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DEMO-16-3032Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. DEMO -11-16-3032 Permit Type: Demolition Work Classification: Building Permit Status: APPROVED Issue Date: 1/4/2017 Expiration: 07/03/2017 Parcel Number Applicant 165 NE 109 Street Miami Shores, FL 33161-7041 1121360040500 Block: Lot: MODESTO ECHEZARRETA Owner Information Address Phone Cell MODESTO ECHEZARRETA 165 NE 109 Street MIAMI SHORES FL 33161- Contractor(s) Phone Cell Phone ARTEK CONSTRUCTION MANAGEME (786)255-6124 (305)443-5778 Valuation: Total Sq Feet: $ 1,000.00 0 Type of Demo: Building Additional Info: REMOVAL OF DRYWALL FROM GARAGE DOOR Classification: Residential Scanning: 3 Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Plan Review Fee (Engineer) Scanning Fee Technology Fee Total: Amount $0.60 $2.00 $2.00 $0.20 $100.00 $120.00 $9.00 $0.80 $234.60 Pay Date Pay Type Amt Paid Amt Due Invoice # DEMO -11-16-61963 01/04/2017 Credit Card $ 184.60 $ 50.00 11/04/2016 Check #: 1012 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Final Review Electrical Review Electrical Review Building Review Building Review Structural In consideration the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto : nd 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. Futhermore, I authorize the above-named contractor to do the work stated. January 04, 2017 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date January 04, 2017 1 BUILDING PERMIT APPLICATION BUILDING ❑ ELECTRIC Miami Shores Village 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 ❑ ROOFING NOV 042016 FBC 2014 Master Permit No. DK)l., Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑ PLUMBING ❑ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF CONTRACTOR 05 109 S+r d JOB ADDRESS: City: ❑ CANCELLATION ❑ SHOP DRAWINGS Miami Shores County: Miami Dade Zip: 3310 Folio/Parcel#: 11 Z 1 3Co - 004" QOfl Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: GBS Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): 1"t OcerOCa-}�' Address: S4S SW '7O st' . Phone#: 786 8SR G`720 City: Hi ZVr1 t State: 1-- Zip: 3317 Tenant/Lessee Name: Phone#: Email: A'- Coos-+'rtx...-rton 2.330 st,v act .eLvE . CONTRACTOR: Company Name: Address: Phone#: 186 2 -ss 424 City: 1Zlni State: -- Zip: 3..S14-.. Qualifier Name: ?-7►Gb+442.4) tri fl9 EQ._ State Certification or Registration #: cc>3cc Leo 6137 Certificate of Competency #: Phone#: 7B 6 2S 6124 DESIGNER: Architect/Engineer: Address: Phone#: City: State: Zip: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration Description of Work: ❑ New Repair/Replace ❑ Demolition Specify color of color thru, tile:. Submittal Fee $50:(3-.) Scanning Fee $ G. 00 Technology Fee $ 0 • GG Permit Fee $. 100 . `'�.) CCF $ 0 . 66 Radon Fee $ W DBPR $ 2 •-W Training/Education Fee $ • 23 3 Structural Reviews $ (Zo . 04 (Revised02/24/2014) CO/CC $ Notary $ Double Fee $ Bond $ ,tok c' TOTAL FEE NOW DUE$ (G l • 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.YOU'R'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 permi t 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 th ence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature y I OWNER or AGENT 'r Signature • . CO RACT( R The foregoing instrumer}t was acknowledged beforeme this The foregoing instrument wa acknowledged before me this 3 day of /VvVe M . ea , 20 1 /I b , by ' ad- day of 3JO 'E»,Y3 eb , 20 14. , by T C-144210 9,r11 5�, who is personally known to I -LOr2t ICI 61-'56me or who has produced �f/ 0N*'�/ {t Was me or who has produced SIG.S' 7 4 -O as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: f j im 'TUE e2 J 0 -LC refrivho is personally known to Sign: Print: Seal: ********* ROBERTO E ARRIETE •: MY COMMISSION # EE849666 *fif - EXPIRES November 06 2016 (407) = .153 Floridallo4eySsrvlc�} f APPROVED BY (Revised02/24/2014) Cha-I��`-t. /01# Sign: Print: Seal: Plans Examiner f Leee-ro '_ 4,16t -i "; ROBERTO E ARRIETE i': ;. 'Ai MY COMMISSION # EE849666 EXPIRES November 06, 20t6 ** ******* *** *�#,*��u�#t�a�* ***** (401) 398.0153 Floddel o erYbI �• ^ *********** Zoning Structural Review Clerk A - k STATE OF FLORIDA '` DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION l CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 SPRINGER, RICHARD ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29TH AVE MIAMI FL 33145 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 from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services. please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and team more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! RICK SCOTT, GOVERNOR STATE OF FLORIDA DEPARTMENT -OF BUSINESS AND PROFESSIONAL REGULATION CGC1506737_ �14SSUED:- 05/31/2016 •CERTIFIED GENEtCONTRAGTOR. SPRINGER, RICIf1R}3`>." ARTEK CONSTF 15 CERTJFIEO under,the provisions of Ch:489'FS. ibpitabon date : AUG 3t: 2018 • L180.5310000793 DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The GENERAL CONTRACTOR :.. Named below.IS:CERTIFIED . Under.. the of. Chapter489 FS. Expiration date::: AUG 31, 2018 ISSUED: 05/31/2016 DISPLAY AS REQUIRED BY LAW .. ., .: SE4 # L1605310000795 006910 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 5269410 BUSINESS NAME/LOCATION ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29 AVE MIAMI TL 33145 RECEIPT NO. RENEWAL 5506408 EXPIRES SEPTEMBER 30, 201 Must be displayed at place of business7 Pursuarn to County Code Chapter SA - Art 9 & 30 OWNER SEC. TYPE OF BUSINESS ARTEK CONSTRUCTION MGMT CORP 196 GENERAL BUILDING CONTRACTOR CGC1506737 Worker(s) 1 PAYMENT RECEIvEri BY TAX COLLECTOR $45.00 07/25/2016 CREDfTCARD-16-043500 This Local Business Tax Receipt only confirms payment of the Local Rosiness Tax. The Receipt is nota license, permit or a certification of the holders qualifications,to do business. Holder Oust convoy with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPTRO. above mast be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-278. For more information. visit 3a+twmiamidadesu x 011oc` ACCPRE CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THS 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 poilcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions at 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 DATE IMMIDDIYYYY) 11104/16 Real Insurance 1400 SW 67th Ave Miami, FL 33144 Phone (305)264-8536 INSURED ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29 Ave MIAMI, FL 33145 - Fax (305)264-6732 8E - ISSUF COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: Thus is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW .HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE:POLICY PERIOD IND/CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS : CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. It45R! LTR TYPE OF INSURANCE :ADDLSUEIR. POLICY EFF POLY EXP POUCY NLINI8ER _IMMIDO/YreyLIMS1/00/YYYyL ,LIMITS GENERAL LIABILITY IJ COMmEncIAL GENERAL L:AEiLzre cLAms_mADE 2 °cc:JR CONTACT PHONE NAME; Jitott.4LEs: INC_ No, Ext): (311.15)264-3536 Noy (305)264-6732 JFERNA9262©BELLSOUTHNET .SURER(S)AFFORDING. COVERAGE INSURER A: UNITED SPECIALTY INSURANCE CONIPANY INSURER 8: INSURER t: INSURER : INSURER E • A . . HIRED AUTOS 0 UMBRELLA UAB 12 OCCUR • GEN1 AGGREGATE LIMIT APPLIES PER ' CGD0003898-01 POLICY ri PRO 01 : : • '—' ...EC'S_ LT—I LOC • • . . AUTOMOBILE LIABILITY 0 A.NY AUTO 7-1 ALL OWNED SCHULED L,J AUTOS L...1 AUTOS 0 EXCESS LIAB 0 CLAWS -MADE • E:1 Rg:TEr±rreONI S : WORKERS COMPENSATION . AND EMPLOYERS' LIABILITY Y 1 N • ANY PRoPRIETORIPARTNEREXEC,...:TIVE. OFFICERIMEMBER EXCLUDM7 • (Mandatory in NH) Zyes. racscn. he under • ECRPTION OF OPERATIONS bow • • .• • • . 05/07/2016 05-07,2017 NAIL EACH OCCURRENCLE S 1.000,000.00 DAMAGE 7 RENTPD :MSS rEa a'ac:rr r.pel • ri,E0 EXP (Any ene $ 5,000.00 PERSONAL 5 ADV NIURV . S 1,000,000.00 GENERAL A3GREOA7E: S 2.000,000.00 pRool.P.77$ - ccmp:(,,p;:.tc,o •5 2,000,000.00 COMBNED SINGLE LMtT. • .(=3 accidenti • ECCSLY faILIURY (Per serSst 5 'BODILY INJURY (Pc,dert.t) 5 PROPERTY DAti:ASE acciCent2$ EACH OCL:URBENCE AGGREGATE 5 E L EACH ACCCENT 5 L DISEASE - EA EMPLOYE EL PCLiCs, :0,117- . • • . .__. .. „............. _ - - • . DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is ragwort) . . GENERAL CONTRATOR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 AVENUE MIAMI SHORES VILLAGE,FLA 33138 ACORD 25(2010105) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE wm-t THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE (C.. 1988-2010 AC CORPORATION. All rights reserved. The ACORDparrie 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: 6x7/2016 zN EXPIRATION DATE: 8/6/2017 PERSON: SPRINGER RICHARD FEIN: 113679186 BUSINESS NAME AND ADDRESS: ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29TH AVE MIAMI FL 33145 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR i`ursuartt to Chapter 440,05f 14), FS.. sr; offa icer v a corporation who elects exemption from :his chapter by ft -;G a certificate may not recover benefaS or cem,^ensation under this chaptar. aursuatr: to Chapter 440.c t2,. F.S.. CeRfrstes of e whirs the sw;.a of the business or trace tib � jcate of election under thi; seetiorr e,. w the notice of etecon to be exempt. Pursuant to Chapter 440:O5r13 $ to c cbe exempt... es a ect,on tcebe exempt and cert tee of election to be exempt Ghee be subject to revocation if. at any tir:te after the filing or the notice ar the issuance of the ce:ttf=de. the person named an the n.^trx or cat't: ate rrs longer meets the requirements or the seceen for isuance c! a ce,.i;crie.1't;e CeFartmettt shag revoke. a DFS -F2 -NC -252 CERTIFICATE OF ELECTION TO SE EXEMPT REVISED 48-13 QUESTIONS? (85O)413-1609 Miami Shores Village Building Department 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: J/flr,./�;Q v ° Ow er State of Florida County of Miami -Dade The foregoing was acknowledge before me this T day of Uve/-1 t�e#4.20 l By / / Cv'Psra cC 4e 2 t'iW/ Oho is personally known to me or has produced ISE' wy /Ivo ltd Notary: f � e- asy SEAL: as identification. ;", ROBERTO E ARRIETE �' 'E MY COMMISSION # EE849666 EXPIRES November 06, 2016 (40713398-0153 FlorldeNotaryService.com ARTEK CONSTRUCTION MANAGEMENT, CORP. 2330 SW 29TH AVENUE - MIAMI FLORIDA 33145 - CGC1506737 01/04/2017 State of Florida County of Dade Before me this 4th day of January, 2017, personally appeared Richard Springer, of Artek Construction Management, Corp. who, being duly sworn, deposed and says: The only he will be the only person working on the project located at: 165 NE 109 Street, Miami Shores, FL 33161 a°t►'pufF LILLIAN FERNANDEZ * 1 * MY COMMISSION It FF 091848 EXPIRES: March 15, 2018 ST `5F eyQ mtarySenkea Sworn to and subscribe befor By: Richard Springer, Printed name of sig / COUNTY OF MIAMI DADE this LI day of OA, 20 17 Type of Identification: 42,E 12.0 Signature of Notary Public VOICE: (786) 255-6124 - FAX: (305) 443 -5778- E -MAIL: artekconstruction@hotmail.com " Enhancing people's lives through extraordinary construction work solutions " SKETCH/AREA TABLE ADDENDUM File No 16-08272 Property Address 165 NE 109 Street o City Miami Shores County Warm -Dade State Florida Zip Lu m Borrower 0 Lender/Client Appraiser Name gf. itoVia- 0 71A, 13.4' 2.4 2.5 8_5 Receptacle--- Receptacle--- _•••• 0 w Receptacle--- N• 24.4' Z ill N r+ 1.6 Garage -Door Light fixture 9 Garage ---Receptacle ----Wall AC • • • •• • • • • • •• • • • • • • • • • • ••••• • • • • •••••• •••• •••• ---Window--- • • • •• ••• •• •••• • > o el WH (NIAbove Water Heater is 3 Ft floor level - • • • • • • •• • • • • • • Recept�cJ --' a N 2.9 - 1.3 •••• • • •ght Switch--- • • • •• s rj ir-P.9"C NOVA; rr . L u Receptacle---- Receptacle----/ 1 i� 4 O t oo„ Staff , i Water Lines ---- [Hot & Cold] Miami Shores Vlll.,�.. =gip •, re. APPROVrD BY DATE Q Maiin_Houss ',. 7OFill"r1 DEPT r yb fa; ,,DnnrPT i, n ,i, is;, ,;,IT,iA'L -f i ;C/V- Scale: 1 = 5 • ' JULIO E. SUNE, JR -rtryld(o APEX SOFTWARE 800-5589858 Page 1 of 2 Apx7200-w Apex Medina ACC:PR/7i CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDIYYYY) 11 04116 THIS CERTIFICATEISISSUED 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.thicertifiCate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION ISWAIVEDsubject to the terms and conditions or the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the CONTACT — JC . . .. .. ... . tAIT.NNEs , EX13: . (305)264:8535 '305)264-6732 • FAX ..1PERNA9262@SELLSOLITH.NET (AIC Nor. ,•,,,..,,,._,___ ivsyREfi(s)AFFORDING COVERAGE INSURER A: UNITED SPECIALTY INSURANCE COMPANY INSURER B: I!,(I-IPARP ,__ ....... . . certificate holder in lieu of such endorsement(s). PRODUCER Real Insurance 1400 SW 67th Ave Miami. FL 33144 Phone (305)264-8536 Fax (305)2646732 INSURED ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29 Ave MIAMI, FL 33145 - COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BLOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE:POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF AJW CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN LS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. iNSR LTR TYPE OF INSURANCE :A0OLSUEIR POUCY EFF POLICY 1E1,P POLICY NUMBER •.(141)1100PfYYY): ftatAIDD(YYYy) UN TS INSURER 0; INSURER E /NSURER F GENERAL LABILITY COMMERCIAL GENERAL LIABIUTY 0 0 CLAMS -MADE RI oc c :A GEhrl. AGGREGATE LII,MT APPLIES PER 0I Loc. AUTOMOBILE LIABILITY • AIIY AUTO ALL CNVNED AUTOS • • Cj Hmr-20AtiTo s • SCHEDULE:0 ▪ ATOS NON -OWNED AUTC."-' • 0 UMBRELLA UAB 0 OCCUR EXCESS LIAB 0 CLAIMS -MADE. ............... ..... _.... . : WORKERS COMPENSATION • . . AND EMPLOYERS' LIABILITY Y 1N ANY PROPRIETOR.1--ARTNERJEXECL:TIVF. : 0FF1.7.E.RceEmsER EXCLUDE.D7 • • (Mandatory in NH) • 2yes. descnde tinder .• : r—SCRPTION AGGP.EGAT2 00 C..) -F OPERAT:-ONS be:ow . • . . ....-•-- _ '...• CGD0003898-01 NAIC ' EACH OCCURRENCE 5 1.000,000.001 • : DAMAGE TO RENTED (ED S Vt-•WVV•UV • • MED EXP (Any one pe:•sart ,s 5,000.00 • 05107/2016 • 0B0712017 • PERSONALPER5A5 ADV INJURY . 5 1000,000.00 • GENE -RA- E DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space M requIred) GENERAL CONTRATOR CERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2 AVENUE MIAMI SHORES VILLAGE,FLA 33138 ACORD 25 (2010/05) QF .5 0.000.00 pnca,x-rs s 2,000,0130.00 . 5 COMBiNED SINGLE. LIMIT • ,(Ea accident) Eccm_y p4,4/RY 1P0:- er#on) BODILY INJURY (Pef al.:-::::dert.!) • PROPERTY DAmAGF_ (Pet andMentt EACH OCC:URR:ENCE 5 AGGREGATF 5 •• —• • •••••• . EED E EACt-i ADDIDENT 5 E- LlSEASE.4EMPQyE.. 5 EL SF - POLIC:v !imIT 5 . ........„ • • • • • • • CANCELLATION .• . . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ------- - - AUTHORIZED REPRESENTATIVE 1388-2010 AG CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JEFF ATWATEft 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: 817/2015 EXPIRATION DATE: 8/6/2017 PERSON: SPRINGER RICHARD FEIN: 1/3673186 BUSINESS NAME AND ADDRESS: ARTEK CONSTRUCTION MANAGEMENT CORP 2330 SW 29Th AVE MIAMI FL 33145 SCOPES OF BUSINESS OR TRADE: LICENSED GENERAL CONTRACTOR Furauartt t4 Chapter 440,7_041, FS.. . sn officer of a corporation who eloca exemption fmr, this chapter by fling a certir- may not recover benefits or CORtpepSatib't under this chapter. Pursue:It to Chapter 440.06(12). F.S.. Certificates of e n:"Jitn the scope of rte business or (rade fisted On the notice certificate o; election under the; section . of etedion to be exempt . Pu-rsuant to Chapt r 44ti;Q5i.t3) F.5.. icn #o DAcesef election toly o be exempt and certjctes of election to be exempt shall be subject to revocation if, at any lane after the. filing of the notice or the ibsuan.^,e of the certilii rte: the person turned on "'.t n.^;lw or =on`i;xte riot tat ra meets the requirements delis section for ssuance at a certificate. te. The department strati revoke a DFS-F2-D1,VC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS (550)413-1608 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insuranbe 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. State of Florida County of Miami -Dade 1 j The foregoing1 egwas acknowledge before me this T day of 'Vuve�'1 44'4-20 1 By i / apP 'r ga-4 e 2 et-XeG- % Alio is personally known to me or has produced PeatO a 1k4' d as identification. Notary: SEAL: ROBERTO E ARRIETE 'c MY COMMISSION # EE849666 • �t,,c EXPIRES November 06, 2016 (407)1398-0153 FlorldeNotaryServlce.com ARTEK CONSTRUCTION MANAGEMENT, CORP. 2330 SW 29TH AVENUE - MIAMI FLORIDA 33145 - CGC1506737 01/04/2017 State of Florida County of Dade Before me this 4th day of January, 2017, personally appeared Richard Springer, of Artek Construction Management, Corp. who, being duly sworn, deposed and says: The only he will be the only person working on the project located at: 165 NE 109 Street, Miami Shores, FL 33161 4:4N LILLIAN FERNANDEZ * c_ * MY COMMISSION 1 FF 091848 EXPIRES: March 15, 2018 STAVE15F8tIttiftakterYServices COUNTY OF MIAMI DADE Sworn to and subscribe befor = this `I day of , 20 17 By: Richard Springer, Printed name of sig Type of Identification: P QD Signature of Notary Public. VOICE: (786) 255-6124 - FAX: (305) 443 -5778- E -MAIL: artekconstruction@hotmail.com " Enhancing people's lives through extraordinary construction work solutions " SKETCH/AREA TABLE ADDENDUM File No 16-08272 Property Address 165 NE 109 Street City MFloridaMiami Shores County Miami -Dade State Zip �v m Borrower Lender/Client Appraiser Name T ` t IA - t/A'G a C (17 Illi 13.4' 2.4 2.5 8.5 Receptacle --- Receptacle--- _ U w Receptacle--- Tn•••• cn 24.4' z T^ N .1 16 .• Garage'Door�' "-`r Light fixture g Garage ---Receptacle ----Wall AC • • • •• •• • • • • • • • • • • • • • • • • •••• •••• • • • • • • •••• •••• ---Window--- • • ••...• ... w > N WH (NI Water Heater is 3 Ft Above floor level - • •• • •• • •• • • • : • • Receptve-: ao _ N 2.9 - 1.3 •••• • • 'ght •Switch--- • • • •• s EC 1r"C NOV8 4 Fr* .• Receptacle---- Receptacle---- t c�� /4 Oo ' 0 11, Staff o i Water Lines ---- [Hot & Cold] ,.,. iVill'.tra en �AamtShores y: d; ;:,i � _ .F APPROVED BY DATE Main;House N....1 h /0"/0"111\171'DEPT 5.0. 1.,• r - -"' 9 or PT l r), -In;. --1 WI'IIAlLI-1 'i AL Scale: 1 =5 , ,1 n , ry ,q JUDO E. 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