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MC-16-2549-2,/ 1 Vie Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 n 1 / Inspection Number: INSP-273036 Scheduled Inspection Date: December 14, 2016 Inspector: Perez, JanPierre Owner: Job Address: 525 NW 111 Street Miami Shores, FL 33138-0000 Project: <NONE> Contractor: BEL AIR SERVICES & AIR CONDITIONING INC Permit Number: MC -9-16-2549 Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: Addition/Alteration Phone Number (786)580-8923 Parcel Number 3021360210720 Phone: (954)895-1534 Building Department Comments NEW DUCT WORK AND A/C UNIT "lnfractio Passed Comments INSPECTOR COMMENTS False Passed Failed Correction Needed Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid, Inspector Comments December 13, 2016 For Inspections please call: (305)762-4949 Page 28 of 40 Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138-0000 Phone: (305)795-2204 Project Address 525 NW 111 Street Miami Shores, FL 33138-0000 Permit Permit NO. MC -9-16-2549 Permit Type: Mechanical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 9/22/2016 Expiration: 03/21/2017 Parcel Number 3021360210720 Block: Lot: Applicant DAVID WILLIAM PROPERTIES L Owner Information Address Phone Cell DAVID WILLIAM PROPERTIES LLC 1680 MICHIGAN Avenue MIAMI BEACH FL 33139- (786)580-8923 1680 MICHIGAN Avenue MIAMI BEACH FL 33139- Contractor(s) Phone BEL AIR SERVICES & AIR CONDITION (954)895-1534 CeII Phone Valuation: Total Sq Feet: $ 4,000.00 0 Tons: 3 Additional Info: NEW DUCT WORK AND NC UNIT Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved: : In Review Type of Work: Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $2.40 $2.10 $2.10 $0.80 $140.00 $3.00 $3.20 $153.60 Pay Date Pay Type Invoice # MC -9-16-61350 09/15/2016 Credit Card 09/22/2016 Credit Card Amt Paid Amt Due $ 50.00 $ 103.60 $ 103.60 $ 0.00 Available Inspections: Inspection Type: Final Rough Duct Review Mechanical Underground In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all 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. September 22, 2016 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date September 22, 2016 1 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION IVIIdI I11 JI IUI CJ V IIIdge 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 Master Permit No. Sub Permit No. ❑PLUMBING [MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF CONTRACTOR JOB ADDRESS: S2S /iv /1 / 57— City: r City: Folio/Parcel#: Miami Shores // Z/3' OZ/ 0720 Occupancy Type: Load: Fsc io g.Th M0,16-- 2G1-9 ❑ EXTENSION ❑RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS County: Miami Dade Is the Building Historically Designated: Yes Zip: 33 /ZS' NO Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): Oa vi i,,. , dor+ Address: /G 9U / it &4/f 4/1 �c 70J City: if/et k reeA Crg State: /G BFE: FFE: Phone#: 711' se ro 11 Z3 Zip: 33J3 r Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: /)�I e/ l�/ Sr lai e'S ��/ (°,10641;Pho e#: 75% PfS/S� Address: 2706 V 71- Q City: l4 //y 4.w) 4 -,Qualifier Name: ia/1 State Certification or Registration #: C /51-e l S'/ 42/3 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: State: Zip: 3 8 0 zy Phone#: 17(4/ S' %0 Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration/LNew ❑ Repair/Replace Description of Work: ,t4 / - A/c_ I�.rr/i oto/ /0 ;✓" ❑ Demolition Specify color of color thru tile: Submittal Fee $ 5"C) • Permit Fee $ 1 it) i Ow $ 2 • qo CO/CC $ Scanning Fee $ 3• CO Radon Fee $ 2 • 1 b DBPR $ 2 • 10 Notary $ Technology Fee $ 3 2 0 Training/Education Fee $ 0 . Ja1 Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUES 1 03- GO 11:?1P-(',TrTN7F,T)I Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not bggpproved and a reinspestrgn fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this /Y day of Sc/' , 20 /' , by /F day of SP, ,20 _‘ , by �%a✓/c/ I i/-4no , who is personally known to >#7 A/c) , who is personally known to me or who has produced as me or who has produced identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: Sign: Print: Seal: SANCHEZ or It • State of Fl ti - res pr , 0 Commissionxp a FAA11711528218 or+ Bonded Through National Notary Aun. as *************************** ***** ************************************************************************ Cti APPROVED BY 14 Plans Examiner Zoning Structural Review Clerk Miami Shores Viiiage Building Department CONTRACTORS' REGISTRATION 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. I/ 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: e/ 4r $c7a,GcS ' Jt Pe,���o� 2-7.1 BUSINESS ADDRESS: '1700 ,/ 72 %.c CITY A/ uo J STATE /-%/ ZIP .362y BUSINESS PHONE: ( ) FAX NUMBER ( ) CELL PHONE ( i5Y) 9'S 5- /S3 `/ QUALIFIER'S NAME: Dw; 6 a . QUALIFIER'S LIC NUMBER: 62/3 } STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 ROJO, IAN 1 BEL AIR SERVICES & AIR CONDITIONING INC 8310 NW 15TH CT PEMBROKE PINES FL 33024 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 LICENSE7NUMBER STATE OF FLORIDA j DEPARTMENT OF BUSINESS AND PROFESSIONAL/REGULATION CACI 816213 . r 4"(1SSUED:- 07/04/2016 -t CERTIFIED AIR CQND CONTR. , ROJO, IAN 1 :- : •'�•' , . .=: BEL AIR SERVICES &AlR'COI4DLTIONIN =,G .x r• %, IS CERTIFIED under the provisions of Ch.489 FS. ExpemiceCue •AUG 31.2018 - _ L1607040001228 1�`.. • �_ ..- �.,,.._. DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD The CLASS B AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED • • Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 -, • {, ROJO, IAN I - BEL AIR SERVICES & AI ft.CQ DITIONING INC 2700 NORTH-72NDAVENUI►"�^+;*;*-^-w-3��\`` HOLLYWOOD ..• ,J1.. 33024 i N • f r• . r �,., „„,,,-0:1/4. , f . -rte '�+� - �� � •�4, - LAW it -te a` .x � `.J... , � ,+....].�....J►�a1 �3...�� � 1��, ,4�� 4 c: ~ \ ` - `\ ' � \20.2-,„ ISSUED: 0710412016 LL DISPLAY AS REQUIRED BY LAW SEQ # L1607040001228 Scanned by CamScanner BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2015 THROUGH SEPTEMBER 30, 2016 Receipt #:HEAT NG/AIRCONDITION CONTRACTR Business Type:(CLASS B AIRCONDITION CONTRACTR) Business Opened:05/21/2009 State/County/CertlReg: CAC 1816 213 Exemption Code: DBA: Business Name .BEL AIR SERVICES & AIR CONDITIONING INC Owner Name: IAN I ROJO Business Location: 2700 N 72 AVE HOLLYWOOD Business Phone: Rooms Seats Employees 1 Machines Professionals For Vending Business Only Number of Machines: Vending Type: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 ��0.00 _ 0.00 Y 0.00 0.00 0.00 __7 200 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 and/or 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 moved 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: IAN I ROJO 2700 N 72 AVE HOLLYWOOD, FL 33024 2015 - 2016 Receipt #1CP-14-00023922 Paid 09/03/2015 27.00 To: Page 2 of 2 2016-09-15 15:35:26 (GMT) 19547567377 From: Rebeca Rojo .+4cia,R0.:.. ... -. CERTIFICATE OF LIABILITY Dttr¢4a4r�un,7m^�rr) INSURANCE E . . . • . . 08110/15 ,.THIS CERT1FICATE is ISSUED AS A MATTER QF INFORMATION tSM1ti.:Y,I ND •GOtliFERS HO RIGHTS UPON'THE CER_TIFICATE HQLDER THIS:... CERTIFICATE :DOS NOT AFF1RM.ATIVELy' OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE. AFFORDED BY THE_PGUcrES: " .: BELQW; _This CERTIFICATE OF:INSURANCE: DOES:NOT .CONSTITUTE 'A CONTRACT Re7WEEN THE IS.SUIN+3'INSURER($): AUTHORIZED fiEPRESENTATIVE.ORPREtDi10EI2;:At,ID.THE GERIRFRCAIEI4OL13E .. .....:. . ... 1M ORTANT: it the, certifleata holder fs.anA.DO TIIQNAt.1NSLIRE3, tha:POilcy(iesji i tbe:endorsod. if SURR.CGA7iW31S WRSIMES; seubjt to . • tfhe ttarins:and concnteons of the, p4fcy, i ettain policies may quwe an e3ldorseliiert•,. A.gatemen* .!Sn. this sertifcata does not Cofferr 91ttsto certificatedie hold r.in IiEu of such endprsentent(.). . . RQDUCIlk Accredited tnsurence .. e099 Hollywood Blvd`. Floltywood; FL•33024 Pisorie (954 98.4 4'44 Bel AirServlces 8::A Coniitianing,.Inc' Z7{9R N 72i^tl Avenue: :. I oll;pwo.od, F1..33074' COVERAGES• CONTACT NAVE: yuc.ate;. Exn (054)964-5444 hBAii _____=__ weyoushorne Sol corm wC.wa4: . (954)964=0772.. nistiRER(5) AFFORDING COVERAGE INSURER A i MAXUM INt.3ETNNITY INSURAWE ,.-.u"..._ INSURER 1.sda R c • msulz:Ro: (954) 895-1534. ' .. i KStiagft'.:' ... •CERTIFICATE NUMBER;• REVt$ION NUMBER .: THIS •fS TO CERTIFY:.THAT THE.PbllciES.OF NSURAi+tcE LI§TED BELOW HAVE EEN ISSUED,TO: THC INSURED NAMEDAS.0 VE Ff.3P,11-1E. (?CX,IY FEEZIOO • :-ENDICATED: *NOT ITHSTAND.ING`AIY RE LICREME(J't . f613M.O CONOI z ION OFANY CONTF'ACr.OR'OTH;EI .QOCL HENT W3TH :RESPECT TOWHIC3 . THIS CERTIFICATE MAY:6E 1SSUED,ORNIM'PERTAI.N,' THE tMSLikANCE AF ORMIO 8YTHE"POLICIES DESCRIBED :HEREIN I.S•SUS;IECT 10.At:[,TH,E TERMS, EXOLUSfONSAND.€ 0 DrTIONS'OF SUUCH:IoLICtES, LI? its S (IWM MAY' iVE B">'EIJ REDUCED EY'PAID CLAIMS. ' UMSR • . • I . Tit -TYPE .OF.IWBUPhttc ADOLI&U8R POLICY EFF PQ_��rCY. EXP NSR END 'POLICY NUMBER A p(Y,gx) GENERAL. UAt#tuTt' I€E . CO•MMERCIAL GENERAL UA01LMT/ l�'Jj .fl'cl„iLlfa2 1ADE' ;,P1 ,occiR U..: t317G00B9J31702 06/0912016 ®EN'L A'r,P1466ATE LIMIT APPLIES, RsP . poitex •i pti .......`'l,cc ... '... AUTQtItQ gll-..E:UA BUJTY. ... o . •ANY Al)TQ_ . . SCHEDJLED. --1.AU769 .... ...'L_-�.I .AL770S 0 H;REDAU't'o5 . L NGNUK NE,U Soros, .Ci • EXCESSL9A8:... "L j CLAIMS-MADE •.,pu,.....-RETENTIONS ' . • .WORKERS. COMPENSATION " . ANDEMPLQVEftwl-1AS:S.ITY•Y:r-0r . 'ANY #R 1ETORfpARTNERtEXECUi'I'VE • OFFtcER)MEMBER EXCWDEal . :cMaMararyn.NNr • Iryos,. Wacrlbo Vndnr DESCRIPTIGQN.0 OPERAT,'ONSbatrrw EACH OCCURRENCE', 931 0R_.TED PonnosES (Eo�:Cwrrunceo MED 'EXP '(Any one person s 1,000.00 .. " PL^:RfiOMAL &'ADV L RY S 1.,000,000.00 'GENERAL .AGGREGATE :. 2 000,00O.00 PRODDCTS..:••O /DP ACC S .1,000,00.00a . COMBINED UMIT (Ea scddentl S. - .. . SOOE: ` FNJURY {P ( perm) ...5. " ODP Y VilDf a {Ear acctden:). S'. - .. PROPERTY DAMA.OGE: • (Per accatent) ?CH ::CCUR+AE'NCE 'AGGREGATE F 1 WC E.TATt)-- ant-. •E.L.EACH Ac.opEr1T''. S 'EL, DISEASE - EA EMPLOY E.I _ DiEE•KSE - PQUCY UMrT" ,D cRIR.Ttof.1"9F.0PeRAflONg.er,OCA1idNS/VEHICLES,.(AttoehACORiWtOr,.AcMftlon:Isdent; AIR .CONC ITIONINt3°.SERVICE. REPAIR: INS fAL'LA71OiV ..ETC 9chsduls;.M maceNNISe lI:mgUITi CANCELLATION THE VILLAGE OF MIAMI. SHORES .. 10054 NE 2ND AVENUE M,IAt tt Si-IORJES; FI 33138 .REXPIRATlO(+1DA:raTHeeesp;.Ncroc We-Lse. D I�tV QH • •T ACCORDANCE EOWEi0Ai5..' AUTRORRED RERREsE;3TA: rUE ... .. ..yam;.:. .. ©.4988=2010 ACOf CORI'O. RATION Alt'Yight3.reselved • The ACORO m•ane:and Iwo. are registered,trterke otrACORD icepvrL viewer 100% rage 1 of 1 JEFFATWATER 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: 4/8/2015 EXPIRATION DATE: 4/7/2017 PERSON: ROJO IAN FEIN: 202895759 BUSINESS NAME AND ADDRESS: BEL AIR SERVICES & AIR CONDITIONING INC 8310NW15THCT PEMBROKE PINES FL 33024 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR-COND Pursuant to Chapter 440.06(14), F.S, an officer of a corporstlen vale sleds exemption front this chapter by fang s censals of Woollen wrier Ws ssdlnn trey not mom' b.n.ats or comp•nsabon ureter UW envier Pentangle Chapter 440.05(12), F.8., Certlfoett.• of election b he sxunpt_ wary 007 wC,M the scop of the business or trade Wee on the maim of election to be exempt Pursuant to Chapter 440.00(14 F.S. Hoban of ebcbon t0 be went and attaluaba of *ace b be exerts* shM be subject to favoraeon 11, at any time der the fano of the ncbce or ria issuance of 1M certificate, the person named on the notice of pertalcete no longer mesh the rpuhenwnts of this sec0on for issuance of s cents:re. The O.pxun.M shell n obs a DFS-F2-DWG252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1809 https://apps8.fldfs.com/crreportviewer/reportV iewer.aspx?data=kdvpginc9D7Q3gH6TER6... 8/18/2016 Bel Air Services & Air Conditioning Inc 2700 N 72 Ave Hollywood ,FI 33024 9/13/16 State of i�c,/ County of pe, Before me this day personally appeared i'A 4 0 who,being duly sworn,deposes and says: That he or she will be the only person working on the project located at: 52S *iv /1/ sr Sworn to (or affirmed) and subscribed before me this day of Q, ,2011 , by io,o Personally know Or Produced Identification Type of Identification Produced -��04S Commission k FF 117115 �,.. 8 ed Throe N Print, �•+ 7 ota ry IVliami Shores Viiiage 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 BE J W YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: wner State of Florida County of Miami -Dade The foregoing was acknowledge before me this /3 day of se/ , 20 /e . By %avtJ //nc�• Notary: SEAL: who is personally known to me or has produced _ azidenLification. RI DO SANCHEZ Illi - Stout of Florida r y Cbmm. Expires Apr 2a, 2015 Commission N FF 117115 Bonded Through Notional Notary Ann.