ( FAX NUMBER CELLPHONE( 67,3 - / QUALIFIER'S NAME: ` Z QUALIFIER'S LIC NUMBER:- d as-o-4 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850)487-1395 ° 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 ZANDER,KARL A SUNBAY AIR CONDITIONING AND HEATING INC 6919 BROWARD BLVD #160 PLANTATION FL 33317 Congratulatio nsl With this license you become one of the one million Flotdim licensed by ttm Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yadit brokers,from boxers to barbeque restaurants. DEPARTMENT OF BUSINESS AND and they keep Florida's economy sboN. PROFESSK)NAL REGULATION Every day we work to improve the say we do business In order to CAC057042 ISSUED: 08125=14 serve you better. For information about our services,please log onto www.myflorldaHeers&com. There you can find moa information CERTIFIED AIR COND CONTR about ono divisions and ft regulations that impact you,subscribe ZANDER,KARL to department newsletters and learn mom about the Deparbrient's initiatives. SUNRAY AIR GONDf1IalvINt3AND IiFATIN Our mission at the Department is:I-Icense Eftldently,Regulate Fairly. We cxxns strive to serve you better so that you can serve your cuss rners. I you for=business in Florida, IS CERTtf1E0 under the brOVISIone of Chale®Fs. and congrabutations on your new l nsel d.t AUG 31,orals t1 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD �4 CltCOM2 The CLASS AAIB CONDITIONING CONTRACTOR Named below IS CERTIFIED '� R Under the p ovlslons of Chapter 489 FS. VM Expiration date: AUG 31,2016 a90 'M LANDER, KARLA ' SUNBAY AIR CONDITIONINOAND HEATING INC #6919 160 HROWARD BLVD _ v i PLANTATION FL 33,317 ■ ISSUED: W25=14 DISPLAY AS REQUIRED BY LAWµ SEO tt 1.140025MIN 3 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S.Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 VALID OCTOBER 1,2014 THROUGH SEPTEMBER 30,2015 DiaA.SUNBAY AIR CONDITIONING AND ReCBipt#'HEATING/AIRCONDITION CTI Business Name'HEATING INC Business Type'(CLASS A AIR COND CO R3 Owner Name:KARL A ZANDER Business Opened:09/26/2011 Business Location:6919 W BROWARD BLVD #160 State/COunty/Cer I`R":CAC057042 PLANTATION Exemption Code: Business Phone:954-848-4121 Rooms Seats Employees Machines Professionals 1 For Vending Bushms Only Number of Machhwes: Vending Type: Tax Amount Transfer Fee NSF Fee Penally Prior Yea rs CoilecWn Cost Total Paid 27.00 0.00 0.00 2.70 0.00 0.00 29.70 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax Is levied for the privilege of doing business within Broward County and Is non-regulatory in nature.You must meet all County andtor 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 proved 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. Mailing Address: SUNRAY AIR CONDITIONING AND HEATNNi Receipt #03B-14-00000151 6919 W BROWARD BLVD #160 Paid 10/09/2014 29.90 PLANTATION, FL 33317 2014 . 2015 .4� !]�► DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE19/4/2015 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 WANED, 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 CONTACTLarry Chiet THE TAILOR GROUP LLC PHONE 754 444-8865 FAX WC No,.(754)444-3699 411 N State Rd 7 -MAILarry arrythegarageguy.com Margate, FL 33063 INSURERS AFFORDING COVERAGE NAIC# Granada Insurance Co. INSURED Sunbay Air Conditioning and Heating, Inc INSURER B: 6919 W. Broward Blvd. #160 INSURER Q Plantation, FL 33317 INSURER D: (954)673-6920 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000.000 CLAIMS-MADE El OCCURoocirrencel�rUL TV RENTED $ 100 000 0185FL00064418 11/5/2014 1/5/2015 MED EXP(Anyone rson) $ 5 000 A PERSONAL&ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMITAPPPLIIE—S PER: GENERAL AGGREGATE $ 2,000,000 g POLICY D PRO- JECT --�r 1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ti ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Par UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE If es,tlescribe under RI"ON OF PW=ONSbelow EL n11FASE-POLICY LIMIT Is DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schetlule,may be attached if more space is required) Heating & Air Conditioning Equipment- Sales/Service/Repair NO LPG License #CAC057042 ERTIFICATE HOLDER CANCELLATION Miami Shores Village Bldg Depot SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 10050 ne 2 Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD JEFF ATWATER 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 be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 11/7/2014 EXPIRATION DATE: 11/6/2016 PERSON: ZANDER KARL FEIN: 753049653 BUSINESS NAME AND ADDRESS: SUNBAY AIR CONDITIONING AND HEATING INC 6991199 W BROWARD BLVD ORITATION FL 33317 SCOPES OF BUSINESS OR TRADE: HEATING,VENTILATION, AIR-COND Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption 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.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,at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for Issuance of a certificate.The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS?(850)113-1609 Sunbay Air conditioning and Heating Inc Karl Zander 6919 Broward Blvd#160 Plantation, FL 33317 State of Florida County of Miami Dade Before me personally appeared Karl Zander who is duly sworn and says that he will be the only person working on the property located at 88 NW 111th St Miami Shores, FL 33168 Sworn to (and affirmed)and subscribed before me this 21s'day of August 2015 by Karl Zander. Personal known by Eliana Medaglia, Licensed Notary. X 44 ELIANA MEDAGLIA • Notary Public•State of Florida Commission#FF 132491 �' My Comm.Expires Jun 15.201S . 5�OR$,S ,,,, ,,,,,►� Miami Shores Village Building Department �NTES IN�� YORiDA 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 in ce cove om the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING OW Y U KNO EDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTE . Sign Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this a day of 5,PT£yYlgE1 ,20_L:; . By DA i ra C-nif Lug who is personally known to me or has produced as identification. Egg . ELIANA MEDAGLIA Notary:y — �0 FFeof FWft 132491 SEAL: MY Contin.E�ree Jun 18,2018 To: Miami Shores Village Page 2 of 3 2016-02-17 20:24:23(GMT) 19543372238 From: Daniel Gitlin SUMBAi1 OF€d3 d91fd RAC.E* oArM�V�07Y,YYt 0lrlerld;. ' 7Hi3�ERTIFICACTfi:f�i'195(9EO.:E1S!k iuU47Y R,OM 19Fr.RoATION..09LY J4ND.CC+NE9RS Wt *mr.HTS up,,O t:Ti4E gERfitMtCAi "MCAE.DLi2 7HtS .. ... Cdr6dPiF1C1lTx:CDirS:istCr'rA*ffRRt TiV#LY:AR,'NEd$AT(vP__Ly-AMRN0- EXT-Mo OR ALTER'.THE..POi RAG9:A PORDED'SY.THE.POUCIES.. . 615L bW .' .T"M:t;ER31F#CATE Od?.rdi3[dp Ri9C�.?YC? .H4T':Gf}d9$T#TlJTH.Q:COd+#Tt�AGT" M' .'.TH dS$'iJiAdCp IAB:SURW4S),AOTHPOVEED . 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