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SGN-15-2864 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-247696 PermitNumber: SGN-11-15-2864 Scheduled Inspection Date: January 20,2016 Permit Type: Sign Inspector: Rodriguez,Jorge Inspection Type: Final Owner: , SHORES SQUARE INVESTMENTS Work Classification: New Job Address:9017 Biscayne Boulevard Miami Shores, FL 33138-0000 Phone Number Parcel Number 1132060110070-17 Project: <NONE> Contractor: CAPITOL SIGNS Phone: (954)578-9340 Building Department Comments INSTALL CHANNEL LETTER WALL SIGN WITH Infractio Passed Comments ELECTRIC INSPECTOR COMMENTS False Inspector Comments Passed Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. January 19,2016 For Inspections please call: (305)762-4949 Page 18 of 56 ill Miami Shores VillageOW Permit Na,Si 4 Y ion g 10050 N.E.2nd Avenue �,, ,��• � � '' �vrk ClGf��sia9catrt��ta)51e*t . • Miami Shores,FL 33138-0000 # tt +�t /I►PAR � '�. Phone: (305)795-2204 Expiration: 06/06/2016 Project Address Parcel Number Applicant 9017 Biscayne Boulevard 1132060110070-17 SHORES SQUARE INVESTMENT Miami Shores, FL 33138-0000 Block: Lot: Owner Information Address Phone Cell SHORES SQUARE INVESTMENTS 3850 BIRD Road MIAMI FL 33146- Contractor(s) Phone Cell Phone Valuation: $ 1,950.00 CAPITOL SIGNS (954)578-9340 Total Sq Feet: 33 Type of Sign:Wall Sign Available Inspections: Electrical Sign:Yes Inspection Type: Height: Final Width: Review Building Color:ORANGE/RED/GRAY Elevation: Review Electrical Plans Submitted:Yes Additional Info:INSTALL CHANNEL LETTER WALL: Review Planning Classification:Commercial Scanning:3 Review Structural Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $1.20 Invoice# SGN-11-15-57743 DBPR Fee $2.00 12/09/2015 Check#:1048 $ 146.20 $50.00 DCA Fee $2.00 Education Surcharge $0.40 11/12/2015 Cash $50.00 $0.00 i Permit Fee $100.00 4 Plan Review Fee(Engineer) $80.00 j Scanning Fee $9.00 Technology Fee $1.60 Total: $196.20 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 wo1K. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will b do in compliance with all applicable laws regulating construction and zoning. Futhermore,I authorize the above-named contractor to do stated. Decerber 09, 2015 Authorized Signature:Owner / Applicant / Contractor Date Building Department Copy December 09,2015 1 \� 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 F'B-C 20141 { BUILDING Master Permit No. N 15—z-., �y PERMIT APPLICATION Sub Permit No. $BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: ��/? �/S c .��.� '5 City: Miami Shores County: Miami Dade Zip: 9 3 ,p Folio/Parcel#: _ _ a_ _ Is the Building Historically Designated:Yes NO V" Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name(Fee Simple Titleholder): f &jJGI Y d�re/-ea.Lz C Phone#: (3031 IV? gf5s Address: (oq� 146 /2! 57- 7� City:,kk" State: Zip: .331(O t Tenant/Lessee Name: Phone#: Email: �'/aE!'Asiiv®r L � r?iJl vii i�stzt �Fipv�aJ'e fsa� � ��(� osd 3' t CONTRACTOR:Company Name: d` �� = � Phone#: Address: ! ®y I NO 173 4pe- City: e i-y hnulu- p�".4 State: �� Zip: 3 s":?Ct Qualifier Name: W I LL/A Al k?-to Phone#: State Certification or Registration M 1O,S Certificate of Competency M {� C 5S DESIGNER:Architec ngin r: C/� a' •kap L Phone#: -3g9-9 iV Address: Z City: ✓`0. a vlov!State: Zip: 3 t Value of Work for this Permit:$ Square/Linear Footage of Work: Type of Work: ❑ Addition/ �❑ Alteration YNew ❑ Repair/Replace ❑ Demolition Description of Work: L_ LSA�"l C t, 0141-A P- � (� �'� co Specify color of color thru tile: Submittal Fee$� _Permit Fee$ -) CCF$ CO/CC$ Nu ft—rO- Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ 1 TOTAL FEE NOW DUE$ q e (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. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature eas r AGENT CONTRACTOR The foregoing instrutentcknowledged before me this The foregoing instrument was acknowledged before me this day of / /�/� ZO 15' by day of C,4- 20 ,by who is perso kir nown to bV C ^'� ® 2�(T® Q,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 PUB NOTARY PUBLIC: TERESA MEYERS ;ro* tate,,f Florida Sign: Sign: x it c 19,2018 Print: Print: omaDIM ' t. slon#FF 177270 .,s F,o u •� Expires u 017 Seal: gf;, 4`' eanm,TrorFe�nm,wsoa3ssama Seal: - APPROVE `Y �j / D BY l Plans Examiner l ! Zoning Structural Review Clerk (Revised02/24/2014) Detail,by Entity Name Page 1 of 2 NNEP � Deta II by Entity Florida Limited Liability Company SHORE SQUARE PROPERTIES, LLC Filing Information Document Number L11000075982 FEI/EIN Number 45-2672348 Date Filed 06/30/2011 Effective Date 06/28/2011 State FL Status ACTIVE Principal Address 696 NE 125TH STREET NORTH MIAMI, FL 33161 Mailing Address 696 NE 125TH STREET NORTH MIAMI, FL 33161 Registered Agent Name &Address Reyes, Daisy 696 NE 125TH STREET NORTH MIAMI, FL 33161 Name Changed: 03/20/2014 Authorized Person(s) Detail Name &Address Title MGR IZHAK, YORAM 696 NE 125TH STREET NORTH MIAMI, FL 33161 Title MGR LIPTON, ALAN 649 OCEAN BLVD GOLDEN BEACH, FL 33160 Annual Reports http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/12/2015 Detail,by Entity Name Page 2 of 2 Report Year Filed Date 2013 04/04/2013 2014 03/20/2014 2015 03/31/2015 Document Images 03/31/2015 --ANNUAL REPORT View image in PDF format 03/20/2014 --ANNUAL REPORT View image in PDF format 04/04/2013 --ANNUAL REPORT View image in PDF format 03/29/2012 --ANNUAL REPORT View image in PDF for 06/30/2011 -- Florida Limited Liability View image in PDF format Cauvr'iahY '0 and Privacy Policies State of Florida,Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entit... 11/12/2015 SIGN APPROVAL LETTER DATE PROPERTY OWNER/MANAGER Share Snuare P'OoGAeS , LL C OWNER'S ADDRESS (aqU Nf 116 :!�r N. Miami 331(0l OWNER'S PHONE NUMBER (3D,5 PROPERTY TAX FOLIO y�j• 2.(p, ,2�� To Whom It May Concern: I,4Q ram 0 Zlw k property owner/manager of the property located At 4'0l7 ,5W did AaWS �C 33/3B Authorize Capitol Signs to act on behalf to obtain necessary permits and install proposed signage at the property listed above. The proposed signage complies with all sign criteria set forth by the laws and code of the local municipality. Thank you. Own s 'gnature Vor- 7 "{ Print name NOTARIZEDat ares July 2,2017 d Thm Troy Fdn Immm 800.395.7019 DBPR Professions - Electrical Contractors' Licensing Board- Codes Page 1 of 2 IE A•ak us Contact US usineS s j Regulation HOME VERIFY A LICENSE APPLY FOR/UPDATE LICENSES RENEW YOUR LICENSE OUR BUSINESSES&PROFESSIONS ELECTRICAL CONTRACTORS' LICENSING BOARD oard foe FAOs N Forms and Publications Definition of Occupation and Class Codes Statutes and Rules General Terms Public Records 2. Annual ReQulatorw Plans in general an "alarm system contractor"means a person whose business includes the execution of contracts requiring the experience and skill to lay out,fabricate, install, maintain,alter,repair,monitor, inspect,replace,or service any electrical device,signaling device,or combination of electrical devices used to signal or detect a burglary,fire, robbery,or medical emergency. Ruthanne Christie, A'registered contractor"means any contractor who has registered with the department Executive Director pursuant to fulfilling the competency requirements in the jurisdiction for which the registration is issued.Registered contractors may contract only in such jurisdictions. Division of Professions Electrical Contractors'Licensing Board 1940 North Monroe Street Definitions including the occupation codes and class codes,where applicable. Tallahassee,FL 32399-0783 EC-An"electrical contractor"means a person who conducts business in the electrical Phone: 850.487.1395 trade field and who has the experience and knowledge install, repair,alter,add to, or Fax Information design electrical wiring,fixtures,appliances,apparatus,raceways,and conduit,including the electrical installations and systems within plants and substations and ALL alarm systems and specialty categories. Board Meeting information EF-An "alarm system contractor I"means an alarm system contractor whose business includes all types of alarm systems for all purposes. Bureau of Education &Testing EG-An"alarm system contractor II"means an alarm system contractor whose business includes all types of alarm systems other than fire,for all purposes. ? EY(EH)*-A"registered alarm system contractor I"means an alarm system { contractor whose business includes all types of alarm systems for all purposes.A •••.; j registered"alarm system contractor i"may contract only in the cities and/or counties for ,r.,. which his or her registration is issued. T 1EY and EZ are the alpha letters currently being used.No new licenses are issued with EH and EI,however old licenses with these designation can be renewed. EZ(EI)*-A"registered alarm system contractor II"means an alarm system contractor whose business includes all types of alarm systems,other than fire, for all purposes.A'registered alarm system contractor II"may contract only in the cities and/or counties for which his or her registration is issued. *EY and EZ are the alpha letters currently being used. No new licenses are issued with EH and EI,however old licenses with these designations can be renewed. EJ-A"registered residential alarm system contractor"means an alarm system contractor whose business is limited to burglar alarm systems in single-family residential, quadruplex housing,and mobile homes of a residential occupancy class.A"registered residential alarm system contractor"may contract only in the cities and/or counties for which his or her registration is issued. ER-A"registered electrical contractor"means an electrical contractor who has registered with the department pursuant to fulfilling the competency requirements in the jurisdiction for which the registration is issued.A"registered electrical contractor"may contract for electrical systems,including all specialty categories, only in the cities and/or counties for which his or her registration is issued.A"registered electrical contractor"MAY NOT contract for any alarm system. ES-A"specialty contractor"means a contractor whose scope of practice is limited to a specific segment of electrical or alarm system contracting, including, but not limited to: elevator specialist(class code 066),utility line electrical specialist(class code 068), low voltage system specialist(class code 069),residential electrical contracting (class code 043),maintenance of electrical fixtures(class code 065),and fabrication,erection, installation,and maintenance of electrical advertising signs(class code 067). ET-A"registered electrical specialty contractor"elevator specialist(class code 066), utility line electrical specialist(class code 068),low voltage system specialist(class code 069), residential electrical contracting(class code 043), maintenance of electrical fixtures http://www.myfloridalicense.com/dbpr/pro/elboard/codes.htm] 11/12/2015 4PSTALE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL CONTRACTORS LICENSING BOARD (850)487-1395 Q�� 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 BARROW WILLIAM A CAPITOL SIGNCO INC D/B/A CAPITOL SIGNS, INC. 401 NW 93 AVE PEMBROKE PINES FL 33024 - -ConZjratuTatiarrst With this 6caenseyou become-one oMe-neariy -- - one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range STATE OF FLORIDA from architects to yacht brokers,from boxers to barbeque restaurants, DEPAR and they keep Florida's economy strong. TME T OF BUSINESS AND PROF E-;- t"GULATION Every day we work to improve the way we do business in order to ECA001251 tjft..04/09/2015 serve you better. For information about our services,please log onto .a www.myfloridalicerrse.com. There you can find more information CERTIFIED ELE :� IS#1 Wt� OR about our divisions and the regulations that impact you,subscribe BARROW,bVll ato ;f initiatives rtment newsletters and learn more about the Department's CAPITOL SIG , iTTflL S Our mission at the Department is:License Efficiently,Regulate Fairly. ,T We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, IS CERTIFIED under the provisions of Ch.488 FS. and congratulations on your new license! ,dole:AUG 31,2ots L1504090000810 DETACH HERE RICK SCOTT,GOVERNOR KEN LAWSON,SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION ELECTRICAL C0IVTRACTORS LICENSING BOARD 1:44 4 . . ECA001251 ADDITIONAL BUSINESS.QUA + 4TZON The ELECTRICAL CONTRACTOR '` -' Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Z Expiration date: AUG 31,2018 `` ` BARRaW, WILLIAM A CAPITOL SiGNCO LLa1G 4101,NW93 f3EMBROKE# r Q24 2 �s�_": .. • - _- ISSUED: 04=12015 DISPLAY AS REQUIRED BY LAW SEa# 1-1504090000810 tom^ �,. 5•n L bd'k`T:{: Y ,.QTS(r., .:^;I 3iH141`&t'i?s ..1'v�.§b,#'i o-i�,� 3; `t"FN4 ;... T,S�iG�. 'P — BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895—954-831-4000 «1 VALID OCTOBER 1,2015 THROUGH SEPTEMBER 30,2016 DBA: Receipt#:181-2313PL/ALARMS/CONTRACTORS CAPITOL SIGNS INC Business Type: �I Business Name: Yp (ELECTRICAL CONTRACTOR) Owner Name:WILLIAM BARROW BusinessOpened:03/03/1995 ( ' Business Location:401 NW 93 AVE State/County/Cert/Reg:ECA001251 f" �i PEMBROKE PINES Exemption Code: Business Phone:954-578-9340 Rooms Seats Employees Machines Professionals f+ 10 For Vending Business Only c Number of Machines: Vending Type: j Tax Amount Transfer Fee NSF Fee Penalty �PriorrCollection Cost Total Paid 27.00 0.00 0.00 0.00.00 27.00 r. 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 w the business is sold, business name has changed or you have moved the j 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. 1 Mailing Address: ^7 WILLIAM BARROW Receipt #10B-14-00010292 401 NW 93 AVE Paid 06/24/2015 27.00 PEMBROKE PINES FL 33024 2015 - 2016 - �' i CERTIFICATE OF LIABILITY INSURANCE a 15"'=;;;;' THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORWTiON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NATIVELY 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),AUTHOR® REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the eerlilloate holder is an ADDITIONAL INSURED,the poley(im)must be endorsed. If SUBROGATION IS WANED,subject to the torn and conditions of the policy,certain polices may require an endorsement.A stfstementon thfs cer6'ficate does notconfer frights tothe cerliticate holder in Ieu of such eruft rsemen a). PROmXw =AM REEL INSURANCE AGENCY PHONE 958.0!06 Fax 958-0555 =Af COVER ALL 9=RANCE reellnsuran oo wM 5$00 W.ATLANTIC BLVD. INSUREIM AFFORDING COve E wltic e MARGATE FL 33083 INSURER A:ATLANTIC CASUALTY INSURANCE CO. u�ISFFRED CAPITAL SKINS INC.&CAPITOL SIGNCO INC. 401 NW 93RD.AVENUE D. PEMBROKE PINES FL 33024 E_ INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. + IASRLTR TYPE OF INSSURAN CEJOU � POUCY EV fMMIDlMAnnM Lam i X COMMERCA-GENERAL LIABlLJ7'Y EACH OCCURRENCE S 1 000 A cwmmADE ff]OCCUR DAMWETO RENTED $100,000 f L144M"463-2 OU1412015 01/1412016 tmEu ori $5,000 PERSONA.&ADV INJURY I 1000000 GEMS TE LIAR APPLIES PER: GENITAL AGGREGATE POLICY JET D LOC PRODUCTS-COMINOPAGG 000 OTHM $ AUTOMOBILE LUUMJTY COMBSRED SINGLE LIMIT $ ANY AUTO BODp-Y 1NA Rir OW Pte+) S �� SCHEDULFD D BODILY INJURY(P8r8=wwd) $ AUTOS AUTOS PROPERTY DAMAGE— HIRED $ s UiB9RELLA LIAROCCUR EACH OCCURRENCE D(CESS LIARH( -MADE AGGREGATEF DFD REI�- $ S NIORKERS CANPIDMTiONIPER OTH- AND EMPLOYERS'LIABILITY ANYY/IBM") NIA E.LEACH IDENT $ OFFICERlf�M") EXCLUDEXCLUDED?ter E.L.DISEASE-EA EMPLOYEE $ B user Rv E.L DISEASE-POUCYLwr $ 710N OF OPFRATION.RI LOrATFONSI VEMK ES(ACORD 191,Addiftnei Ramada Schedule,maybe of ached if mora apace Is required) SIGN PAINTING OR LETTERING-ON BURDING OR STRUCTURE EXTERIORS-NO SPRAY PAINTING CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPT SHOULD ANY OF THE ABOVE DESC�-POLIQR�-BB BEFORE 10050 NE 2 AVE THE EUmxnoN DAIM SOF, Nps aqL)„ IN MIAMI SHORES,FL 33138 M CORDANce I THE CC PROVISI AUTHORIZED REP AUf6 .'.:. FAX:305-7568972 " ®1988-2014 ACORD CORPORATION. All tights reserve& ACORD 25(2014101) The ACORD nam and logo are regislonni rnarks 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: 4/9/2015 EXPIRATION DATE: 4/8/2017 PERSON: BARROW WILLIAM A FEIN: 061683006 BUSINESS NAME AND ADDRESS: CAPITOL SIGNCO INC CAPITOL SIGNS INC 401 N.W.93 AVE PEMBROKE PINES FL 33024 SCOPES OF BUSINESS OR TRADE: LICENSED ELECTRICAL SIGN INSTALLATION, CONTRACTOR MAINTENANCE 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 fisted 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 tiling 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 08-13 QUESTIONS?(850)413-1609 sign Miami Shores ills e 9 Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tet: (305)795.2204 Fax: (305)756.8972 Notice to Owner— Workers' Compensation Insurance Exem tion 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 exemptthemselves 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 CONTENTS. THIS NOTICE AND UNDERSTAND ITS Signature: --A-- r State of Florida County of Miami-Dade The foregoing was acknowledge before me this--26 --t—day of 041 20_!S , By ^4 who is p to me or has produced iasidentification. Notary:SEAL: Notary De L State of FJorge De La Rosa.9� My Commission EE 19 c� Expires 04/2312019 A"d 015W.4 401 N.W. 93rd Ave. Pembroke Pines, Fl. 33024 Ph. 954.578.9340 Fax. 954.704-8062 www.capitolsignco.com November 10, 2015 State of Florida County of Broward Before me this day personally appeared William Barrow, who being duly sworn, deposes and says: That he will be the only person working on the property located at 9017 Biscayne blvd. Sworn to and subscribed before me this 10 day of November 2015 William Barrow Qualifier PaY PGe, TERESA MEYERS Notary Public-State of Florida • My Comm.Expires Dec 19,2018 Commission#FF 177270 Bonded through National Notary Assn. Teresa Meyers Notary to qualifier Personally known to me SEEM Miami shores Village Building Department �ORT� 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._l 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: I; I Y �L� I C. BUSINESS ADDRESS: N . CITYR✓ ,L7 F STATE --Li ZIP33 0 z BUSINESS PHONE:t-=�1- S 3``1 V FAX NUMBER S LJ0 '`1 - V Cz CELL PHONE I •oJA � QUALIFIER'S LIC NUMBER: E CA 00 / Z V