The URL can be used to link to this page

PL-16-2288 s Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores,FL Phone, (305)795-2204 Fax:(305)756.8972 I �- Inspection Number. INSP-265424 PermitNumber: PL-8-16-2288 Scheduled Inspection Date:August 29,2016 Permit Type: Plumbing - Residential Inspector: Hernandez,Rafael Inspection Type: Final Owner. NETKIN,ROBERT AND MELISSA Work Classification: Gas Job Address:1266 NE 94 Street Miami Shores,FL 33138- Phone Number (305)965-5110 Parcel Number 1132050100170 Project: <NONE> Contractor: BLUE FLAME GAS SERVICES CORP Phone: (305)479-7894 Building Department Comments RUN 1/2 POLLY PIPE FROM METER TO HOUSE, UNDER nfra o cmments HOUSE WORD FLEX PIPE 1/2 TO COOK TOP INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction a Needed Re-Inspection Fee No Additional Inspections can be scheduled until re-inspection fee is paid. BLUE FLAME GAS SERVICE License Number 32861 1787 NE 180 Street, N Miami Beach, FL 33162 (305)479-7894 • renzo@blueflamegas.com DROP TEST CERTIFICATION Florida Building Code, Fuel Gas SECTION 406(IFGS)INSPECTION,TESTING AND PURGIN 406.1 General. Prior to acceptance and initial operation,all piping Installations shall be Inspected and pressure tested to determine that the materials,design,fabrication,and Installation practices comply with the requirements of this code. Owners Information: Permit Number: 0 Name: Address: City: Sl 14 14� ONS State: FL zC-'531 S13 Contractor: Blue Flame Gas Service License Number: 32861 Description work: S V-Mfo fro/Z fd IWIA7 Test Result: 8"W/C .OK Test Duration: 10 Minutes TestDat Contra or(Qualifier) Signature Rt=RZ® rI 6/4 I I0 Print Name STATE OF FLORIDA, COUNTY OF MIA MJI DADE Sworn to and subscribed before me this S'J day of Ado 2016 by /?4p-jr-o logy 1=Lu _Personally Known 'Produced Identification V t- -zx2.,A y Aj C—b (SEAL) Signature of eqr vpB` ?C" ° ENRIQUE BARTHE WO MY COMMISSION#FF108347 �` EXPIRES:April 22,2018 a�V Miami Shores Village 10050 N.E.2nd Avenue NE * � Miami Shores,FL 33138-0000 R ; Phone: (305)795-2204 ' ytue�, t2� Expiration: 18/2017 Project Address Parcel Number Applicant 1266 NE 94 Street 1132050100170 Miami Shores, FL 33138- Block: Lot: ROBERT AND MELISSA NETKIN i Owner Information Address Phone Cell ROBERT AND MELISSA NETKIN 1266 NE 94 Street (305)965-5110 MIAMI SHORES FL 33138-2947 Contractor(s) Phone Cell Phone Valuation: $ 1,200.00 BLUE FLAME GAS SERVICES CORP (305)479-7894 Total Sq Feet: 35 Type of Work:RUN 1/2 POLLY PIPE FROM METER TO HO Available Inspections: Type of Piping: Inspection Type: Additional Info:RUN 1/2 POLLY PIPE FROM METER TO HO Final Bond Return: Press Test Classification:Residential Scanning:1 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 DBPR Fee Invoice# PL-8-16-60982 $2.25 08/22/2016 Credit Card $ 110.70 DCA Fee $2.25 $50.00 Education Surcharge $0.40 08/15/2016 Credit Card $50.00 $0.00 Permit Fee $150.00 Scanning Fee $3.00 Technology Fee $1.60 Total: $160.70 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,WINDO DOORS,ROOFING and SWIMMING POOL work. r OWNERS AFFIDAVIT: I certify that all the foregoing informal* is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-na ed contractor to do the work stated. August 22,2016 Authorized Signature:Owner / Applicant / ontractor / Agent Date Building Department Copy August 22,2016 1 19 ISI (� Miami Shores Village Building Department AU 5 2016 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 20(4 BUILDING Master Permit No. V-4c `b- e PERMIT APPLICATION Sub Permit No. PL 16 - 2— S ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL EE�PLUMBING ❑ MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP y, (� ! CONTRACTOR DRAWINGS ly JOB ADDRESS: ; 6 6 � C- L �I S T City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): Ra t3C(z'I- K( E-f K /� Phone#: Address: + City: NA I'my1 0 ��v-e S State: �f'®I^;C�� Zip: IRS on Tenant/Lessee Name: _ Phone#: Email: / / /� / 7 ay CONTRACTOR:Company Name: k3 L(fir/�� L/-�� (a S Phone#: 3d E- V C 7 1 Y Address:' N F l 00 ST- City: 7- t- 61QuaCity: f4 I� State: I- L A Zip: 97 1612- Qualifier lifier Name: 1 c') Phone#: tateCertificatloA �� F6 Certificate of Competency#: DESIakw.- ckiitect/Engineer: Phone#: Address: G� City: State:: Zip: Value of Work for this Permit:$ d_OCA Square/Linear Footage of Work: 7 Amt r Type of Work: 2 Addition ❑ Alteration ElNew ElRepair/Replace ❑ Demolition Description of Work:R U 1/ Z QQ 11L/ PI P F_ F 170,N1• 0%V-�7'F/7 7`0 1'40 U S E" w"LgrL PooSr U) ORb )-ei--X P/PF VZ fia Cv(9te -to/p 0 Specify color of color thru tile: Submittal Fee$ �® �' Permit Fee$ CCF$ 0 '2-0 CO/CC$ Scanning Fee$ Radon Fee$ DBPR$-_ -2-9 Notary$ 92 Technology Fee$ G Training/Education Fee$ t:)•�j o Double Fee$ ��/�,� Structural Reviews$ Bond$ 0 TOTAL FEE NOW DUE$ 9 (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. ! the absence of such posted notice, the inspection will not be a ov and a reinspection fee will b - I Signature Signature OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this dayof 20 I,o .by (IIU day of 4'5" ,20 /�O ,by who is personally known to i4 'v70 '�41� ,who is personally known to me or who has produced c7-� L \L as me or who has produced del'\,."— L �•� as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: Print: a S Print: '' � I: 2a�� U�Vol' Ligan ra amac o Seal: aPA1 P&O Leo au en ectu COMMISSION#FF216530 State of Florida EXPIRES: May 4, 2019 _ Y COMMISSION # FF 18540 WWw,AARONNOTARY.COM �h� aQ M APPROVED BY f�G O �� Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ♦eHOREs tt Boom auotlf � " Miami shores Village �h- � Building Department �IRIDA 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 tNSURANCE*' 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 MUNICIPA 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: " �j U—Aificate H61—der-,-1 --M iAMI vomsVIttAGE13LDG_OEPTJ ' 10050 NE 2ND AVE ' MIAMESHORESt FL33136_'_ Certificate must specify the description of operations or contracto e n mber BUSINESS NAME: 13Z l- V.405,oc y1A-C 5�/Z V e 4:s BUSINESS ADDRESS: It 00 ST CITY �` • Q STATE FL ZIP 3?1 e�-2- BUSINESS PHONE: ( ) �� y FAX NUMBER�) CELLPHONE05 ) W- c- tOR QUALIFIER'S NAME: R M?o I-I Gf� lo QUALIFIER'S LIC NUMBER:—1 - P. 3Q 0 6 Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 License Number: 32861 Business Mailing Address Licensed Location Address BLUE FLAME GAS SERVICES BLUE FLAME GAS SERVICES 1787 NE 180TH ST 1787 NE 1 BOTH ST NORTH MIAMI BEACH,FL 33162-1501 NORTH MIAMI BEACH,FL 33162-1501 The liquefied petroleum gas license at the bottom of this form is valid ONLY for the company located at the address on the license. Each business location of a"company must be.censed. All LP GAs licenses must be renewed annually. Any license allowed to expire shall become inoperative because of failure to renew. The fee for restoration of a license is equal to the original license fee and must be paid before the licensee may resume operations. IN THE EVENT OF AN OWNERSHIP CHANGE AT THIS BUSINESS LOCATION: This license may be transferred to any person,firm or corporation for the remainder of the current license year upon written request to the department by the original license holder. License transfers must be approved by the department. All licensing requirements must be met by the transferee and a transfer fee of$50 will apply. To apply for a transfer,contact the Bureau of LP Gas Inspections at(850)921-1600. Pursuant to Chapter 527,Florida Statutes, LP Gas licensees must present proof of licensure to any consumer, owner,or end user upon request when engaged in the business of servicing,testing,repairing,maintaining or installing LP Gas systems and/or equipment. For future correspondence,please make any needed corrections or changes to your business mailing address and/or your licensed location address and return the UPPER PORTION with corrections to: Florida Department of Agriculture and Consumer Services P.O. Box 6700 Tallahassee, Florida 32399-6700 Cut Here GO 3titatto of.Flo ida Department of Agriculture and Consumer Services Division of Consumer Services License Number. 32861 Bureau of Liquefied Petroleum Gas Inspection Expiration Date: August 31,2016 (650) 921-1600 Dole of I Fee: $200.00 tember 1,2015 POST LICENSE Tallahassee, Florida Type and Class: 0408 CONSPICUOUSLY Liquefied Petroleum Gas License SPECIALTY INSTALLER C -APPLIANCES, EQUIPMENT AND PIPING GOOD FOR ONE LOCAT"ONLY ANY CHANGE OF OWNERSHIP OR SALE OF THIS BUSINESS RENDERS THIS LICENSE INVALID This license Is Issued under authority of Section 827.02,Florida Statutes.to: BLUE FLAME GAS SERVICES � 1787 NE 180TH ST A D A M H.PUT NORTH MIAMI BEACH, FL 33162-1501 COMMISSIONER OF AGRICULTURE City of North Miami Beach Thank you for choosing the City of Community Development Division North Miami Beach! Business Tax Receipt 17050 NE 19 Avenue You can now visit us on-line at www.citynmb.com North Miami Beach,FL 33162 or you can e-mail us at NMBBTR@citynmb.com OW MAIL TO: BLUE FLAME CCAS SERVICES S 1 787 NE 180 STREET —, NORTH MIAMI BEACH,FL 33162 NOW More l! TITS IS YOUR 2015-2016 BUSINESS TAX RECEIPT. Important Reminders:. Business Tax Receipts expire September 30th of each year. You must submit all fees and documents(if applicable) prior to that date or you may be subject to delinquency fees, an additional Cost Collection Fee of$250,04, placement of a lien on the property, and/or Involuntary shutdown of this business by the Police Department. You are required to notify the City, in writing, if there have been any changes in ownership, location, nature of business, any contact information, and/or when this business ceases operations. This is In order to ensure that you.are not billed In error. Failure to notify this office of such changes may result in the assessment of penalty feesand collection activities. Have any more auestions? Our friendly staff is here to assist you by phone,(305)948-2917,Monday-Friday from 8:30 a.m.-5:00 p.m.,or at our office Monday-Friday from 9:00 a.m.-4:00 p.m. We would love to hear from youl ** THIS IS NOT A BILL—DO NOT PAY **� Please detach the below receipt and display in a conspicuous place. City Of North Miami Beach Valid 10/01/2015 - 2015-2016 BUSINESS TAX RECEIPT 09/30/2016 No.: 169721 - RENEWAL Acct No: 793934 Taxes: 142.05 DBA: BLUE FLAME GAS SERVICES Penalty-.Fee: 0.00 Location: 1787 NE 180 STREET Credit: 0.00 NORTH MIAMI BEACH, FLORIDA TOTAL PAID: $ 142.05 Activity BUSINESS OFFICE/RESIDENTIAL LOCATION: ONLY This receipt is nontransferable without City approval and is only valid at the location(s)listed herein Remarks:HOME OCCUPATION: AS PER ORDINANCE NO. 94-10 & 2010-6. �� 4 �y. �tawMore ! CERTIFICATE OF LIABILITY INSURANCE DATE YYYY) 088/18/1/18/16 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 policypes)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 ALBERT MENDEZ Mendez&Associates PHONE (954)436-3776 1 ROC,No): (866)461-0503 9953 Pines Blvd. AE-MAJLDDRESS. INFO@MENDEZINSURANCE.COM Pembroke Pines,FL 33024 INSURER AFFORDING COVERAGE NAILlt Phone (954)436-3776 Fax (866)461-0503 INSURER A: UNITED SPECIALTY INSURANCE COMPANY INSURED INSURER B: Renzo Figallo Dba:Blue Flame Gas Services INSURER C: 1787 NE 180 Street INSURER D: North Miami Beach,FL 33162 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. ILTR TYPE OF INSURANCE ADD UBR POLICY NUMBER MUDY EFF OL DY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 13E TO RENTED Q COMMERCIAL GENERAL LIABILITY PREM SES Ea occurrence) $ 100,000.00 A ❑ F—] CLAIMS-MADEQ N 03/05/2016 03/05/2017 OCCUR USA4122677 MED EXP(Any one person $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 2,000,000.00 GEN'L AGGREGATE LIMIT APPLES PER: PRODUCTS-COMP/OP AGG $ 1,000,000.00 ❑ POLICY ❑ PRO ElLOC $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT Ea acct ent ❑ ANY AUTO BODILY INJURY(Per person) $ ❑ AALL UTOS OWNED ❑ SSC�HEEDULED BODILY INJURY(Per accident) $ AOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ F-] HIRED AUTOS Per accident ❑ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED ❑ RETENTION$ $ WORKERS COMPENSATION ❑W C STATU- ❑OTH- LIM AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) ElE.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) New gas house line installation and repairs residential and commercial. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Avenue AUTHORIZED REPRESENTATIVE Miami Shores,FL 33138 Fax#305-756-8972 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05)OF The ACORD name and logo are registered marks of ACORD Report Viewer Page 1 of 2 JEFF ATWATER CHEF 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: 5128!2015 EXPIRATION DATE: 5/27/2017 PERSON: FIGALLO RENZO F FEIN: 462220148 BUSINESS NAME AND ADDRESS: BLUE FLAME GAS SERVICES CORP 1787 KE 180 STREET NORTH MIAMI BEACH FL 33162 SCOPES OF BUSINESS OR TRADE: GAS MAIN OR CONNECTION?CONST Pursuard to Chapter 440.05(14),F.S.,an officer of a crorporation who sleds exemption from this chapt a certificate of election under thts sedion may:dh- ecover b scope ofexend certifitirs n named on the notice or certificate no longer meds the requbernerds of ti,rs sedlott for rssuarxe of a oertificete.The department aheA revoke a DFS-F2-DVVC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 https://apps8.fldfs.com/cffeportviewer/reportViewer.aspx?data=kdvpginc9D7Q3gH6TER... 29/05/2015 BLUE FLAME COMPANY LETTER HEAD LP&NATURAL GAS SPECIALIST LICENSED&INSURED DATE: ✓ /b State of I z(9/z/op County of D A 0E Before me this day personally appeared , (-,A/4/, who, being duly sworn,deposes and says: That he or she will be the only person working on the project located at: Sworn to (or affirmed) and subscribed before me this Z day of �.�� 201 , by 2b fe v\c>,11 A0 tylu Personally know OR Produced identification Type of Identification Produced FL I�c..1$F'L�10`1Z6611�11 �A r' LUIS JAVIER LAVALLE � �,a! z a U! NOTARY PUBLIC STATE OF FLORIDA®/o�� / e e Comm#FF080296 L' Expires 1/1/2018 Print,Type or Stamp Name of Notary omM Miami shores Village R 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 TVA Florida Law requires Workers' Compensation i allows corporate officers in the construction indnsurance coverage under Chapter 440 of the Florida Statutes. Fla.-Stat. § 440.05 . ustry 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 employe' 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: L 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 ACKNOWLED THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND CONTENTS. ITS Signature: , wn r State of Florida County of Miami-Dade The foregoing was acknowledge before me this !� -day of 20 l who is personally know t duced �f Z as id c JESSE WALTERS °» „• Notary Public State of Florida uei''�. Notary: My Comm.Expires Sep 23,2016 Commission# EE 837922 SEAL: W; 2016 10 �ee-r '/2 WJQCt 0000 0000.. .. .. . • . • • . 0000.. •• .9000. 0000 . 0000.. 0000 0000• . • 0000.. 0000 0000. 0 . • 0000 .. . 0000.. . c:oc 4 Tb i> """. • . • TL; • . . 0000.. 0000.. I ,n . • . . T 10* 0000 6000: ---- — — BY DATE =J oFPr _ r BLDG DEPT — SL!BJECT iO Ctf,JL'L,ESI`TICE Tf�i ALLFEDERAL STATE AND CGAr10 REGULATIONS J 7_ r' .r } 2 Co IC � Nt E FLAVE FIG,.m0®.O®0mm®ON Nai Aa ER