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CLB Agenda 01/15/2014 CONTRACTORS LICENSING BOARD Agenda January 15 , 2014 4 ok � &IF f Coder County COLLIER COUNTY CONTRACTORS' LICENSING BOARD AGENDA JANUARY 15, 2014 9:00 A.M. COLLIER COUNTY GOVERNMENT CENTER ADMINISTRATIVE BUILDING BOARD OF COUNTY COMMISSIONERS CHAMBERS ANY PERSON WHO DECIDES TO APPEAL A DECISION OF THIS BOARD WILL NEED A RECORD OF THE PROCEEDINGS PERTAINING THERETO, AND THEREFORE MAY NEED TO ENSURE THAT A VERBATIM RECORD OF THE PROCEEDINGS IS MADE, WHICH RECORD INCLUDES THAT TESTIMONY AND EVIDENCE UPON WHICH THE APPEAL IS TO BE BASED. ROLL CALL ADDITIONS OR DELETIONS: III. APPROVAL OF AGENDA: IV. APPROVAL OF MINUTES: DATE: November 20, 2013 V. DISCUSSION: VI. NEW BUSINESS: VII. OLD BUSINESS (A) Orders Of The Board (B) Victor Treissa, Kitchen Installations of SWFL, LLC. —Six month credit review (C) Nathan Hinz, Nathan Contracting Services, LLC. —Six month credit review (D) Mico Urica Jr- Zen Group, LLC- Review of verification of construction experience (E) Paul Bolcavage — Review of Credit Report VIII. PUBLIC HEARINGS: (A) Case 2014 -01— Mario Rodriguez - K.C. Tiles & Marble, Inc (B) Case 2014 -02 — Seth B. Hollander - Hollander Construction Company, Inc. IX. REPORTS: X. NEXT MEETING DATE: WEDNESDAY, FEBRUARY 20, 2014 COLLIER COUNTY GOVERNMENT CENTER ADMINISTRATIVE BUILDING THIRD FLOOR IN COMMISSIONERS CHAMBERS 3299 E. TAMIAMI TRAIL NAPLES, FL 34112 November 20, 2013 MINUTES OF THE MEETING OF THE COLLIER COUNTY CONTRACTORS' LICENSING BOARD November 20, 2013 Naples, Florida LET IT BE REMEMBERED, that the Collier County Contractors' Licensing Board, having conducted business herein, met on this date at 9:00 AM in REGULAR SESSION in Administrative Building "F," 3rd Floor, Collier County Government Complex, Naples, Florida, with the following Members present: Chairman: Richard Joslin Vice Chair: Patrick White Members: Michael Boyd Ronald Donino Terry Jerulle Kyle Lantz Thomas Lykos Gary McNally Robert Meister ALSO PRESENT: Michael Ossorio — Supervisor, Contractors' Licensing Office Kevin Noell, Esq. — Assistant County Attorney James F. Morey, Esq. — Attorney for the Contractors' Licensing Board November 20, 2013 Any person who decides to appeal a decision of this Board will need a record of the proceedings and may need to ensure that a verbatim record of the proceedings is made, which record includes the testimony and evidence upon which the Appeal is to be based. I. ROLL CALL: Chairman Richard Joslin called the meeting to order at 9:02 AM and read the procedures to be followed to appeal a decision. Roll call was taken and a quorum was established. Seven voting members were present. The Board's new member, Gary McNally, introduced himself and was welcomed by Chairman Joslin. Michael Ossorio stated: Mr. McNally resides in Golden Gate Estates He will represent the "consumer" (Michael Boyd arrived at 9:03 AM. Eight voting members were present.) II. AGENDA — ADDITIONS, DELETIONS, OR CHANGES: Deletion: Under Item VIII -(A), "Public Hearings" o Case 2013 -11: Eusebio Perrier, d/b /a "Tiki Huts, Inc. " was withdrawn. Correction: • Under Item X, "Next Meeting Date" o The correct date is January 15, 2014 III. APPROVAL OF AGENDA: Vice Chairman Patrick White moved to approve the Agenda as amended. Thomas Lykos offered a Second in support of the motion. Carried unanimously, 8 — 0. IV. APPROVAL OF MINUTES — OCTOBER 16,2013: Corrections: • Eight voting members were present. At every occurrence where it was noted that 7 members voted, the number was changed to 8. • Page 16, 2 °d paragraph - following "A. Through me." o A new paragraph was inserted, beginning at "Without putting words into anyone's mouth..." Vice Chairman Patrick White moved to approve the Minutes of the October 16, 2013 meeting as amended. Thomas Lykos offered a Second in support of the motion. Carried unanimously, 8 — 0. 2 November 20, 2013 (Vice Chairman White left at 9: 05 AM. Seven voting members were present.) V. DISCUSSION Michael Ossorio, Supervisor — Contractors' Licensing Office, stated he met with an attorney for the State of Florida's Construction Industry Licensing Board ("CILB ") regarding the CILB's position concerning Second Entities which is similar to that of the Contractors' Licensing Board, i.e., very strict review of the application. He further stated the CILB may issue a new policy in the near future concerning approval /rejection of applications for a Second Entity. One requirement may be for the Qualifier to be an employee of the company or have a 20% ownership interest in the company, especially for Divisions 1 and 2. There is a much higher percentage of rejection for such applications. He will advise the CLB of any developments. He further stated the CILB is looking more closely at "experience" letters and requiring verification of previous experience, i.e., the letter must detail the experience and be notarized. (Kyle Lantz arrived at 9: 07 AM. Eight voting members were present.) Chairman Joslin mentioned Lee County conducted a "sting" operation recently in Cape Coral concerning unlicensed contractors operating in the area. He stated he was very surprised at the number of "contructors" who were cuught. Mr. Ossorio noted his office issues an average of 60 Citations a month to unlicensed contractors. The goal is to bring each individual into compliance. He stated the fines issued by the Contractors' Licensing Office are higher than those imposed by the Court. VI. NEW BUSINESS: (Note: With reference to the cases heard under Section VI, the individuals who testified were first sworn in by the Attorney for the Board.) A. Herman Rudolph — Application for Waiver of Examination(s) Michael Ossorio explained the application for Waiver of Examination is under the "Renewals" section of the Ordinance. • A contractor must renew his/her license in September of each year. • If a license has not been renewed by the end of November, the license is considered to be "delinquent." • In January, the license will be suspended for a period of twelve months. • After the suspension period, if the contractor has done nothing, the license is considered to be null and void. • The Ordinance states if a license is null and void and the license holder has not taken a competency exam in three years, he /she will be required to take the exam before an application for renewal can be approved. November 20, 2013 • Exception: If the exam is superfluous to the job or task the contractor is doing. Mr. Ossorio stated Mr. Rudolph chose to petition the Contractors' Licensing Board rather than take the exam. If he proves to the Board's satisfaction that he has continuing experience in his trade, the Board may grant his application for a Waiver and not require additional testing. Chairman Joslin questioned the Applicant: Q. You were licensed for pool cleaning in 2009? Is that correct? A. (Herman Rudolph) That is correct. Mr. Rudolph examined: • He did not have the funds to renew his license during the renewal period due to the downturn in the economy • He did not receive any renewal notices from the Cowity • He admitted it was an oversight on his part, i.e., not paying the fees for the subsequent years • He also holds a current license in Lee County Thomas Lykos asked the Applicant if his license in Lee County had also lapsed. A. Yes, it did. Mr. Lykos asked Michael Ossorio how long the Applicant's license had been null and void in Collier County. Michael Ossorio stated Mr. Rudolph did not renew his license in 2011 or 2012; it has been null and void since January, 2013. He noted Staff had delineated the total amount of fees due on the first page of the application, i.e., $740. When asked if he was prepared to pay the fees, Mr. Rudolph replied affirmatively. Gary McNally asked the Applicant if he had remained informed of possible changes to procedures during the past two years. Herman Rudolph responded he continued cleaning pools as an employee of Oasis Pool Service during that period of time. Chairman Joslin asked if he had taken any continuing education courses. Mr. Rudolph stated he had obtained his CPO license ( "Certified Pool Operator ") and took pool classes in Orlando (Note: CPO Certification is valid for three years from the date of issuance.) Chairman Joslin explained the CPO course prepares an operator to service a swimming pool, use the chemicals required, and maintain the safety of a pool. Operators become certified to comply with health and safety regulations when servicing commercial pools. He further stated the Applicant should attend at least one continuing education course every two years. Mr. Rudolph stated his son has also obtained the CPO Certification. November 20, 2013 Chairman Joslin noted the Certificate of Exemption from Workers' Compensation insurance coverage provided in the information packet became effective on June 11, 2009. He further stated, since he is a pool contractor, he knew the exemption expires two years from the date of issuance. He stated Mr. Rudolph should have again applied for an exemption in 2011. Michael Ossorio explained: • swimming pool cleaning is categorized as non - construction • there is no expiration for non - construction exemption certificates • there is no fee to obtain the exemption certificate and a pool cleaning company may employ up to three people before Workers' Compensation insurance coverage is required • the cost to obtain a construction exemption is approximately $50.00 Chairman Joslin asked the Applicant if he was aware of certain restrictions, i.e., he was not allowed to change a pool filter and his response was affirmative. Thomas Lykos moved to approve the application to renew Mr. Rudolph's license without required additional testing. Ronald Donino offered a Second in support of the motion. Discussion: Gary McNally asked if the Motion contained a requirement to attend the 13 -hour training class. Mr. Rudolph stated he would comply. Chairman Joslin reminded the Applicant he must pay all fees before his license will be renewed and he agreed. Thomas Lykos amended his Motion to include the training component. Ronald Donino again offered a Second in support of the amended motion. Motion carried, 7 — "Yes 71— "No. " Terry Jerulle was opposed. B. Brian J. Cleary — Application for Waiver of Examination(s) Brian Cleary stated: • He has been in business as Bonita Beach Pools, LLC. since late 2005 — beginning of 2006 • Approximately two years ago, he experienced several health issues • He is licensed in Lee County • He obtained CPO Certification in January, 2013 and has his continuing education requirements • He admitted missing the renewal deadline was an oversight on his part for which he accepted responsibility • He did not realize he had not renewed his Collier County license until notified by his insurance carrier that his license was not current November 20, 2013 Chairman Joslin stated Mr. Cleary's test results for the Business & Law exam were dated March 17, 2009. Mr. Cleary clarified he started his business in 2006 in Lee County. He stated he did not do any business in Collier County until 2009. Chairman Joslin asked how many pools the Application maintained and the response was, "We have about 235 stops right now." He clarified that Mr. Cleary was applying for a Swimming Pool Cleaning License and the Applicant stated, "Yes." When asked if he replaced any pumps or filters, the Applicant noted he is legally able to refer that work to licensed Contractor who bills the client separately. Thomas Lykos asked the Applicant if he maintained his license in Lee County and remained active in business in Lee County. Brian Cleary responded, "Yes." Michael Ossorio verified that Mr. Cleary's license became null and void in 2011 and the amount of fees due was $740.00. Mr. Cleary stated most of his business is in Lee County but he has acquired accounts in Collier County. Thomas Lykos moved to approve the application to renew Brian J. Leary's license without required additional testing. (Vary McNally ojftred a Second in support of the motion. Discussion: • (None) Chairman Joslin called for a vote. Motion carried, 7 — "Yes "/ 1— "No." Terry Jerulle was opposed. VII. OLD BUSINESS: A. Orders of the Board Thomas Lykos moved to approve authorizing the Chairman to sign the Orders of the Board. Kyle Lantz offered a Second in support of the motion. Carried unanimously, 8 — 0. VIII. PUBLIC HEARING: (Note: Regarding case heard under Section VIII, the individuals who testified were first sworn in by the Attorney for the Board.) A. Case #2013 -11: BCC vs. Eusebio Verrier, d/b /a "Tiki Huts, Inc." Note: The case was withdrawn by the County. (Reference: "Item 11 —Agenda") November 20, 2013 Michele Ossorio stated the case was the first time he has dealt with a Special Contractor for Tiki Huts. There are only two Specialty Contractors in the State who have been certified by Tallahassee. He noted there is an exemption in the Florida Building Code that applies to Native Americans who are not required to obtain a license to construct a Tiki Hut. They are required to go through the permit process only if there are set -backs issues. IX. REPORTS: • Ordinance: Michael Ossorio noted the Executive Summary written by Ken Kovensky concerning the changes to the revised Ordinance will be presented to the Board of County Commissioners in December. If approved by the BCC, the increases to fees and fines should become effective on January 1, 2014. • Workers Compensation Violations: Mr. Ossorio stated the Contractors' Licensing Office has been working with the Department of Financial Services concentrating on violations in the Construction industry. He stated one violator received a sentence of two years' probation and was fined $4,000. A violator may be prosecuted for civil violations in addition to the criminal case. X. MEMBER COMMENTS: • Thomas Lykos asked Attorney James Morey, Counsel to the Contractors' Licensing Board, to provide an overview the section of the Ordinance concerning Applications requesting a Waiver of Examination for the benefit of the Board's newest member. • Mr. Morey referenced Section 22 -184 of the Code under "Standard for the Issuance or Denial of a Certificate of Competency:" (a) Contractors. The Contractor Licensing Supervisor, or his designee, shall issue a Certificate of Competency to the Applicant if it appears, on the face of the application, as submitted by the Applicant, that: 1. The application is complete in accordance with the requirements of this division; 2. The Applicant possesses the experience required by Sections 22 -162 and 22 -183 3. The credit report submitted indicates no facts and circumstances which show a failure to pay contracting related bills promptly; 4. The Applicant or Qualifier meets the requirements for financial responsibility set forth in Rules 61 G4- 15.005 and 61 G4- 15.006, Florida Administrative Code, as they may be amended from time to time; 5. The Applicant meets one of the following criteria: a. The Applicant has taken and passed an examination approved and recognized throughout the state, as provided November 20, 2013 for in Section 22 -185, for the area of competency for which application has been made; or b. The Applicant meets all licensing requirements provided for by this division; 6. All required affidavits have been submitted; 7. All required fees have been paid; 8. The Applicant possesses a current County occupational license; and 9. The Applicant or the Qualifying Agent is at least 18 years of age. (b) Referral of application to Contractor's Licensing Board for decision. If it does not appear on the face of the application that the Applicant has complied with the requirements of this Article so as to be eligible for a Certificate of Competency, then the Contractor Licensing Supervisor shall refer the application to the Contractors' Licensing Board for a decision regarding approval or denial of the application. (c) When an application is referred to the Contractors' Licensing Board, the Board shall take testimony from the Applicant and shall consider other relevant evidence regarding whether the application meets the requirements of this division. Upon the evidence presented by the Applicant and the Contractor Licensing Supervisor, the Contractors' Licensing Board shall determine whether the Applicant is qualified or unqualified for the trade in which application has been made. Findings of Fact and Conclusions of Law regarding the approval or denial of the application shall he made by the Contractors' Licensing Board. The Board may consider the Applicant's relevant recent experience in the specific trade and based upon such experience may waive testing requirements if convinced that the Applicant is qualified by experience whereby such competency testing would be superfluous. 1. If the Contractors' Licensing Board determines that an Applicant is qualified for a particular type of Certificate of Competency, a competency card shall be issued by the Contractor Licensing Supervisor or his /her designee. Chairman Joslin noted the Ordinance is not "cut and dry." He stated sometimes testing is necessary. Attorney Morey stated one of the most relevant questions asked by the Board was whether or not the Applicant was currently licensed in another County and had he /she been working continually in that County. Chairman Joslin asked Michael Ossorio to explain the notification policy followed by the Contractors' Licensing Office. Michael Ossorio stated: • The Code requires the Licensing Supervisor to send a renewal notice in September. • If a license is not renewed by December, the license is suspended as of January Is'. The office sends a letter notifying the license holder of the suspension of his/her license to the license holder's last known address. November 20, 2013 Chairman Joslin wished the members a "Happy Holiday" season. XI. NEXT MEETING DATE: Wednesday, January 15, 2014 BCC Chambers, P Floor — Administrative Building "F," Government Complex, 3301 E. Tamiami Trail, Naples, FL There being no further business for the good of the County, the meeting was adjourned by the order of the Chairman at 10:30 AM. COLLIER COUNTY CONTRACTORS LICENSING BOARD Richard Justin, Chairman The Minutes were approved by the (Past) Chairman on 32014, "as submitted" U OR "as amended' [ ]. LULLIEK UUU1N I Y UU vhl�JN1V hA I COMMUNITY DEVELM1v1ENT AND ENVIRONMENTAL SERVICES DIVISION 2900 N. Horseshoe Dr. Naples.. Florida 34104 ® 239 -403 -2400 FA.X 239 -403 -2334 `? 45 It MEMORANDUM DATE: Novernber 29, 2007 TO: Applicant's FROM: Michael Ossorio, Contractor Licensing Supervisor. CC.: Robert Dunn, Collier County Building Director. AIamar Finnegan, Collier County Permitting Supervisor. Robert Zachary, County Attorneys Office. All Contractor Licensing personnel SUBJECT: Collection of social security numbers. Pursuant to Chapter 119, Florida Statues and Collier County Contractor Licensing Ordinance 2006 -46 Sec. 2.1 -1, all applicants are required to submit their social security number (SSN} for the following purposes: a) Asscss applic;aut.'s ability to satisfy ctedituis by ieviawiiig their Cledit histi,ry. bi Verification ofapplicanCs test,5cores and information. OLT office will only use your SSN noted above for those reasons pursuant to Chapter 119, Florida Statues and as niay otherv,-ise be authorized by law. We are fully committed to safe - guarding and protecting your SSN raid once collected, will be maintained as confidential and exempt under Chapter 119, Florida Statues. V11$ Findings of Fact, Conclusions of Law and Decision of the Board Collier County Contractors` Licensing Board For Applications Submitted to the Board for Review Type vfApplleaUvtt: X Credit Report Review Waiver of Testing Requirements Reinstatement of License Request to Quality Second Entity Other (specify) THIS CAUSE came on for public hearing before the Contractors' Licensing Board (hereafter Board) on December 9, 2012, for consideration of the application submitted to the Board for review. The type of application is set out above. The Board having heard testimony under oath, received evidence, and heard arguments relative to all appropriate matters, thereupon issues its Findings of Fact, Conclusions of Law and Order of the Board as follows: FINDINGS OF FACT 1. That Victor Treissa d /b /a Kitchen Installations of SWFL, LLC. (the "Applicant ") has submitted an application to the Collier County Contractor Licensing Supervisor or his designee for a Certificate of Competency as a Cabinet Installation Contractor and based on the credit reports supplied by the Applicant the Licensing Superviser determined a review of the credit by the Board is necessary. Z That pimmianf to SPotion ?2- 184(h) of the Cnllier County Contractors' Licensing Ordinance (Ordinance 90 -105, as amended) applications which do not appear on their face to be sufficient require referral to the Board for a decision regarding approval or denial of said application. M 1 305469.1 11412013 3. That the Board has jurisdiction over this matter and that Victor Treissa d /b /a Kitchen Installations of SWFL, LLC was present at the public hearing on December 19, 2012, and was not represented by counsel. 4. All notices required by Collier County Ordinance No. 90 -105, as amended, have been properly issued. 5. The facts in this case are found to be: a. Applicant has adequately demonstrated through testimony and evidence presented at this hearing that her licensure will not result in risk of economic loss �resuiting from the Applicant's ability to pay lawful uurylrautual obligations, subject to her Satisfaction of the terms set out herein. b. Credit report does not meet the standards of Florida Rule 61G4- 15.006 for Financial Rpspor sibility. C. It Is appropriate for the Applicant to be issued a probationary license and subject to further credit review. CONCLUSIONS OF LAW 1. Based upon the foregoing facts, the Board concludes that the applicant has met the standard set out in Ordinance 90 -105, as amended, subject to the restrictions and stipulations set out herein. 1. Based upon the foregoing Findings of Fact and Conclusions of Law, and pursuant to the authority granted in Chapter 489, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, by a vote of 5 in favor and 2 opposed, a 2 305469.1 1/4/2013 unanimous vote of the Board present, the Applicant's credit report is approved so that a license may be granted subject to the following conditions: 2012. a. Six (6) month probationary license shall be issued; b. Applicant is to provide updated approved form of credit report within thirty (30) days; c. Applicant is to provide updated business and personal credit reports to the Contractor Licensing Supervisor six (6) months from the date of the heating held December 19, 2012 and shall appear before the Board for a review of the credit reports at the next regularly scheduled Board meeting after 6ubmit6iig [Ile teputts. ORDERED by the Contractors licensing Board effective the 19th day of August, CONTRACT'OR'S LICENSING BOARD COQ IER COUNTY, FLORIDA By: Richard Aslin, Chairman I HEREBY CERTIFY that a true and correct copy of the above and foregoing Findings of Fact, Conclusions of Law, and Order of the Board has been furnished the Applicant, and Michael Ossorio, Licensing Compliance Supervisor, 2800 North HorsPshow DrivP, Naples, FL 34103 on this ` ,;r th day, DLD,-,qember, 2012. 3 is Licensing Board 305469.1 1!4/2013 Prepared By: Merit Credit (239) 277 -3202 (800) 371 -3348 TRANSUNION CREDIT REPORT (k`OR] CSUB NAME] (MKT S B] ATE] (TIME] (I) Z NP6284423 MERIT CREDIT 16 NP TO 28/13 13:18CT (SUBJECT] C... SPI - [BIRTH DATE] TREISSA, VICTOR M. 3z (ALSO KNOWN AS] VICTOR,TRESSA [CURRENT ADDRESS] [DATE RPTD] 3730 WHITE BV., NAPLES FL. 34117 i 6/06 [ FORMER ADDRESS) 441 NE. 12TH AV., NAPLES FL. 34120 ='-_' "'f 4/06 200 FOREST LAKES RV., #206. NAPLES FL. 34105 [POS ION-- [CURRENT EMPLOYER AND ADDRESS] [RPTD] SMART BY KITCHEN 12/06 (FORMER EMPLOYER AND ADDRESSI SELF EMPLOYED SALES ---------------------------------------------------------------------------- 11 0 D E L P A 0 @ 1 L k, ** '* A L E R T * * * * * *FICO CLASSIC 04 ALERT: SCORE +504 : 038, 013, 020, 018 * ** IN ADDITION * * *TO THE FACTORS LISTED ABOVE, THE NUMBER OF INQUIRIES ON THE CONSUMER'S ** *CREDIT FILE HAS ADVERSELY AFFECTED THE CREDIT SCORE. cXh; U1 1` S U M M A R Y * * * TOTAL FILE HISTORY PR-1 COT, -G NOG-4 113TNEG -1 -40 TRD =9 RVL =3 INST =4 M1'U =1 OPN =1 INQ =4 HIGH CRED CRED LIM BALANCE PAST DUE MNTHLY PAY AVAILABLE RPVOLVI140. -; 0 1300 {,0 $u loot MORTGAGE: $324K $ $317K $65.OK $3163 CLOSED W /BAL: $7416 $7416 $289 TOTALS: $324K $300 $324K ---------------------------------------------------------------------------- $72.4K $3452 P U B L I C R E C O R D S SOURCE DATE LIAB ECOA COURT ASSETS DOCKET# TYPE PLAINTIFF /ATTORNEY Z 5064186 10 /09R $241 I RD 4346846 STATE TAX LIEN B4496P407 C O L L E C T I O N S - ------- ------ SURNAME SUBCODE ECOA OPENED CLOSED $PTAACFD CREDITOR MOP ACCOUNT# VERIFIED BALANCE REMARKS ARO Y 2BO4002 I 6111 $5I i Ml,,I)tVAL 09B 000000000000000000 11/19A $513 PLACED k'UK VOLLY,t TIo ARS Y 2BQ4002 I 7/11 000000000000000000 11/12A ARS Y 2BQ4002 I 7/11 000000000000000000 11 /12A $1140 MEDICAL 09B $1140 ACCT INFO DSP BY CSM $815 MEDICAL 09B $815 ACCT INFO DSP BY CSM ARS Y 2BQ4002 I 7/11 $760 MEDICAL 09B 000000000000000000 11 /12A $760 ACCT INFO DSP BY CSM MERCHANTSCOL Y 2057001 I 3/12 $133 10 FLORIDA POWER L 09B 12396158 9/12A $133 ACCT INFO DSP BY CSM ENHANCRCVRCO Y 26MT002 I 6/11 $339 11 SPRINT 09B 52833676 7/11A $339 PLACED FOR COLLECTIO ----------------------------------------------------------------------------- T R A D E S SUBNAME SUBCODE OPENED HIGHCRED TERMS MAXDELQ PAYPAT 1 -12 MOP ACCOUNT# VERFIED CREDLIM PASTDUE AMT -MOP PAYPAT 13-24 ECOA COLLATRL /LOANTYPE CLSD /PD BALANCE REMARKS MO 30/60/90 REGIONAL ACC F 85UD091 11/04 $12.1K 66M289 109 62545101 12/12A $6641 C AUTOMOBILE 5/09F $6641 UNPAID BLNC CHRGD OFF SUNCOAST CU Q 298QODI 8/04 $0 009 12/12A $775 C DEPOSIT ACCT OVRD 2/07F $775 UNPAID BLNC CILRGD OFF CHASE AUTO B 8251008 2/04 $14,5K 72M301 I09 11/09A co C: AUTOMOBILE 1/09F $0 RESLVD RPT BY GRANTOR BK OF AMER B 427SO02 5/06 $324K 36OM3163 2/08 55555555555X M05 12/12A $65.OK $11.5 05 XXXXX5555555 I CONVENTIONAL REAL $317K FORECLOSURE INITIATED 48 2/ 2/36 FST PREMIER B 41PFOOI 8/05 $332 11/07 R01 8/12A $200 $Q $'IOU OS I CREDIT CARD 8/07C $0 ACCT CLSD BY CONSUMER 48 0/ 0/ 0 CHEVRON 0 103T001 12/05 $426 11111X11111X R01 8/07A $300 $0 1111X1 I CREDIT CARD 8/07C $0 PURCH BY OTHER LENDER 18 0/ 0/ 0 PEAK 5 F 1YZ9001 11/04 $12.1K 66M289 111111111111 I01 9/06A $0 111111111 C AUTOMOBILE 9/06C $0 CLOSED 21 0/ 0/ 0 BLAIR CORP C 24LE006 10/03 $0 1X1111111111 R01 87427 11/05A $300 $0 11 I CHARGE ACCOUNT 8/04P $0 14 0/ 0/ 0 FRD MOTOR CR F 3796761 8/01 $3211 24MI64 11111111 101 8/03A $0 C AUTOMOBILE 8/03C $0 CLOSED 8 0/ 0/ 0 1 P) Q U 1 R 1 E u DATE SUBCODE SURNAME TYPE AMOUNT 1/28/13 ZNP6284423(FLA) MERIT CREDIT 4/29/12 FPC1246538(NTL) COAF 4/29/12 ACH0217602(CHI) BILL HOLT CH 3/03/11 YPE1334717(IND) PINNACLE C R E D I T R E P O R T S E R V I C E D BY TRANSUNION 800 - 888 -4213 2 BALDWIN PLACE P.O. BOX 1000,CHESTER, PA. 19022 Consumer disrlosvres can be obtained online through Tran3Union at: http : / /www.transunion.com -------------------------------------------------------------------------- CREDITOR CONTACT .T.NFRRMATTON COLLIER CIR ZP5064186 (94 1) 774 -8800 3301 TAMIAMI TRL E NAPLES FL. 34101 ARS YC2BQ4002 (954) 321 -5957 1801 NW 66TH AVE FORT LAUDERDAL FL. 33313 MERCHANTSCOL YC20S7001 (800) 226 -6188 PO BOX 2842 TAMPA FL. 33602 ENHANCRCVRCO YC26MT002 (800) 496 -8941 8014 BAYBERRY RD JACKSONVILLE FL. 32256 REGIONAL ACC FA85UD091 (817) 794 -0001 110 WEST RANDILL M ARLINGTO14 TX. 76011 SUNCOAST CU QU298QOOI (813) 621 -7511 PO BOX 11904 TAMPA FL. 33680 CHASE AUTO BD0251000 PO BOX 901076 FORT WORTH TX. 76101 RK nF AMPR BM127EO02 (000) 451 -6362 4161 PIEDMONT PKWY STMI VALLEY CA. 93065 PST PREMIER BZ41PF001 (605) 357 -3440 3820 N .LOUISE AVE SIOUX FALLS SD. 57107 CHEVRON OC103TO01 (800) 243 -8766 POB 5010 CONCORD CA. 94524 PEAK 5 FZIYZ9001 (877) 236 -7672 6782 S POTOMAC ST ENGLEWOOD CO. 80112 BLAIR CORP CZ24LE006 220 HICKORY ST WARREN PA. 16365 tYKU MOTUR CR FA3796761 (R00) 727 -7nnn POB 542000 OMAHA NE:. 68154 COAF F 1246538 (888) 396 -2623 3905 N. DALLAS PAR PLANO TX. 75093 BILL HOLT CH A 0217602 (706) 635-5454 250 LIBERTY BLVD CANTON GA. 30114 PINNACLE Y 1334717 (952) 345 -5322 7825 WASHINGTON AV MINNEAPOLIS MN, 55439 END OF TRANSUNION REPORT MERIT CREDIT HAS RETRIEVED THE ABOVE PERSONAL CREDIT REPORT FOR LICENOING PURPO3E3 A3 REQUESTED BY THE BUSINESS OWNER/ PROPRIETOR. PUBLIC RECORDS FOR THIS REPORT HAVE BEEN CHttOKM:I1 AN11 VERIFIRD AT THPL COUNTY, STATE AND FEDERAL LOVLL3. PUBLIC RECOPmi HAVE ALSO BEEN VL1tlPIED FOR PYNEI AS COUNTY. PUBLIC RECORDS LEARNED 1 SOURCES OF INFORMATION: TRANS UNION LLC IRS LIEN SECTION COUNTY COURTHOUSE RECORDS 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 fisted below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 1/29/2013 PERSON: TREISSA FEIN: 461410822 BUSINESS NAME AND ADDRESS: KITCHEN INSTALLATIONS OF SWFL LLC 3730 WHITE BLVD NAPLES FL 34117 SCOPES OF BUSINESS OR TRADE: CARPENTRY? INSTALLATION OF CA EXPIRATION DATE: 1/29/2015 VICTOR Pursuant to Chapter 440,05(14), F.5, An nfftr,Pr of a mrpmrstinn whn etw:ts exemption from thla uhaptor by filing a certificate of U& be%'UurI may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S„ Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation If, at any time after the filing of the notice or the Issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shalt revoke a certificate at any time forfallure of the person named on the cerliUCate to meet the requirements of this section. DFS- F2 -DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07 -12 QUESTIONS? ($50)413 -1609 Findings of Fact, Conclusions of Law and Decision of the Board Collier County Contractors' Licensing Board For Applications Submitted to the Board for Review Type of Application: X Credit Report Review Waiver of Testing Requirements Reinstatement of License Request to Qualify Second Entity Other (specify) THIS CAUSE came on for public hearing before the Contractors' Licensing Board (hereafter Board) on June 19, 2013, for consideration of the application submitted to the Board for review. The type of application is set out above. The Board having heard testimony under oath, received evidence, and heard arguments relative to all appropriate matters, thereupon issues its Findings of Fact, Conclusions of Law and Order of the Board as follows: FINDINGS OF FACT 1. That Victor Treissa dba Kitchen Installations of SWFL, LLC. (the "Applicant ") had previously submitted an application to the Collier County Contractor Licensing Supervisor or his designee for a Certificate of Competency as a Cabinet Installation Contractor and based on the credit reports supplied by the Applicant the Licensing Superviser determined a review of the credit by the Board was necessary. 2. The Board previously issued the requested license subject to a probationary period and a six (6) month review period. 3. That pursuant to Section 22- 184(b) of the Collier County Contractors' Licensing Ordinance (Ordinance 90 -105, as amended) applications which do not appear on their 1 311323.1 7!3/2013 I face to be sufficient require referral to the Board for a decision regarding approval or denial of said application. 4. That the Board has jurisdiction over this matter and that Victor Treissa dba Kitchen Installations of SWFL, LLC. was present at the public hearing on June 19, 2013, and was not represented by counsel. 5. All notices required by Collier County Ordinance No. 90 -105, as amended, have been properly issued. 6. The facts in this case are found to be: a. Applicant has adequately demonstrated through testimony and evidence presented at this hearing that her licensure will not result in risk of economic loss resulting from the Applicant's ability to pay lawful contractual obligations, subject to her satisfaction of the terms set out herein. b. Credit report does not meet the standards of Florida Rule 61G4- 15.006 for Financial Responsibility. C. It is appropriate for the Applicant to be issued a probationary license and subject to further credit review. CONCLUSIONS OF LAW 1. Based upon the foregoing facts, the Board concludes that the applicant has met the standard set out in Ordinance 90 -105, as amended, subject to the restrictions and stipulations set out herein. ORDER OF THE BOARD 2 311323.1 7/3/2013 1. Based upon the foregoing Findings of Fact and Conclusions of Law, and pursuant to the authority granted in Chapter 489, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, by a vote of 7 in favor and 0 opposed, a unanimous vote of the Board present, the Applicant's credit report is approved so that a license may be granted subject to the following conditions: a. Probationary License shall continue for a period of six (6) months, b. Applicant is to provide updated business and personal credit reports to the Contractor Licensing Supervisor six (6) months from the date of the hearing held June 19, 2013 and shall appear before the Board for a review of the credit reports at the next regularly scheduled Board meeting after submitting the reports. ORDERED by the Contractors Licensing Board effective the 19th day of June, 2013, CONTRACTOR'S LICENSING BOARD ;ri COUNTY, FLORIDA ( - , By: Richard Joslin, Ch irman I HEREBY CERTIFY that a true and correct copy of the above and foregoing Findings of Fact, Conclusions of Law, and Order of the Board has been furnished the Applicant, and Michael Ossorio, Licensing Compliance Supervisor, 2800 North Horseshoe Drive, Naples, FL 34103 on this th d , 9.3. Secr tary /Cont6r's Licensing Board 3 311323.1 71312013 Prepared By, Merit credit (2]9) 277-3202 (800) 271-3348 TnAmSUmzOm CREDIT oEeouT [ FO RI [ SOB NAME) [MKT sno ] zmF TIME) (z) o mP6284423 MERIT CREDIT 16 NP 8/01 13.58Cz [SUBJECT) [SSN] ro DATE} rsozooa, nzcron M. __ N�N��-~ (ALSO KNOWN 8G] vICIon,roE3oa (CURRENT ADDRESS] (DATE DPTo] 3730 Wozzo ov', NAPLES FL. 34II7 6/06 (FORMER aooRoss) 441 NE. 12rn AV., wAnT.my FT- 3*120 1/86 zOO roRoor Laxos BV., #206. QagLoS FL. 34105 [POSITION] [ComaE0T 2mezoxsn Awn AnnRnSS] [Rezo] SMART BY xzrcoEm l2/06 (FORMER EMpznzEn AND ADDRESS] SELF oorzoxEo SALES ---------------------------------------------------------------------------- MODE L enorzL E +°°aL E Rr+°~ ~~~rzC0 CLASSIC 04 aLonr: 000Ro +523 ' 038, 013, 020, 0I8 ^°^ IN 8DDT7Tnw ~°+To THE FACTORS LISTED &oovE, THE NUMBER OF zm0oznzEo ON THE CONSUMER'S °^^cgsoz7 FzLF HAS ADVERSELY AFcscTou THE Cut;L)j'X ---------------------------------------------------------------------------- CnEozr aVMMA R Y ?0T AT. Frr.F nrnTovx ex~l CoL~5 mUa=o uuTmoG=1-41 rao=9 avL=3 INor~o mTG~I oPN=l 3m0~5 uIaa Cuno CRED LIM BALANCE paaT 000 amraLr PAY anuzzaBLE REVOLVING: $O $300 $O $O l00%' MORTGAGE: $324K $ $3I7K $65,UK $3163 CLOSED =/B&L; $7416 $7416 $289 TOTALS: $324K $300 $324x $72.4D $3452 ---------------------------------------------------------------------------- pOaLIC R C0BoS SOURCE DATE LzAB Eo]A COURT ASSETS o0CKDr# TYPE eLazmzzrF/ATzoumEx Z 5064186 10/09n $241 z RD 4546846 STATE TAX Lzom o4496e407 . �� ----------- cnL LuCTIO0S �nnwxmn �nnrnnp oC0A 0P8NEu CLOSED $PL&CED GBEDZT0D 140 ACC0VNc0 VnnrrTnn nnLnmro REMARKS am3 r 2o04002 I 7/1I $815 MEDICAL 09B 000000000000000000 11/I2A $815 ACCT zmrO DSp BY CSM auS Y 2BO4002 I 6/12 $513 MEDICAL 09B 000000000000000000 1I/I2a $513 PLACED FOR ooLLECTzO unS x 2B04002 z 7/11 $760 MEDICAL 09a 000000000000000000 11/12A $760 aCcr Imro ose BY CoM ARS Y 2BQ4002 I 7/11 $1140 MEDICAL 09B 000000000000000000 11 /12A $1140 ACCT INFO DSP BY CSM ENHANCRCVRCO Y 26MT002 I 6/11 $339 11 SPRINT O9B 7/11A $339 PLACED FOR COLLECTIO - -- ---------------------------- T R A D E S SUBNAME SUBCODE OPENED HIGHCRED TERMS MAXDELQ PAYPAT 1 -12 MOP ACCOUNT# VERFIED CREDLIM PASTDUE AMT -MOP PAYPAT 13 -24 ECOA COLLATRL /LOANTYPE CLSD /PD BALANCE REMARKS MO 30/60/90 REGIONAL ACC F 85UD091 11/04 $12.1K 66M289 I09 4/13A $6641 C AUTOMOBILE 5/09F $6641 UNPAID BLNC CHRGD OFF SUNCOAST CU Q 298Q001 8/04 $0 009 4/13A $775 C DEPOSIT ACCT OVRD 2/07F $775 IINPATn RT,NC CHRGD OFF CHASE AUTO B 8251008 2104 $14 ..9T< 72M301 109 1 /09A $0 C AUTOMOBILE 1 /09F $0 DISP INV CMP -BY GRNTR BK OF AMER B 4275002 5/06 $324K 360M3163 2/08 555555555555 M05 3/13A $65.OK $11.5 05 55XXXXXX5555 I CONVENTIONAL REAL $317K FORECLOSURE INITIATED 48 2/ 2/37 FST PREMIER B 41PF001 8/05 $332 11/07 R01 8/12A $200 $0 $100 05 I CREDIT CARD 8/07C $0 ACCT CLSD BY CONSUMER 48 O/ 0/ 0 CHEVRON 0 103T001 12/05 $426 11111X11111X ROl 8/07A $300 $0 7171X1 I CREDIT CARD 8/070 $0 PURCH BY OTHER LENDER 18 0/ O/ 0 PEAK 5 F lYZ9001 11/04 $12.1K 66M289 111111111111 I01 9/06A $0 111111111 C AUTOMOBILE 9/06C $0 CLOSED 21 0/ 0/ 0 BLAIR CORP C 24LE006 10/03 $0 1X1111111111 R01. 11 /05A $300 $0 11 I CHARGE ACCOUNT 8/04P $0 14 0/ 0/ 0 FRD MOTOR CR F 3796761 8/01 $3211 24M164 11111111 I01 8/03A $0 C AUTOMOBILE 8 /03C $0 CLOSED 8 0/ 0/ 0 ---------------------------------------------------------------------------- I N 0 I) T R T F S uA,rh SUBCUUL SURNAME TYPE AK')ttNT 5/20/13 ZNP6284423(FLA) MERIT CREDIT 5/11/13 UWA3747126(WAS) T- MOBILE 1/28/13 ZNP6284423(FLA) MERIT CREDIT 4/29/12 FPC1246538(NTL) COAF 4/29/12 ACH0217602(CHI) BILL HOLT CH ---------------------------------------------------------------------------- C R E D I T R E P O R T S E R V I C E D B Y: TRANSUNION 800 - 888 -4213 2 BALDWIN PLACE P.O. BOX 1000,CHESTER, PA. 19022 Consumer disclosures can be obtained online through TransUnion at: http: / /www.transunion.com CREDITOR CONTACT INFORMATION COLLIER CIR ZP5064186 (941) 774 -8800 3301 TAI. 111-1 °11 iixL 1; NriYLYa rL. .i41U1 ARS YC2BQ4002 (954) 321 -5957 1801 NW 66TH AVE FORT LAUDERDAL FL. 33313 ENHANCRCVRCO YC26MT002 (800) 496 -8941 8014 BAYBERRY RD JACKSONVILLE FL. 32256 REGIONAL ACC FA85UD091 (817) 794 -0001 110 WEST RANDILL M ARLINGTON TX. 76011 SUNCOAST CU QU298QO01 (813) 621 -7511 PO BOX 11904 TAMPA FL. 33680 CHASE ATJTO BB8251008 (800) 336 -6675 PO BOX 901076 FORT WORTH TX. 76101 BK OF AMER BM427SO02 (800) 451 -6362 4161 PTFDMONT PKWY STMI VALLEY CA. 93065 FST PREMIER BZ41PF001 (605) 357 -3440 3820 N LONTSF AVE STr)TTW FAT,T.G Sn 571 n7 CHEVRON OC103TO01 (800) 243 -8766 POB 5010 CONCORD CA. 94524 PEAK 5 FZIYZ9001 (877) 236 -7672 082 S POTOMAC ST ENGLEWOOD CO. 80112 BLAIR CORP CZ24LE006 220 HTCKORY ST WARREN PA. 16365 FRD MOTOR CR FA3796761 (800) '727 -7000 POO 542000 OMAHA NE, 68154 T- MOBILE TJ 3747126 (Snn) 318 -9270 12920 SE 38TH STRE BELLEVUE WA. 98006 COAY F 1246538 (888) 396 -2623 3905 N. DALLAS PAR PLANO TX. 75093 BILL HOLT CH A 0217602 (706) 635 -5454 250 LIBERTY BLVD CANTON GA. 30114 END OF TRANSUNION REPORT MERIT CREDIT HAS RETRIEVED THE ABOVE PERSONAL CREDIT REPORT FOR LICENSING PURPOSES AS REQUESTED BY THE BUSINESS OWNER /PROPRIETOR. PUBLIC RECORDS FOR THIS REPORT HAVE BEEN CHECKED AND VERIFIED AT THE COUNTY, STATE AND FEDERAL LEVELS. PUBLIC RECORDS HAVE ALSO BEEN VERIFIED FOR PINELLAS COUNTY. PTIRT,T(' RF( nRT1G T,FARNED I SOURCES OF INFORMATION: TRANS UNION LLC IRS LIEN SECTION COUNTY COURTHOUSE RECORDS IF YOU HAVE ANY QUESTIONS REGARDING THIS REPORT, PLEASE CONTACT MERIT CREDIT AT: 1- 800 - 371 -3348 OR (239) 277 -3202. 7 Merit Credlet INN- Fast, Accurate & Secure. MERIT CREDIT HAS RETRIEVED THE ABOVE BUSINESS REPORT FOR LICENSING PURPOSES AS REQUESTED BY THE BUSINESS OWNER /PROPRIETOR. PUBLIC RECORDS FOR THIS REPORT HAVE BEEN CHECKED AND VERIFIED AT THE COUNTY (INCLUDING PINELLAS), STATE AND FEDERAL LEVELS. PUBLIC RECORDS LEARNED: 0 SOURCES OF INFORMATION: EXPERIAN BUSINESS INFORMATION SERVICES IRS LIEN SECTION COUNTY COURTHOUSE RECORDS IF YOU HAVE ANY QUESTIONS REGARDING THIS REPORT, PLEASE CONTACT MERIT CREDIT AT: 1- 800- 371 -3348 OR 239- 277 -3202. rnMPANY NAW, KIT( -HFN INSTAL I ATI(1NS OF 5WFL, LLC FEDERAL ID: 461410822 CURRENT STATUS: ACTIVE PRINCIPAL(S): VICTOR TREISSA TITLE: MANAGER DATF IN('nRPnRATFn, 11110. 2012 Business Profile - KITCHEN INSTALLATIONS OF SWFL, LLC Subcode: 970135 Ordered: 05/20/2 13 14:00:53 CST .�S`� +� Experian, Transaction Number: C510218642 .�..� C . . , Search Inquiry: KITCHEN INSTALLATIONS OF SWFL, LLC /3730 TE Aworid ofirtsight BLVD/NAPLES/FL/34117/US/N/A/940891890 Identifying Infoffnation This information is the primary name and address for the business you inquired on. All data in this report pertains to the business KITr.HFN INRTAI I ATInNR nF RWFI , t I r Huoinaaa Idantifiaation Number: 940001000 3730 White Blvd Experian File Established: 1112009 Naples, FL 34117-4126 Date of Incorporation: 11/18/2012 SIC Code: Construction, Single- family Houses - 1521 Bankruptcy filings: Tax lien filings: Judgment filings: Total collections: Sum of legal filings: UCC filings: Cautionary UCC filings present? 0 Monthly average DBT: 0 0 Highest DST previous 6 months: 0 0 Hiuiw-5l n8T previous 5 quarters: 0 0 Total continuous trades: 0 $0 Current continuous trade balance: $0 0 Trade balance of all trades (0): S0 No Averaqe balance previous 5 quarter$: so Highest credit amount extended: $0 6 month balance ranqe: so-so top 0 THE FOLLOWING INFORMATION WAS PROVIDED BY THE STATE OF FLORIDA. State of Origin: FL Date of Incorporation: 11/1812012 Current Status: Active Business Type: Profit Charter Number: L120001457 Agent: TREISSA VICTOR Agent Address: 3730 WHITE BLVD NAPLES, FL KL-v Feisumiel rrincipai(s): VICTOR TREIGGA, OWNER Operating Information Primary SIC Code: CONSTRUCTION, SINGLE - FAMILY HOUSES - 1521 TOP Q Experian prides itself on the depth and accuracy of the data maintained on our databases. Reporting your customer's payment behavior to Experian will further strengthen and enhance the power of the information available for making sound credit decisions. Give credit where credit is due. Call 1 -800 -520 -1221, option #4 for more information. End of report 1 of 1 report The information herein is furnished in confidence for your exclusive use for legitimate business purposes and shalt not be reproduced. Neither Experian Information Solutions, Inc.. nor their sources or distributors warrant such information nor shall they be liable for your use or refiance upon it. Business Profile - KITCHEN INSTALLATIONS OF SWFL, LLC 112 C Experian 2013. All rights reserved, Privacy polic e. Experian and the Experian marks herein are service marks or registered trademarks of Experian. Business Profile - KITCHEN INSTALLATIONS OF SWFL, LLC 2/2 Dec 301312:06p 239 - 277 -0167 Prepared 3y: Mer_t Credit (239) 277 -3202 (800) 371 -3348 TRANSUNICN CREDIT REPORT [FOR_ [SUE NAME] (I) Z NP6284423 MERIT CRECIT 2392770167 [MKT SUB] [INFILE) [DATE] 16 NP 8/01 12/30/13 p.2 DEC 3 0 2013 [TIME] 11:OICT [SUBJECT] (3SNJ [BIR ^r DATE) TREISSA, VICTOR M. - [ALSO KNOWN AS} VICTOR,TRESSA [CURRENT ADDRESS] [DATE RPTD] 3730 WHITE BV., NAPLES FL. 34_17 6/06 [FORMER ADDRESS) 441 NE. 12TH P.V., NAPLES FL. 34120 4/06 200 iQREST LAKES BV., #206. NAPLES FL. 34105 (CURRENT EMPLOYER AND ADDRESS] [POSITION] [RPTD: SMART BY KITCHEN jFQRMER EMPLOYER AND ADDRESS] 12/06 SELF EMPLOYED SALES M O D E L P R O F I L E ------ - - - - -- ***FICO CLASSIC 04 ALERT: SCORE +539 : 038, 013, 018, 016 * ** IN ADDITION * * *TO THE FACTORS LISTED ABOVE, THE NUMBER OF INQUIRIES ON THE CONSUMER'S *x *CREDIT FILE HAS ADVERSELY AFFECTED THE CREDIT_ SCORE. ---------------------------------- C R E D I T S U M M A P , v * * * T 0 T A L F I L E -H I S T O R Y Hoosc PR =2 COL =„ NEG =4 HSTNEG =1 -42 TRD =8 RVL =3 INST =3 MTG =1 OPN =1 INQ=E SOO =SIGH CRED CRED LIM BALANCE PAST DUE NINTHLY PAY AVAILABLE O" 69,op-TSAGe' REVOLVING: SO $300 $0 $0 100% MORTGAGE: S324K $ $317K $65.OK $3163 CIOSIN6 ?>AT6- CLOSED W /3AL: 1 $7416 $7416 $289 TOTALS: $324K $300 $324K $72.4K $3452 -------------------- ---------------------------- P U B L I C R E C O R D 3 SOURCE DATE =IAB ECOA COURT ASSETS PAID DOCKET# TYPE PLAINT :FF /ATTORNEY Z 5064304 8 /13E I FE 9/13 131114_ CHAPTER 13 BANKRUPTCY DISMISSED PRO SE Z 5064186 10 /09R S241 I RD 1/13 4346846 RELEASE OF TAX LIEN ------------------------------- B4:96P407 C 0 L L E C T I O N S --------------- SUBNAME SUBCODE ECOA OPENED CLOSED $PLACED CREDITOR MOP ACCOJNT# VERIFIED BALANCE REMARKS CRD PRT ASSO Y 43260C1 I 6/13 $1172 11 COMCAST 09B 1734558802 10 /13A $2E2 PLACED FOR COLLECTIO ARS Y 2BQ4002 I 7/11 $760 MED -CAL 09B 000000000000000000 6/13A $760 ACCT INFO DSP BY CSM ARS -- 2BQ4002 I 6/12 $513 MEDICAL 09B 00DO00000000000000 6/13A $513 PLACED FOR COLLECTIO Dec 30 13 12:06p 239 - 277 -0167 ARS Y 2BQ4002 I 7/11 000030000000000000 6/13A 2392770167 $1140 MEDICAL 09B $1140 ACCT INFO DSP BY CSM ARS Y 2BQ4002 I 7/11 $815 MEDICAL 093 000000000000000000 ------------------------------ 6/13n $815 ACCT INFO DSP BY CSM T R A D E S 1X111111111' R01 11/05A $3.00 $0 11 I CHARGE ACCOUNT 8/04P $0 ------------------------- 0/ 0/ 0 N Q U I R I E S - - - -14- -- - - - - -- DP_TE SUBCODE SUBNAME TYPE AMOUNT 12/30/13 ZNP6284423(FLA) MERIT CREDIT 5/20/13 ZNP6284423(FLA) MERIT CREDIT 5/11/13 U4JA3747126(WASi T- MOBILE 1/28/13 ZNP6234423(FLA) MERIT CREDIT 4/29/12 FPC1246533,NrL! C-OAF 4/23/12 ACf102l7602,CHI,' BILL HOLT CH ---------------------- C R E D I T R E P O R T S E R V I C E D B Y: --------------------- TRANSUNION 800- 888 -42 =3 2 BALDWIN PLACE P.0. 5OX 1000,CBESTER, PA. 19022 Consimer disclosures can be obtained online through T= ansUnion at: http: / /m4 .transunion.com ---------------------------------------- CREDITOR CONTACT INFORMATION - HILLSBORO BK ZP5064304 ;8131 301 -5065 p.3 Dec 3013 12:06p 239 - 277 -0167 2392770167 801 N FLORIDA AVE TAMPA FL. 33634 COLLIER CIR ZE5064186 (941) 774 -8800 3301 TAMIAMI TRL E NAPLES FL. 34101 CRD FRT ASSO YC4326001 (972; 991 -3171 ONE GA__LERIA TOWER DALLAS TX. 75240 ARS YC23Q4002 (954; 321 -5957 1801 Nod 66TH AVE FORT LAUDERDAL FL. 33313 REGIONAL ACC FA85UD091 (8171 794 -0001 110 WEST RANDILI M ARLINGTON TX. 76011 SUNCOAST CU QU298QO01 (8131 6621 -7511 FO BOX 11904 T70MPA FL. 33680 CgASE AUTO BB8251OC8 (800) 336 -6675 PO BOX 901076 FOR'_ WORTH TX. 76101 RK OF AMER 3M4273002 (800) 451 -6362 4_61 PIEDMONT PKWY GREENSHo?o NC. 27410 FST PREMIER BZ41PF002 (605) 357 -3440 3820 N LOUISE AVE SIOUX FALLS SO. 57107 C EVRON OC103TO01 (BOO) 24-3-8766 POB 5010 CONCO3D CA. 94524 PEAK 5 F21YZ9001 (87.) 23-9-7672 6762 S POTOMAC ST ENGLEWOOD CO. 80112 B=A--F. CORP CZ24LE006 22C HICKORY ST WARREN PA. 16363 T- MOBILE U 3747126 (800) 318-9270 12920 SE 38TH STRE BELLEVUE WA. 98006 COAF F 1246538 (88S) 39E -2623 3705 N. DALLAS PAR PLAKO TX. 75093 B =LL HOLT CH A 0217602 (706) 635 -5454 250 LIBERTY BLVD CANTON GA. 30114 END OF TRANSUNION REPORT MERIT CREDI= HAS RETRIEVED THE ABOVE PERSONAL CREDIT REPORT FOR LICENSING PURPOSES AS REQUESTED BY THE BUSINESS OWNER. /PROPRIETOR. PUBLIC RECORDS FOR THIS REPORT HAVE BEEN CHECKED AND VERIFIED AT THE COUNTY, STATE AND FEDERAL LEVELS. PUBL =C RECORDS HAVE ALSO BEEN VERIFIED FOR PINELLAS COUNTY. PUBLIC RECORDS LEARNED `Z. SOURCES OF INFORMATION: TRANS UNION LT,C IRS LIEN SECTION COUNTY COURTHOUSE RECORDS IF YOU HAVE ANY CUES-IONS REGARDING THIS REPORT, PLEASE CONTACT MERIT CREDIT AT: 1 -800- 371 -3348 OR (2?9) 277 -3202. pA Dec 30 13 12:06p 239 - 277 -0167 2392770167 p.5 Premier Profile - KITCHEN INSTALLATIONS OF SINFL, LLC Subcode:970135 •�••• Ordered: 12!30/20131i:14:16CST •; LEXJefia1�- Transaction Number: C500237541 .•�•s Search Inquiry: KITCHEN ZTALL.A i IONS OF SlIWL. LLC13730 WHITE A wcrlr �� irrsi�l�t BLAND!NAPLES!FLr34l l 71'US!N1A194089 i 990 Model Description: lntelliscore Pius V2 Doing Business As: KITCHEN INSTALLATIONS OF SWFL, LLC Primary Address: 3730 WHITE BLVE, NAPLES. FL 34117 -4126 Risk Scores and Credit Limit Recommendation Dayc Royond Tone Derogatory Legal Fraud Alerts Intelliscore Plus Financial Staoifity Risk Company D3T Original Filings High Risk Alerts 0 Q MEDIUM G b1EDIUNi -HIGF �7 RISK 6 RISK DBT Uravaiiable e�Cr Score range: 1 - 100 percentile Credit Limit Recommendation: $1,000 Years on File: State of Incorporation: Date of incorporation: Business Type: Contacts: Business Alerts Active Business Indicator: Possible OFAC Match: Business Victim Statement: lop a 4 (FILE ESTABLISHED 1112009) SIC Code: CONSTRUCTION, SINGLE - FAMILY HOUSES - 1521 FL NAICS Code: Res!dential Building Construction - 236114 111118/2012 PrcSt VICTOR TREISSA - OWNER MARCELC MEDINA - NWJAGER Experian shays this business as alive No OFAC matzh round 140 victim statement on file Credit Risk Score: Intelliscore Plus Current Intelliscore Plus Score: 28 __ ... ........ 26 High Lot,., Risk rJ trf 2S `U 75 lirfi T--P jo VerMcation Triggers BUSINESS ADDRESS IDENTIFIED AS RESIDENTIAL Risk Class: 3 , snLLMNA MZ1% The risk class groups scores by risk. into ranges cf similar performance. Range 5 is the highest risk, range 1 is the lowest risk. Pre -'iier Profile, - KITCHEN INSTALLATIONS OF S%'VFL, LLC 113 Dec 30 13 12:07p 239 - 277 -0167 This score predicts the like:ihood of serious credit delinquencies for this business within the next 12 months. Payment history and public record along Arith other variables a:e used to predict future risk. Higher scores indicate lower risk. Factors lowering the score RISK ASSOCIATED WITH THE CONIPANY'S INDUSTRY COMPANYS BUSINESS TYPE Quarterly Score Trends 100- !90 - e0 - 70 - d0 50 - -lo - 30 30 .. 10- 0- .... -- _ . P- Ou tertyScoreTrerms 2s 28 28 28 Credit Risk Score: Financial Stability Risk Current Financial Stability Risk Score: E ----- : c6. Hig', 0 3, 111 �: t 5 Ira -.•� This score predicts the likelihood cf financial stability risk within the next l2 months. T,e score uses traeeline and collections information, public filings as welt as other variables io predict future risk. Higher scores indicate lower risk. 2392770167 p.6 Industry Risk Comparison 27 °/n of businesses indicate a higher likelihood of severe delinquency- The Quarterly Score Trends provide a v;ew of the likelihood of deliaquency over the pest 12 months for this business. Tae trends -,-Al indicate if the score imrroveo, renoincd etable. fluctuated or declined over ti,.e last 12 months. Risk Class: 4 The risk Gass groups scores by risk into ranges of similar performance. Range 5 is the highest risk, range 1 is he lot. est risk. Factors lowering the score Industry Risk Comparison > LACK OF ACTIVE TRADES 5% of businesses indicate a higher likelihood of financial > RISK .ASSOCIATED WITH THE BUSINESS T--(PE stability risk. > EMPLOYEE SIZE OF BUSINESS > RISK ASSOCIATED WITI THE COMPANY'S INDUSTRY SECTOR Credit i-imlt Recommendation Credit Limit Recommendation This recommendation compares this business against similar businesses in the Experian business credit database - It is basec on trade information. industry, age of business and the Intelliscore $1.000 Plus. The recommendafon is a guide. The final decision must be made basec on your company's business policies. Payment Performance Current DST: Not Available Predicted DST: NIA Monthly Average DST: 0 Highest DST Previous 6 Months: 0 Highest DBT Previous 5 Quarters: 0 Payment Trend Indication: Trader and CoUectfon Balance Legal Filings Total trade and collection (0): SO Bankruptcy: All trades (0): SO Tax Lien filings: All collections (0): so Judgment filings: Sum of legal filings: Continuous trade (0): $0 UCC filings: 6 month average: NIP Cautionary UCC filings: Highest credit' amount extended: WA Top ,jo No 0 0 $0 0 No Rerrier Profile - KITCHEN 'NSTALLATIONS OF SWFL, LLC `,r 3 Dec 30 13 12:07p 239 - 277 -0167 Payment ,rend indicator not available Most frequent industry purchasing terms: Industry purchasing terms not available Industry Comparison Industry DBT Range Comparison The current DBT of this busiress is Not Available. DBT for this business: Not Ava- iiab!e I - 05T Range r —j s, f, -icy j,ti }' Corporate Registration THE FOLLOWING INFORMATION WAS PROVIDED BY THE STATE OF FLORIDA. State of Origin: FL Date of Incorporation: 1"1312012 Current Status: Active Business Type- Profit Charter Number: L120001457 Agent. TREISSA VIC -OR Agent Addrocm: 3:30 u11HITE BLVD NAPLES, FL Summary of Inquiries 2392770167 p.7 Top o TCn+ Business DEC13 NOV13 OCT1 3 SEP13 AUG13 JUL13 JUN13 MAY13 APR13 Cateaor BUREAU 1 Totals 1 Experian prides itself on the depth and accuracy of the data maintained or. our databases. Reporting your customer's payment behavior to Experian will further strengthen and enhance the power of the information available for making sound credit decisions. Give credit where credit is due_ Call 1- 800 - 520.1221, option #4 for more information. End of report ' of 1 report The inionralion herein is him:shed in confi,knee for your exclusive use for legitimate business purposes and shall no! be reprcriuced• NeiOer Experian fMomtaU x1 Sol itior , inc- rror theirsources cr disuibutors warrant such informaiior, nor s!!aff they lie liable for your use or reiiance upon it. O Experian 2313. All rights reserved. Pivac.v pnocv. Exaarian and the Experian marks herein are service marks or registered lradernarks of Experian. P -emier Profile - KITCHEN INSTALLATIONS OF SM,'FL, LLC 313 MERIT CREDIT HAS RETRIEVED THE ABOVE BUSINESS REPORT FOR LICENSING PURPOSES AS REQUESTED BY THE BUSINESS OWNER /PROPRIETOR_ PUBLIC RECORDS FOR THIS REPORT HAVE BEEN CHECKED AND VERIFIED AT THE COUNTY (INCLUDING PINELLAS), STATE AND FEDERAL LEVELS. PUBLIC RECORDS LEARNED: 0 SOURCES OF INFORMATION: EXPERIAN BUSINESS INFORMATION SERVICES IRS LIEN SECTION COUNTY COURTHOUSE RECORDS IF YOU HAVE ANY QUESTIONS REGARDING THIS REPORT, PLEASE CONTACT MERIT CREDIT AT: 1- 800 -371 -3348 OR 239 -277 -3202. COMPANY NAME: KITCHEN INSTALLATION OF SWFL LLC FEDERAL ID: 461410822 CURRENT STATUS: ACTIVE BUSINESS PRINCIPAL(S): VICTOR TREISSA DATE INCORPORATED: 11/19/2012 CO e-r Coz i.-"ty Growth Management Division Planning & Regulation Operations Department Licensing Section January 7, 2014 Nathan J. Hinz 129 Tahiti Street Naples, FL 34113 RE: Review of Credit Report Dear Mr. Hinz, vii co You have been added to the agenda for the Contractor Licensing Board meeting on Wednesday, January 15, 2014. The meeting is held at 9:00 a.m. at the W. Harmon Turner Building (Bldg. F, Admin. Bldg.), 3299 Tamiami Trl. E., Naples, FL in the Commissioner's Meeting Room on the 3rd floor. If you have any questions or concerns, please call (239) 252 -2431. Sincere. , 'YX Consuela Thomas Administrative Supervisor Licensing /Operations Growth Management Division* Planning & Regulation *2800 North Horseshoe Drive *Naples, Florida 34104* 239 - 252 - 2400 *www.colliergoa..net Findings of Fact, Conclusions of Law and Decision of the Board Collier County Contractors' Licensing Board For Applications Submitted to the Board for Review Type of Application: Credit Report Review X Waiver of Testing Requirements Reinstatement of License Request to Qualify Second Entity Other (specify) T_ THIS CAUSE came on for public hearing before the Contractors' Licensing Board (hereafter Board) on June 19, 2013, for consideration of the application submitted to the Board for review. The type of application is set out above. The Board having heard testimony under oath, received evidence, and heard arguments relative to all appropriate matters, thereupon issues its Findings of Fact, Conclusions of Law and Order of the Board as follows: FINDINGS OF FACT 1. That Nathan Hinz dba Nathan Contracting Services, LLC has submitted an application to the Collier County Contractor Licensing Supervisor or his designee for waiver of testing requirements for reinstatement of a Certificate of Competency as a Sealing and Striping Contractor. 2. That pursuant to Section 22- 184(b) of the Collier County Contractors' Licensing Ordinance (Ordinance 90 -105, as amended) applications which do not appear on their face to be sufficient require referral to the Board for a decision regarding approval or denial of said application. 3. That the Board has jurisdiction over this matter and that Nathan Hinz was present at the public hearing on June 19, 2013, and was not represented by counsel. 1 4. All notices required by Collier County Ordinance No. 90 -105, as amended, have been properly issued. 5. The facts in this case are found to be: a, Applicant has demonstrated through testimony and evidence presented at this hearing that he has been active in the trade in another jurisdiction and has adequate knowledge of the contracting specialty to make re- testing in the trade superfluous. b. His knowledge of the contracting business is adequate, when combined with a full application to protect the public health and safety of the citizens of Collier County. C. A review of the Applicant's credit warrants a probationary period and further review. CONCLUSIONS OF LAW Based upon the foregoing facts, the Board concludes that the applicant has met the standard set out in Ordinance 90 -105, as amended, and that the testing requirement may be waived. ORDER OF THE BOARD Based upon the foregoing Findings of Fact and Conclusions of Law, and pursuant to the authority granted in Chapter 489, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, by a vote of 7 in favor and 0 opposed, a majority vote of the Board, the applicant's request to waive testing in the trade for reinstatement of his license is granted for a probationary period of six (6) months during which time the Applicant is to provide credit reports and come before the Board for a review of the 2 reports, and further subject to his payment of all back fees due and owing as set out in Collier County Ordinances. 2013. ORDERED by the Contractors Licensing Board effective the 19th day of June, CONTRACTOR'S LICENSING BOARD C LIER COUNTY, FLORIDA l By: Richard Joslin, C airman I HEREBY CERTIFY that a true and correct copy of the above and foregoing Findings of Fact, Conclusions of Law, and Order of the Board has been furnished the Applicant, and Michael Ossorio, Licensing Compliance Supervisor, 2800 North Horseshoe Drive, Naples, FL 34103 on thi�"i�i day of July, 2013. Secretary/Contractor's Licensing Board 3 4Z;o e-r cunt GMD Operations & Regulatory Management Licensing Section 2800 North Horseshoe Drive - t- -1 Naples, FL 34104 APPLICATION FOR COLLIER COUNTY /CITY OF NAPLES /CITY OF MARCO I ' FIRM OR [:Q 1 N&L INSTRUCTIONS: This application must be typewritten or legibly printed. The application fee must accompany this application. The fee is not refundable after the application has been accepted and entered on the records. All checks should be made payable to the Board of Collier County Commissioners. For further information, consult Collier County Ordinance No. 90 -105, as amended. NAME OF COMPANY: Exact Corporate/ Business Name: M41140 6.)AT1214774&- R!/tLe 5 L 4- 1 Fiction Name /DBA: Qualifier Name: ,n" U" j-' (Number & Street) (City) (State) (Zip Code) Malling Address., 2�d; � 3.1 t r 3 (Number & Street) (City) (State) (Zip Code) Telephone: E- Mail: r't`� C:ti +a�.5 'C--4 -, -co,, TYPE OF LICENSE: ❑ General $230.00 ❑ Electrician $230.00 ❑ Building $230.00 ❑ Plumber $230.00 ❑ Residential $230.00 ❑ Air Cond. $230.00 ❑ Mechanical $230.00 ❑ Swimming Pool $230.00 ❑ Roofing $230.00 211�pecialty 4 _ 00 S ecialt trade: . �! CHANGE OF STATUS: ( ) Reinstatement ( ) From One Business to Another ( } Dormant License to Active Page 1 of 4 1. The names, titles(, home address and phone numbers of all Officers /Managing Members of the Firm. �.a,:fil r..l t`i't ►=� '�- r r 5 r 1,4Pt&s FY 3�Vit.3 2. List all businesses, firms, entities or contracting businesses you have been associated with during the last ten years (ex. Held a license for or been a partner). Attach extra pages if needed. 3. List all debts you or any company(s) associated with you refused to pay and the reasons for the refusal to pay. Attach extra pages if needed. AFFIDAVIT I,►4 f'14► -1� ►y certify that the foregoing is true and correct to the best of (ny knowledge. f 4 thvi W d O(fivvi V Lhu Fli rm STATE OF FLORIDA ? (A ) i I N' I Y 01- „LEO The foregoing instrument as acknowledged before me this -5 -7- / 3 Jj (Date) By iJ a- Mttft'l 7% N -- of lit t1i -c-e& Le (Name of officer, title /agent) (Name of Co oration) a 00Y-1'00 Corporation on behalf of the corporation. (State or Place, Hof Corporation) i He /She has produced DY( :> L. i�C .Pry} �' - identification and did not take an oath. r7 Sao130 74, (Type of identification) NOTARY'S SEAL NOTARY PUBLIC -STATE OF FIORM, 6 F 1 5 i5an E. Heasley SIGNATURE OF NOTARY Climrnission # DD947761 ( ) Expires: DEC. 17, 2613 BONDED TIIRL' ATI.A.'�Z•IC BONDING CO., INC. Page 2 of 4 QUALIFIER INFORMATION: Name: Address: ( 7 t` A 144 7-I N(At c q ji 3 (Number & Street) (City) (State) (Zip Code) Telephone: Date of Birth: S.S. #: 000- 00 -'f7 E- Mail: ��c� Driver's License: 1. Type of Certificate of Competency for which application is made. 2. The names and telephone numbers of two persons who will know your whereabouts. 3. Have you ever been convicted of a crime related to Contracting ?`�' (If yes attach extra shpPt with Pxnlanatinn) 7. Have you or any firmo you have been aa3ociiated with ever filed baiiki upti�y? 8. List all debts you or any company(s) associated with you refused or failed to pay and reasons why. 9. List your business or work experience � during the past ten years. F. d3 JC t4. :_ s4A r Kit +il cf' r i If 10. Statement of any formal training you have had in the area for which the application is made: I,, Page 3 of 4 AFFIDAVIT The undersigned hereby makes application for Certificate of Competency under the provisions of Collier County Ordinance No. 2006 -46, as amended, and vouches for the truth and accuracy of all statements and answers herein contained. The undersigned hereby certifies that he is legally qualified to act on behalf of the business organization sought to be licensed in all matters connected with its contracting business and that he has full authority to supervise construction undertaken by himself or such business or organization and that he will continue during this registration to be able to so bind said business organization. The qualified license holder understands that in all contracting matters, he will be held strictly accountable for any and all activities involving his license. Any willful falsification of any information contained herein is grounds for disqualification. K�A —,RA &( 0Gtr-,,- APPLICANT (PLEASE PRINT) �Armd C"o-newrIM& NAME OF COMPANY t SIGNATURE AP LICANT I» I E f41F FLORIDA COUNTY OF U &t The foregoing instrument as acknowledged before me this W _ c>2.)L, ;.) Date) .. ,1 BY Atb"'4' who has produced �/Z}-�9&Aj Y r ,a. i �1. z, 3o 7� 3 (Name of person acknowled f ) (Type of identification) as identification and did not take an oath. NOTARY'S SEAL NOTARY K13LIC -STATE OF FLORIDA r " Susan E. Heasley CoMmission # DD947761 Expires; iDEC. 17, 2013 BONDED Mu An4A "ric BozN;bjNG Co., D<Ic. Page 4 of 4 IGNATURE OF NOTARY) me Print Data Analysis Import/Export Settings Configuration Diagnostics Gros Revenue / Sales Deposits and Bonds I Documents and Images Correspondence I Vehicle Registration Insurance Licensee Information Licensee Number LCC20120t}4702 _ Description Type Pr d art Name Hinz, Nathan 3. -� Type , Contractor .status Open T View Master Proiect View All Artivities for this Licensee Add a new ep rson or business to Address Book Examination Results f Add Exam Result rnk�� Ex n -'T-�st Ty De Date: of Fiaant Test City Score received ExarrvTest result iRESIDENTId I.(70NI5TPfirTTrill n,4iftgl7jl1j _ Onn!fa 1�prinQs F�iil BUSINESS AND LAtiN 04/09/2013 Bonita Springs ; 76 Pass ............. ShoNr More Fields f Hide or Clear Fields Active ?;✓� Charge Exam Fee [✓� Exam Code F10353 Sponsoring County COLLIER COUNTY Sponsorship App Date 11/14/2012 F Sponsorship Expiration Date 05/14/2013 F Testing Facility PROMETRIC Tuesday, May 21, 2013 10:59 AM A A Che MAY-21-2013 15:0? Credit Check r i 561 616 5553 P.0-2 S 12 C T""V%IT CH ECK-,�,-, CONFIDENTIAL Individual Cre9`Repai t le. HINZ, NATHAN JAMES F.� � r - V .N.. 1, N A L rdered By ! Ire-ss 129 TAHITI STREET Customer 9999 Received 05/21/13 NAPLES, FL 34113 Completed :05/21/13 :ial Applicant -2379 Bill Ant $50.04 CREDIT RECORD edit history has been checked for a period of s2y2D years or from open jute,) calico: DA t u D.-. ho Wiqb Unpaid Past pay 11.1st=ia St:4-: Current Mow --nunt timber Ren-oz: lzed oponna Crodiz Balance Due Term- 30 60 90 $totLAV PLOV 1X0A x DSNB AS AGREED 748174161 04/13 09/11 0 0 0 REV 0000 00 R1 16 C A=04/13 COLLECTION 3000000000000000 12/12 09/12 lio 110 110 COLL -- -- -- 09-* 00 A G1NAL CREDITOR: MEDICAL OF AMER COLLECTION 76 01/11 10/06 9S5 955 955 28 -- -- -- R►-* 05 A k=06/oe LYSBANKDE AS AGREED )069687 04/13 02/08 680 CLOSED 0 REV 00 00 00 RI 48 A ONE COLLECTION 7805925553 05/13 07/11 1190 1190 1190 35 R9-* 02 A ')L=11/11 ONE PD COLLECT ?0+900461'- 09/12 01/12 513 0 0 REV R9-* 00 A k=09/12 �LRY PORT COLLECTION 05/13 09/12 523 540 540 COLL 09-* 00 A FINAL CREDITOR: HSBC BANK NEVADA A4600- 02/10 10/08 113 PAID 'INAL CREDITOR: (MEDICAL /, FINANCI-A 4007418349993 07/08 03/08 4487 CLOSED ,=0'7 / 0 6 ed by: APPLICANT - SEE NA14E ABOVE PD, COLLECT 0 0 -- --- -- 09- * 01 A AS AGREED 0 0 0000 00 11 04 A M€Y -21 -2013 15:07 Credit Check 561 616 5553 P.03 CI��'DIT CHE%11"KM CONFIDENTIAL ie ..... HINZ, NA'T'HAN JAMES Customer: 9999 Page . 2 CREDIT RECORD edit history has been checked for a R riod of seven years or from oEen date.) 79diC0): Dot. Date Hiq): unpaid Pa-r fay Hi?tcrla Stat current H *% :c:?un� c]umYer Repoeted OpQncd credit 5aian_e Due s^rrmz 30 60 90 star —ua :kev ECOA 'TFINANCIA AS AGREED 08/03 108/02 2522 CLOSED 0 0 0000 00 11 11 A A =08/03 -T SGLUTNS COLLECTION 05/13 07/12 1173 1173 1173 COLL -- --- -- 09-* 01 A GINAL CREDITOR: HSBC ORCHARD BANK G.N REC COLLECTION THMTRIO00684332 05/13 11106 306 489 469 COLL -- -- -- 0}-* 07 A GINAL CREDITOR: MEDICAL COVER FIN AS AGREED 08/08 11186 1426 PAZ'S 0 REV 0000 00 R1 37 A A =07/08 B MACYS AS AGREED ) 04/13 09111 1039 0 0 REV 00 0C 00 R1 17 C A =10/11 RB /SMRTCN PD COLLECT 04/09 02/00 124 PAID 0 REV -- 01 :tA =07/08 --0 CA An COLLECTION 05/12 03/C8 965 964 964 28 -- -- -- R9-* 05 A N =08/08 MART. PD WAS =20 ! 01/09 12/07 142869 0 0 0 01 03 02 M5-* 13 A � =07/08 AS AGREED AS AGREED 0!�5u4354 03/04 0_/04 9,319 CLOSED 0 0 0000 00 11 02 A i =03/Q4 BANS PD COLLECT ed by: APPLICANT - SEE NAME ABOVE MAY -21 -2013 15:08 Credit Check 561 616 5553 F.04 SA9 "T'IT CHErvONFIDENTIAL ie....; HINZ, NATHAN JAMES Customer: 9999 Page: 3 CREDIT RECORD edit history has been checked for a_ period of seven_ __ears or _rem open date.) •edlzor cn =r mate Hieh Unpaid p5st Pay -intone $ult Cvrrartz Nos :.uurc :Ia:nbRr Reporced Opened Crrd_r, faslance cue Terms 30 50 ge status Rov ECOA ,LAND FUND COLLECTJ0N 04/13 03/09 303 377 377 COLL -- -- -- 09-* 04 A GINAL CREDITOR: GE MONEY BANK IONSTAR FORECLOSURE 6464006 07/1.0 12/07 142369 0 0 0 0000 05 15-* 10 A A =07/08 STUDNTLN PD WAS 120 03/13 08/08 7000 0 0 0 0003 10 I5-* 39 A A =03/13 STUDNTLN PD WAS 120 03/13 01/02 1750 0 0 0 00 03 10 :1 Sr 48 A A =07/08 STUDNTLN PD WAS 120 5497899 C3/13 06/08 5500 0 0 0 0003 10 15-* 48 A D,=03/13 STUDNTLN PD WAS 120 ,4 ?!699 031/13 09/02 5500 0 0 0 00 03 10 15 40 A =07/08 3TUDN T'L'N PD WAS 120 497799 03/13 11/C3 5500 0 0 0 00 03 10 I5-* 48 A. �,=07 /08 STUDNTLN EyD WAS 120 ;497999 03/13 08/02 5000 0 0 0 0003 10 15-* 39 A z =07/08 3TUDNITLN PD WAS 120 498099 03/13 11/03 4483 0 0 0 00 03 10 15-* 39 A ,=07/08 ,IATMFUDGE COLLECTION 5986 05/13 07/12 442 589 589 COLL -- -- -- 09-* 01 A ;1NAL CREDITOR: TECHNICAL COLL LGWCO'J.gTRY Total trade lines on this report: 30 _IC RECORDS; =d by: APPLICANT - SEE NAME ABOVE MAY -21 -2013 15:08 Credit Check 561 616 5553 P.05 . SM � L "TT CHE%...Av C��NTIAL me....: HINZ, NATHAN JAMES Customer: 9999 Pace; IBLIC RECORDS: SLIC RECORDS HAVE BEEN CHECKED AT THE COUNTY, STATE AND FEDERA., LEVELS WITH E FO- Z,OWING RESULTS: CLEAR AS OE' 05/21/ =3. URGE ; S) : EQUI FAX TRAN'SUNION ZUIRIES. /21/13 by CREDIT CHECK (TU) #00630273 )MMENTS: BUD RECORDS HAVE BEEN SYSTZMaTTCALLY CHECKED BY THE ABOVE ACCESSED BUREAUS. FESCA.N /EQUIFAX, HAWK ALERT/ TRANSUNION CHECKED FOR FRAUD. ?ORT WORKED By- RENEE EDIT SCONE: ?LZCANT`ICO SCOREC51� (scores range from 300 to 650) * ** END OF REPORT ** ds irxomiaeon is m(*dontlal and Is not to be divulged axrept o, required ey the Nr Credu P"ting AU 'rtes perso.xpl roport fs Asdshee aimpty ae an aid Im 40Sem"rq the treat daalrabUlry of tha *pllo*s). It Is based aRon Ift(MMbn obWlaed In o10d faith ny dva aganay firxr =Wcos dearer rellabia. YAe acetrrany of same, hev:over, I; In noway guaranteed. gy your a xwilancB and as of dy1 report, you Rprifically agree to 1014 credit Chbek, Inc, harmlass irorn any tlabully wharsoavar. 'ed by: APPLICANT - SEE NAME) ABOVE rting Agency: Credit Check, .Inc - 3017 Exchange Court, Suite H, West Palm Beach, FL 33409 . (561) 616 -5556 STATEMENT OF OWNERSHI This certifies that 1, AvKo am a member or Managing member of �—�'*4&1 (LIMITED LIABILITY COMPANY NAME) own of the units issued by the Limited Liability Company listed above. Affidavit of Applicant.-.1 Certify that the information. contained is a true and correct statement to flic best of my linowledge. (PRJNTWXI!) Detail by Entity Name No Events No Name History Return to Search Results ►etail by Entity Name lorida Limited Liability Company ATHAN CONTRACTING SERVICES LLC ment Number L13000062218 IN Number NONE Filed 04/29/2013 or Country FL s ACTIVE Live Date 04/29/2013 29 TAHIT ST IAPLES, FL 34113 29 TAHIT ST IAPLES, FL 34113 P IIN7. NATHAN J 29 TAI IITI OT IAPLES, FL 34113 llanaaer /Member D lame & Address 'itle MGR IINZ, NATHAN J 29 TAHITI ST IAPLES. FL 34113 4nnual Reports No Annual Reports Filed 04/29/2013 -- Florida Limited Liabilitv View image in PDF format Page 1 of 2 Entity Name Search Search httn• / /cearnh ¢ltnhi7. nrv/ Tnniiirv/ C.. nrnnratinngearch/ SPa rnh RPCnItTlPtail /FntitvNama /flal_l 1 5/,? 1 /x()1'1 Detail by .Entity Name No Events No Name History Page 2 of 2 Entity Name Search Return to Search Results Search Horne II Contact us I l3tgu� irnent e,icn��., E -Film Servi es I Form � Help � Home Contact Us E- I mg ervrnces ��bocumen arches Forms Help Coovdaht i Print Subject Corporate Filing — 700247353947 From: limitedonline @dos.state.fl.us (limitedonline @dos.state.fl.us) To: NATHANHINZ57 @YAHOO.COM; Date: Monday, April 29, 2013 11:23 AM The Articles of Organization for NATHAN CONTRACTING SERVICES LLC were filed electronically on April 29, 2013, effective April 29, 2013, as verified by the letter and authentication number shown below and were assigned document number L13000062218. Please refer to this number whenever corresponding with this office. Electronic filing and certification is provided for in section 15.16, Florida Statutes and has the same legal effect as any other filing or certificate. To maintain "active" status with the Division of Corporations, an annual report must be filed yearly between January 1 st and May 1 st beginning in the year following the file date or effective date indicated above. If the annual report is not fled by May 1st, a $400 late fee will be added. It is your responsibility to remember to file your annual report in a timely manner. A Federal Employer Identification Number (FEUEIN) will be required when this report is filed. Contact the IRS at,..._. for an SS -4 form or go to www.irs.gov. Plt::as : lit aweue. if the limited liability t;uflip4ity's ttddie4s clt ttge�, it is the responsibility of the limited liability company to Should you have any questions regarding this matter, please contact this office at the address given below. Deidre Butler Regulatory Specialist 11 Registration Section --Division of Corporations - P.O. Box 6327 - Tallahassee, FL 32314 Letter Number: 130429142342 - 700247353947 Page 1 of 2 httn• / /n-z -mff6 mail -uahnn rnm /nan /lniinr hi ran.l= r7hlrltr, Gnrlrrh ti1)n /17ni tat e..�,,,CO�ioa 33elittrtmrnt of O§tatr I certify from the records of this office that NATHAN CONTRACTING SERVICES LLC, is a limited liability company organized under the laws of the State of Florida, filed on April 29, 2013, effective April 29, 2013. The document number of this company is L13000062218. I further certify that said company has paid all fees due this office through December 31, 2013, and its status is active. CR2EO22 (1 -11) Given under my hand and the Great Seal of the State of Florida at Tallahassee, the Capital, this the Twenty -first day of May, 2013 VRA4,, 1991 175PrrEfarV a 'Sfafr. C0 IRS INTERNNALNREVENUEESERVICE Y CINCINNATI OH 45999 -0023 Date of this notice: 05 -21 -2013 Employer Identification Number: 46- 2820721 Form: SS -4 Number of this notice: CP 575 G NATHAN CONTRACTING SERVICES PLC NATHAN JAMES HINZ SOLE MBR 129 TAHITI ST For assistance you may call us at: NAPLES, FL 34113 1- 800 - 829 -4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (BIN). We assigned you BIN 46- 2820721. This BIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records.. When filing tax documents, payments, and related correspondence, it is very important that you use your BIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. A limited liability company (LLC) may file Form 8832, Entity Classification Election, and elect to be classified as an association taxable as a corporation. If the LLC is ol.igiblo to bo troatod ao a corporation that mecto certain teats and it will be elecLiny 3 oorpor.,Ation �,,tatttg, it mtigt rim61y Pilo N'bi d 1553, W.4ectaQn by a 61maU .Juszness Corporation. The LLC will be treated as a corporation as of the effective date of the S corporation election and does not need to file Form 8832. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1- 800 - 829 -3676 (TTY /TDD 1- 800 - 829 -4059) or visit your local IRS office. IMPORTANT REMINDERS: * Keep a copy of this notice in your permanent records. This notice is issued only one time and the IRS will not be able to generate a duplicate copy for you. You may give a copy of this document to anyone asking for proof of your EIN. * Use this EIN and your name exactly as they appear at the top of this notice on all your federal tax forms. * Refer to this EIN on your tax - related correspondence and documents. If you have questions about your BIN, you can call us at the phone number or write to us at the address shown at the top of this notice. If you write, please tear off the stub at the bottom of this notice and send it along with your letter. If you do not need to write us, do not complete and return the stub. Your name control associated with this EIN is NATH. You will need to provide this information, along with your EIN, if you file your returns electronically. Thank you for your cooperation. AFFIDAVIT IT IS understood and acknowledged by the Collier County Contractors' Licensing Board and myself that if I fail to acquire, or maintain at all times effective Workmen's Compensation Insurance it will result in the possible revocation of my Certificate of Competency. SIGNATUR /OF APPLICANT BUSINESS NAME DATE ;EFORE ME this day personally appeared ) -1 i 944 who affirms and says that he as less than one employee and does i1ol require Workmen's Compensation understands that at any .me he employees one or more persons he must obtain said Workmen's Compensation Insurance. TATS, OF FT,O'R,TT)A OUNTY OF ae foregoing instrument was acknowledged before me this _ ��`� � , ► j _ {( te) who has produced 3 (/Or (name of person acl }awledging) . (Type of identification) identification and who did not take an oath. NOTARY'S SEAL NOTARY PUBLIC -STATE Of FLORIDA r Susan E. ;Heasley Commission # DD947761 Expires: DEC. 17, 2013 BONDED THRUATLA- TICd0N LNG CO.,MC. {y7 SIGNATURE OF NOTARY (PRINT NAME OF NOTARY PUBLIC) NOTARY PUBLIC a' ©� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 05122/2013 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 poiicy(ies) 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 NAME: Susan H Titanium Insurance, Inc. ac, No, Ezt : 239-417-1636 (Arc No)_ 239 -417 -2864 ADDRESS: 4280 Tamiami Trail E Suite 302- E INSURERS AFFORDING COVERAGE NAIL S EACH OCCURRENCE INSURERA: Canopius US Insurance Inc Naples FL 34112 INSURED INSURER B : MED EXP (Any one person) Nathan Contracting Services LLC INSURERC: 129 Tahiti St INSURER D: GEN'L AGGREGATE LIMIT APPLIES PER: rPOLICY �JEa �LOC OTHER: INSURER E: s 2,000,000 PRODUCTS - COMP /OPAGG Naples FL 34113 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. WSR LTR TYPE OF INSURANCE ADD SUBR POLICY NUMBER POLICY EFF IMMIDDAYYYI POLICY EXP (MMIDDNYYY) LIMITS A ® COMMERCIAL GENERAL UABIUTY ❑ CLAIMS -MADE M OCCUR 13 -0030 05/2212013 05/22/2014 EACH OCCURRENCE S 1,000,000 PREMISES (Ea occurrence) S 100,000 ❑ MED EXP (Any one person) S 5,000 ❑ PERSONAL & ADV INJURY g 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: rPOLICY �JEa �LOC OTHER: GENERAL AGGREGATE s 2,000,000 PRODUCTS - COMP /OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED SCHEDULED ❑ AUTOS ❑ AUTOS ❑ HIRED AUTOS NON -OWNED ❑ AUTOS ❑ ❑ (Ea accident) g BODILY INJURY (Per person) S BODILY INJURY (Per accident) s (Per accident) " - -- $ S ❑ ❑ UMBRELLA LIAR EXCESS LAB ❑ ❑ OCCUR CL...MADE NIA EACH OCCURRENCE S AGGREGATE $ ❑ rrr, ❑ RETEtdTIGiJ S D EMPLOYERS' LIABILITY ANY PROPRIFTORIPARTNER/EXECUTIVE YIN FFICERIMEMBER EXCLUDED? iMStidAt6ty hf NH) t yes, describe under DESCRIPTION OF OPERATIONS below ❑ slAlult ❑ �6V S E.L. EACH ACCIDENT S F I ni,,,FA,9F • FA FMpi nYFF S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 701, Additional Remarks Schedule, may be attached if more space Is required) pressure washing and sealing of paved driveways, walkways, pool decks and patios. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Collier County Contractor Licensing Board ACCORDANCE WITH THE POLICY PROVISIONS. 2800 N. Horseshoe Dr. AUTHORIZED REPRESENTA VE . Naples FL 34104 ACORD 25 (2013/04) ©1988 -2013 ACORD CORPORATIOK All r1hhts reserved. The ACORD name and logo are registered marks of ACORD 05 -23 -2013 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: PERSON: FEIN: 05/23/2013 EXPIRATION DATE: 05/23/2015 HINZ NATHAN J 462820721 BUSINESS NAME AND ADDRESS: NATHAN CONTRACTING SERVICES LLC 129 TAHITI ST NAPLES FL 34131 SCOPES OF BUSINESS.OR TRADE: 1- PAVING (5221) 2- SEALCOATING 3- PAINTING STRIPES(STREET (9402) IMPORTANT: Pursuant to Chapter 440 . 05114), 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 440.05112), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate go longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -1609 DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW AND R6TAIfI FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVIVON OF 1.61ORKERS' 60MP012ATiON CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW 0 EFFECTIVE: 05/23/2013 EXPIRATION DATE: 05/2372015 PERSON: NATHAN J HINZ FEIN: 462820721 BUSINESS NAME AND ADDRESS: NATHAN CONTRACTING SERVICES LLC 129 TAHITI ST NAPLES, FL 34131 SCOPE OF BUSINESS OR TRADE: I- PAVING (5221) 2- SEALCOATING 3- PAINTING STRiPES(STREET (9402) IMPORTANT Pur3uont to Chapter 440.00(14), r0., at) officer of u gut pui otiuil wliu elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. H Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply only within the scope of the business or trade listed on Rthe notice cf election to be exempt. E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 VERIFICATION OF CONSTRUCTION EXPERIENCE` GAM Operations & Regulatory Management Department Licensing Section 2800 N. Horseshoe Drive Naples, FL 34104 kpplicant's Name: �b� 4 ,ertificate Category Requested: 'he Applicant is seeking a Collier County Certificate of Competency in the trade indicated above. As part of the pplication for this certificate the Applicant must verify their experience within this trade. You are being requested to ,rovide information that will aid the Applicant in meeting this requirement. You should verify time of active experience yorking as an apprentice or a skilled worker (e.g. as a worker commanding the wage of mechanic or better in the trade). 'ime served solely in a supervisory or administrative role should be described, but may or may not be considered efficient to demonstrate required trade experience. The person verifying trade experience must provide the following iformation: fame, Title and licensee number of the person signing below and verifying Applicants relevant experience: ame: 13 itle: P2 Sv� V License Number if applicable): � �OQ ame of Business: usiness Address: W usiness Phone: �3C% �� _3 The The Applicant's years of experience from , to dkvo he nppliennt'9 sroPn of work (specific duties) included: _ Y-cr= iditional Comments: ilsifying any information provided herein may subject your license to revocation. 4 S ature Print Name: ite of Florida runty of Collier 7 , c forgoing instrument was acknowledged before uie u►i this ,' /% day of / ,r4 Ct -� who is personally known to me or produced. % fr identification and who did take an oath. /- ANGELA REYP OSO `= MY COMMISSION # DD929178 E, 13 Seoternber 29. 2013 398 -0153 flnada'dctary venne.conr 3V 1Y, Applicant's Name: certificate Category Requested: CATION OF CONSTRUCTION EXPE GMD Operations & Regulatory Management Department Licensing Section 2800 N. Horseshoe Drive JtJ Naples, FL 34104 The Applicant is seeking a Collier County Certificate of Competency in the trade indicated above. As part of the application for this certificate the Applicant must verify their experience within this trade. You are being requested to ) rovide information that will aid the Applicant in meeting this requirement. You should verify time of active experience vorking as an apprentice or a skilled worker (e.g. as a worker commanding the wage of mechanic or better in the trade), rime served solely in a supervisory or administrative role should 'be described, but may or may not be considered sufficient to demonstrate required trade experience. The person verifying trade experience must provide the following nformation: dame, Title and license number of the person signing below and Verifying Applicants relevant experience: dame: Amz 'itle: Tanic of Business: _ ;usiness Address: _2 usinessPhone: 57 License Number (if applicable): 1J,3 / `Z r� The Applicant's years of experience from ,� c �% Q to 261 -Z— 'he applicant's scope of work (specific duties) included: e, A-"c", f ddiduual CU111jacids. alsifying any information provided herein may subject your license to r ocation. Signq4re Prin ame: � G7lr IUK (1i'� ate of Florida - :)unty of Collier ie far ing instrument vacl . owle ed before me on this �, 1 P) I /t Q i who is personally known 1 identification and who did not1take an oath. ANGELA REYNOSO vs Y ISSION # DD929178 I AFFIDAVIT OF INTEGRITY AND GOOD CHARACTER am a resident ofi,/�'j ,ounty, 69'( �"� (State) and ha e resided h re for more than five (5) years. During the last five years I have known � of %� Z--- applicant). I have had :he opportunity to observe his or her business and personal dealings and find him or her to be a person of ionesty, integrity and good character. (Signature) (Name)G (Address) Telephone) 2_3` S STATE OF FLORIDA COUNFPY OF The fo going instrument was acknowledged before me t -�C:j/ 1� b at wbo has produced Illy i;YS, t A 6f poNsnll lij," ,1owlodging) ('I'rpe of ideii 'oation) as i.dentzfirstaon and who did not take an oath, SI o)�) NOTARY'S SEAL --(PRINT OF NOT PUBLIC ::� y'PUg��• ANGELA REYNOSO *: MY GOMMISSiON # DD929178 '? • • d�` EXPIRES Sk. ;teniber 29, 2013 i OF FV, (407)398 -0753 i'c: %;_fb!eryServica.COm AFFIDAVIT OF INTEGRITY AND GOOD CHARACTER am a resident of County, (State) and have resided here for more than five (5) years. Y During the last five years I have known (Applicant). I have had ;he opportunity to observe his or her business and personal dealings and find him or her to be a person of .aonesty, integrity and good character. (Signature) (Name) X4 Ma S I (Address) f ':' 6 Cl 1; f1p ecr"L— .� L-Telephone)'° STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before zxlo this 1 5 'ye —ql,�Mllr e) who has produced K /J C)A-j (namo of pomeml Ae'.l ti(wlS'(lging) ('l rpo of id i4ioation) as identification and who did not take an oath. i SIGNM --eo 'jo NOTARY'S SEAL -- (PRINT AME OF NOTARY PUBLIC radaYPUS4, ANGELA RE1(CtOSO MY "M iISSiON # DD929178 EX-� 11 September 29, 2013 10 RESOLUTION OF AnHORIZATON WHEREAS fdW%t+(J ( y t l��¢� . �t+Jr> ��?�� 4 proposes to (Name of Business Entity) engage in contracting as _ L in of legal (Type entn g ty: Corp.', partnership, etc. .Collier-County, Florida, according to Collier County Ordinance 2006 -46, as amended; and W%1ERBAS _ f pia t v,illi2ri i rria- cee ( cg 4, L .proposes to (Name of B mess EntitN ) qualify ,for a Certificate of Competency with ,,; 72, (Name of Individual) NOW, TBEREFORE, BE IT HEREBY RESOLVED THAT: We the undersigned _ I w a t E-A of t (Officers, Owners, partners) hereby resolve and rePresent to the Collier County (Name. ofBusiness Entity) Contractors' Licensing Board that the qualifying agent; fij t ''2 is active in all maticrs carmected Witb the coiittmsting business of , Warne 1 oflnciividuttl) 41-- C , and We further resolve and represent that (Name ofBusiness Entity) �tt a 1Y&,& /J 2. i legally empowered to act for /r< R l (,str, TIN S� JuS Ler ��dual) -------- _____�_ in all matters connected with its (Name ofBusiness Entity) Contracting business, and has the authority to supervise construction undertaken by (Name ofBusiness Entity) DULY PASS) D AND ADOPTED MS day of (t7fiicers, Partners, Owners — with De 'on mess WltuCSS in SS Corpotate SM (ifApplicablc) . L5 Or/NotaryPublic Certificate Swotr to atad subscrilsed before me this day of W , by_/l(j � nI Y1 Notary Public Name Printed Commission Number 0 b q4 C t My Commission expires: NOTARY OF FLORIDA ,. Heasley ,` ` -Comm ss or3 * DD947761 - E Aires: DEC. 17, 2013 K! `i7 -.' 71C BONDLNG CO., INC. Notary Public Signature ` -�'`' V" NATHAN ,JAMES "< HINZ ;`129 TAHITIST NAPLES, FL 34113-0000 60_ $: SEX: M .. s r oxoarr Y =; D7272012 9AtN'�an ofamator vehicle constkutes emsum to any sotxi vyt t required by Izw. , t �c ol e- Yrcrz�ty 12-7, L, ', " GMD Operations & Regulatory Management Licensing Section 2800 North Horseshoe Drive -�7 5 Naples, FL 34104 �i APPLICATION FOR COLLIER COUNTY /CITY OF NAPLES /CITY OF MARCO FIRM INSTRUCTIONS: This application must be typewritten or legibly printed. The application fee must accompany this application. The fee is not refundable after the application has been accepted and entered on the records. All checks should be made payable to the Board of Collier County Commissioners. For further information, consult Collier County Ordinance No. 90 -105, as amended. NAME OF COMPANY: Exact Corporate /Business Name: ZEN (jV-O u P )— �— C... Fiction Name /DBA: Qualifier Name: WC-0 I-,lky- LkGa'M "5Q Physical Address: ( 11{q I S M LANF NA -PIES (Number & Street) (City) (State) (Zip Code) Mailing Address: 1 � �q LAS iayA-06 1-ANC- I A-PLZ (=l._ -314103 (Number & Street) (City) (State) (Zip Code) Telephone: `139 TYPE OF LICENSE: ❑ eneral $230.00 l.y Building $230.00 ❑ Residential $230.00 ❑ Mechanical $230.00 ❑ Roofing i $230.00 Specialty trade: CHANGE OF STATUS: ( ) Reinstatement ( ) From One Business to Another Page 1 of 4 E -Mail: °ZENGcz�-1� , swt=�&Gr -�Ai -,c-0" ❑ Electrician $230.00 ❑ Plumber $230.00 ❑ Air Cond. $230.00 ❑ Swimming Pool $230.00 ❑ Specialty $205.00 ( ) Dormant License to Active 1. The names, titles, home address and phone numbers of all Officers /Managing Members of the Firm. M�co M�� uC�2'�el\ JCL M RM 9 tAS WA-i)A LANE rJ V ic-S l L, -S H �0' - x'69 -q LS- 2s� 2. List all businesses, firms, entities or contracting businesses you have been associated with during the last ten years (ex. Held a license for or been a partner). Attach extra pages if needed. tom 3. List all debts you or any company(s) associated with you refused to pay and the reasons for the refusal to pay. Attach extra pages if needed. AFFIDAVIT I, 16 kc-2 LE- :2\eA -sO- certify that the foregoing is true and correc to the best of my knowledge. L , I\, I � f Auth . ri d fficer of the Firm STATE OF FLORIDA COUNTY OF CaLLinz The foregoing instrument as acknowledged before me this 1J oyema' Z �- l aL')/ (Date) By A G2,1 CA Tr2 of IAN [a e�,7 1-1-C. (Name of officer, .title /agent) (Name of Corporation) a Corporation on behalf of the corporation. (State or Place of Corporation) He /She has produced /Q- it )� identification and did not take an oath. (Type of identification) NOTARY'S SEAL MICHAEL T. DUNZELMAN NOTARY PUBLIC STATE OF FLORIDA Comm# DD955093 Expires 4/26/2014 Page 2 of 4 C (SIGNA E OF NOTARY) QUALIFIER INFORMATION• Name: M\C O t -A \\LE t, &ax c,A SfL Address: 1114 9 LA-STan_L-A L4N N/V 5 Fl- (Number &. Street) (City) (State) (Zip Code) Telephone: _3� S.S. #:.000 -00- - - — Driver's License: Date of Birth: D Ems- -1 '� - l c1'T(,, E -Mail: u 1. Type of Certificate of Competency for which application is made. 1�C:i \LAlf�in �t�7��}C \�Q 2. The names and telephone numbers of two persons who will know your whereabouts. AL_Iu v-sANiCz.A LtuakA H 9 SON-SA C-T 3. Have you ever been convicted of a crime related to Contracting? N C� (If yes attach extra sheet with explanation) 7. Have you or any firms you have been associated with ever filed bankruptcy? 'N0 8. List all debts you or any company(s) associated with you refused or failed to pay and reasons why. No►�� 9. List your business or work experience during the past ten years. 10. Statement of any formal training you have had in the area for which the application is made. Page 3 of 4 AFFIDAVIT The undersigned hereby makes application for Certificate of Competency under the provisions of Collier County Ordinance No. 2006 -46, as amended, and vouches for the truth and accuracy of all statements and answers herein contained. The undersigned hereby certifies that he is legally qualified to act on behalf of the business organization sought to be licensed in all matters connected with its contracting business and that he has full authority to supervise construction undertaken by himself or such business or organization and that he will continue during this registration to be able to so bind said business organization. The qualified license holder understands that in all contracting matters, he will be held strictly accountable for any and all activities involving his license. Any willful falsification of any information contained herein is grounds for disqualification. M \C-%D �A \\ C- u C�Zsc-A --50- APPLICANT (PLEASE PRINT) ZFN CcR�� LLC NAME OF COMPANY SIGNATUR PLICANT STATE OF FLORIDA COUNTY OF _c,p1 j �Z The foregoing instrument as acknowledged before me this =R — I — �p (Date) By l rl \Co U (2g=� gA -Sa_ who has produced n- (Name of person acknowledging) (Ty of identification) as identification and did not take an oath. NOTARY'S SEAL MICHAEL T. DUNZELMAN NOTARY PUBLIC STATE OF FLORIDA Comm# DD955093 Expires 4/26/2014 (S NATURE OF NOTARY) Page 4 of 4 -Licensee Information Licensee Number LCC201300032.65 Des-cription Type Propertj 4,zrt Name Ugrica Jr., Mico M. Type Contractor Status Open View Master Proiect View All Activities for this Licensee Add a new person or business to Address Book Examination Results A Add Exam Result, Lusk i Exarrw7est Ty Date of Ex-w est gy score received Ex,,,T,,t msuit BUILDING CONTR. - B 11/13/2013 Ocala 61 Fail ................. .... . .......... ........... . .................... ........... BUSINESS PROCEDURES 11114/2013 Ocala 82 Pass .............. . ..... ............... ............ ........... BUILDING CONTR. - B 11/14/2013 t Ocala 84 Pass li- ................ ................. ............................. .......... : - ................... ............... .................... �:- - .............................. .......... L.- 1 1.1- .................... [ Show More Field [ Hide or Clear Fields Active Charge Exam Fee 9 Exam Code GBEIA Sponsoring County JE;Iii:er Sponsorship App Date 09/2612013 Sponsorship Expiration Date 1 03/26/2014 Testing Facility IGITS. AFFIDAVIT IT IS understood and acknowledged by the Collier County Contractors' Licensing Board and myself that if I fail to acquire, or maintain at all times effective Workmen's . Compensation Insurance it will result in the possible revocation of my Certificate of Competency. SIGNA PLICANT - Z-a-,-.� Gac�-� LLB BUSINESS NAME DATE 3EFORE ME this day personally appeared _ k \ c c j_AGK& k S who affirms and says that he ias less than one employee and does not require Workmen's Compensation understands that at any ,ime he employees one or more persons he must obtain said Workmen's Compensation Insurance. 'TATE.OF FLORIDA 'OUNTY OF he foregoing instrument was acicnowlcdgod before me this N cvEMz �1� 5►Z (Date) who has produced (name of person acknowledging) a of identification) identification and who did not take an oath. SIGNA F NOTARY MHAEL T. DUNZELMAN lWc (PRINT NAME OF NOTARY PUBLIC) OF FLORIDA NOTARY PUBLIC m# DD9JW93 res 4/26/2014 I City Clerk's Office October 29, 2013 Mr. Mico Ugrica 72 Wikander Way Toronto, Ontario L6V 3X3 Dear Mr. Ugrica: City Hall, 13' Floor, West 100 Queen Street West Toronto, Ontario M5H 2N2 Ulli S. Watkiss City Clerk Tel: 416. 392.8011 Fax: 416. 392.4900 Email: clerk@toronto.ca Web: www.toronto.ca FOR FURTHER INFORMATION Denise Stuckless 416- 338 -5636 Subject: City of Toronto Access Request Number 2013 -02195 I am replying to your access request under the Municipal Freedom of Information and Protection of Privacy Act. You have requested access to "a copy of the complete building file pertaining to 645 Manning Avenue under permit #05- 209426." We asked staff of Toronto Building to conduct a search for records responsive to your request. This decision reflects the results of that search. Access is granted in full to the responsive records and a copy is enclosed. Should you have any questions, please contact Denise Stuckless or email: dstuckl @toronto.ca. or Yours truly, Ili S. Watkiss City Clerk �410RGNTOCity Corporate services Clerk's Office LA) $ 'I -- - - - - -- R d ecewe the sum of - - - - -T we� y-------------------------------- from------- I'----- - - - - -� (I-CA ---------------------- No.010762 Toronto- --------- - - - - -- --------- - - - - -, 20- i3 - - -- ❑,Cash Dollars LJ Cheque 100 ❑ M/0 ❑ Credit Card ------------------ ❑ Interact Being For------- - - - - -- - - - - -- -- - - - - -- ------ ,- )-f ---- u Credit Ulli S. Watkiss City Clerk ri -�— per---------------------------------------------------- C4- 059(03)(13 09/03) GST Registration No. 86740 - 2299- RT0001 REQUESTER COPY Number of Pages Disclosed 10 Application for a Perm Construct or Demolish This form is authorized under the Building Code Sentence 2.4.1.1 A.(2). `t-or 6i tir.Pnncipal Authoitty Application number. Permit number (if different): C —2454f �) 7 Date received: Roll number. Application submitted to: City of Toronto District Offices: n k! _— v a, e1a_aorL7nnn =Ttn and Fact York 416-392.7539 (-1 Scarborough 416-396 -7526 ❑ Etobieoke York 416 -394 -8002 Personal information contained in this form and schedules is collected bader thdAithority of subsection a(1.1) of the Building Code Act, 1992, and will be used in the administration and enforcement of the Building Code Act, 1992. Questions about the collection of personal information may be addressed lo: a) the Chief Building Official of the municipality or upper -tier municipality to which this application is being made, or, b) the inspector having the powers and duties of a chief building official in relation to sewage systems or plumbing for an upper -tier municipality, board of health or conservation authority to whom this application is made, or, c) Director, Building and Development Branch, Ministry of Municipal Affairs and Housing 777 Bay SL, 2nd Floor. Toronto, M5G 2E5 (416) 565 -6666. oWOTros Building number, streMet name Unit number Lodixln. _'' 'S tiNNtnrC� !\Jl= Municpality Postal code Plan number /other description ) oQ v Project value est. S W �i5 ct:e. � Area of work (m ) 1 l o Last name First name Corporation or partnership Lt, (3, 1 G t C Street address. Unit number LoUcon. 0-44- NANP,)iA3 , Avar Municipality_— Postal code Province E -mail oacN f o orsT Telephone number Fax Cell number (41e C2. e) SCl ( ) ( ) ... C l7wner._ alrfaf+.rtrrroi;ra plica .�r,r', -�i7 _. „.k.�.�;�h, }�....:�.��.m �,.,"?a,�y..,.:�•,�?��;�� .3..:E.a. �.:; Last name First name Corporation or partnership Street address Unit number Lot/con. Municipality Postal code Province E -mail Telephone number Fax )r CON number ( .�• . ... ;. � - �� D 8ufldar.loptional..�.�,. _ ., , 1 •,S�`r -�� . ';'S�a�"'�rr 9 r •: �'i.z - t ..:.., . �- �e'�r' � ra>i�`� � y:F �� t;e'°�''�v, .. _.�� ..�.. �. _ `��.'._.:�_: Last name First name Corporation or partnership (if applicable) Street address Unit number Lotloon. Municipality Postal code Province E -mail Telephone number Fax Cell number ( ). ,:.- ': '--. 6 .EZ__;a.,. ;�#.` xt -'s -rr� y. 'frE:� E Pu of ( )mot' _• tn`r'v ❑ New construction ❑ Addition to an existing building Afterationlrepair QDemolition ❑ Conditional Permit Proposed use of building Current use of building A►a t V-10” _. Description of proposed work J4'W4 V__ AtLMF24Tc)n4S �s'T, t.s'(& Gr- �1�u r ► N,.t Ct� S F� on Werrar1111i, rporation ^ {OrtYatio New Hon elNena ityr roQ am) T r 1, 6_ r, a r� - a;` .,;' 1. Is proposed construction for a new home as defined in the Ontario New Home ❑ Yes ❑ No Warranties Plan Act? If no, go to section G. ii. Is registration required under the Ontario New Home Warranties Plan Act? ❑ Yes ❑ No iii. If yes to (ii) provide registration number(s): G "Attachments`',Y �dH.•!( �.- ^v^4}?�J.S,t � � r� �t FTt�. ^t +y:g ��Lay.,' {-:i 'ice -.r r W: j. .f .nlle'.S. YR.,.n,. -. I. Attach documents establishing compliance with applicable law as set out in Article 1.1.3.3. ii. Attach Schedule 1 for each individual who reviews and takes responsibility for design activities. iii. Attach Schedule 2 where application is to construct on -site, install or repair a sewage system. iv. Attach types and quantities of plans and specifications for the proposed construction or demolition that are prescribed by the by -law, resolution, or regulation of the municipality, upper -fier municipality, board of health or conservation authority to which this application is made. H . Daclatation of appUcant r? ' t ` Id r -• �<j*Eu; F--t l CO U (--a\ CA certify that: (print mama) 1. The information contained in this application, attached schedules, attached plans and specifications, and other attached documentation is true to the best of my knowledge. 2. 1 have authority to bind the corporation or partnership (if appli ). Date d 4 Sir ture of applicant Personal information contained in this form and schedules is collected bader thdAithority of subsection a(1.1) of the Building Code Act, 1992, and will be used in the administration and enforcement of the Building Code Act, 1992. Questions about the collection of personal information may be addressed lo: a) the Chief Building Official of the municipality or upper -tier municipality to which this application is being made, or, b) the inspector having the powers and duties of a chief building official in relation to sewage systems or plumbing for an upper -tier municipality, board of health or conservation authority to whom this application is made, or, c) Director, Building and Development Branch, Ministry of Municipal Affairs and Housing 777 Bay SL, 2nd Floor. Toronto, M5G 2E5 (416) 565 -6666. oWOTros DaTBROMMISouth District Urban Development Services Receipt No: 532668 A pe: ; 05 209426 BID 00 SR December 13, 2005 ;. .10: 16 AM �A "�4 ffl 'w MICO UGRICA JR 645 MANNING J AVE TORONTO, ON M6G 2W2 2 CANADA A� 645 MANNING AVE TORONTO ON Small Residential Projects; SFD - Semi - Detached; Inferior Alterations r L. �•. per r3• +r�` � .. — _d.. _ r Initial Building Permit Fee S 9010BL0001 $796.95 Total $796.95 ❑ Cash ❑ Cheque ❑ Credit Cards Debit Card SBAVARO ❑ Money Order ❑ Certified Cheque per Treasurer, City of Toronto ❑ Journal Entry ❑ Fee Exempt V 10ROMM South h District NSPECTION REPORT Urban Development Service: PAGE Of IOINSPECTOR: KOWALYK, MYRON (416) 33/•0850 ISSUE DATE t DATE: December 13,2005 December 13,7005 SFD Semi-Detached Small Residential Projects 05 209426 BLD 00 SR PROJECT t t a5o,000.00 PL'847.BLK`A PT LTS i 1 t2 stso3 645 MANNING AVE OF A D Chiu, Richard (416) 392,7449 SR Code Review Giuliani, Michael 14161338.5935 SR Zoning Review �NORK PROPOSED: t . NAME Interior Alterations 645 MANNING AVE i >! DESCRIPTION Interior alterations to existing home basement; first floor and second floor. Removal of existing interior wall and ceiling finishes and upgrading of ! insulation wall coverings.. Replacement of plunbing factures. 6z= 1 t PPLIC , NT ARCHITECT: ENGINEER: i MICOUGRICAJR MICOUGRICA:JR 645 MANNING AVE 645 MANNING AVE TORONTO, ON M613 2W2 TORONTO, ON M66 2W2 CANADA CANADA H H. B ,6 INSPECTION CHECKLIST. PART 9 BUILDING.:. DATE t r STRUCT. FRAMING rOUNOATION NS & AIR VAPOUR FIRE SEPARATIONS Y SYSTEM 1 CCUPANCY FINAI IkTERIOR RIOR i Printed Datar Dee 16, 2005 9:25 AM dTORONTO, Urban Derdoprnmt Services Building Divisies Ward No. Location: File No.: Permit No.: - File Type: Date Comments Follow -up Date Q� nrd /ubCnec,�'SrS o Y1T hs�� - , , Arl location i i Sirjani Engineering Inc. STRUCTURAL & SOIL ENGINEERS Tel: (905) 787 0003 Fax: (905) 597 -4009 Page: 1 GENERAL FIELD REVIEW REPORT: From: Iradj Sirjani, MSc.,P.Eng. Project : 645-Manning Ave., Toronto, Ontario - Date: May,30,2007. Description : Following our previous site visits I performed general field review of the site on May,30,2007, 10am. The existing third floor structure has been renovated and everything is in general conformance with the Ontario Building code. • Please call me If ou have any y questions. Regards, OFESSICN Iradj Sirjani, P.Eng. BCIN #25374 „F,,.:•;n:,:;l FIRM #29742 CE OF 0 5 0 CONAIR MECHANICAL INC. 2 VALHALLA INN RD. UNIT #305 ETOBICOKE, ON M913 3C6 Phone: (416) 707 -2513 DATE: JUNE 5, 2007 To whom it may concern: RE: 645 Manning Ave Toronto Ontario M6G 2W2 DESCRIPTION OF WORK TO BE PERFORMED Performed site inspection of at 645 Manning Ave. HVAC systems comply with HRAI standard. iInspected furnace complies with Technical Standards and Safety Authority standards. System operational and in good working order. If there are any question, please contact us. Technician at site Dan Cmojevic, T.S.S.A # 0707080 Thank you, Conair Mechanical Inc. 416 - 707 -2513 • 11 . 4 j Application for a Permit Construct or Demolish This form is authorized under the Building Code Sentence 2.4.1.11A(2). >. "For use by; Principal:Autho Application number Permit number (if different): C �� , (C1 5 ►`.i�r. r�vJLi .LJc J Date received: Roll number. O 1 Carla lJ Application submitted to: City of Toronto District Offices: 11 North York 416395 -7000 iB Toronto and East York 416 -392 -7539 ❑ Scarborough 416 -396 -7526 ❑ Etobicoke York 416 - 394 -8002 J ( A. ;`_P R eat irifonnetitin' _f , , . T , r. Building number, street name Unit number Lot/con. (C1 5 ►`.i�r. r�vJLi .LJc Municipality Postal code Plan numbedottw description 1 Carla lJ M Project value sell. $ 4 T , CVO, A wo Area of rk (m ) 2 1 0 Imo• ... .: CBnt la. - .d1.G7 OWflef'+'Or 'Y�:.AUIIIOfRe�:a :•,Of OYYf18f�..te�-y Yt' �'iri_r,� Yd S..t ...,:'�'t� �. >- .: >�.._:. i'B:�:ApPlicanE.., ,�`'j5.�.Appfi Last name First name Corporation or partnership Street address. Unit number Lot/con. (.IFS NAPriiIoa AV& Municipality_— Postal code Provinrd3 E-mail I caQcN t M Ca �w� CNT Telephone number Fax Cell number C �.o�lt►i, err (H.`di)tf6Rnt'frorn °.applit�nt) : .: ._: « . �..: .:.:.� , _�,.::,p,. � pn, �. .k..� -'� tn;�.�t . °i, :`�`�.:- Last name Fast name Corporation or partnership Street address Unit number Lot/con. Municipality Postal code Province E -mail Telephone number Fax Call number Last name First name Corporation or partnership (if applicable) Street address Unit number Lot/con. Municipality Postal code Province E -mail Telephone number Fax , Cell number Ems, .. �� F•t �. to cz,r- h,.!S ; r•. ofapplfwtiof4 , thy., , . �t:rr... � r�:::... . �`. ;:.�3 � . ^',.: »,.� 'K.• � ..�.;t.�., Yl3 y ,•, k !: % 4�.i; ?•t4•..v: .w�11.(�,•$ . �'.:r(,?.. ❑ New construction ❑ Addition to an existing building Alteretionfrepair QDemolition ❑ Conditional Permit Proposed use of building Current use of building a►, L V1,0 1L., Ab\1L to =. Description of proposed work IN�csarL �.�r>= 24Tc��4S �o gs"+T, tsT & �t� ftGx�'2 Op— t i 'NNetic HoneNt� ra ny r^g� aWi ;opaim w m) rr : ..: :..u;; , .. �' .7" F `Talion`V40A1_I_ Ont' I. Is proposed construction for a new home as defined in the Ontario New Home ❑ Yes ❑ No Warranties Plan Act? If no, go to section G. ii. Is registration required under the Ontario New Home Warranties Plan Act? ❑ Yes ❑ No iii. If yes to (ii) provide registration number(s): ' V _...,. . r V 1 : .. y ��•tt ". T J. \ y.. 41fy�.' . r}Y1 Y'f b,.ntK :r7.r ti'L 1�,. ^,' ir4' .� 1`. /. 4 C:'�i. �•-� G - •Attachments r S•-'.; :. ��- 4:. L Attach documents establishing compliance with applicable law as set out in Article 1.1.3.3. ii. Attach Schedule 1 for each individual who reviews and takes responsibility for design activities. iii. Attach Schedule 2 where application is to construct on -site, install or repair a sewage system. iv. Attach types and quantities of plans and specifications for the proposed construction or demolition that are prescribed by the by -law, resolution, or regulation of the municipality, upper -tier municipality, board of health or conservation authority to which this application is made. H. Declaration of applicant l I C '::1 L C4)- t C: -\ certify that: (print name) 1. The information contained in this application, attached schedules, attached plans and specifications, and other attached documentation is true to the best of my knowledge - 2. 1 have authority to bind the corporation or partnership (if applic ). �� c - 13- `1 ooS �-• Dale /I A sigh*h!uriof.pPli=nt Personal information contained in this forth and schedules is collected tilhder thdAithority of subsection 8(1.1) of the Building Code AU 1992, and will be used in the administration and enforcement of the Building Code Act, 1992. Questions about the collection of personal information may be addressed to: a) the Chief Building Official of the municipality or upper -tier municipality to which this application is being made, or, b) the inspector having the powers and duties of a chief building official in relation to sewage systems or plumbing for an upper -tier municipality, board of health or conservation authority to whom this application is made, or, c) Director, Building and Development Branch, Ministry of Municipal Affairs and Housing 777 Bay St., 2nd Floor. Toronto, MSG /] 2E5(416)585 -6666. 06107105 / �ATOROMOBuildin 9 Fareed Amin, Deputy City Manager THE PLUMBING DATA SHEET IS A PERMIT DOCUMENT AND MUST BE AVAILABLE AT THE WORK SITE DURING THE CONSTRUCTION FOR THE CHIEF BUILDING OFFICIAL AND /OR THE INSPECTORS. Plumbing and Drain Permit Information: " - Application # 12-00 Address: jS N+A#v r-a tti (� ,�V = Type of Worku �U qty Date: T�EL_ t3 -ZouS To Install: Floors: Fixture Type-S: Below ground Ground Second Third Typical Top Other Totals Kitchen Sinks: 1 Dishwashers: Wash Basins: ( 1 Z Bath Tubs: + 1 Showers: i 1 Water Closets: 1 1- a Urinals- Bidets: Washers: Laundry Tubs: 1 1 Vented Traps: Floor Drains: Slop Sinks: Drinking Fountains: Hot Water Tanks: Other Sinks: Bar sink: I 1 Miscellaneous: Totals: TOTAL NUMBERS OF FIXTURES _ UNDERGROUND: Domestic Water Service SIZE: LENGTH: @ _ Fire Line SIZE: LENGTH: @ _ Sanitary Piping SIZE: LENGTH @ Storm Piping SIZE: LENGTH: @ Number of Catch Basins: Number of Service Holes: TOTAL X Number of Interceptors: No. of Rainwater Leaders: NUMBER OF BACKFLOW DEVICES (Testable) X = TOTAL FEE ALL PLUMBING. DR,4INAGE & VENT PIPING SHALL CONFORM TO ONT. REG 403/97 OBC PART 7 White -Office Pink - Applicant • I Plurnbing(PSI. 105 209426 PLB 00 PS December 13,2005 December 13,2005 SFO - Seni- Detached CONSTRUCTION VALUE LOT NUMBER UNI�: AREA: PROJECT LOCATION: $0.00 PL 841 BLK A PT LTS 11,12 I 51903 645 MANNING AVE OF A O Giuliani, Michael (416) 338.5935 PS Plumbing Review H IAIDRK PROPOSED: C Building Permit Related(PS) 645 MANNING AVE DFSCRIPTIW Plumbing - Interior aherations to existing home basement, first floor and second floor: Removal.of existing interior wall and ceiling finishes and upgrading of insulation wall coverings. Replacement of plumbing fixtures.:,- Interior Alterations ... <<>> Fixtures :I Kitchen Sinks @1st Fixtures :4 Wash Basins @BsmLIst, 2nd Fixtures:2 Bath Tubs @Bsmt, 2nd Fixtures: I Showers @2nd OVjNER: ALTERNATE D APPLICANT: ARCHITECT: MICO UGRICA JR MICO UGRICA JR 645 MANNING AVE 645 MANNING AVE TORONTO, ON M6G 2W2 TORONTO,.ON M6G 2W2 CANADA CANADA H H. B INSPECTION CHECKLIST PLUMBING Prirrhd DUE Dee 16, 2005 9:24 AM TORONTO Urbm Devebop rent Services Building Divisive • Ward No. Location: File No.: Permit No.: File Type: Date Comments Follow -up Date 1 c7 cw location _ . r.. RIFICATION OF CONSTRUCTION EXPERIEN GMD Operations & Regulatory Management Department Licensing Section 2800 N. Horseshoe Drive Naples, FL 34104 Applicant's Name: 1"\ lC0 u &11-'k CA 3— Certificate Category Requested: J'�i�{ I b I N The Applicant is seeking a Collier County Certificate of Competency in the trade indicated above. As part of the application for this certificate the Applicant must verify their experience within this trade. You are being requested to provide information that will aid the Applicant in meeting this requirement. You should verify time of active experience working as an apprentice or a skilled worker (e.g. as a worker commanding the wage of mechanic or better in the trade). Time served solely in a supervisory or administrative role should be described, but may or may not be considered sufficient to demonstrate required trade experience. The person verifying trade experience must provide the following information: Name, Title and license number of the person signing below and verifying Applicants relevantexperience: J Name: t` 1 1' l 1* t2C P-1 Title: Name of Business: Business Address: Business Phone: License Number (if applicable): The Applicant's years of experience from The applicant's scope of work (specific duties) included: Additional Comments: Falsifying any information provided herein may subject your license to revocation. Signature Print Nan State of Florida County of Collier The foregoing instrument was acknowledged before me on this day of by who is personally known to me or produced as identification and who did not take an oath. Signature of Notary RIFICATION OF CONSTRUCTION EXPERIENC GMD Operations & Regulatory Management Department Licensing Section 2800 N. Horseshoe Drive Naples, FL 34104 Applicant's Name: NA 1 C-v M \V-Tz lAua \CA Certificate Category Requested: V -i \L:-v) \1'y6 C,,,D N C—,,t - The Applicant is seeking a Collier County Certificate of Competency in the trade indicated above. As part of the application for this certificate the Applicant must verify their experience within this trade. You are being requested to provide information that will aid the Applicant in meeting this requirement. You should verify time of active experience working as an apprentice or a skilled worker (e.g. as a worker commanding the wage of mechanic or better in the trade). Time served solely in a supervisory or administrative role should be described, but may or may not be considered sufficient to demonstrate required trade experience. The person verifying trade experience must provide the following information: Name, Title and license number of the person signing below and verifying Applicants relevantexperience: Name: I EP-N IT q Title: Name of Business: Business Address: Business Phone: License Number (if applicable): The Applicant's years of experience from The applicant's scope of work (specific duties) included: Additional Comments: Falsifying any information provided herein may subject your license to revocation. Signature Print Name: State of Florida County of Collier The foregoing instrument was acknowledged before me on this day of by who is personally known to me or produced as identification and who did not take an oath. Signature of Notary AFFIDAVIT OF INTEGRITY AND GOOD CHARACTER �7 am a resident of �x� 1 l / i.�` County, (State) and have resided here for more than five (5) years. .During the last five years I have known 1,A 1 C o M W- U (:;�t CA -�St2 (Applicant). I have had the opportunity to observe his or her business and personal dealings and find him or her to be a person of honesty, integrity and good character. (Signature) �T (Name) C' L'7 (Address) i a i-7 L. u s 7tYuc} 4 /) les , Telephone) STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before me this /�'lQ i by (Date) Q� who has produced _ � 'b' U t rz s Cie eAJs e- (name of Jerson acknowledging) (Type of identification) as identification and who did not take an oath. KATHY K CHESSER biY COMMISSION # DD 966226 EXPIRES: April 12, 2014 fl Bonded Thru Notary Public Underwriters NOTARY'S SEAL SIG A F NOTARY K. C'4.e S5 '.,z_ (PRINT NAME OF NOTARY) NOTARY PUBLIC Z-4 j 3 AFFIDAVIT OF INTEGRITY AND GOOD CHARACTER E-! E 01 1 _,am a resident of rf" CK County, P-IA'l I2- l h4 (State) and have resided here for more than five (5) years. During the last five years I have known A Ko W& U&60 0 Sa applicant). I have had the opportunity to observe his or her business and personal dealings and find him or her to be a person of honesty, integrity and good character. (Signatur (Name) { k'.'� L t�j 11 (Address) 1 HK K L A-&0%449A-(.N AJ APL is Pt- 3 q 1-03 Telephone) FS �— 4 b L( _ si ,z STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before me this 1141113 by r�I \ (Date) 11-C. `� who has produced 14 1 (name of persda acknowledging) (Type of identification) as identification and who did not take an oath. MICHAEL T. DUNZELMAN �BLIC ORIDA Comm# DD955093 Expires 4/26/2014 S C,NATURE F NOTARY (PRINT NAME OF NOTARY) NOTARY PUBLIC STATEMENT OF OWNERSHIP This certifies that I, kA" �-At \LC (A&Ak A ,)a am a member or (APPLICANT'S NAME) Managing member of ZEN &Q -0LAP �--)-C (LIMITED LIABILITY COMPANY NAME) I own � 00 % of the units issued by the Limited Liability Company listed above. Affidavit of Applicant:.I certify that the information contained is a true and correct statement to the best of my knowledge. C O %\\4Z U (,,Q- i CA -Z(2- (PRINT NAMF) 4P i,ICANT'S MGNATITRF) (DATE) RESOLUTION OF AUTHORIZATON WHEREAS -Z-1E-:t--3 LA—C proposes to (Name of Business Entity) engage in contracting as _ _ 1_ LC in (Type of legal entity: core., partnership, etc. Collier County, Florida, according to Collier County Ordinance 2006 -46, as amended, and WHEREAS Zero (L- a L -\p Lt-c- proposes to (Name of Business Entity) qualify for a Certificate of Competency with !�. LC.-o h- N Via U&,;2 lCA � :2 (Name of Individual) NOW, THEREFORE, BE IT HEREBY RESOLVED THAT: We the undersigned 0 wcv IW- of (Officers, Owners, Partners) hereby resolve and represent to the Collier County (Name of Business Entity) Contractors' Licensing Board that the qualifying agent, lCO fv, - Z�: I t &C �cyi v is active (Name of Individual) in all matters connected with the contracting business of _ Zi✓tN G;nzcy:2 0-C , and (Name of Business Entity) We further resolve and represent that o ,,a' 2 is (Names of Individual) legally empowered to act for_ZG -t,-) 1- in all matters connected with its (Name of Business Entity) contracting business, and has the authority to supervise construction undertaken by (Name of Business Entity) LJ& Witness Witness Witness DULY PASSED AND ADOPTED THIS I I $1 day of N_ , 101A. (Officers, Partners, Owners - with Designatio undern eath) Corporate Seal (if Applicable) Or Notary Public Certificate Sworn to and subscribed before me this 9 C. day of by 4. � � c�,J r Notary Public Nan4nqk � Commission Number My Commission expires: cl 1 Notary Publ' ignature MICHAEL T. DUNZELMAN NOTARY PUBLIC STATE OF FLORIDA Comm# DDWA3 Expires 4/26014 COLLIER COUNTY GOVERNMENT COMMUNITY DEVELOPMENT AND ENVIRONMENTAL SERVICES DIVISION 2800 N. Horseshoe Dr.. Naples, Florida 34104 • 239- 403 -2400 • FAX 239 -403 -2334 MEMORANDUM DATE: November 29, 2007 TO: Applicant's FROM: Michael Ossorio, Contractor Licensing Supervisor. CC: Robert Dunn, Collier County Building Director. Alamar Finnegan, Collier County Permitting Supervisor. Robert Zachary, County Attorneys Office.. All Contractor Licensing personnel. SUBJECT: Collection of social security numbers. Pursuant to Chapter 119, Florida Statues and Collier County Contractor Licensing Ordinance 2006 -46 Sec. 2.1.1, all applicants are required to submit their social security number (SSN) for the following purposes: a) Assess applicant's ability to satisfy creditors by reviewing their credit history. b) Verification of applicant's test scores and information. Our office will only use your SSN noted above for those reasons pursuant to Chapter 119, Florida Statues and as may otherwise be authorized by law. We are fully committed to safe - guarding and protecting your SSN and once collected, will be maintained as confidential and exempt under Chapter 119, Florida Statues. Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 1 of 8 EgvlFax Equifax Credit Report and Score Tm as of 11/18/2013 Name: Mico Urgica Confirmation Number: 3040080917 Credit Score Summary Where You Stand The Equifax Credit Score TM ranges from 300 -900. Higher scores are viewed more 833 Excellent favorably. Your Equifax credit score is calculated from the information in your Equifax Credit Report. Most lenders would consider your score excellent. Based on this score, you should be able to qualify for some of the lowest interest rates available and a wide variety of competitive credit offers should be available to you. Range 300-559 560-659 660-724 725-759 760+ Poor Fair Good Very Good Excellent Canada Population 4% 1Q% 15% 14% 57% What's Impacting Your Score Below are the aspects of your credit profile and history that are important to your Equifax credit score. They are listed in order of impact to your score - the first has the largest impact, and the last has the least. Number of inquiries in previous 12 months. Percentage of revolving trades opened within the last 2 years to total trades. Total number of national credit cards inquiries. Your Loan Risk Rating 8331 Excellent Your credit score of 833 is better than 89% of Canadian consumers. The Equifax Credit Score TM ranges from 300 -900. Higher scores are viewed more The Bottom Line favorably. Lenders consider many factors in addition to your score when making credit decisions. However, most lenders would consider you to be a very low risk. You may qualify for a variety of loan and credit offers at some of the lowest interest rates available. If Delinquency Rates" you're in the market for credit, this is what you might expect: You may be able to obtain high credit limits on your credit card. Many lenders may offer you their most attractive interest rates and 55% offers. 33 Many lenders may offer you special incentives and rewards that are 21 geared to their most valuable customers. 11 5% https: / /www. econsumer. equifax. ca/ canadaotc/ viewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 2 of 8 It is important to understand that your credit score is not the only factor that lenders evaluate when making credit decisions. Different lenders set their own policies and tolerance for risk, and may consider other elements, such as your income, when analyzing your creditworthiness for a particular loan. Personal Information Personal Data Name: SIN: Date of Birth: Current Address Address: Date Reported Current Employment Employer: Occupation: Special Services MICO URGICA JR 503XXX776 1976 -12 -XX 2% rifll 650- 700- 60440- 699 749 ' Delin uencyte is oefined as the percentage of borrowers who reVY90 days past due or worse (such as bankruptcy or It,unt charge -off) on any credit account oinr a two year penod. 1% CREDIT REPORT 26 GUILDCREST DR SCARBOROUGH,ON 2012 -12 2012 -11 2012 -04 SELF EMPLOYED No Special Services Message Consumer Statement No Consumer Statement on File Credit Information 750- 900+ 799 Other Names: Also Known as: MIKE UGRICA XX Previous Address Address: 725 DON MILLS RD #1701 NORTH YORK, ON Date Reported: 2012 -12 2012 -11 2012 -04 Previous Employment Employer: MIKE Occupation: Employer: KELDEER CONSTRUCTION INC Occupation: This section contains information on each account that you've opened in the past. It is retained in our database for not more than 6 years from the date of last activity. An installment loan is a fixed- payment loan in which the monthly payment does not change from month to month. Examples of such loans are a car loan or a student loan. Mortgage information may appear in your credit report, but is not used to calculate your credit score. A revolving loan is a loan in which the balance or amount owed changes from month to month, such as a credit card. Note: The account numbers have been partially masked for your security. FIDO Phone Number: (888)288 -2106 Account Number: High Credit/Credit Limit: Payment Amount: Not Available https:// www. econsuiner. equifax. ca /canadaotc /viewPopUpDetail.eht nl ?prod_cd= CAECS... 18/11 /2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 3 of 8 Association to Account: Type of Account: Date Opened: Status: Months Reviewed: Payment History: Prior Paying History: Comments: TDCT TR0241 Phone Number: Account Number: Association to Account: Type of Account: Date Opened: Status: Months Reviewed: Payment History: Prior Paying History: Comments: CIBC Phone Number: Account Number: Association to Account: Type of Account: Date Opened: Status: Months Reviewed: Payment History: Prior Paying History: Comments: TOYOTA CANADA Phone Number: Account Number: Association to Account: Type of Account: Date Opened: Status: Months Reviewed: Payment History: Prior Paying History: Comments: Individual Open 1999 -06 Paid as agreed and up to date 47 No payment 30 days late No payment 60 days late No payment 90 days late Closed at consumer request Account paid (866)222 -3456 Individual Revolving 2011 -01 Paid as agreed and up to date 34 No payment 30 days late No payment 60 days late No payment 90 days late Personal line of credit Amount in h/c column is credit limit (416)421 -3845 Individual Revolving 2012 -06 Paid as agreed and up to date 17 No payment 30 days late No payment 60 days late No payment 90 days late Personal line of credit Amount in h/c column is credit limit (905)513 -8200 Joint Installment 2010 -11 Paid as agreed and up to date 35 No payment 30 days late No payment 60 days late No payment 90 days late Account paid Lease account Balance: Past Due: Date of Last Activity: Date Reported: High Credit/Credit Limit: Payment Amount: Balance: Past Due: Date of Last Activity: Date Reported: High Credit/Credit Limit: Payment Amount: Balance: Past Due: Date of Last Activity: Date Reported: High Credit/Credit Limit: Payment Amount: Balance: Past Due: Date of Last Activity: Date Reported: $0.00 $0.00 2013 -11 2013 -11 $12,500.00 Not Available $0.00 $0.00 2011 -08 2013 -10 $15,000.00 Not Available $0.00 $0.00 2012 -06 2013 -11 $22,108.00 $460.00 $0.00 $0.00 2013 -09 2013 -10 https:// www. econsumer. equifax .calcanadaotclviewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 4 of 8 CIBC CARD SERVICES Phone Number: Not Available High Credit/Credit Limit: $7,500.00 Account Number: Payment Amount: Not Available Association to Account: Individual Balance: $0.00 Type of Account: Revolving Past Due: $0.00 Date Opened: 2012 -06 Date of Last Activity: 2013 -08 Status: Paid as agreed and up to date Date Reported: 2013 -10 Months Reviewed: 16 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Amount in h/c column is credit limit Monthly payments TD CREDIT CARDS Phone Number: (800)983 -8472 High Credit/Credit Limit: $25,500.00 Account Number: Payment Amount: $23.00 Association to Account: Individual Balance: $4,250.00 Type of Account: Revolving Past Due: $0.00 Date Opened: 2005 -05 Date of Last Activity: 2013 -09 Status: Paid as agreed and up to date Date Reported: 2013 -10 Months Reviewed: 47 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Amount in h/c column is credit limit Monthly payments SCOTIABANK Phone Number: (416 )421 -3900 High Credit/Credit Limit: $122,000.00 Account Number: Payment Amount: $585.00 Association to Account: Individual Balance: $119,000.00 Type of Account: Mortgage Past Due: $0.00 Date Opened: 2012 -11 Date of Last Activity: 2013 -07 Status: Paid as agreed and up to date Date Reported: 2013 -07 Months Reviewed: 09 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Mortgage Monthly payments * This item is not displayed to all credit grantors and will not impact your credit score. SCOTIALINE Phone Number: (800)387 -6556 High Credit/Credit Limit: $0.00 Account Number: Payment Amount: Not Available Association to Account: Balance: $0.00 Type of Account: Revolving Past Due: $0.00 Date Opened: 2008 -04 Date of Last Activity: 2010 -08 Status: Paid as agreed and up to date Date Reported: 2011 -02 Months Reviewed: 15 Payment History: https: / /www.econsumer. equifax. ca/ canadaotc/ viewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 5 of 8 No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Account Closed Monthly payments TOYOTA CANADA Phone Number: (905)513 -8200 High Credit/Credit Limit: $25,290.00 Account Number: Payment Amount: $465.00 Association to Account: Individual Balance: $0.00 Type of Account: Installment Past Due: $0.00 Date Opened: 2009-04 Date of Last Activity: 2010 -12 Status: Paid as agreed and up to date Date Reported: 2011 -01 Months Reviewed: 14 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Account paid Monthly payments SCOTIA BANK Phone Number: (416)439 -2333 High Credit/Credit Limit: $130,000.00 Account Number: Payment Amount: $547.00 Association to Account: Individual Balance: $0.00 Type of Account: Mortgage Past Due: Not Available Date Opened: 2008 -04 Date of Last Activity: 2010 -06 Status: Paid as agreed and up to date Date Reported: 2010 -08 Months Reviewed: 10 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Account Closed Mortgage This item is not displayed to all credit grantors and will not impact your credit score. SCOTIABANK VISA Phone Number: (800)387 -6556 High Credit/Credit Limit: $6,900.00 Account Number: Payment Amount: Not Available Association to Account: Balance: $0.00 Type of Account: Revolving Past Due: $0.00 Date Opened: 1998 -09 Date of Last Activity: 2009 -10 Status: Paid as agreed and up to date Date Reported: 2010 -04 Months Reviewed: 05 Payment History: No payment 30 days late No payment 60 days late No payment 90 days late Prior Paying History: Comments: Monthly payments Amount in h/c column is credit limit FINANCIALINX Phone Number: (416)753 -4000 High Credit/Credit Limit: $25,583.00 Account Number: Payment Amount: $295.00 Association to Account: Individual Balance: $0.00 https:// www. econsumer. equifax .calcanadaotclviewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 6 of 8 Type of Account: Date Opened: Status: Months Reviewed: Payment History: Prior Paying History Comments: Installment 2004 -12 Paid as agreed and up to date 01 No payment 30 days late No payment 60 days late No payment 90 days late Monthly payments Past Due: $0.00 Date of Last Activity: 2009 -11 Date Reported: 2009 -11 Credit History and Banking Information A credit transaction will automatically purge from the system six (6) years from the date of last activity. All banking information (checking or saving account) will automatically purge from the system six (6) years from the date of registration. No Banking information on file Please contact Equifax for additional information on Deposit transactions at 1 -800- 865 -3908 Public Records and Other Information Bankruptcy A bankruptcy automatically purges six (6) years from the date of discharge in the case of a single bankruptcy. If the consumer declares several bankruptcies, the system will keep each bankruptcy for fourteen (14) years from the date of each discharge. All accounts included in a bankruptcy remain on file indicating "included in bankruptcy" and will purge six (6) years from the date of last activity. Voluntary Deposit - Orderly Payment Of Debts, Credit Counseling When voluntary deposit — OPD — credit counseling is paid, it will automatically purge from the system three (3) years from the date paid. Registered Consumer Proposal When a registered consumer proposal is paid, it will automatically purge three (3) years from the date paid. Judgments, Seizure Of Movable /Immovable, Garnishment Of Wages The above will automatically purge from the system six (6) years from the date filed. Secured Loans A secured loan will automatically purge from the system six (6) years from the date filed. (Exception: P.E.I. Public Records: seven (7) to ten (10) years.) Secured Loans Court Name: MINISTRY GOVT SERV Date Filed: Industry Class: Creditor's Name and Amount: Maturity Date: 2014 -12 Comments_ Security Discharged Secured Loans Court Name: MINISTRY GOVT SERV Industry Class: Maturity Date: 2014 -04 Comments: Security Discharged Collection Accounts Date Filed: Creditor's Name and Amount: 2010 -12 666400599 TOYOTA CREDIT CANADAINC 2009 -04 652956435 TOYOTA CREDIT CANADAINC A collection account under public records will automatically purge from the system six (6) years from the date of last activity. https: / /www.econsumer. equifax. ca/ canadaotc/ viewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 hquitax Personal ZSolutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 7 of 8 No Collections information on file Credit Inquiries to the File The following inquiries were generated because the listed company requested a copy of your credit report. An Inquiry made by a Creditor will automatically purge three (3) years from the date of the inquiry. The system will keep a minimum of five (5) inquiries. 2012 -10 -19 SCOTIABANK (416)288 -1460 2012 -10 -18 MORTGAGE INTELLIGENC (905)283 -3600 2012 -06 -27 CIBC (416)421 -3845 2012 -06 -27 CIBC CREDIT CARD SVC (800)465 -4653 2012 -05 -30 NORDON COLLECTION (416)291 -2113 2010 -11 -20 TOYOTA CREDIT CANADA (905)513 -8200 2013 -09 -17 INTLUSA 403FA01043 WORLD OMNI 2013 -06-18 INTLUSA 403FA01043 WORLD OMNI 2010 -03 -03 INTLUSA 91OUE01458 FL PWRLGT 2010 -03 -02 INTLUSA 91OUE01458 FL PWRLGT The following "soft" inquiries were also generated. These soft inquiries do not appear when lenders look at your file; they are only displayed to you. 2013 -11 -18 AUTH ECONSUMER REQUE (Phone Number Not Available) 2013 -11 -18 EQUIFAX PERSONAL SOL (800)871 -3250 2013 -10 -31 CIBC ACCOUNT UPDATE (800)465 -2255 2013 -09 -11 CANADA GUARANTY MORT (877)244 -8422 2013 -09 -11 TDCT (866)222 -3456 2012 -10 -19 CANADAGUARANTY INS (416)640 -8924 2012 -10 -08 AUTH ECONSUMER REQUE (Phone Number Not Available) 2012 -10 -08 EQUIFAX PERSONAL SOL (800)871 -3250 How can I correct an inaccuracy in my Equifax credit report? Complete and submit a Consumer Credit Report Update Form to Equifax. By mail: Equifax Canada Co. Consumer Relations Department Box 190 Jean Talon Station Montreal, Quebec H1S 2Z2 By fax: (514) 355 -8502 Equifax will review any new details you provide and compare it to the information in our files. If our initial review does not resolve the problem, we will contact the source of the information to verify its accuracy. If the source informs us that the information is incorrect or incomplete, they will send Equifax updated information and we will change our file accordingly. If the source confirms that the information is correct, we will not make any change to our file. In either case, you may add a statement to our file explaining any concerns you have. Equifax will include your statement on all future credit reports we prepare if it contains 400 characters or less. If Equifax changes our file in response to your request, we will automatically send you an updated credit report to show you the changes. At your request, we will also send an updated credit report to any of our customers who received one within 60 days before the change was made. https: / /www. econsumer. equifax. ca/ canadaotc/ viewPopUpDetail .ehtml ?prod_cd= CAECS... 18/11/2013 P{quifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 1 of 10 EQUIFAX Equifax 3- Bureau Credit Report and Scores as of November 19, 2013 Name: MIKE M UGRICA Confirmation Number: 3823908416 Section Title Section Description 1. Credit Score Summary, Understanding Your Score, How Lenders See You 2. Credit Report Personal, Credit, Account, Inquiry, Public and Dispute Information CREDIT SCORE Section Title Section Description 1. Credit Score Summary Summary of how your score rates 2. Understanding Your Score Summary of factors that are affecting your score 3. Your Loan Risk Rating The bottom line on how lenders may view your credit risk Credit Score Summary Where You Stand 6691 Good Experian 696i Good TransUnion 6571 air The Equifax Credit Score TM ranges from 280 -850. Higher scores are viewed more favorably. Your 3 credit scores are calculated by Equifax using the information contained in your Equifax, Experian, and TransUnion credit reports. Equifax & Experian: Your score is considered good. Based on this score, you should be able to qualify for credit with average interest rates and offers. TransUnion: Your score is considered fair. You may have challenges qualifying for credit and you should expect to pay high interest rates when you do qualify. Range 280-559 560-659 660-724 725-759 760-850 Poor Fair Good Very Good Excellent US Population 12 21 18 12 37 What's Impacting Your Scores Below are the key areas from these credit reports that are impacting your scores. Experian TransUnion Payment History Your history of paying bills on time. Very Good Very Good Very Good Amount of Debt Your total amount of outstanding debt. Fair Fair Fair https: / /www.econsumer. equifax. com/ otc/ viewPopUpDetail .ehtml ?prod_cd= 3N3 &arnp;su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 2 of 10 Length of Credit History How long you've had credit Poor Poor Poor Amount of New Credit Your recent credit history of new loans or applications Good Excellent Fair Type of Credit The various types of credit accounts that you have. Good Good Good Understanding Your Score Helping your score Experian TransUnion Your payment history is excellent. You have not applied for credit recently. Hurting your score Experian TransUnion There is insufficient information about mortgage accounts. The outstanding balance on your revolving accounts is too high. What's helping your score Below are the aspects of your credit profile and history that are helping each of your 3 credit scores. They are listed in order of impact to your scores - the first has the most positive impact, and the last has the least positive impact. You should make an effort to continue these good credit habits. Experian TransUnion Your payment history is excellent. You have an excellent payment history on your accounts, which helps your credit score. Paying your bills on time will continue to benefit your credit score. Your number of accounts that were either 30 days past due in the last 6 months, or in charge -off, repossession, collections, bankruptcy or foreclosure status in the last 2 years: 0 Equifax 760+ Club About 97% of Equifax 760+ Club members have accounts that were neither 30 days past due in the last 6 months nor in charge -off, repossession, collections, bankruptcy or foreclosure status in the last 2 years. You have not applied for credit recently. You don't have recent credit inquiries, which helps your credit score. In general, your score benefits when you are not actively seeking credit. What's hurting your score Below are the aspects of your credit profile and history that are hurting each of your 3 credit scores. They are listed in order of impact to your scores - the first has the most negative impact, and the last has the least negative impact. Experian TransUnion There is insufficient information about mortgage 0 0 0 accounts. https: / /www.econsumer.equifax. com/otc /viewPopUpDetail .ehtml ?prod_cd =3N3 &su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 3 of 10 Experian TransUnion You either have no mortgage accounts, or there is insufficient information about mortgage accounts, in your credit file. People without mortgage accounts or those who do not have sufficient information about mortgage accounts are considered riskier by lenders. It is important to have various types of credit that are held in good standing in your credit file, including mortgage accounts. Equifax 760+ Club About 82% of Equifax 760+ Club members have either no mortgage account, or a total mortgage loan amount of less than $200,000. The outstanding balance on your revolving accounts is too high. Your credit report shows that the outstanding balance on your revolving accounts is too high. People who have higher amounts outstanding on revolving accounts are considered riskier to lenders than those with lower outstanding balances. You should strive to pay down this balance. Your total balance on revolving accounts is: $3,331 Equifax 760+ Club On average, Equifax 760+ Club members have a total balance of $978 on revolving credit accounts. Your Loan Risk Rating 669 Good Experian 696 ;Good TransUnion I Fair 657 - The Equifax Credit ScoreTm ranges between 280 and 850. - Higher Scores are viewed more favorably by lenders because they represent a lower risk of delinquency or default. The Bottom Line: Equifax & TransUnion Lenders consider many factors in addition to your score when making credit decisions. However, most lenders would consider you to be a moderate risk. You may not qualify for credit with all lenders. When you do qualify for credit, you may pay higher interest rates and be subject to more restrictive loan terms than those with lower risk ratings. If you're in the market for credit, this is what you might expect: You may not qualify for high credit limits on your credit card. You are likely to pay higher interest rates on all types of loans than those with lower risk ratings. The loan terms you receive may be somewhat restrictive. The Bottom Line: Experian Lenders consider many factors in addition to your score when making credit decisions. However, most lenders Delinquency Rates* 72% ® �1 50% 33% 20% 12% 7% 4% 2% 1% Up to 546- 603 - 648- 667- 722- 753- 777- 796- 545 602 647 686 721 752 776 795 850 *Delinquency Rate is defined as the percentage of borrowers who reach 90 days past due or worse (such as bankruptcy or account charge -off) on any credit account over a two year period. https: / /www.econsumer. equifax. com/ otc/ viewPopUpDetail .ehtml ?prod_cd =3N3 &su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 4 of 10 would consider you to be a moderate risk. While you may be able to qualify for certain types of conventional loans and credit cards, you will pay higher interest rates than those with lower risk ratings. If you're in the market for credit, this is what you might expect: You may not qualify for high credit limits on your credit card. You are likely to pay higher interest rates on all types of loans than those with lower risk ratings. You should qualify for most loan terms that are offered to the general public. It is important to understand that your credit score is not the only factor that lenders evaluate when making credit decisions. Different lenders set their own policies and tolerance for risk, and may consider other elements, such as your income, when analyzing your creditworthiness for a particular loan. CREDIT REPORT Section Title Section Description 1. Credit Summary Summary of account activity 2. Account Information Detailed account information 3. Inquiries Companies that have requested or viewed your credit information 4. Negative information Bankruptcies, liens, garnishments and other judgements 5. Personal Information Personal data, addresses, employment history 6. Dispute File Information How to dispute information found on this credit report Credit Summary Your Credit Summary highlights the information in your credit file that is most important in determining your credit standing, distilling key credit information into one easy -to -read summary. Accounts Lenders usually take a positive view of individuals with a range of credit accounts - car loan, credit cards, mortgage, etc. - that have a record of timely payments. However, a high debt to credit ratio on certain types of revolving (credit card) accounts and installment loans will typically have a negative impact. https:// www. econsumer. equifax .comlotclviewPopUpDetail.ehtml ?prod— cd =3N3 &su... 19/11/2013 Equifax TransUnion Experian Total Mortgage Accounts 0 0 0 Balance $0 $0 $0 Credit Limit _. N/A - - - - -- - - N/A - - - - - -- - - -- N/A - - -- - -- - ------------ - - - - -- - -- - - - - -- -- - - -- Debt to Credit Ratio - NIA N/A N/A Total Installment Accounts 0 - - -- - ------ - - - 0 - -- - - - - - -- - - 0 - -- - - - - -- - -- --- ...� - -- - -- - - -- ..- - - - - - - -- - Balance — - - - - - - - -- $0 - - - - -- - -- $0 -- - - - -- - $0 __------..------ .... -- - - -- ._— - - - -- - -- - - -- - - -- _ High Balance ._...._... - - -- - N/A N/A N/A Debt to Credit Ratio N/A N/A N/A Total Revolving Accounts 1 1 1 Balance $3,331 $3,331 $3,331 Credit Limit = $5,000 $5,000 $5,000 Debt to Credit Ratio 67% 67% 67 °k Total Other Accounts 0 0 0 Balance $0 $0 $0 Total Open Accounts 1 1 1 _ Total Balance $3,331 $3,331 -- - $3,331 https:// www. econsumer. equifax .comlotclviewPopUpDetail.ehtml ?prod— cd =3N3 &su... 19/11/2013 • Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 5 of 10 Total Credit Limit $5,000 $5,000 $5,000 Total Debt to Credit Ratio 67% 67% 67% Total Monthly Payment Amount ------ $84 $84 ------ $84 ------- ------ Total Open Accounts with a Balance - 1 -- - - -- ---- -.- -------------- -- .... . ......... - - I--..,- — - 1 Debt by Account Type Equifax 1004'r Transunion Experian C-ait is -e-i ;g --r-pr-d =')r print. nt. C:;nar is king repay _d --0-, p,-int. Mortgage 01 Installment Revolving I Cther Q--"r hups://www.econsumer.equifax.comlotclviewPopUpDetail.ehtml?prod—cd=3N3&su... 19/11/2013 • Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 6 of 10 NOTE: Total may not equal 100% due to rounding Account Age Usually it is a good idea to keep your oldest credit account open, as a high average account age generally demonstrates stability to lenders. Also, especially if you have been managing credit for a short time, opening many new accounts will lower your average account age and may have a negative impact. Length of Credit History Average Account Age Oldest Account Most Recent Account Equifax 1 Years, 5 Months TransUnion 1 Years, 5 Months Experian 1 Years, 5 Months 1 Years, 5 Months 1 Year 1 Years, 5 Months 1 Year 1 Years, 5 Months 1 Year BANK OF AMERICA (Opened 06/2012) BANK OF AMERICA (Opened 0612012 BK OF AMER (Opened 06/2012) BK OF AMER (Opened 06/2012 BANK OF AMERICA (Opened 06/2012) BANK OF AMERICA (Opened 06/2012 Inquiries - Requests for your Credit History Numerous inquires on your credit file for new credit may cause you to appear risky to lenders, so it is usually better to only seek new credit when you need it. Typically lenders distinguish between inquiries for a single loan and many new loans in part by the length of time over which the inquiries occur. So, when rate shopping for a loan it's a good idea to do it within a focused period of time. Equifax TransUnion Experian Inquiries in the Last 2 Years 4 4 0 Most Recent Inquiry SE TOYO (Opened BK OF AMER (Opened N/A 092013) 11/2013 Potentially Negative Information Late payments, collections and public records can have a negative impact on your credit standing. The more severe they are and the more recent they are, the more negative the potential impact. Equifax TransUnion Experian Public Records 0 0 0 Negative Accounts 0 0 0 Collections 0 0 0 Mortgage Accounts Mortgage accounts include first mortgages, home equity loans, and any other loans secured by real estate you own. You have no Mortgage accounts on file Q Back to Top Installment Accounts Installment accounts are credit accounts in which the amount of the payment and the number of payments are predetermined or fixed, such as a car loan. You have no Installment accounts on file Q Back to Top Revolving Accounts Revolving accounts are charge accounts that have a credit limit and require a minimum payment each month, such as most credit cards. Open Accounts BANK OF AMERICA hups: / /www.econsumer. equifax. com /otclviewPopUpDetail .ehtml ?prod_cd =3N3 &su... 19/11/2013 • Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 7 of 10 BANK OF AMERICA Account Type: Account Number: Payment Responsibility: Date Opened: _ - - - -- - Balance Date: Balance Amount: Monthly Payment: High/Limit: Account Status: Past Due Amount: Equifax Revolving Individual 0612012 10/2013 -- - - - - -- ---- - $5,000______ As Agreed $0 OPEN CURRENT ACCOUNT LAST PAID: 10/2013 -- ---- ;k --- --- NR NR NR NR NR NR NR NR Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov 13 13 13 13 13 13 13 1-3-1313 12 12 12 12 12 12 12 12 12 12 12 12 11 11 TransUnion NR NR NR NR NR NR NR NR NR NR NR NR ---------- Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct 13 13 13 13 13 13 13 13 13 12 12 12 12 12 12 12 12 12 12 12 12 11 11 11 Experian NR NR NR NR NR NR NR NR NR NR NR _Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan Dec Nov ------------ ,13 13 13 13 13 13 13 13 13 13 12 12 12 12 12 12 12 12 12 12 12 12 11 11 Seven-Year Payment History Past Due: Equifax- I TransUnion Experian ---1 .. . ....... 0 0 �60 Days Past Due: 0 ------ 0 0 ------- --- 90 Days Past Due: 0 0 0 13 Back to Top Other Accounts These are all accounts that do not fall into the other categories and can include 30-day accounts such as American Express. You have no other accounts on file 0 Back to Top Payment History Key Meaning: Symbol Meaning Symbol h"s://www.econsumer.equifax.com/otc/viewPopUpDetail.ehtml?prod—cd=3N3&su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 8 of 10 --------------- -- ----- Meaning Symbol Meaning Symbol Pays or Paid as Agreed: 180+ Days Past Due: 180 ---------------- 30-59 Days Past Due: 30 Collection Account: CA 60-89 Days Past Due: 60 Foreclosure: F - ---------- 90-119 Days Past Due: 90 Voluntary Surrender: VS ------- ------ ----------- 120-149 Days Past Due: 120 Repossession: R -------- -- ------- ------ ------- ------ - --- ----- 150-179 Days Past Due: 150 Charge Off. CO Inquiries A request for your credit history is called an inquiry. Inquiries remain on your credit report for two years. These inquires are made by companies with whom you have applied for a loan or credit. Equifax Name of Company Date of Inquiry Type of Business SETOYO 09/16113 Finance .... . . ..... SETOYO 120 Jim Moran Blvd,Mail Drop WOFDF1 15 Deerfield Beach, FL 334421702 (800) 553-2650 SETOYO 06118/13 Finance SETOYO 120 Jim Moran Blvd,Mail Drop WOFDF1 15 Deerfield Beach, FL 334421702 (800) 553-2650 GERMAIN TO 06/17/13 Automotive ------- ------- ----- GERMAIN TO 13315 Tamiami TrI N Naples, FL 341106338 (941) 592-5550 ---------- - ----- BK OF AMER 03/25/13 Oil And National Credit Cards ----------- BK OF AMER PO Box 17054 Wilmington, DE 198507054 (800) 421-2110 TransUnion Name of Company Date of Inquiry Type of Business BKOFAMER 11/15/13 Banking BK OF AMER PO BOX 982238 EL PASO, TX 79998 (800) 421-2110 CBCINNOVIS 09/30/13 Miscellaneous And Public Record CBCINNOVIS h4s:llwww.econsumer.equifax.conilotclviewPopUpDetail.ehtrnl?prod—cd=3N3&su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity Th... Page 9 of 10 PO BOX 1667 PITTSBURGH, PA 15230 (877) 237 -8317 BK OF AMER 09/21/13 Banking BK OF AMER PO BOX 982238 EL PASO, TX 79998 (800) 421 -2110 BK OF AMER 03/25/13 Banking BK OF AMER PO BOX 982238 EL PASO, TX 79998 (800) 421 -2110 Experian You have no inquiries on file Negative Accounts Accounts that contain a negative account status. You have no Negative accounts on file 0 Back to Too Q Back to Top Collections A collection is an account that has been turned over to a collection agency by one of your creditors because they believe the account has not been paid as agreed. You have no collections on file 0 Back to Top Public Records Public record information includes bankruptcies, liens or judgments and comes from federal, state or county court records. You have nopublic records on file p Back to Top Personal Information The following information is added to your file either when creditors enter requests to view your credit history, or when you report it to the three nationwide credit reporting agencies directly. Registration Information Name: MIKE UGRICA Address: 1149 LASTRADA LN NAPLES, FL 34103 Social Security Number:XXX -XX -2385 Identification Information TransUnion Experian _ Name: MIKE M UGRICA JR MIKE M UGRICA JR MIKE M UGRICA JR Social Security Number. Age or Date of Birth: — 1211976 —_ 1211976 Address Information uifax TransUnion Experian https:// www. econsumer. equifax.comlotclviewPopUpDetail .ehtml ?prod_cd =3N3 &su... 19/11/2013 Equifax Personal Solutions: Credit Reports, Credit Scores, Protection Against Identity ... Page 10 of 10 Address: _ 1406_HAYES_ST 1.149 LASTR_AD_A_LN_ 1149 LAST_R_A_DA_LN_ HOLLYWOOD FL 33020 NAPLES FL 34103 NAPLES FL 34103 Date Reported 03/2013 03/2013 09/2013 Not Reported Address: 1.149 LAST_RADA LN 1406 HAYES ST NAPLES FL 34103 HOLLYWOOD FL 33020 Date Reported: 1112013 06/2012 Employment Information Equifax TransUnion Experian Not Reported Not Reported Not Reported Address: Date Consumer Statement Equifax You have no Consumer Statement on file. TransUnion You have no Consumer Statement on file. Experian You have no Consumer Statement on file. 0 Back to Top Dispute File Information The 3 -in -1 Credit Report provides a valuable comparative review of your credit report based on information from the three major credit reporting agencies. As you review your 3 -in -1 Credit Report, you may find potential inaccuracies in the information provided by one or all of the credit reporting agencies. The information below outlines how you may dispute the information with the appropriate credit reporting company using your 3 -in -1 Credit Report. Equifax When you file a dispute, the credit bureau you contact is required to investigate your dispute within 30 days. They will not remove accurate data unless it is outdated or cannot be verified. To initiate a dispute online please visit https: / /www.ai.equifax.com To check the status or view the results of your dispute please visit https: / /www.ai.equifax.com TransUnion Online Go to http: / /www.transunion.com /dispute to begin an online investigation of information found in your file. No confirmation number is required. By Mail Write to TransUnion at P.O. Box 2000, Chester, PA 19022. No confirmation number is required. Experian Online Go to http: / /www.experian.com /rs /equifaxinvestigations.htmi to begin an online investigation of information found in your file. No confirmation number is required. 0 Back to Top https:// www. econsumer. equifax. com/ otc/ viewPopUpDetail .ehtml ?prod_cd= 3N3 &arnp;su... 19/11/2013 Detail by Document Number etail by Document Number 0117.1 N GROUP, LLC ocument Number EI /EIN Number ate Filed tate tatus !Dal A 149 LASTRADA LANE IAPLES, FL 34103 149 LASTRADA LANE APLES, FL 34103 eaistered Aaent Nam L13000050619 NONE 04/05/2013 FL ACTIVE .ORPORATE REGISTERED AGENT, LLC 147 CASTELLO DRIVE IAPLES, FL 34103 e & Address e MGRM GRICA, MICO (MIKE), JR 149 LASTRADA LANE APLES, FL 34103 n No Annual Reports Filed 04/05/2013 -- Florida Limited Liability I View image in PDF format Page 1 of 2 http: / /search. sunbiz. org/ Inquiry/ CorporationSearch/ SearchResultDetail lDocumentNumber /... 12/6/2013 Detail by Document Number State of Florida, Department of State Page 2 of 2 Home Contact Us E- Filing Services Document Searches Forms Help http: / /search. sunbiz. org/ Inquiry/ CorporationSearch/ SearchResultDetail lDocumentNumber /... 12/6/2013 Electronic Articles of Organization For Florida Limited Liability Company Article I The name of the Limited Liability Company is: ZEN GROUP, LLC Article II L13000050619 FILED 8:00 AM April 05, 2013 Sec. Of State jbryan The street address of the principal office of the Limited Liability Company is: 1149 LASTRADA LANE NAPLES, FL. 34103 The mailing address of the Limited Liability Company is: 1149 LASTRADA LANE NAPLES, FL. 34103 Article III The purpose for which this Limited Liability Company is organized is: ANY AND ALL LAWFUL BUSINESS. Article IV The name and Florida street address of the registered agent is: CORPORATE REGISTERED AGENT, LLC 5147 CASTELLO DRIVE NAPLES, FL. 34103 Having been named as registered agent and to accept service of process for the above stated limited liability company at the place designated in this certificate, I hereby accept the appointment as registered agent and agree to act in this capacity. I further agree to comply with the provisions of all statutes relating to the proper and complete performance of my duties, and I am familiar with and accept the obligations of my position as registered agent. Registered Agent Signature: CASEY WOLFF, AS ITS MEMBER Article V L13000050619 The name and address of managing members /managers are: FILED 8:00 AM April 05 2013 Title: MGRM Sec. Of 15tate MICO (MIKE) UGRICA JR jbryan 1149 LASTRADA LANE NAPLES, FL. 34103 Signature of member or an authorized representative of a member Electronic Signature: CASEY WOLFF, ESQ. I am the member or authorized representative submitting these Articles of Organization and affirm that the facts stated herein are true. I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S. I understand the requirement to file an annual report between January 1 st and May 1 st in the calendar year following formation of the LLC and every year thereafter to maintain "active" status. BINDER & CERTS RE: Quote from Ott Ins Agency - zengroup.swf@agmail.com - Gmail Page 1 of 2 Gmail CERTIFICATE OF LIABILITY INSURANCE 72f0272D73 COMPOSE Vocalo Inbox (t) See th Starred BINDER Important Thank Sent Mad Don Drina (1) to Rae Circles MWC 12O=`I4 More From- Cen - Collier LIC.pdf 2of3 TM CERTIFICATE A ISSUED AS A MATTER OF INFORMATION ONLY AND COIO'ERS No RRINrS UPDN THE CE;NnF CATS IWLDER THIS C9nf1M4E DOER NOT AFFIRNATMMY OR NEGATRRiY AIBEItD. IDOEMD ON ALTER THE COVERAGE AFFORDED BY THE POUCIES IN LOW THR CERTIMMTE OF INSURANCE GOES NOT OOMMMITE A CONTRACT BETWEER THE ISSUING OEDREIM AUnmWLEO REntltfBLiATIVE ORPRODtlCE I Am THECERUFMTE HOLOHL NpoRTAHr. N r milfte uurr M.en AimI001TAL INBImED. tiM Pa41ra1 aunt d . rda+eed IF ELIBROaAT10tI IS IIFAIVEU FegNi m Me VMS NId OMrNBan dr ab puff. eeITala DelMlPe arY+egaheae LIIBNINNNIa. AFPaOPNNat on iRY bNNnbdooe aN CenNr.dg4C to TIN conI csIF keNKia OW.19av Dear,& M-- _ Donald Sheehas See th Search people_. IIIaC1 amm.A- 16 ifNUOrID@ I alex Thank Brett Fa Don Dave Lockwood N Don Sheehan MWC 12O=`I4 FranCeSOD Porretta From- Georgina Kwoum Stmt Greg Roe TIN 'ze ockth sukie RapdLlvi¢, Ardh... F 1.000= Steve Murphy Dear A Seeth Cen - Collier LIC.pdf 2of3 TM CERTIFICATE A ISSUED AS A MATTER OF INFORMATION ONLY AND COIO'ERS No RRINrS UPDN THE CE;NnF CATS IWLDER THIS C9nf1M4E DOER NOT AFFIRNATMMY OR NEGATRRiY AIBEItD. IDOEMD ON ALTER THE COVERAGE AFFORDED BY THE POUCIES IN LOW THR CERTIMMTE OF INSURANCE GOES NOT OOMMMITE A CONTRACT BETWEER THE ISSUING OEDREIM AUnmWLEO REntltfBLiATIVE ORPRODtlCE I Am THECERUFMTE HOLOHL NpoRTAHr. N r milfte uurr M.en AimI001TAL INBImED. tiM Pa41ra1 aunt d . rda+eed IF ELIBROaAT10tI IS IIFAIVEU FegNi m Me VMS NId OMrNBan dr ab puff. eeITala DelMlPe arY+egaheae LIIBNINNNIa. AFPaOPNNat on iRY bNNnbdooe aN CenNr.dg4C to TIN conI csIF keNKia OW.19av Ott Insurance AOBnCy, LLC 10913 Bonita Beach Rd. Ste. 1141 Bonita Springs FIL 34135 M-- _ Donald Sheehas 11p F>m d rmmrn IIIaC1 amm.A- 16 ifNUOrID@ I Mico LVica DBA Zen Group LLC 1149 L astrada Lane Naples FL 34103 f LaaT6 A 01F MINIM X euReRrr A`BQ"w wuTti Z OiFilF: N TIBS rS TO CERfFT TTMT TI¢ POUCEE OF NNIRANCE LISTED BELOW HAVE BEST MM TO THE NaUREU WOW ABOVE FOR THE POLICY P a loo NWATEO NOTWJnWAINNG AW REOME113117. TEW OR CONOGION OF ARV CONINACT OR OTWER DOCUMENT WTH R-WEOT TO VMCH THIS CERRRCATE NAY BE ISSrEO ON MY PMNN THE HAKIMANDE AFFO"M IFY THE IOUCKS DESCRIBED 1EREN IS SUBIECr TO ALL THE TERMS eIF31, NDrLS AND COIOIRONS OP SUCK POLCEL LWITZ$110M MKIrHAVE NESHREDUCED BY PAD CLAWS. 11r -.WW RN:E f LaaT6 A 01F MINIM X euReRrr A`BQ"w wuTti Z N N PGLOD5777 -13 MWC 12O=`I4 tAaoGi:tl6uoc � — .EDD. I 1000.GOO F 700 rNMD wFAp NR{e1 . t,O00.000 6alABBNDAIF rHNAteIT aN3t X Pouex DC afton FCIeryvE i 2,0o0.GDo PaONLtq- OOIAO'A'33 F 1.000= AlnNOSeullsrrr ywnpMAnNO� A1106 +ert�� RamAVTOF N MFC*NAalrM1w�O F M10.YwAn M1MUla4 i P F s rNIFMUAxr! DtMFtaFI I.,�RR I . GAWCCGNiGtF S � Y aF�NNC IF I� a�p>E, q ■ aaer.la. tA� RtA 1 I I ' EL 61OUCMDW F EL pa•A! -G S tI OffAPE- TOICeI,M i �IYl6OaaATF]Qf1001/1aRFt�IBiaS pIY.ACON1N.iY.f�BmawbeYl aAy,PwFypy4 Certified BuddRtg Convactor COlfrerCOUOtyCorlhadorsLicBoard SID"AMOFUMABMQ POUCESBErANWeUjMg� 2800 N horseshoe Dr nff E]VWLMI DATE M.Nrn NOTai VAL IE CEUVERED M ACOOImAIAEW T1EPOLICYNIOLRNOIN. Naples FL 34104 APMp�pap,NaNgTR[ ®TBBB -aMa ACDRD�Mft Mftl SnNNw ACOImiS M"Q" TiPACARD acre eadlnyp Pre regi iamd marks ed ACORD FTT�o Open Whh +Mild https : / /mail.google.com/mail/ ?tab=wm 05/12/2013 copy of business tax receipt - zengroup.swf(agmail.com - Gmail Gmail CCMPCSE Vocalo I inbox (1) Starred Important Sent Mad Drafts (1) Circles More Search people.._ alex Brett Fa Dave Lod3xood Dort Sheehan Francesco Porretia Georgina Kano nos Greg Roe 1LKfdh Raptiewiq Anth... Steve Murphy copy of ( KMBT35020131205090007.pdf 1 oft Caroly to me Perou Vft K 2800 I, Fax _2 SERVI From: Sent 7 To: Ca Sublec FRO! Image the E4 Page 1 of 2 COLLIER COUNTY BUSINESS TAX BUSINESS TAX NUMBER: 122511 COL L ER COU4TY TAX COLLECTOR. 2000k. HOFMMIDE DRIVE - /MPIES FLORRKA 34 t (K -4230) 252.2477 VWTOURYIMSITEAT-�.A.4 =w TMS RECEIPT R EIPT EXPIRES SEPTEM8 3q /4 2D LOCATION 114PLASTPADALAME �l:�—'fEt C0., °�fyiuRE mF 110s°io aLS IISI�� LBILICl.0 �cEGTrL'fdFaLl BUSINESS PHONE-- 465-201 OCCUPATION �Y LLC mot' �� • THIS TAXIS MON- REFUNDABLE - T `• �! ♦ ZEN GROUP. LIZ 1 - / 7 IIGPoCJ* MICQla1fE,R 11491ASTRADA LANE 4 NAPLES FL 341034000 L NUMBER or EMPLOYEES QNBrER ONLY44O E ♦ ti —may iO CLASSIFJCOK*t WlWr.soiVmmDcONTRACTDRM�CG [i.- - RATE 05271=3 OLASW CUION COM CX 033M NO FERTEJaNG' - -.__ _ _. AMOUNT 1000 Tm doaewst astXmon{ nary. Tairf -s ml mlBuGm OW kwow is gAkw RECEIPT =40 BdwfdP"AT1w1i- - bviolow nyauafiy 4 +n - r0a- am+lptusfwna -hda O'!YOa?ar taaeemPwnRltne msy beNWiaaq M+e .i. azTV W Izif f3pae vlth +Mik. https : / /mail.google.com/mail/ ?shva =l 05/12/2013 .copy of business tax receipt - zengroup.swf(agmail.com - Gmail Page 2 of 2 COWER COUNTY BUSINESS TAX BUSINESS TAX NUMBER: 922511 CDLLER CDL M TAX COLLECTOR - 2800 N HORSESHOE DRIVE • NAPLES FLORDA 34 t 0a -aX) 252.2477 YISIT OUR WESSREAT-- mlieAax my THIS FIECEWT EXPlAn SEPTEMBER M" LOCATION ,1+9 LAS7RxDA LANE V C ©� w f-A LL; RE TOP BOSD D cCOWMARr TO LOOrAL LAVJL ZONED HOMEOOOUPATION �+� �L'E �� . MUS -TAX IS MOWEPUNDABLE - B./SINESS PHONE 455 -2557 LLC - _ : t ZEN GROUP. LLC _ 1 t UGNCA MICOMINEA2 1149LASTNAOA LANE NAPLES R34103-M NUMBER Of EMPLOYEES. OWNER ONLY -NO EM.„ ClASS1PI OKW RAW. SER6'ICEtNDCONTRACTORL fl LL 'E ' DATE Oa'21a013 OLASSFf10Arm tat, CVO= NO FERTAJLNC -0 L -.. AMOUNT 10.09 FtECEFT 727249 Tlu/dmunx0wb�lre�ay. Tail "s mlmnKu9mUlt fnlua- vlgnYEed "doa nw pmd"i 12 "Disk wymr"'mdso7 amp Mwsc(Nr.r �eautgaciiac L vFv -;T(. .�ZCZl� nor Omrs iaoaT1P18tl kanOa�hOm #nYCty tlaltOr psm9ctOt rlD➢bl NtW� IMc KMRT35020131205090007.pdF 1 of 1 https://mail.google.com/mail/?shva=l Dp�tt �t D D 05/12/2013 COLLIER COUNTY BUSINESS TAX RECEIPT APPLICATION 2800 N. Horseshoe Drive, Naples, FL 34104 Make Check Payable to: Collier County Tax Collector Phone: 239 - 252 -2477 Fax: 239 - 643 -4788 Website: www.coluertax.com CHECKLIST Copy of Articles of Incorporation and/or Fictitious letter Yellow Fire Compliance (list of fire district phone number from the State stating that your business name is on file. enclosed) (850- 245 -6052 or 6058) www.sunbiz.org Copy of Marco Zoning Certificate. (239- 389 -5000) Copy of State license from Department of Business and Professional (850 -487 -1395) or Department of Health. (850 -488 -0595) Copy of City Business Tax Receipt. (239- 213 -1800) Copy of Motor Vehicle Repair Registration Certificate from Department of Agriculture. (800 -435 -7352) Copy of Health inspection from Department of Hotels and Restaurants (850487 -1395) or Department of Agriculture. (800435 -7352) F jHE EVA O _ `# P CDD w.E .rµ Completed Zoning application with appropriate fee made payable to: Board of County Commissioners. (239- 252 -5603) Completed Business Tax Receipt application with appropriate fee made payable to: Collier County Tax Collector. (239- 252 -2477) Other: Please contact the Property Appraiser's office at 239 - 252 -8145 regarding tangible tax. CHECK ONE: Date: Original Application Classification Transfer of License # Code Number - - Renewal of License # License Amount 1) CORPORATE NAME - _ —EN) CV_cA_-> L-2-C la) DBA NAME - 1b) BUSINESS OWNER OR QUALIFIER'S NAME - k) C0 P�LfC- �,k(,r_� CA 'St2 2) PHYSICAL ADDRESS - i j 4 9 (No P.O. Box allowed) 2a) IS RESIDENCE USED AS AN OFFICE - `-- Yes No 3) BUSINESS MAILING ADDRESS - 1 M hls -miiA LN WiRZ 0,3 Street City Zip 4) OWNER OR QUALIFIER'S RESIDENTIAL ADDRESS - 5) TELEPHONE -Business: Home: 2S9 " - 2. 119 6) LEGAL FORM OF BUSINESS: Sole Proprietorship Partnership Corporation *I"— LLC LLP 7) OPENING DATE OF BUSINESS OR DATE ASSUMED - A P Z 11., j o � '3 8) OFFICE WITHIN CITY LIMITS OF NAPLES - _ Yes ✓- No If Yes, City License No. 9) SOCIAL SECURITY NO. or FEDERAL EMPLOYER IDENTIFICATION NO. — (O ti -see back of application for explanation 9a) TYPE OF BUSINESS CONDUCTED:�)Lfl,�1(o 10) NUMBER OF EMPLOYEES - Including number of owners: 11) FILL IN THE APPROPRIATE AREAS - a) Rental units (motel/hotel/apts.) Number of units: b) Seating Capacity (rest. /cafes, etc) Number of seats: c) Number of coin- operated machines owned by business or individual: 12) STATE LICENSE OR CERTIFICATION NUMBER - Must have photo copy of state license if state licensed and certified UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED IN IT ARE T UE TO THE BEST OF MY KNOWLEDGE. xxxAPPLICANT'S SIGNATURE: DATE: —20 J `j (Owner and/or representative of business) TITL * ** *THIS LICENSE IS NON - REFUNDABLE FOR BUSINESS STATED ABOVE * * ** J 510 _603_� - / 94-7 Form $$-4 I Application for Employer Identification Number L___ oMB No. 1545 -0003 (Rev. January 2010) (For use by employers, corporations, partnerships, trusts, estates, churches, EIN Deparenent of the Trea U sury `7 govemment agencies, Indian tribal entities, certain Individuals, and others.) n^ _ (Q (Q J (Q Internal Revenue sarAca ► See separate Instructions for each line. ► Keep a copy for your records. 1 Legal name of entity (or IndlvlduaQ for whom the EIN is being requested ZEN GROUP, LLC m 12 Trade name of business of different from name on line i) 13 Executor, administrator, trustee, "care of" name MICO UGRICA JR. a 4a Mailing address (room, apt., suite no, and street, or P.O. box) 5a Street address (if different) (Do not enter a P.O. box.) c 1149 LASTRADA LANE C. 4b City, state, and ZIP code (if foreign, see Instructions) 5b City, state, and ZIP code (if foreign, see instructions) `o NAPLES, FL 34103 O. 6 County and state where principal business is located COLLIER COUNTY, FLORIDA 7a Name of responsible party 7b SSN, ITIN, or EIN MICO UGRICA, JR. 8a Is this application for a limited liability company (LLC) (or 8b If 8a is "Yes," enter the number of a foreign equivalent)? . ® Yes ❑ No LLC members ► 1 Sc If 8a is "Yes," was the LLC organized in the United States? . . ... . . . . . . * . . . . . . 0 Yes El No 9a Type of entity (check only one box). Caution. If Be is "Yes," see the instructions for thx eck. ❑ Sole proprietor (SSN) ❑ Estate (SSN of decedent) ❑ Partnership ❑ Plan administrator (TIN) ❑ Corporation (enter form number to be filed) ► ❑ Trust (TIN of grantor) ❑ Personal service corporation ❑ National Guard ❑ Stste/local government ❑ Church or church - controlled organization ❑ Farmem' cooperative ❑ Federal government/military ❑ Other nonprofit organization (specify) ► ❑ REMIC ❑ Indian tribal govemments/enterprises m Others ► DISREGARDED ENTITY Group Exemption Number G if any lo- 9b If a corporation, name the state or foreign country State Foreign country (If applicable) where Incorporated FLORIDA 10 Reason for applying (check only one box) ❑ Banking purpose (specify purpose) ► 21 Started new business (specify type) ► ❑ Changed type of organization (specify new type) ► LIMITED LIABILITY COMPANY ❑ Purchased going business ❑ Hired employees (Check the box and see line 13.) ❑ Created a trust (specify type) ► ❑ Compliance with IRS withholding regulations ❑ Created a pension plan (specify type) ► ❑ Other (specify) ► ICE Date business started or acquired (month, day, year). See Instructions. 12 Closing month of accounting year DECEMBER APRIL 5, 2013 14 If you expect your employment tax nobility to be $1,000 13 Highest number of employees expected in the next 12 months (enter -0- If none). or less In a full calendar year and want to file Form 944 If no employees expected, skip line 14. annually instead of Fors 941 quarterly, check here, (Your employment tax liability generally will be $1,000 Agricultural Household or less if you expect to pay $4,000 or less In total Other wages.) If you do not check this box, you must file 0 0 J 0 Form 941 for every quarter. ❑ 15 First date wages or annuities were paid (month, day, year). Note. If applicant Is a withholding agent, enter date income will first be paid to nonresident alien (month, day, year) . . . . . . . . . . . . . . . . ► 16 Check one box that best describes the principal activity of your business. ❑ Health care & social assistance ❑ Wholesale - agent/broker m Construction ❑ Rental & leasing ❑ Transportation & warehousing ❑ Accommodation & food service ❑ Wholesale -other ❑ Retail ❑ Real estate ❑ Manufacturing ❑ Finance & insurance ❑ Other (specify) 17 Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided. GENERAL CONTRACTING, RESIDENTIAL CONSTRUCTION 18 Has the applicant entity shown on line 1 ever applied for and received an EIN? ❑ Yes ® No If "Yes," write previous EIN here lo- Complete this section only if you want to authorke the named individual to receive the entity's EIN and answer questions about the completion of this form, Third Designee's name Deslpnee's telephone number (Include area code) Party LORI IRONS ( 239 ) 261 -0544 Designee Address and ZIP code Designee's fax number (include area code) 5147 CASTELLO DRIVE, NAPLES, FL 34103 239 ) 261 -2795 Under penalties of perjury, ) declare that I have examined this application, and to the best of ml' knowledge and belief, it Is true, coned, and complete. Applicant's telephone run bar (Include area code) NameancItttleltypeorprilitcleariyA MICO UGRICA, JR., AS ITS MEMBER ( 647 ) 932 -6700 c Applicant's fax number (Include area code) gnature ► Date loon?' �- 2b-11 ( 1 For Privacy Act and P4Jlerwfork Reduction Act Notice, see separate instructions. Cat No. 16055N Form SS -4 (Rev. 1 -2010) V11 Liq January 1, 2014 Collier County Contractors' Licensing Board Collier County Government Center Administrative Building Third Floor 3299 E. Tamiami Trail Naples, FL 341.12 In the summer of 2007, we decided to move our family to Southwest Florida. The next two years brought financial hardship to my personal life due to the downturn in the economy and the slow sale of my home in Pennsylvania. It took two and one -half years to sell; and, we were stripped of all equity that we had in it. Thus, it created a large credit card debt that I was unable to repay. The economy left me unable to start my Electrical Contracting business here, so I looked to find other employment, but was left with only being able to secure part time work. This debt was incurred in my personal life and did not pertain to my business. The economy is starting to turn around, so I am looking to start my Electrical Contracting business here to be able to provide for my family once again, and to eliminate debt that accumulated over this historic downturn of our economy. I am appealing to your understanding in seeing that my situation is a result of unavoidable circumstances and ask for your confidence in seeing that I will be an asset to the Collier County construction field. Thank you for your consideration. ti �y Paul avage Paul Bolcavage, 500 Ibis Way, Naples, FL 34110, Ph -(239) 249 -1480 37 r77 33 3 er C;ar4 gty .w G D Operations & Regulatory Management . BY ........................ Licensing Section 2800 North Horseshoe Drive C ' Naples, FL 34104 ) APPLICATION FOR COLLIER COUNTY/CITY OF NAPLES /CITY OF MARCO FIRM INSTRUCTIONS: This application must be typewritten or legibly printed. The application fee must accompany this application. The fee is not refundable after the application has been accepted and entered on the records. All checks should be made payable to the Board of Collier County Commissioners. For further information, consult Collier County Ordinance No. 90 -105, as amended. NAME OF COMPANY: Exact Corporate/ Business Name: Fiction Name /DBA: Qualifier. Name: L-L_ C. LL L Physical Address: S Gt > J: O 1 � '+ k" is " F (-- � �i l l C �'y�,,,, A ,,},,y,,� ( jNumber` & Street) ( (City) (State) (Zip Code) Mahngllddress. (Number & Street) (City) (State) (Zip Code) Telephone: 13'1- d 49- ) 4 �C' E -Mail: _ j- UOLC n C C=v:,'h.iv TYPE OF LICENSE: ' ❑ General $230.00 Electrician $230.00 ❑ Building $230.00 ❑ Plumber $230.00 ❑ Residential $230.00 ❑ Air Cond. $230.00 ❑ Mechanical $230.00 ❑ Swimming Pool $230.00 ❑ Roofing $230.00 ❑ Specialty $205.00 trade: ri ie r �� ,�� i i Ct CHANGE OF STATUS: ( ) Reinstatement ( ) From One Business to Another ( ) Dormant License to Active Paae 1 of 4 The names, titles; home address and phone numbers of all Officers /Managing Members of the Firm. i _ r 2. List all businesses, firms, entities or contracting businesses you have been associated with during the last ten years (ex. Held a license for or been a partner). Attach extra pages if needed. rain- F ✓ii *✓C �1:' Y�c� i:� � l_C. c_'( f` t c... 7 `: 7 �` C..`.S 3. List all debts you or any company(s) associated with you refused to pay and the reasons for the refusal to pay. Attach extra pages if needed. AFFIDAVIT certify that the foregoing is tree orrect to the best of my knowledge. I .J i Authorized -Offce-r- of the Firm STATE OF FLO IDf� COUNTY OF The foregoing instrument as acknowledged before me thisC�C(�/�'�f (Date) )icyc, SY � ' of fQYf s` ,- Et ZCfYt (Name of officer, title /agent)`r (Name of Corporation) a Pb Corporation on behalf of the corporation. (State or Place of Corporation) He /She has producedR 13 4 -2 k 0 0-7 0177 identification and did not take an oath. {Type ofi identific ^+ ^ ^` NOTARY'S SEAL DENISSE NENNINGER „ Notary Public - State of Florida My Comm. Expires Nov 25, 2016 Commission # EE 853640 Bonded Through National Notary Assn. Page 2 of 4 QUALIFIER INFORMATION: Name: Address: (Number & Street) (Ci{ Telephone: S.S. 4: 000 -00- Driver's License: (State) (Zip Code) Date of Birth: _S / 7 _ G E -Mail: }7��+�c �► C2 C vj,% 64r G1 MOIL, 1. Type of Certificate of Competency for which application is made. -rrt C A- 2, The names and telephone numbers of two persons who will know your whereabouts. 137 - DS -2 . 3 `10 yLl y �33i 3. Have you ever been convicted of a crime related to Contracting? (If yes attach extra sheet with explanation) 7. Have you or any firms you have been associated with ever filed bankruptcy? 8. List all debts you or any company(s) associated with you refused or failed to pay and reasons why. S c -, Ti cl,t -0 C VNoi, i ice T r 9. List your business or work experience during the past ten years. -T 10. Statement of any formal training you have had in the area for which the application isJ made. V- 1 t-c r 11 C - 1 �- Page 3 of 4 AF.F'IDAWT IT IS understood and acknowledged by the Collier County Contractors' Licensing Board and myself that if I fail to acquire, or maintain at all tunes effective Workmen's Compensation Insurance it will result in the possible revocation of my Certificate of Competency. SIGNATURE CANT BUSINESS NAME P-,,93 -13 DATE BEFORE ME this day personally appeared Awi 80j.00 'now., who affirms and says that he has less than one employee and does not require Workme s Compensation understands that at any time he employees one or more persons he must obtain said Workmen's Compensation Insurance, STATE, OF FLORIDA COUNTY OF The foregoing instrument was acknowledged bofore me this 'J (�I a? /-V -/- _ (Date) by by 11,t��1J( ! who has produced (name dpersoj acknowledging) (Type of identification) is identificatinn and who did not take an oath DENISSE NENNINGER Notary Public - State of Florida _ My Comm. Expires Nov 25, 2016 Commission hP EE 853640 Bonded Through National Notary Assn. r.--.- NOT S 1 lam' c� /�•Q;'1dl I � (PRINT NAME OF NOT Y PUBLIC) NOTARY PUBLIC STATEMENT OF OWNERSHIP This certifies that L 4 L am a member or (APPLICANTS XAME) t-,� Managing member of (LIMITED LUBILM CO MPANY NAME) ,-) .-,j e- own 103 % of the units issued by the Limited Liability Company listed above. Affidavit of Applicant.-.1 certify that the information contained is a true and correct statement to the best of my knowledge. 0:3 (DATU) PROMETRIC EXAMINATION RESULTS NOTIFICATION September 13, 2013 Paul Bolcavage PO Box 112188 Naples, FL 34108 Dear Candidate: We are pleased to inform you that you achieved a passing score on your recent Collier County examination. Your score(s) are as follows: 09/07/2013 Bonita Springs, FL Master Electricial 78 Pass Collier County requires a passing percentage of 75 %. Please note that passage of the exam is no guarantee a certificate of qualification will be issued by the Licensing Board. To help you gain the recognition you deserve, Prometric has prepared a Certificate of Achievement, beautifully designed and very suitable for framing (8 -1/2 x 11) for only $30.00 per category. Please fill out the order form below, cut along the dotted line, then send the completed form to Prometric . Payment options: check, money order, Visa or MasterCard. Credit card orders may be faxed to (800)813 -6670. All others send to Prometric , 7941 Corporate Dr, Nottingham MD 21236. Allow 2 -3 weeks for delivery. Certificate of Achievement Request Paul Bolcavage PO Box 112188 Naples, FL 34108 Collier County - Master Electricial - 09/07/2013 For credit card payment, complete the following. Card No. Signature Quantity x $30.00 = Card Type: Visa _ Mastercard _. Exp. Date F159 - fl -bonsp - C PROMETRIC * 7941 Corporate Dr * Nottingham, MD 21236 Toil Free: 800.280.3926 * Fax: 800.813.6670 * www.prometric.com PROMETRIC EXAMINATION RESULTS NOTIFICATION November 11, 2013 Paul Bolcavage PO Box 112188 Naples, FL 34108 Dear Candidate: We are pleased to inform you that you achieved a passing score on your recent Collier County examination. Your score(s) are as follows: 11/02/2013 Bonita Springs, FL Business and Law 88 Pass Collier County requires a passing percentage of 75 %. Please note that passage of the exam is no guarantee a certificate of qualification will be issued by the Licensing Board. To help you gain the recognition you deserve, Prometric has prepared a Certificate of Achievement, beautifully designed and very suitable for framing (8 -1/2 x 11) for only $30.00 per category. Please fill out the order form below, cut along the dotted line, then send the completed form to Prometric Payment options: check, money order, Visa or MasterCard. Credit card orders may be faxed to (800)813 -6670. All others send to Prometric , 7941 Corporate Dr, Nottingham MD 21236. Allow 2 -3 weeks for delivery. Certificate of Achievement Request Paul Bolcavage PO Box 112188 Naples, FL 34108 Quantity Collier County - Business and Law - 11/0212013 x $30.00 = For credit card payment, complete the following.. Card Type: Visa _____- Mastercard Card No. - _ — _ Exp. Date -- - - __ - - - - -- Signature F159 - fl -bonsp - C PROMETRIC ' 7941 Corporate Dr ` Nottingham, MD 21236 Toll Free: 800.280.3926 ' Fax: 800.813.6670 " www.prometric.com State of or • a Department of State I certify from the records of this office tl��t STARFISH ELECTRIC & HOME SERVICES, LLCI, is a Fictitious Name registered with the Department of State on Dece'm ber 17, 2013. The RegistrationNunnber ofthis Fictftiotis Name is 613000123536. I further certify that said Fictitiow Name Registration is active. I further certify that this office began filing Fictitious. Name Registrations on January 1, 1991, pursuant to Section 865.09, Florida Statutes. Given under inav hand and the Great Seal of Florida, at Tallahassee, the Capital this the Eighteenth day ofDeeeinher, 2013 0 = _ Secretary of State Ili 1 * * Authentication ID: 900254315589- 121313- GI3000123536 �►Q� To authentzate this certifieate,visit the fo 1b'A-ing site, enter this ID, and then follow the instivctions displaved. https : / /efik.sunbiz.oig /cei-tauthve r.htmi Certificate of Status I certify from the records of this office that STARFISH ELECTRIC & HOME SERVICES, LLC, is a limited liability company organized under the laws of the State of Florida, filed electronically on December 17, 2013, effective December 17, 2013. The document number of this company is L13000173834. I further certify that said company has paid all fees due this office through December 31, 2013, and its status is active. I further certify that this is an electronically transmitted certificate authorized by section 15.16, Florida Statutes, and authenticated by the code noted below. Authentication Code: 131217143608- 000254801530 #1 Given under my hand and the Great Seal of the State of Florida at Tallahassee, the Capital, this the Seventeenth day of December, 2013 OA*_ 6* %.erg et In etxetarro of 6t& My Federal Tax Number is: 81-0564955. Paul B Icavage Starfish Electric & Home Services., LLC Ot CREDIT CHEC sm CONFIDENTIAL Individual Credit Report r PA NAPLES, 7 ES, F7 34: 1 Scc-ia1 4: App- -�cant: -cm-leted 2 -4 11 A--, t 12,''30;/13 CREDIT RECORD (Credit history has been checked -`= a peric-d of seven years or from cpen date,) C:7e d- toz Date Sate = an, " T 7, P a -' = Past F a Stat; C'-ir-cnt Dies Account Number Repnfl:ed -:renea Ea-aTLcc 6 C, r, statl? R." ECOLL BK OF AMER NO STATUS 3235 11/09 08/04 11481 11481 1497 344 R9- 06 A ACCOUNT INFORMATION DISPUTED BY CONSUMER CAP ONE COLLECTION 12/13 11/99 16846 1751517515 525 R9- 16 IC DLA=05/08 CHASE PD COLLECT 10/10 11/06 21377 PAID 0 0 09-* 04 A DLA=05/08 CHASE PD COLLECT 08/10 02/94 16927 PAID 0 REV R9- 19 A DLA=05/08 CHASE PD COLLECT 08/10 06/05 12912 PAID 0 REV R9- 06 -A -/08 DLA=O:,D CHASE PD COLLECT CITIZENS BNK PD COLLECT 131/10 05/06 G 0 0 0 19-* 04 P DTA=07/09 CITIZENS 2NK PD WAS120 09/09 4f G6 1-2/4976 CLOSED 01 C1 0 Il-* 40 DLA=07/09 CONVERGENT T COLLECTION /13 0 4/'11 303 31-3 COLL 09-* 02 A- ORIGINAL CREDITOR: SPRINT Ordered by: AP PT T CANT - SEE NAME AB-0�,'E Reporting Agency Credit Check, Inc. - 3017 Exchange Court, Suite H, West Palm Beach, FL 33409 . (561) 616-5556 CREDIT CHECK name..... BOLCAVAGE, FAJL CONFIDENTIAL . ustc ner. 9999 Page. CREDIT RECORD credit h' story has peen checkee cr a F ter_ ��e: �r �r z ate ) Account Numhe_ Rerc -tei Opened -_ --_- = a =an -_ -le 7=2 o ^_ __ Status Rev =k DISCOVER FIN ENHANCRCVRCO COLLECTION SPRINT EXXMBLCITI DISCOVER FIN 12/13 08 /10 1833 ORIGINAL CREDITOR: CITIFINANCIAL NCA 02/13 10/10 28380 ORIGINAL CREDITOR: CHASE ONEWEST BANK COLLECTION 304 304 COLL -- -- -- 09-* 00 A PD COLLECT PAID 0 REV - - -- -- R9-* 14 A AS AGREED PAID 0 REV 0000 00 R1 16 A COLLECTION 3125 3125 COLL -- -- -- 09-* 04 A COLLECTION 2563 2563 COLL -- -- -- 09-* 04 A COLLECTION 28380 25380 COLL -- -- -- 09-* 02 A 08/09 09/02 346700 CLOSED 0 DLA =08/08 PD WAS120 0102 09 M1 -* 48 (Ordered by APPLICANT - SEE NAME ABOVE Reporting Agency Credit Check, Inc. - 3017 Exchange Court, Suite H, West Palm Beach, FL 33409 . (561) 616 -5556 CREDIT CHECKM CONFIDENTIAL Narne .... : BOjLCAVAGE, PAUL 9999 Page: 3 (Cred�Jt 1--,istcry has teen ch- woke d -P m 3 p (zl 1, "date.) seven v ifs c r f r Reported Cp ene d 3a --an Ce :ue 7erms Stat,-s Rev ECCA PORTFOLIO RC COLLECTION 12/13 01/09 4973 5338 5338 COLL 09-* 05 A ORIGINAL CREDITOR: CHASE BANK USA RAYMR&FLNIGN DLA=07/07 RBS CITIZENS DLA=04/08 TARGET/TD DLA=05/08 WORLD OMNI F DLA=11/13 AS AGREED 09/09 10/03 7 3 rD 0 PAID 0 REV 0000 00 R1 48 F AS AGREED 04/08 07/04 21684 CLOSED 0 0 0000 00 11 16 A COLLECTION 12/13 02/07 5307 5307 5307 159 -- -- -- R9-* 08 A CUR WAS 90 11/13 02/08 27496 2818 0 476 0204 01 I1 -* 48 C Total trade lines on this report: 25 PUBLIC RECORDS: PUBLIC RECORDS HAVE BEEN CHECKED AT THE COUNTY, STATE AND FEDERAL LEVELS WITH THE FOLLOWING RESULTS AS OF 12/30/133: SEE BELOW. --- TRANSUNION PUBLIC RECORD - -- SOURCE DATE LIAB ECOA DOCKET# TYPE COURT LOC PLAINTIFF/ATTORNEY Z 04780232 10/30/08 $6123 C 08/06/09 00800052634 PAID CIVIL JUDGMENT LACKAWANNA COURT (PA) ABINGTON HEIGHTS SCHOOL Z 05064186 08/18/09 $5652 C BK4483PG1565 CIVIL JUDGMENT "COLLIER CNTY CIRCUIT CT TARGET NATIONAL BANK Z 05064186 04/07/10 $8364 1 20093420CC CIVIL JUDGMENT COLLIER CNTY CIRCUIT CT DISCOVER BANK SOURCE(S): EQUIFAX TRANSUNION INQUIRIES: 12/30/13 by CREDIT CHECK (TU) 400630273 COMMENTS: Ordered by: APPLICANT - SEE NAME ABOVE Reporting Agency. Credit Check, Inc. - 3017 Exchange Court, Suite H, West Palm Beach, FL 33409 . (561) 616-5556 CREDIT CHECK C I ONFIDENTIAL Name, BOLCAVAGE, PA-0T .-ast--mer: 9999 Page: 4 COMMENTS: FRAUD RECORDS HAVE 2FE7N _2HE-FE-D F---'7 -HE -ESSEr) E-7REA-10 �"j 71j -H E:-_ K E: E F-u_` -D SAFE SCAN/ EQU__ FAX-, HAWK ALERT REPORT WORKED BY RENEE CREDIT SCORE: APPLICANT FICO SCORE: 626 (scores range from 300 to 850) *** END OF REPORT *** This inforrrg ion is confidential and is not to ,e df✓ulger, except as reaui red by the Fair Credit Reporting Act. This personal report is furnished simply as an aid in determining the credit desirabilitv of the applicard(S). I is eased upon Into nil ion odainedin good taith ay this agency from sources deemed reliable. The accuracy of sarne, h owe/ er, is in noAW guaranteed. By ywraccpptance and LISP if this report you specifically agree to hold Credit: Check, Inc. harmless from any liabilb whatsoever. Ordered by APPLICANT` — SEE MAIME ABOVE Reporting Agency. Credit Check, Inc. - 3017 Exchange Court, Suite H, West Palm Beach, FL 33409 . (561) 616-5556 CITY OF SCRANTON NSk RANTON PE Ai > FEE 150.00 �PORATED APRIt'l)" DATE 1/04/96 ISSUED TO PAUL BOLT ADDRESS 301 MAIN EYNON PA BUSINESS ADDRESS 301 RAIN EYNON PA FOR THE PURPOSE OF 'AVAGE STREET 1 341)3 8510 STREET 18403 8510 DESCRIPTION/SPECIFICATION -f R A C 'f 0 THE ABOVE INDIVIDUAL HAS REGISTERED AS AN ELECTRICAL CONTRACTOR, AND HAS AGREED TO CONFORM TO ALL RULES AND REGULATIONS, 15 ENTITLED TO PERFORM ELECTRICAL CONSTRUCTION WORK IN THE CITY IN ACCORDANCE WITH THROUGH DECEMBER 31, 1996 EXPIRES 12131196 TAG NO. 00001170 Dec, 4, 2013 2:1 PM Valley��JVlew HS uulNArel�4lfAtlddp r,fsr /"Lt wont VALLEY VIEW SCHOOL DISTRICT AACNBALD. PFNNA. 16403 Ao0N666' TELFJTONC: / FA7FI GA+ 06CUTAY10d: y0 14M occu -naYt IONO rJl1YYN: Ley ,,{{ _ +silo a•.4c� ::.K,r n � ctwH .0sccr17 %%I'9 scc. siuYll[ S c4c sTVOI.. 601KC ]r6r+.G SU9YCC (rL.0 YG YL,1111G 1[A I .uH+IG Yom NDstc G5' .5 10GSL YUNI Y� L..{ L.a LiYi,IL _ rPftG wu tic sxwlc sr(W� rnr, co. ANT, m. U04 MNKL IOCAL M4NG lt6.L y[[ uLLi4 AAi UAGAL AA149cl YARM95% AlgY1.. LEGAL AA[[K( ...rrmlo rvY 9AL4AL AfflNcf src w .01rmc Yw_ 07 INST. YSSI( All 'Jrl L[YAL A .... C. &U ASS[N4 TAr.1N.(L .l4wmto .61ASYAa ' ,Vp d c c rIY4 'r f(AU 1. No. 0651 --P, 1 :- viFaff V , nl Side 1 superior Above Av. C L ve.f Below Av. evel S-f- -Above Grade - o Level -On Grade Leve -Below Grade Level _ B8502 .• B MiNUCTIONAL LEYr, 'READiNO lANO. ARTS MATH. TR )MFrRRM TO. DATE: —ICI ------ - - - - -- ' - -- - - - - -- - � .w1 of, - ; BOLCAVAGE PA 8815302 ,Q E GL� ISIi 9 WORLD CULTURE .ALGEBRA I w EARTH A SPACE SPANISH I _ MFG PROD I PHYS ED 9 16, 0p La rim _ ktCAAVA E• ki I.V.W.• WpW2 7M G DEV READ 7 1100 74 'GE�NFDG�7�L2 1,600 67 - "-G'-P "' 1,00 72 �+. MAIN 71 1-00 68 SStttt 7 1 J v 77 fHr ARTS 7 0,40 S PNY EDUL 7:0,40 c MUSIC 7 0-40 B- ' _ t_p _ iiuu (Q -t D.O ,y. T '12Q 6 -''71144 ' D0'' ".'.'.`r'• DEV READING B 11087 EMBLIPH 6 1.074 PA HIS? CIVICS 1.000 MgTM 8 1.0 71. 01110E 8' p11.0 67 AMY A T, B 4-� B PANT 8 ' - 0n.4 8- HEALTH 8 0.6 8d _ , AD8 5r0 �, =6180 pV 76,4 RAM[ . 0 ACORIC M. A, EXTRA ffw 01"1149 1[A I LAM A1rs � ( u9Y. arc YAM[rITC6 YLIYlGtlI4Gf 34G. 6rrwci Y� L..{ L.a LiYi,IL _ rPftG * Laaec sxwlc sr(W� ■unAC ..m9c III Ym.L YU(iG IOCAL M4NG .9LH. YYL,1 � IN1f. rYM LEGAL AA[[K( Ll9LL lY1lnGL YAt4AL Ni9K[ 9AL4AL AfflNcf TAp1Aci3 A1411a1La ;=ML-990 r14r4TLa - 9 /I4AfY GATE GRAVA C. A. ,NAME OF TEST FORM 4Q. `I I I MiNUCTIONAL LEYr, 'READiNO lANO. ARTS MATH. TR )MFrRRM TO. DATE: —ICI ------ - - - - -- ' - -- - - - - -- - � .w1 of, - ; BOLCAVAGE PA 8815302 ,Q E GL� ISIi 9 WORLD CULTURE .ALGEBRA I w EARTH A SPACE SPANISH I _ MFG PROD I PHYS ED 9 16, 0p La • Dec, 4. 2013= 2:10PVV-!!--'--;Valley View HS _ No. 0657— P, 2 rA �O M, � xozor •czGrtrn o z rn , oa y "" PLA i i •� ERBAC" A I, _ _ MT e 03 O 0) 0-4 00 xr +n m (fl NRIl N 01 5 10 2 20 3 w " � WW O Z -0 D 0 o C r I 6M tlWW DIFFERENTIAL APTITUDE TESTS A E_' No GR.- M 0G'NM 5PEE6 (m" r w 60� itE10�n l x4,5 6 hit 1.urn wu.e rcwv,d U '� N ons F Fr , _ma� r i .mm o 00000. N 47 6 5. lq StMl.Aid i'TtST; OP•;ACA99NY� SKELis;: � �- R��gp •: p��p�� ry sP.ELLIN6 .v;,.•. EN6LIS NRTH fir,. ... SGORE;iYPE AC7 AOE UL6�FQ•E: , ..; .,.,�BO i'•MIID.'•-VDCA6 :7l`66yy-G'O• �.:� -'$f.,553 1 $ ,r.••;. i 20 37:5: CA7t a- .. s• �,'�. ' OfcS�. ��8:�. . '11:'S� p:� AGE g e RPA9alfir f•. `' N,. SYc' eo�P�e 9a TOY' 9A F, ;.; opE ,,AA,,AA�CCCCyfy6•�[ 2F •. - - ,.... — _ jrj}rC C ''r' ' ' '•70 Y ' "'; Y97 E0'- S, 50.0 BBBBffNNAWWW1E L011r.iiiiii ,� _ STANDARDIZED TEST RFeULTS * f •.. ^-o:.. NATt .PC7Lfc PCfLrs 05/7T RURAL�YoWN 1 VRC56'•GOR! J BOLCAVAGE PAUL '05 /TB el 3 at -6AO Q 6AlO 3 -3 914 MAT" 3— 199 GW •Ty"ATYR1 1 a -79 - 0 1 d: m: 2 rm ""..we rneesw�e et i OOLCAVAGE PAUL cacao II oor..coq SCHOOL LOC BOLCAVAGE PAU 1OLCAVAGE PA=" o. a SCHOOL LOC s 6140! NP � 06.7 NS WE 04/02 llli aTVINLMrs. =AW. -mead r�� •!�.�!•lxlrlf!r:- 1•f \T1i r.H�' f "�•r.7♦I flf'��Tfl'vlr \F.•f 1Tlr� oa y "" PLA i i •� ERBAC" A I, _ _ MT e M1 %&T% 1 ` srAmmFOR07 ST Of" A u1K SrJL S NO F5K SCI SOr, ? 5.1 9. 8.7 l - 65 731 722 ;. 2e 91 75 if 4 7 6 i i oa y "" PLA i i •� ERBAC" A I, _ _ MT e 5 10 2 20 3 34 I I DIFFERENTIAL APTITUDE TESTS BOLGAVAGE A PAUL rvogUF s S 08 M Mr _ B A• S Sn 5PEE6 (m" 15 x 60� itE10�n l x4,5 6 hit 1.urn wu.e rcwv,d U '� N ons F Fr , _ma� r i .mm NO F5K SCI SOr, ? 5.1 9. 8.7 l - 65 731 722 ;. 2e 91 75 if 4 7 6 i i City ol Scranton )irector 3484216 Cammnmity Development 348-4193 Fax 348-4123 ��RANTON, I[NAS�e Fax 348-4171 lousing 348 -4168 i lnspedions & liomsmg 348-4194 istoric Preservation 348-4229 v > 3484195 g 348-4280 • '�(L f � ' Electrical 348 -4196 a� 348-4154 % f .� Housing (City) 3484197 iterprise Zone 34&4282 'PORATED APRIL-0. Plumbing 348-4198 abor Standards 3484272 - Tepartment o /Community 2)eveLpment 340 r —IW,.L y%n.i --, A 18503 April 10, 1995 Dear Sir: On behalf of the Electrical Advisory Board I am pleased to inform you that you have passed the Electrical test. Please contact me at your earliest convenience so I can process your contractor's license. (717) 348 -4193 extension #16. S'ncerely, ectrical Advisory Board City of Scranton JG:cg Nov, 14. 2013 1:48PM No, 3931 P. 1 DEPARTMENT OF LICENSING. INSPECTIONS AND PERMITS CRY HALL • 340N0RiH WASHINGTON AVENUE -SCRANTON. PENNSYLVANIA 16503 -PHONE: 57034 8-4193 .FAX: 570.348.4171 11 -12 -2013 TO WHOM IT CONCERNS: MR PAUL BOLCAVAGE WAS LICENSED BY THE CITY OF SCRANTON UNTIL 2005 HIS LICENSE NUMBER MASTER ELECTRICAL 1170. WAS IN GOOD STANDING UNTIL THAT DATE. NAME AND ADDRESS ON FILE PAUL BOLCAVAGE P.0 BOX # 132 ARCHBALD PA 18403 IF YOU HAVE ANY QUESTIONS FEEL FREE TO CALL JOM4 I. BANNON EELECTRICAL INSPECTOR CITY OP SCRANTON PA 18503 (570) 3484193 M. 4516 'w�mo B O L C AVA G E ELECTRIC R I C ELECTR 301 MAIN STREET EYNON, PENNSYLVANIA HEATING /J DEA f� • - - Phone 570- 876 -1136 December 5, 2013 To Whom It May Concern: Subject: Resume "I am the father of Paul Bolcavage. I owned and operated an Electrical Contracting business beginning in 1960. Paul began working with me summers starting in 1983 until 1988. He also attended a Electrical Vocational - Technical program for 3 years during his Sophomore - Senior years of high school. He also participated in a Co -Op program during his senior year of high school whereas he worked afternoons with me. Starting in 1990, Paul started assisting me in running jobs until 1993, when he obtained his own license and then ran the business for me until 1996. Paul has been proficient in residential, commercial and light industrial projects that my company has completed over the years. Paul always held the highest level of integrity from my personal observations and through feedback from customers during his tenure with me." Sincerely, AntrzI6 . Bo lcavage 1115 113 1 IV C0"l1 V0 ,1n n i T IA wrcu, i s =� � ALLEY VIEw HIGH SCHOOL ONE COLUMBUS DRIVE • ARCHBALD • PENNSYLVANIA • 18403 Telephone: 570- 876 -4110 Fax: 570 - 803 -0217 December 9, 2013 To Whom It May Concern: My name is Ken Marchegiani. I was the Director of Buildings & Grounds for the Valley View School District and supervised maintenance and repair work throughout the districts four school buildings. I have overseen Paul's work in maintaining these buildings from 1989 until 2007. The work entailed from commercial applications to industrial applications. This included, but was not limited to: parking lot lighting, fluorescent and HID indoor lighting, industrial pool filters, heaters and dehumidification system, HVAC units, water pumps, main distribution panel equipment, back -up generator /emergency lighting systems, computer networking cable and security surveillance system. In my time served with Paul, I found him to be good moral character and-professional. Sincerely, ,l Kenneth Marchegiam Retired Valley View School District Director of Buildings & Grounds C0bWNWEAL'TH OF PENNSYLVAM A NOTARIAL SEAL Sbarw Marok Notary Public J=* Bow, LwJmwama County M c0mmissi0n expires October 24, 2017 "t B r BUILDING INSPECTION UNDERWRITERS Tuesday, December 03, 2013 RE: Recommendation Letter on Mr. Paul Bolcavage. To Whom It May Concern: My name is John Hudak, Pennsylvania State Manager and President of Building Inspection Underwriters, Inc., serving this company for over 25 years. It is a pleasure to give you a commentary on the Qualifications and Character of Mr. Paul Bolcavage. I have been associated with Mr. Bolcavage for over 15 years. During such time I have found Mr. Bolcavage to be trustworthy, dependable, of good moral character with a high degree of comprehension and initiative! Throughout the numerous inspections performed by this office on the various commercial and residential projects that Mr. Bolcavage has implemented over the years, we have always found his work to be well organized, of good quality and meeting the requirements of the National Electrical Code. Paul is a respected, established and well- received associate and friend and with such, carries this recommendation. JCH /dmh file Sincerely, John C udak —PA State Manager/Pr Buildi Inspection Underwriters, Inc. 1010 ALBRIGHT AVENUE, SCRANTON, PENNSYLVANIA 18508 866.344.9681 570.344.9681 FAX 570.969.9700 www.biupa.com CATION OF CONSTRUCTION EXPERIEN MD Operations & Regulatory Management Department Licensing Section 2800 N. Horseshoe Drive ?Naples, FL 34104 Applicant's Name:: 1 IR U L t� O L c W F Certificate Category.Requested: E LC -L T CIC vJ Z The Applicant is seeking a Collier County Certificate of Competency in the trade indicated above. As part of the application for this certificate the Applicant must verify tlzeir experience within this trade. You are being requested to provide information that will aid the Applicant in meeting this requirement. You should verify time of active experience working as an apprentice or a skilled worker (e.g. as a worker commanding the wage of mechanic or better in the trade}. Time served solely in a supervisory or administrative role should be described, but may or may not be considered sufficient to demonstrate required trade experience. The person verifying trade experience must provide the following information: Name, Title and license number of the person signing below and verifying Applicants relevant experience: Name: LID ,& Title: �i,A 11 Mq,T -f- [,�1 01 License Number (if applicable): R C^ n q (F Name of Business: s4 �- Business Address: r Business Phone:5. -M ` Ltq 21LS j The Applicant's years of experience from j 9 to t�rL The applicants scope of work (specific duties) included: t�.�c �7c' 0 15 A dd:ttvnal Comaiewt= J., 04;-o Cy 1 e-'i a7 _ _ .4, ri Falsifying any information provided herein may subject your license to Signature Print Nan The foregoing instrument was acknowledged before me on this 3 day of __T r� 2 6L3 by -- -- {�� G J {7l �-i( who is personally i -.own to me or produced t as identification and who did not take an oath. - COMMONWEAL t NOTARIAL SEAL DENISE M. FOLEY, NOTARY PUBLIC CITY OF SCRANTON, LACKAWANNA COUNTY MY COMMISSION EXPIRES NOVEMBER 212017 •� a DATE (MPAIDONYYY) A� CERTIFICATE OF LIABILITY INSURANCE 12/23/2013 f THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGA11VELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 NAME: Pv ary Betz .._. Lutgert Insurance -Ft Myers PHONE � a ._ a�i;�3_�- X36 -u?6.6 12660 World Plaza Ln Bldg 73 E-MAIL ERI Fort Myers FL 33907 ADDRE ._.._._,___ - _ INSURER(S) AFFORDING COVERAGE NAItC# INSURED STARF-2 INDICATED. NOTIVITHSTAPJDING ANY REQUIREMENT, TERRA OR CONDFTION OF ANY CONTRACT OR OTHER DOCUNIENT'vVITH RESPECT TO WHICH THIS INSURER B : Starfish Electric & Home Services, LLC INSURERC: 500 bis Way Naples FL 34110 LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER tAIM/DDNYYYI ! A7MlDDNYYY INSURERD: INSURER E : COVERAGES CERTIFICATE NUMBER: 7C1nG -AAAA REVISION NUMBER: TH IS IS TO CERTIFY THAT THE POs ICIES OF INSURANCE LISTED BELOb'! HAVE BEEN ISSUED TO THE INSURED NAtAED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIVITHSTAPJDING ANY REQUIREMENT, TERRA OR CONDFTION OF ANY CONTRACT OR OTHER DOCUNIENT'vVITH 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 SHOVvIN MAYHAVE BEEN REDUCED BYPAID CLAIMS - ---- __ .. _. _.._.._ Ni SR - . --__.. _ - - ....._ __......._....... i POLICYEFF POUCYEXP _ ,.. _. _ ---- _. - LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER tAIM/DDNYYYI ! A7MlDDNYYY LIMITS A €GENE RALLIABILITY TBA 121;20.:2013 1Z'20i2014 EACH OCCURRENCE $'L000.000 .X , COMMERCIAL GENERAL LIABILITY DAM GE TO RENTED PREI I E. iE3 yrrurrefp 5300.000 C'LAtMS -MADE :.X '.. OCCUR '', '' '.., IAEDEXPtznycneperson) 115,000 _..__ .._... ...... GENERAL AGGREGATE '... $2.000,000 S_._ PER R GENL AGGREGATE UL4 APPUE PRODUCTS - COHAPiOPAGO ' $2,000.000 X POLICY! I PRO- LOC S AUTOMOBILE LIABILITY,. ! UUMBINED SINGLE ' IF E 3 3cc:dent .... e ANYAUTO 1-1--.1-1-1-1-- BO DILYINJURY(Perperson S _ _ . _ ALL OWNED SCHEDULED _.. POCILYIfULRY� raa:dent y AUTOS A UTOS NON -OWNED HREDAUTOS ',, - Per ERTYCAM -.GE ..... T AUTOS : : ..... . - UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESSLIAB CLAUS -MADE AGGREGATE 1 $ DED RETENTIONS S i WORKERS COMPENSATION 'IVC T'.TU ,OTH -. ' AND EMPLOYERS' LIABILITY YIN I ,..,.._.,TORYL1J:11TS ;__ER ......._.. ., _.._... ......... A ,NYPROPRIETOR•PA.RTNER+EXECUTNE EL EACHACCIDEHT a OFFICERNEMBER EXCLUDED? � NIA .. ._..,... _. _ .._ ._._. (Mandatory in NH) EL DISEASE -EA EMPLOYEE S If yes, descrine under ,.. ........__ _ ........ DESCRIPTION OF OPERATIONS uelcw E L DISEASE - POLICY UIIiT S DESCRIPTION OF OPERAT"S I LOCATION S IVEHILE S !Attach ACORD 101, Additional Remarks Schedule. it n-we space is required) t.;hK Iltit;A I t H 1ULUI=K Collier County Board of County Commissioners 2800 N. Horseshoe Drive Naples FL 34104 SHOULD A NY OF THE A BOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZE D REPRE SENTATIVE l @ 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD NOTICE OF ELECTION TO BE EXEMPT Please thoroughly read the instructions before completing this application. Print legibly in each data entry field. If this application contains incomplete or inaccurate information or if the handwriting is not legible, it may cause a delay in the issuance of your exemption. ,ECTION 1: kpplicant Name (please print): applicant's social security number ipplicant's E -mail address (optional): SECTION 2: I am applying for exemption as a (You must check only one box in this section): - ONSTRUCTION INDUSTRY ($50 FEE REQUIRED) - The Division will accept a money order or a cashier's check made payable u the DFS WC ADMINISTRATION TRUST FUND. J Officer of a Corporation (Title): -OR- Member of a Limited Liability Company (LLC) NON- CONSTRUCTION INDUSTRY (NO FEE REQUIRED) ) � Officer of a Corporation (Title): kn officer electing an exemption under Chapter 440, Florida Statutes is not entitled to benefits under this chapter. ;ECTION 3. The corporation of which you are an officer or the limited liability company of which you area member must be egist 1_I and in an active status with the Florida Division of Corporations. Applicants applying as an officer of a corporation must De listed as an officer of the Corporation with the Florida Division of Corporations. List the document number (document number shown on your Annual Report) on file with the Florida Division of Corporations. 11000 /'73 S'L� SECTION 4. This exemption application applies only to the ep rson signing the application, the Corporation/LLC that is listed oelow, and the scope of business or trade listed: Name of Corporation or LLC: S-� C -f f-iCj Sit f- i e L -7'_If c! u0c SCr v' (e 5 i.I- C . FEIN:1- 5� `15.�j AS REGIS'rIRED WITH THE FLORIDA DIVISION OF CORPORATION5 Business Name: �'�G�r�lS11I�G�� U)) ?� _�i'(✓rC('S LL Phone: ( ;,�i�) �4U IF APPLICABLE - LIST FICTITIOUS NAME; DOING BUSINESS AS (DBA); ALSO KNOWN AS NAME (AKA) Applicant's Address of Record: 50 0 T t) i.s. l 0,` —INCLUDE APARTMENT OR SUITE NUMBER �� ''L I t S State: r L.- Zip: w` t 1 U County: �u 1 I t' C)ty. Scope of Business or Trade: 1. El e Cf-f I C 2. 3. 4. SECTION 5. List all certified or registered licenses issued pursuant to Chapter 489, F.S. held by the applicant, or the certified or registered license numbers held by the qualifier for the corporation or LLC listed on this application of which the applicant is a corporate officer: SECTION 6. If you have submitted an electronic payment for this application, write the transaction confirmation number in the following space: SECTION 7. Are you affiliated with any corporation (including LLC) other than the corporation (including LLC) to which this application applies? ❑Yes)o No IF YES, PLEASE LIST THE NAME(s) AND FEIN(s) OF THE AFFILIATED CORPORATION(s) OR LLC(s): NAME: FEIN: SECTION 8. If your corporation or LLC is engaged in the construction industry, you must provide the required proof of ownership in the corporation or LLC. A. To be eligible for a construction industry exemption as an officer of a corporation, the applicant must be a shareholder, owning at least 10% of the stock of the corporation. A COPY OF A STOCK CERTIFICATE EVIDENCING THE REQUIRED OWNERSHIP MUST BE ATTACHED. B. To be eligible for a construction industry exemption as a member of a limited liability company, the applicant must confirm ownership of at least 10% of the company. THE REQUIRED OWNERSHIP MAYBE ESTABLISHED BY PRODUCTION OF DOCUMENTATION REFLECTING THE REQUIRED OWNERSHIP, OR BY SUBMITTING A STATEMENT ATTESTING TO THE REQUIRED OWNERSHIP. THIS APPLICATION IS CONTINUED ON PAGE 2 DWC 250, NOTICE OF ELECTION TO BE EXEMPT — REVISED 12108; RULE 69L- 6.008, F.A.C. SECTION 9. NOTICE OF ELECTION TO BE EXEMPT — Page 2 FRAUD NOTICE A. Any person who, knowingly and with intent to injure, defraud, or deceive the department or any employer or employee, insurance company or any other person, files a notice of election to be exempt containing any false or misleading information is guilty of a felony of the third degree. B. Attestation of applicant - By signing below, I attest that I have read, understand and acknowledge the foregoing notice. SIGNATURE OF APPLICANT SECTION 10. You must identify the workers' compensation insurance carrier that covers any non - exempt employces of your business. Carrier Name: AFFIDAVIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my knowledge and belief, that this election does not exceed exemption limits for corporate officers, including any affiliated corporations as provided in §440.02 Florida Statutes. APPLICANT'S SIGNATURE NOTARY STATE OF FLORIDA, COUNTY OF Sworn to and subscribed before me this day of Personally Known OR Produced Identification NOTARY SIGNATURE ,by Type of Identification Produced My Commission Expires Please mail or submit your completed application, application fee, and any required attachments to The Division of Workers' Compensation at the district office nearest your place of business. 2295 Victoria Avenue, Suite 163 Ft, Myers, FL 33901 Telephone (239) 461 -4006 610 E. Burgess Road Pensacola, FL 32504 -6320 Telephone (850) 453 -7804 3111 S. Dixie Highway, Suite # 123 West Palm Beach FL 33405 Telephone (561) 837 -5716 1313 N. Tampa Street, Suite # 503 Tampa FL 33602 Telephone (813) 221 -6506 1111 NE 251h Ave., Suite # 403 Ocala FL 34470 Telephone (352) 401 -5350 921 North Davis Street Building B, Suite #250 Jacksonville, FL 32209 Telephone (904) 798 -5806 400 West Robinson Street Room #512, North Tower Orlando FL 32801 Telephone (407) 835 -4406 or (407) 245 -0896 499 Northwest 700, Ave., Suite # 116 Plantation FL 33317 Telephone (954) 321 -2906 Live Oak Business Center 5969 Cattlemen Lane Sarasota FL 34232 Telephone (941) 329 -1120 401 NW 2"d Avenue Suite #321, South Tower Miami FL 33128 Telephone (305) 536 -0306 TALLAHASSEE SUBMITTERS Walk -in submissions: 2012 Capital Circle SE Suite #102, Hartman Bldg. Tallahassee FL 32399 -2161 Telephone (850) 413 -1609 Mail in submissions: 200 East Gaines Street Tallahassee FL 32399 -4228 Telephone (850) 413 -1609 "The collection of the social security number on this form is specifically authorized by Section 440.05(3), Florida Statutes. The social security number will be used as a unique identifier in Division of Workers' Compensation database systems for individuals who have applied for and /or been issued a certificate of election to be exempt. It will also be used to identify information and documents in those database systems regarding individuals who have applied for and/or been issued a certificate of election to be exempt for internal agency tracking purposes and for purposes of responding to both public records requests and subpoenas that require production of specified documents. The social security number may also be used for any other purpose specifically required or authorized by state or federal law." DWC 250, NOTICE OF ELECTION TO BE EXEMPT— REVISED 12108; RULE 69L- 6.009, F.A.C. DATE SIGNED Effective /Issue Date: Expiration Date: Control Number: Postmark Date: Payment Number: Received Date: COLLIER COUNTY BUSINESS TAX RECEIPT APPLICATION 2800 N. Horseshoe Drive, Naples, FL 34104 Make Check Payable to: Collier County Tax Collector Phone: 239 - 252 -2477 Fax: 239 - 643 -4788 Website: www.colliertax.com CHECKLIST Copy of Articles of Incorporation and/or Fictitious letter Yellow Fire Compliance (list of fire district phone number from the State stating that your business name is on file. enclosed) (850- 245 -6052 or 6058) www.sunbiz.org Copy of Marco Zoning Certificate. (239- 389 -5000) Copy of State license from Department of Business and Professional (850- 487 -1395) or Department of Health. (850- 488 -0595) Copy of City Business Tax Receipt. (239 - 213 -1800) Copy of Motor Vehicle Repair Registration Certificate from Department of Agriculture. (800- 435 -7352) Copy of Health inspection from Department of Hotels and Restaurants (850- 487 -1395) or Department of Agriculture. (800- 435 -7352) Tt Sn` •,,• CCU µt 5��,.' Completed Zoning application with appropriate fee made payable to: Board of County Commissioners. (239- 252 -5603) Completed Business Tax Receipt application with appropriate fee made payable to: Collier County Tax Collector. (239- 252 -2477) Other: Please contact the Property Appraiser's office at 239 - 252 -8145 regarding tangible tax. CHECK ONE: Date: Original Application Classification Transfer of License # Code Number - - Renewal of License # License Amount lV CORPORATE NAME - C-1- Vi C�z'_� L —L la) DBANAME- S_1Ar(.Sk + NZ-'1,2 Sc ✓<LS.) LLL. lb) BUSINESS OWNER OR QUALIFIER'S NAME 2) PHYSICAL ADDRESS - S 0 0 T DO (No P.O. Box allowed) 2a) IS RESIDENCE USED AS AN OFFICE - x Yes No 3) BUSINESS MAILING ADDRESS - ( ( & Street City Zip 4) OWNER OR QUALIFIER'S RESIDENTIAL ADDRESS - Sc c' i DO j w, 3 5) TELEPHONE -Business: 6) LEGAL FORM OF BUSINESS: Sole Proprietorship Home: Partnership Corporation -' LLC LLP 7) OPENING DATE OF BUSINESS OR DATE ASSUMED - 8) OFFICE WITHIN CITY LIMITS OF NAPLES - _ Yes v" No If Yes, City License No. 9) SOCIAL SECURITY NO. or FEDERAL //EMPLOYER IDENTIFICATION NO. *see back of application for explanation 9a) TYPE OF BUSINESS CONDUCTED: k f j (''a1 y_tr Y c--ror — R -e.Ci j S� r-e-^l L—o? NUMBER OF EMPLOYEES - Including number of owners: 11) FILL IN THE APPROPRIATE AREAS - a) Rental units (motel/hoteUapts.) Number of units: b) Seating Capacity (rest. /cafes, etc) Number of seats: c) Number of coin - operated machines owned by business or individual: 12) STATE LICENSE OR CERTIFICATION NUMBER - Must have photo copy of state license if state licensed and certified UNDER PENALTIES OF PERJURY, l DECLARE THAT I HAVE READ THE FOREGOING DOCUMENT AND THAT THE FACTS STATED nRUE O THE BEST OF MY KNOWLEDGE. xxxAPPLICANT S SIGNATURE: DATE: -1. f 3 (Owner and /or representative of business) ITLE�y C �� % e <w a —, y ,- * ** *THIS LICENSE IS NON - REFUNDABLE FOR PUSINESS STATED ABOVE * * ** COLLIER COUNTY GOVERNMENT DEPT. OF ZONING & LAND DEVELOPMENT REVIEW WWW.COLLIERGOV.NET (239) 252 -2400 FAX (239) 643 -6968 LAND USE AND ZONING CERTIFICATE HOME OCCUPATION Please take the time to fill out this form as completely as possible. Remember that only someone actually living at the address given below may engage in the home occupation described. Customers or employees not living at this address are prohibited from traveling to and from the residence if visits are related to this home occupation. The applicant is the person in whose name the occupational license will be issued, and the applicant's signature must appear on this form. Verification as property owner or lessee in the form of a Valid Florida's Driver License or Florida Identification Card and/or copy of valid lease agreement is required. APPLICATION DATE + j ZONING CERTIFICATE # TC- :� n APPLICANT'S NAME ✓ -1S r PHONE: �))j C/ % y ryC) APPLICANTS HOME ADDRESS v �—� l S w A r K-) q c C.1 F L 3L OD TYPE OF BUSINESS TO BE CONDUCTED l - t CIA 3r — kle C t 5 tti r C =C BUSINESS NAME (IF ANY) S �� { i �h L�� !� fi tic S,c -: y, c Li LC C 1, the undersigned, hereby affirm that I am the legal owner of the property at the above address or that I have the legal right to conduct the business described above at this address by virtue of my leasehold interest in this property, and that I have read, understood, and agree de by the provisions of LDC Section 5.02.00 'Home, Occupations" (see back of application). % APPLICANT SIGNATURE "' DATE i 3 t..... FEE: $50.00 CHECKS PAYABLE TO: "COLLIER COUNTY TAX COLLECTOR" ZONING: REVIEWED BY TO .BE CO"IMWD BY COUNTY STAFF PROPERTY ID DATE APPROVED HOLD DENIED COMMENTS /RESTRICTIONS: Must comply with Section 5.02.00 of the LDC ('see back of application). 1 ax Collector Staff: Please forward a copy of issued certificate and receipt to Collier County Zoning Department. .� DRIVER LICENSE CLASS € -�! " -_ HAUL BOLLaaVAGE 600 IBIS WAY NAPLES, FL 34110 -0000 - 009: SEX M ISSUEf7.10 -11 -2007 Hot, 5-41 6XRIRES: 06A7-2014 REST: ENDORSE REPLACED: 10- 30 -20EI' (lW f�rl:l rely SAFE OkiVER , IU.v.fr�i I. ...II•Il:l 11 «- ...r1Sa... Ir .. �:rri it elf rc.:ii t,. I.,u BEFORE THE COLLIER COUNTY CONTRACTORS' LICENSING BOARD BOARD OF COUNTY COMMISSIONERS, COLLIER COUNTY, FLORIDA, CONTRACTORS' LICENSING BOARD Petitioner, 181 Mario Rodriguez D /B /A — K.C. Tiles & Marble, Inc. Respondent. Case Number: 2014 -01 License Number: 19105 & 21273 ADMINISTRATIVE COMPLAINT Collier County (County) files the Administrative Complaint against Mario Rodriguez ( Respondent), a Collier County licensed Tile and Marble Contractor (license # 19105) and also Masonry Contractor (license # 21273), and states the following facts and allegations in support of the cited violations below: 1. The Respondent is currently licensed by Collier County as a Tile and Marble Contractor with License number 19105, and also a Masonry Contractor with License number 21273. 2. Under the provisions of Collier County Ordinance 90 -105, as amended, Section 22 -201, the following actions by d holder of a Collier County / city Certificate of Competency shall constitute misconduct and grounds for discipline pursuant to Section 22 -202. a. Ordinance 90 -105, as amended, Section 22- 201 (2) — "Contracting to do any work outside of the scope of his /her competency as listed on his /her competency card and as defined in this Ordinance or as restricted by the Contractors' Licensing Board." Mr. Rodriguez, a Collier County Tile and Marble Contractor and Masonry Contractor contracted and performed the installation of concrete placing and forming, not included within the scope of the Tile and Marble Contractor or the Masonry Contractor, pursuant to Ordinance 06 -46, as amended, Section 1.6.3.45 and /or 1.6.3.28. The minimum licensing requirement for all of the described work contracted for and performed by Mr. Rodriguez is a Concrete Forming and Placing Contractor license, 1.6.3.9. b. Ordinance 90 -105, as amended, Section 22- 201(6) — "Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county." Mr. Rodriguez, by failing to secure and maintain compensation for his employees, violated Florida Statute 440.10(a). c. Thereafter, pursuant to Collier County Ordinance 90 -105, as amended, Section 22 -202 (b) and Section 22 -202 (c), the complaint was investigated and found sufficient cause to file formal charges. 3. Collier County brings the following charge in this formal complaint against the Respondent. COUNT 4. Collier County Ordinance 90 -105, as amended, Section 22- 201(2) - "Contracting to do any work outside of the scope of his competency as listed on his competency card and as defined in this article or as restricted by the contractors' licensing board ". COUNT2 5. Collier County Ordinance 90 -105, as amended, Section 22- 201 (6). "Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county." WHEREFORE, the Petitioner asserts the above facts and charges are grounds for disciplinary action under Section 22 -201 of Collier County Ordinance 90 -105, as amended, and WHEREFORE, in consideration of the foregoing, the Petitioner respectfully requests the Collier County Contractors' Licensing Board to find the Respondent guilty of the violations charged. Dated: _06 January, 2014_ Signed: Collier County Contractors' Licensing Supervisor or Designee Contractors' Licensing Board Case # 2014 -01 Mario Rodriguez — D /B /A — K.C. Tiles & Marble, Inc. Case Summary On 27 June, 2013, I, Reggie Smith, did receive a phone call from Investigator Jack Gumph, Florida Department of Financial Services, Division of Workers' Compensation, Bureau of Compliance; advising his investigation of the accidental death of Robert Wiley while working at a construction site for K.C. Tiles & Marble, Inc., a Collier County licensed contractor. I immediately made a site visit. Upon my arrival at the address of 1365 47th Ave NE, Naples, FL, a new residential home construction site, I began my investigation of Collier County Contractors' Licensing case CEMIS20130009146. I began by speaking with Investigator Jack Gumph, who advised the death of Robert Wiley and possible injuries to Jose Cruz (both employees of K.C. Tiles & Marble, Inc.), due to a lightning strike accident that took place at approximately 1:00 Pm on 26 June, 2013. The lightning had struck the metal scaffolding that the men were standing upon, while performing concrete placing and forming installation for K.C. Tiles & Marble, Inc., supervised by K.C. Tiles & Marble, Inc. employee, Filemon Cendejas. During my site visit I photographed the concrete and forming equipment that had been placed on the new home construction. I interviewed other persons on site such as: Mario Rodriguez, Qualifier for all K.C. Tiles & Marble, Inc. licenses, Tile and Marble Contractor and Masonry Contractor. Mr. M. Rodriguez advised K.C. Tiles & Marble, Inc. was hired to perform the concrete placing and forming work for the new construction home. I also interviewed Ariel Gonzalez, CGC1510731, Qualifier for Ash -Ann Homes, Inc. Mr. A. Gonzalez advised he had hired and was compensating K.C. Tiles & Marble, Inc. for the concrete placing and forming work that was being performed. Prior to leaving the site, I spoke to Jack Gumph again to advise K.C. Tiles & Marble, Inc. did foot hold adequate licensing to perform the concrete forming and placing work. Investigator Gumph provided information concerning possible Workers Compensation violations on behalf of K.C. Tiles & Marble, Inc. I advised my investigation would require review by Supervisor Michael Ossorio for the violations of "working outside the scope" and "workers compensation ". On 28 June, 2013, Supervisor Michael Ossorio, Investigator Jack Gumph, and Ariel Gonzalez held a meeting to review the incident and case. Information concerning the State of Florida Workers Compensation investigation had shown the Owner of K.C. Tiles & Marble, Inc., Joel Trujillo, claimed the deceased man and the injured man were not employees of his and were in fact hired by the Site Supervisor, Filemon Cendejas, without his knowledge. Afterwards, Michael Ossorio advised Collier County's case will wait for any results from a State of Florida Workers Compensation investigation. On 16 June, 2013, 1 received a copy of the State of Florida Stop Work Order served to K.C. Tiles & Marble, Inc. issued on 15 June, 2013. W On 18 July, 2013, 1 met with K.C. Tiles & Marble, Inc. employee, Jose Kenn Alexi Cruz Villamar, a.k.a. Jose Cruz to interview and obtain a signed statement from him in which he claims to be an employee of K.C. Tiles & Marble, Inc. Mr. J. Cruz also advised he sustained injuries due to the lightning strike incident, by falling from the scaffolding to the ground. On 06 November, 2013, 1 received information showing the Owner of K.C. Tiles & Marble, Inc., Joel Trujillo, was arrested on 05 November, 2013, for failure to secure workers compensation and for violation of a State of Florida Stop Work Order. Michael Ossorio advised he would meet with the Collier County Assistant Attorney for case review. On 22 November, 2013, a meeting was held with Mario Rodriguez, Michael Ossorio, and myself to review the case and to serve a Notice of Hearing for the 15 January, 2014 Contractors' Licensing Board Hearing. Mr. Rodriguez signed for and accepted a copy of the notice. On 21 November, 2013, 1 received, via email, an Official Records Request from JCR Investigative & Adjusting Services, Inc., Lourdes Bedgood, requesting all case records for CEMIS20130009146. I later received an Information Request letter dated 26 November, 2013 advising receipt of records and requested any and all additional records. On 06 January, 2014, 1 prepared Contractors' Licensing Board Hearing case 2014 -01. Subpoenas were issued to Jack Gumph and Ariel Gonzalez to appear at the hearing. In review, K.C. Tiles & Marble, Inc. was in contract with Ariel Gonzalez to provide concrete forming and placing services, without having valid licensing in place to perform such work. As per the State of Florida, Division of Workers Compensation, case 13- 172 -D7, case report; "Filemon Cendejas was hired by K.C. Tiles & Marble, Inc. on 29 April, 2013, as a Project Manager /Supervisor for a new Masonry- Cement Division, where he was given full responsibility and authority to work in the field with all contractors in making agreements, hiring workers and all necessary contacts ". The report also states that K.C. Tiles & Marble, Inc. attempted to submit Workers Compensation insurance information for Jose Cruz, to South East Personnel Leasing, Inc., approximately five hours after the lightning strike incident on 26 June, 2013. Contractors' Licensing Board Case # 2014 -01 Mario Rodriguez— D /B /A K.C. Tiles & Marble, Inc. Table of Contents E1 through E3 - Formal Complaint E4 through E8 - Contractors' Licensing CEMIS20130009146 Code Case Details E9 through E11— Contractor Certificate Details, CD Plus E12 through E13— Certificate Detail Report, City View E14 through E15 — Division of Corporations, K.C. Tiles & Marble, Inc. E16 - Notice of Hearing E17 through E20 — Ordinance 2006 -46, as amended, Section 1.6.3.28, 1.6.3.45, & 1.6.3.9 E21 through E22 — Ordinance 90 -105, as amended, Sections 22 -201 (2) & (6) E23 — Florida Statute 440.10 (1)(a) E24 — Collier County Business Tax Receipt for KC Tiles & Marble, Inc. E25 — State of Florida, Division of Workers' Compensation, Stop -Work Order E26 —Joel Trujillo arrest report E27 —Jose Cruz statement and photo ID E28 —JCR Investigative & Adjusting Services, Inc. Information Request E29 — Photograph of Ariel Gonzalez E30 — Department of Business and Professional Regulation, Licensee Details for CGC1510731 E31— Florida Department of Financial Services, Proof of Coverage, Employer Detail Page for Ash -Ann Homes, Inc., Ariel Gonzalez exemption E32 through E37 - Photos of jobsite, 6 total E38 through E69 — Investigative report from Florida Department of Financial Services, Division of Workers Compensation, Bureau of Compliance, case 13- 172 -D7 (32 pages) E70 through E71— Contractors' Licensing Board Subpoenas for Ariel Gonzalez and Jack Gumph Contractors' Licensing Board 2800 North Horseshoe Dr. Naples, FL 34104 Complaint Number- 2014 -01 Complainant: Any person who believes that a Contractor holding a State Certification or Certificate of competency has violated Collier County Ordinance 90 -105, as amended, may submit a sworn complaint to the Contractor Licensing supervisor, or his / her designee. The complaint shall be in substantially the form prescribed by the Contractor Licensing Supervisor. The complainant shall pay a fee of $50.00 to defray the costs of administering the complaint, at the time of filing the complaint. The complaining party shall state with particularity which section(s) of this Ordinance he or she believes has been violated by the contractor and the essential facts in support thereof. Complaint: Please print or type and return signed copies of the complaint. Date: 26 June, 2013 Against: Contractor's Name: Mario Rodriguez Phone: 305 - 900 -8346 Business Name: K.C. Tiles & Marble, Inc. License Number if known: 19105 and 21273 Collier County Competency number: 21273 Contractor's Business Address: 3570 20th Ave NE, Naples, FL Filed By: Name: Collier County Contractors' Licensing / Reggie Smith Address: 2800 N. Horseshoe Dr., Naples, FL 34104 Business Phone: 239 - 252 -2432 Address where work done: 1365 47th Ave NE City: Naples County: Collier e I Date of contract: On or before 24 June, 2013 Date job started: Approximately one week prior to date of contract Date job completed: Not completed Were there plans and specifications? yes Is there a written contract? Initial verbal contract Has Contractor been paid in full? Unknown Was a Building Permit obtained? Yes Was a Building Permit required? Yes Building Permit number if known: PRBD20130408859 Have you communicated by letter with the licensee? Yes Date: 22 November, 2013, Hand Delivery service of the Notice of Hearing Please attach to this form all copies of the purchase agreement, building contract, home improvement contract, copies of receipts and /or cancelled checks available and any additional evidence to substantiate your allegations. List any subsections of Section 4 of Collier County Ordinance number 90- 105, as amended, which, in your opinion, have been violated by the contractor which is the subject of this complaint, (list subsection number): 1. Ordinance 90 -105, as amended, Section 22- 201(2) -"Contracting to do any work outside of the scope of his competency as listed on his competency card and as defined in this article or as restricted by the contractors' licensing board ". 2. Ordinance 90 -105, as amended, Section 22- 201(6) —"Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county." Mr. Rodriguez, by failing to secure and maintain compensation for his employees, violated Florida Statute 440.10(a). Please state the facts which you believe substantiate your charge of misconduct against the subject contractor. List facts separately for each subsection number above: a. Ordinance 90 -105, as amended, Section 22- 201(2). Contracting to do any work outside of the scope of his /her competency as listed on his /her competency card and as defined in this Ordinance or as restricted by the Contractors' Licensing Board. Mr. Rodriguez, a Collier County Tile and Marble Contractor and Masonry Contractor, contracted and performed concrete placing and forming, not included within the scope of the Tile and Marble Contractor, or Masonry Contractor, pursuant to Ordinance 2006 -46, as amended, Section E2 1.6.3.45. The minimum licensing requirement for all of the described work contracted for and performed by Mr. Rodriguez is a Concrete Forming and Placing Contractor license. b. Ordinance 90 -105, as amended, Section 22- 201(6) — "Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county." Mr. Rodriguez, by failing to secure and maintain compensation for his employees, violated Florida Statute 440.10(a). Reggie Smith Collier County Contractors' Licensing State of: Florida County of: Collier Sworn to (or affirmed) and subscribed before me this ion day of 2014, by S L )�\ (signature of per oo making statement). (signature of Notary Public) - Print, t _ox...spmjz-commissioned name of Notary Public: Personally known or produced identification otaaY p`B • `••, `� JOANN GREENBERG MY COMMISSION # EE 066562 ra EXPIRES: April 8, 2015 'Few rod`` " BMW Thru Budget Notary Services E3 CAergou,net Report Title: Code Case Details Date: 1/612014 1:15:14 PM Case Number: cemis20130009146 Case Number: CEMIS20130009146 Status: Preliminary Review Case Type: Misconduct Date & Time Entered: 6/2712013 3:32:20 PM Priority: Normal Entered By: ReggieSmith Inspector: ReggieSmith Case Disposition: Case Pending Jurisdiction: Contractor's Licensing Origin: Building Department Detail Description: K.C. TILES & MARBLE, INC. - EMPLOYEE, ROBERT WILEY WAS ACCIDENTIALLY KILLED BY A LIGHTNING STRIKE AND JOSE CRUZ WAS INJURED, BOTH WHILE WORKING PERFORMING CONCRETE FORMING AND PLACING, ALSO WHILE NOT BEING COVERED BY WORKERS COMPENSATION INSURANCE Location Comments: 11365 47TH AVE NE ,cd Business Management & Budget Office Code Case Details Execution Date 1/6/2014 1:15:14 PM Desc Assigned Required Completed Outcome Comments Preliminary Investigation ReggieSmith 6/27/2013 6/27/2013 Needs 06 -27 -13 1130AM RECEIVED CALL FROM Investigatio INVESTIGATOR JACK GUMPH, n DEPARTMENT OF FINANCIAL SERVICES, DIVISION OF WORKERS' COMPENSATION, BUREAU OF COMPLIANCE, 239 - 633 -3710, WHO ADVISED HIS CASE INVESTIGATION FOR THE ACCIDENTAL DEATH OF ROBERT WILEY WHILE WORKING AT A CONSTRUCTION SITE FOR K.C. TILES & MARBLE, INC., CC21273. HE INQUIRED ABOUT THIS COMPANY'S LICENSING AND ASKED IF IT COVERED THE CONSTRUCTION OF CONCRETE TIE BEAMS ON TOP OF A MASONRY BLOCK WALL. I ADVISED THE COMPANY HAS A VALID MASONRY LICENSE; HOWEVER I CANNOT DETERMINE THE ANSWER BEFORE AN INVESTIGATION IS COMPLETED. I SITE VISITED THE PROPERTY AND SPOKE WITH JACK GUMPH, ARIEL GONZALEZ OF ASH -ANN HOMES, CGC1510731, MARIO RODRIGUEZ, LICENSE QUALIFIER FOR K.C. TILES & MARBLE. A. GONZALEZ ADVISED THE CONCRETE FORMS WERE PLACED, AND WERE SCHEDULED TO BE POURED WITH CONCRETE BY KC TILES & MARBLE, M. RODRIGUEZ CONFIRMED THIS INFORMATION. JACK GUMPH ADVISED ANOTHER MAN WAS INJURED IN THE ACCIDENT, HIS NAME IS JOSE CRUZ. INITIAL REPORTS FROM J. GUMPH SUGGEST NEITHER MAN WAS COVERED BY WORKERS COMPENSATION. PHOTO X 6 OF THE STRUCTURE SHOWING THE CONCRETE FORMS IN PLACE. REQUIRES CASE REVIEW BY MICHAEL OSSORIO, CONTRACTORS' LICENSING SUPERVISOR, WHO RETURNS ON 06 -28- 13. RS Attach Picture(s) ReggieSmith 6/27/2013 6/27/2013 Complete ATTACHED PHOTO X 6. RS Cont. Investigation ReggieSmith 6/27/2013 6/27/2013 Complete 06 -27 -13 30OPM MET WITH CONNIE DEANE, PUBLIC RELATIONS COORDINATOR, AND CONTRACTORS' LICENSING ADMINSTRATIVE SUPERVISOR, CONNIE THOMAS, TO REVIEW MY INVESTIGATION SO THAT C. DEANE MAY BE ABLE TO REFER CORRECT INFORMATION TO THE PUBLIC MEDIA WHEN ASKED. LATER RECEIVED A CALL FROM M. OSSORIO WHO RECEIVED A SHORT CASE REVIEW VIA TELEPHONE AND ADVISED TO SCHEDULE ARIEL GONZALEZ FOR A MEETING EARLY ON 06- 28 -13. RS Business Management & Budget Office 2 Code Case Details Execution Date 1/6/2014 1:15:14 PM Desc Assigned Required Completed Outcome Comments Cont. Investigation ReggieSmith 6/28/2013 6/28/2013 Complete 06 -28 -13 MEETING HELD BY M. OSSORIO, J. GUMPH AND HIS ASSOCIATE, AND ARIEL GONZALEZ. I WAS NOT PRESENT. AFTERWARDS, M. OSSORIO ADVISED THE COUNTY WILL WAIT FOR THE STATE'S DIRECTION OF ANY VIOLATION OF WORKERS COMPENSATION LAWS. RS Cont. Investigation ReggieSmith 7/16/2013 7/16/2013 Complete 07 -16 -13 MEETING WITH M. OSSORIO AND INVESTIGATOR JACK GUMPH, STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES, DIVISION OF WORKERS' COMPENSATION, WHO ADVISED AND PROVIDED A COPY OF THE STATE OF FLORIDA, STOP WORK ORDER FOR K.C. TILES & MARBLE, INC., SWO # 13 -172-D7,, SERVED TO K.C. TILES & MARBLE, INC. ON 07- 15 -13. ATTACHED A SCANNED COPY INTO CITY VIEW. M. OSSORIO ADVISED THIS CASE WILL REMAIN ON HOLD UNTIL AFTER THE STATE'S INVESTIGATION AND POSSIBLE LEGAL HEARINGS HAVE CLOSED. RS Cont. Investigation ReggieSmith 7/18/2013 7/19/2013 Complete 07 -18 -13 MET WITH JOSE CRUZ AT HIS HOME, 4019 MINDI AVE, NAPLES, FL, TO RECEIVE A PREPARED STATEMENT OF EVENTS LEADING UP TO HIS EMPLOYMENT, WHICH HE CLAIMS WAS WITH K.C. TILES AND MARBLE, INC. AS ADVISED, MR. CRUZ DID NOT SIGN THE DOCUMENT UNTIL HE WAS IN MY PRESENCE. VERIFICATION OF IDENTIFICATION, STATE OF FLORIDA DRIVERS ID AND UNITED STATES OF AMERICA EMPLOYMENT AUTHORIZATION CARD, WERE CONFIRMED TO BE THE SAME PERSON, JOSE KENN ALEXI CRUZ VILLAMAR, A.K.A. JOSE CRUZ. PHOTO X 1 OF SIGNED STATEMENT AND PHOTO ID'S. A REVIEW OF THE WRITTEN STATEMENT BY M. OSSORIO RESULTED IN ADDITIONAL INFORMATION REQUIRED IN A REQUESTED MORE DETAILED STATEMENT BY MR. CRUZ, ALSO A DESIRED PUBLIC NOTARY MAY NEED TO BE PRESENT UPON SIGNATURE. CALLED 239 - 298 -2650 AND REQUESTED MR. CRUZ TO VISIT CONTRACTORS' LICENSING TO PROVIDE ADDITIONAL STATEMENT /INFORMATION UPON HIS NEXT CONVIENENCE, HE STATED HE WOULD. RS Irb Business Management & Budget Office 3 Code Case Details Execution Date 1/6/2014 1:15:14 PM Desc Assigned Required Completed Outcome Comments Cont. Investigation ReggieSmith 7/29/2013 7/29/2013 Complete 07 -29 -13 CALLED JOSE CRUZ, 239 -298- 2650, NO ANSWER; LEFT MESSAGE REMINDING /REQUESTING HIM TO CONTACT ME ON HIS NEXT AVAILABLE DAY TO MEET AND COMPLETE A SECOND MORE DETAILED STATEMENT OF EVENTS. RS Cont. Investigation ReggieSmith 1116/2013 11/6/2013 Complete 11 -06 -13 RECEIVED INFORMATION CONCERNING THE ARREST OF JOEL TRUJILLO ON 11- 05 -13, BY THE COLLIER COUNTY SHERIFF'S OFFICE FOR FAILURE TO SECURE WORKERS COMPENSATION AND VIOLATION OF STOP WORK ORDER PLACED BY THE STATE OF FLORIDA, INVESTIGATOR JACK GUMPH, FLORIDA DEPARTMENT OF FINANCIAL SERVICES, DIVISION OF WORKERS' COMPENSATION, BUREAU OF COMPLIANCE. REVIEWED CASE WITH M. OSSORIO, WHO ADVISED HE WILL MEET WITH THE COLLIER COUNTY ASST. COUNTY ATTORNEY FOR CASE REVIEW. RS Cont. Investigation ReggieSmith 11/12/2013 11/12/2013 Complete 11 -12 -13 AS PER M. OSSORIO, SCHEDULED TO MEET WITH MARIO RODRIGUEZ ON 11- 22 -13, 0900AM, TO DISCUSS CASE. RS Cont. Investigation ReggieSmith 11/21/2013 11/21/2013 Complete 11 -21 -13 RECEIVED RECORDS REQUEST FROM LOURDES BEDGOOD, JCR INVESTIGATIONS, 954 - 520 -3267, HIRED BY GRANADA INSURANCE. ADVISED I WILL SEND MY CODE CASE DETAIL REPORT AND AVAILABLE PHOTOS TO EMAIL ADDRESS: JCRPI @BELLSOUTH.NET. REVIEWED REQUEST WITH SUPERVISOR M. OSSORIO WHO ADVISED TO SEND THE INFORMATION. RS Generate CLB Notice of Hearing michaelossori 11/22/2013 11/22/2013 Complete 0 Cont. Investigation ReggieSmith 11/«/2013 11/22/2013 Complete 11 -22 -13 900AM - MEETING HELD WITH QUALIFIER, MARIO RODRIGUEZ, MICHAEL OSSORIO, AND MYSELF, TO REVIEW THE CASE AND SERVE A NOTICE OF HEARING TO MR. RODRIGUEZ FOR THE 15 JAN, 2014 CLB HEARING. MR. RODRIGUEZ REVIEWED AND SIGNED THE HAND DELIVERED NOH; HE ASLO RECEIVED A COPY. M. OSSORIO ADVISED THE CLB HEARING PROCESS AND POSSIBLE OUTCOMES /DECISIONS BY THE CLB. MR. RODRIGUEZ STATED HE UNDERSTOOD. SCANNED THE NOH INTO THE CASE. RS Business Management & Budget Office Code Case Details Execution Date 1/6/2014 1:15:14 PM Desc Assigned Required Completed Outcome Comments Cont. Investigation ReggieSmith 12/2/2013 12/2/2013 Complete 12 -02 -13 RESPONDED VIA EMAIL TO A SECOND RECORDS REQUEST FROM L. GOODBED. SHE REQUESTED JOSE CRUZ'S PHONE INFORMATION, A COPY OF THE PHOTOGRAPH SHOWING J. CRUZ'S SIGNED STATEMENT AND PHOTO ID, AND ALSO ANY PERMITTING APPLICATION ACTIVITY FOR K. C. TILES & MARBLE, INC. ALSO TODAY, I RECEIVED A COPY OF AN EMAIL FROM: KEVIN NOELL, ASSISTANT COUNTY ATTORNEY, COLLIER COUNTY ATTORNEY's OFFICE, TO: JACK GUMPH, REQUESTING A COPY OF THE INVESTIGATIVE REPORT PERTAINING TO THE RECENT WORKER'S COMPENSATION VIOLATION AND SUBSEQUENT STOP WORK ORDER ISSUED AGAINST K. C. TILES & MARBLE, INC. CASE REVIEW WITH M. OSSORIO. RS Cont. Investigation ReggieSmith 12/11/2013 12/11/2013 Complete 12 -11 -13 RESPONDED VIA EMAIL TO AN ADDITIONAL RECORDS REQUEST FROM LOURDES GOODBED, CONCERNING PERMIT PRBD20111005690, ISSUED TO K.C. TILES AND MARBLE FOR MASONRY COLUMNS INSTALLED AT 347 BURNT PINE DR. RS Attach Picture(s) ReggieSmith 12/23/2013 12/2612013 Complete 12 -26 -13 ATTACHED SCANNED DOCUMENTS (TWO SEPARATE) FORWARDED VIA EMAIL FROM Kevin L. Noell, Assistant County Attorney, Collier County Attorney's Office, 239.252.8424, TO M. OSSORIO. THE DOCUMENTS ARE NARRATIVES FROM DEPARTMENT OF FINANCIAL SERVICES, DIVISION OF WORKERS' COMPENSATION, BUREAU OF COMPLIANCE, CASE NUMBER: 13- 172 -D7, IN 2 PARTS (pages 1 thru 16 and 17 thru 32). RS Cont. Investigation ReggieSmith 116/2014 1/6/2014 Complete 01 -06 -14 PREPARED CLB CASE. SCANNED TWO SUBPOENA INTO CITY VIEW FOR JACK GUMPH AND ARIEL GONZALEZ. RS Schedule for CLB michaelossori 1/6/2014 1/6/2014 Complete 01 -06 -14 CEMIS20130009146 HAS BEEEN o ADDED TO THE JANUARY 15, 2014, CLB AGENDA AS CASE 2014 -01. RS Investigation ReggieSmith 1/20/2014 Pending Enter Hearing Results 1/20/2014 Pending Violation Description Status Entered Corrected Amount Comments Business Management & Budget Office 5 t t File Edit Viev. Help 41W Addressing/Property 1 Code Enforcement Permitting Dey. Review � Cash Management Cualifier Certificates Permits Insoections Cert-Occ: Qualifier No First Name Middle Name Last Name Postfix 18965 1M ARIO r RODRIGUEZ 1 Detail Addresses 1 Associated Tables 1. Update Info Monday, Jan 06, 2014 09:47 AM Picture Date 12/18/200311:43:41 AM — 1- QuaNi ees Picture— Social Security No Drivers License No Date of Birth Phone 1[239)253 -6399 Fax Mobile Other Department ICONTRACTOR MANAGEMENT Monday, Jan 06, 2014 09:47 AM Picture Date 12/18/200311:43:41 AM — LMSSQL] Qualifier No First Name Middle Name _ Last Name Postfix 18965 IMARIO RODRIGUEZ- j --------- - - - - -- --- - - -- -- Detai Addresses Associated Tables I Update Info A. l j Cert. No. Description Status DBA State No. Stal 20944 TILE & MARBLE CONTR. 21273 MASONRY CONTR. 21839 MASONRY CONTR. 24532 BUILDING CONTR.- CERTIFIED 25764 INSULATION ALL TYPES Monday, Jan 06, 2014 09:46 AM CANCEL ELITE STONE & MARBLE CORP. INACTIVE K.C. TILES & MARBLE, INC. CANCEL STONES OF TIME, INC. INACTIVE IDEAL BUILDERS CORP. CBC 1250623 8/31 INACTIVE IDEAL INSULATION, INC. 9 6 10 IM -r lus t� Ili i!� Rte./ Addressing /Property Code Enforcement Permitting l Day. Review 1 Cash Management .-IL) f-TJ;6A QrJQAJUT ti'1 r 1 !' r_rq Qualifier Certificates Permits Insoections Cert -Occ III Qualifier No First Name Middle Name _ Last Name Postfix 18965 IMARIO RODRIGUEZ- j --------- - - - - -- --- - - -- -- Detai Addresses Associated Tables I Update Info A. l j Cert. No. Description Status DBA State No. Stal 20944 TILE & MARBLE CONTR. 21273 MASONRY CONTR. 21839 MASONRY CONTR. 24532 BUILDING CONTR.- CERTIFIED 25764 INSULATION ALL TYPES Monday, Jan 06, 2014 09:46 AM CANCEL ELITE STONE & MARBLE CORP. INACTIVE K.C. TILES & MARBLE, INC. CANCEL STONES OF TIME, INC. INACTIVE IDEAL BUILDERS CORP. CBC 1250623 8/31 INACTIVE IDEAL INSULATION, INC. 9 6 10 1k 6 ie Edit View Help "i N1 ED—Plus ILLIER [MSSQLI Qualifier No First Name Middle Name Last Name Postfix 1 10965 1MIARIO I !RODRIGUEZ I Detail Addresses I Associated Tables I Update Info MailingAddresr-- Line. 1 13570 20TH AVE NE City NAPLES State FL -;I Zip 34 120 - ---- ----- ----- -- - — - ------ - ------ Monday, Jan 06, 2014 09:47 AM F-Physical Address---- Line 1 J3570 20TH AVE NE City INAPLES State FL Zip io-- 0 'F11 ------ --------- AddressingiProperty I Code Enforcement Permitting Dev. Review: Cash Management Qualifier Certificates Permits Inspections Cert-Occ Qualifier No First Name Middle Name Last Name Postfix 1 10965 1MIARIO I !RODRIGUEZ I Detail Addresses I Associated Tables I Update Info MailingAddresr-- Line. 1 13570 20TH AVE NE City NAPLES State FL -;I Zip 34 120 - ---- ----- ----- -- - — - ------ - ------ Monday, Jan 06, 2014 09:47 AM F-Physical Address---- Line 1 J3570 20TH AVE NE City INAPLES State FL Zip io-- 0 'F11 CityView Contact Details'(BEvsingl" Oetail nsiN)) a Link Items to Selected Contact Licensee# 021273 Licensee Name K.C. TILES & MARBLE, INC. Available Issuance Types R Contact Type Qualifier Contact Description MARIO RODRIGUEZ, Address:3570 20TH AVE NE, Ph+. Currently Linked Issuances Issuance Type Issuance Number Status Expiration Link Issuance Description Issuance Number Prima TILE & MARBLE CONTR. MASONRY CONTR. 19105 :21273 Delinquent `> 0913012013 : Delinquent 09f3012013 Remove Remove TILE & MARBLE CONTR. MASONRY CONTR. :19105 21273 Available Background Checks Currently Linked Backaround' Checks Background Check ID I Date of Check I Statue I Link Background Check ID I Date of Check Monday, Jan 06, 2014 01:50 PM Finished 61a View Master Proiect Licensee Information View All Activities for this Licensee Add new person or business to Address Book New Licensee (current project) New Licensee (no project) Licensee Number I021273 Status iInactive Name I Description I K.C. TILES & MARBLE, INC. Start Date F Type [Contractor End Date Inspector Submitted on Jurisdiction lCollier County Department 10perations Activity Description All Certificates. from CDPlus., 21273, 19105 Suggest Mailing Address 7 Add this Mailing Address as a Location Street Mailing Address 3773 ARNOLD AVE. Address Line 2 Address Line 3 City/State/Zip NAPLES :F:LL:::EFT04- Country • Email Home Based Business 11 Contractor Attributes Add, Contact Number [ Show More Fields I f Hide or Clear Fields Sub-certificate Required Ej Contractor Type I Business DOB Drivers License Number Sponsorship Appliction Date Workers Compensation Business Tax Receipt? Expiration Date Location [ Add Related Parcels and Addresses ]I Add a Location To link a location to this Licensee, enter location information below. CityViewwill suggest possible matches as you type: Description I Type I Property Alert I Primary? I Display? Contacts Add a Contact� To link a contact to this Licensee, enter contact information below. CityView will suggest possible matches as you type: MARIO RODRIGUEZ, Address-3570 20TH AVE NE, Phone:(239) 253-0359 $ I Go I Link j T"Fpe Descdpbon End Date Primary? Display? ... . ..... Qualifier :MARIO RODRIGUEZ, Address-.3570 20TH AVE NE, Phone: (239)1 Applicant K.C. TILES & MARBLE, INC., Address: 3773 ARNOLD AVE., Ph o n A A A 6 Detail by Entity Name Detail by Entity Name 0 C. TILES & MARBLE, INC. ument Number EIN Number Filed ast Event vent Date Filed vent Effective Date rincipal Address 773 ARNOLD AVE IAPLES, FL 34104 :hanged: 01/14/2008 lailinq Address 773 ARNOLD AVE IAPLES, FL 34104 ;hanged: 01/14/2008 registered Aqent Name & Ac :ODRIGUEZ, MARIO 570 20TH AVENUE NE IAPLES, FL 34120 lame Changed: 03/17/2003 ddress Changed: 09/30/2009 ►fficer /Director Detail lame & Address itle P RUJILLO, JOEL 91 1 ST STREET SW IAPLES, FL 34117 P96000098161 650712052 12/04/1996 FL ACTIVE CANCEL ADM DISS /REV 09/30/2009 NONE Page 1 of 2 ep-p 14 httn: / /search.sunbiz.ora/ Inquiry/ CorporationSearch/ SearchResultDetail /EntityName /domp -p... 1/6/2014 Detail by Entity Name Report Year Filed Date 2011 04/20/2011 2012 03/27/2012 2dTTe Contact '64 /15 /20tFiling Services Document Searches Forms 04/15/2013 -- ANNUAL REPORT View image in PDF format 03/27/2012 -- ANNUAL REPORT View image in PDF format 04/20/2011 --ANNUAL REPORT View image in PDF format 04/26/2010 -- ANNUAL REPORT View image in PDF format 09/30/2009 -- REINSTATEMENT View image in PDF format 01/14/2008 -- ANNUAL REPORT View image in PDF format 11/30/2007 -- Off /Dir Resignation View image in PDF format 11/30/2007 -- Amendment View image in PDF format 05/31/2007 -- ANNUAL REPORT View image in PDF format 02/27/2006 -- ANNUAL REPORT F777View image in PDF format 08/31/2005 -- ANNUAL REPORT View image in PDF format 08/09/2004 -- ANNUAL REPORT View image in PDF format 03/17/2003 -- ANNUAL REPORT View image in PDF format 08/26/2002 -- Amendment F77View image in PDF format 06/11/2002 -- Amendment F777View image in PDF format 05/22/2002 --.ANNUAL REPORT F View image in PDF format 01/24/2001 --ANNUAL REPORT View image in PDF format 11/15/2000 -- Amendment F77View image in PDF format 04/20/2000 -- ANNUAL REPORT View image in PDF format 04/23/1999 -- ANNUAL REPORT F77View image in PDF format 01/15/1999 -- Amendment View image in PDF format 01/15/1998 -- ANNUAL REPORT View image in PDF format 08/19/1997 -- ANNUAL REPORT F7777View image in PDF format 12/04/1996 -- DOCUMENTS PRIOR TO 19971 View image in PDF format 12/0411996 -- Domestic Profit Articles I View image in PDF format Coovrlaht @, and Privacy Policies State of Florida, Department of State Page 2 of 2 Help 6 16 httn://search.sunbiz. ors/ Incluirv/ CorporationSearch /SearchResultDetail/EntityName /dome -p... 1/6/2014 Go � m-Ir Cou.-vatty Growth Management Division Planning & Regulation Operations Department Licensing Section Hand Delivery /C -- Date: r•� Mario Rodriguez 22 November, 2013 K.C. Tiles & Marble, Inc. 3570 20 Ave NE Naples, FL 34120 Dear Mario Rodriguez, A complaint has been filed agaiml. yon by the above referenced ofce in reference to Collier County Contractors' Licensing case CEMIS20130009146, origination date, 27 June, 2013. A hearing of this complaint will be held by the Contractors' Licensing Board on 15 January, 2014, at 9:00 AM in the Board of County Commissioner's Room, Third Floor, Administration Building (W. Harrison Turner Bldg.), at 3301 East Tamiami Trail, Naples, Florida. Your presence before the Contractors' Licensing Board is required at this time. The packet you will receive marked composite exhibit "A" will be delivered to the members of the Contractors' Licensing Board one week prior to the hearing. If you wish to prepare a defense packet and have it delivered in conjunction with composite exhibit "A ", you must make fifteen copies and have them in our office by 8:00 AM on Wednesday, one week prior to the hearing. In your packet, you may give a summary of events. At this meeting, you may present evidence and be represented by an attorney of your choice. In the event the Contractors' Licensing Board finds you in violation of Section number(s) 4.1.2, and 4.1.6 of Ordinance # 2006 -46, as amended, the range of disciplinary sanctions which may be imposed are from an oral reprimand to a suspension or revocation of your Collier County Certificates # 19105 and /or 21273. Sincerely, Reggie Smith \j Licensing Compliance Officer (239) 252 -2432 616 Growth Management Division'Planning & Regulation'2500 North Huvse,huu Diive°Napius, Flutida 34104' 239 .252.2e100 *Mvw.colllergov.net *r,§t 9 t Y' 1.6.3.26. Liquefied Petroleum Gas Installation Contractor means any person qualified and censed pursuant to Chapter 527, Florida Statutes, to install apparatus, piping and tubing, and appliances and equipment necessary for storing and conver=ting liquefied petroleum gas into flame for light, heat, and power. Placement of fire safing and fire stopping materials shall be permitted on wall, ceiling and floor penetrations created within the scope of the work allowed by this section. 1.6.3.27. Marine, Seawall, and Dock Construction Contractor requires thirty-six (36) months experience, a passing grade on a tbxee (3) h an approved test and a passing grade on a twe (2) hour business and law test, and means those who are qualified to build and install bulkheads, revetments, docks, piers, wharves, groins, boathouses, lifts and davits, and to do pile driving. Electrical service and wiring must be provided by a licensed electrical contractor. 1.6.3.28. Masonry Contractor requires thirty-six (36) months experience, a passing grade on euf an approved test and. a passing.grade on a business and law test and means those who are qualified to select, cut, 'and lay brick and concrete block or any other unit masonry products, lay other baked clay products, rough cut and dress stone, artificial stone and precast blocks, glass brick or block, but who shall not pour or finish concrete. 1.6.3.29. Paving Blocks Contractor. Requires twenty -four (24) months experience in the respective construction plus a passing grade on ^ #ffe° (3) h an approved test and a passing grade on a twe (2) houf business and law test, and means those persons who are qualified to construct driveways, sidewalks, patios and decks, using concrete paving units. 1.6.3.30. Painting Contractor requires twenty -four (24) months experience, a passing grade on a +hire (3) h •r an approved test and a passing grade on a twe (2) cur business and law test and means those who are qualified to use spraying equipment as well as hand tools to finish both exterior and interior work. A painting contractor may do paperhanging, sandblasting, waterproofing, and may clean and paint roofs. 1.6.3.31. Paving Contractor (commercial or unlimited) requires thirty -six (36) months experience, a passing grade on ^ +''r °° (3) h •r an approved test and a passing grade on a twe (2) houf business and law test, and means those who are qualified with the experience and skill to construct roads, airport runways and aprons, parking lots, sidewalks, curbs and gutters, storm drainage facilities, and to perform the excavating, clearing, and grading incidental thereto. 1.6.3.40. Non - Electrical Sign Contractor requires twenty -four (24) months experience, a passing grade on a 0:9 ('' -� `�-;eir business and law test, and means any person who is qualified to erect, install, repair, alter, extend or change any non - electrical sign, provided all work is performed in accordance with applicable Collier County and City ordinances. This category does not include the construction of free - standing structural signs. 1.6.3.41. Electrical Sign Contractor requires twenty -four (24) months experience, a passing grade on a t"-° °� an approved test and a passing grade on a business and law test, and means any person who is qualified to install, repair, alter, manufacture, add to, or change any electrical wires, apparatus, raceways, conduit or any part thereof on electrical signs and is qualified to erect signs. Such contractor may contract for, and take out building permits for the erection of signs. The electrical service and wiring from the electrical service to the sign disconnect must be supplied by a licensed electrical contractor. 1.6.3.42. Solar Heater Installation Contractor requires twenty -four (24) months experience, a passing grade onm et an approved test and a passing grade on a twe (2) hetif business and law test, and means those who have the knowledge to install, alter, repair, or replace any solar hot water heating system for residences or for residential swimming pools, including collectors, storage and expansion tanks, heat exchangers, piping, valves, pumps, sensors and low voltage controls which connect to existing plumbing stub -outs and electrical disconnects. 1.6.3.43. Structural Steel Erection Contractor requires thirty -six (36) months experience, a passing grade on s- thfee -k3) -#eta an approved test and a passing grade on a P*e -(2-)- � business and law test, and means those who are qualified to erect structural steel shapes and plates, including such minor field fabrication as may be necessary, of any profile, perimeter or cross- section, that are or may be used as structural members for buildings and structures, and the erection of communication towers, including riveting, welding and rigging, only in connection therewith. . 1.6.3.44. Structure Moving Contractor means persons who are required to be general, building or residential contractors, and who are qualified to Iift and secure structures and transport said structures from one site to another, whether or not such transport is across public roads, including the proper placement of structures at a new location. 1.6.3.45. Tile and Marble Installation Contractor requires twenty -four (24) months experience, a passing grade on a rt,fee-?� �- r� an approved test and a passing grade on a 6we -E2) hetif business and law test, and means those persons who are qualified to set tile, marble and stone. 1.6.3.46. Tile, Marble and Terrazzo Installation Contractor requires twenty -four (24) months experience, a passing grade on &4hfeo (3-)- , an approved test and a passing grade on a 21 Words sirastFt#re are deleted; words underlined are added. I 61a a. Alarm System Contractor I means an alarm system contractor whose business includes all types of alarm systems for all purposes. b. Alarm System Contractor 11 means an alarm system contractor whose business includes all types of alarm systems other than fire, for all purposes. c. Alarm System means any electrical device, signaling device, or combination of electrical devices used to signal or detect a burglary, fire, robbery, or medical emergency. d. Burglar Alarm Contractor means an alarm system contractor whose business is limited to the installation of burglar alarms in single - family homes and two - family homes, mobile homes, and small commercial buildings having a square footage of not more than 5,000 square feet. 1.6.3.5. C2binet Installation .Contractor requires twenty -four (24) months experience with passing grade on a twO42-)-� business and law test and means any person who is qualified to manufacture, assemble, install, dismantle, maintain, adjust, alter, extend, and design cabinets and millwork. The scope of permitted work shall include, but not be limited to kitchen cabinets, bathroom vanities, accessory cabinets, counter tops, office furniture, and millwork items which have been manufactured for installation on job site locations. 1.6.3.6. Carpentry Contractor requires thirty -six (36) months experience with a passing grade on a three "` heuf an approved test and a assin grade on a .. p , g g ��''� � 'v� business and law test and means those who have the knowledge and skill to install any wood and metal products including, but not limited to, rough framing, wood structural wood and metal non - structural trusses, sheathing, paneling, trim, metal framing, and cabinetry. Placement of fire safing and fire stopping materials shall be permitted on wall, ceiling and floor penetrations created within the scope of the work allowed by this section. 1.6.3.7. Garage doors Installation Contractor requires twelve (12) months experience with a passing grade on a tWe�r business and law test and means any person who is qualified to install, repair, adjust or extend garage doors. 1.6.3.8. Commercial Cooking Equipment Exhaust Hood Installation Cnnt,actor means any person who possesses a valid license as an Air Conditioning Contractor, Class A or B; a Sheet Metal Contractor; or a Mechanical Contractor; and who is qualified to install exhaust hoods, duct work, replacement air, exhaust fans, and grease filters. If any hood which is to be installed includes a fire suppression system, the contractor shall be certified by the Florida State Fire Marshal's office. 1.6.3.9. Concrete Forming and Placing Contractor requires thirty -six (36) months experience with a passing grade on a-t#re° " an approved test and a passing grade on a twe (4�business and law test and means those who are qualified to batch and mix aggregates, cement, and water to agreed specifications, to construct forms and framework for the casting and 15 Words 54�� are deleted; words underlined are added. 611 I shaping of concrete to place miscellaneous embedded steel and to pour, place, and finish concrete. This category does not include the plastering of the interior of a pool. 1.6.3.10. Concrete Placing and Finishing Contractor requires thirty -six (36) months experience with a passing grade on c +hfee (3) ;roar an approved test and a passing grade on a two (2 ) hou business and law test and means those who are qualified to pour place and finish concrete flat work (floors, slab on grade, sidewalks, etc.) including placement of mesh reinforcement, plastic vapor barriers and edge forms incidental thereto. This category does not include the plastering of the interior of a pool. 1.6.3.11. Concrete Contractor (restricted to pneumatically placed concrete) requires twenty -four (24) months experience with a passing grade on &4.hfee4-3)4i9ur an approved test and a passing grade on a V 2)- business and law test and means those who are qualified to use and maintain pressure equipment, mix material and apply according to building codes. 1.6.3.12. Decorative Metal Contractor requires twenty -four (24) months experience with a passing grade on a Vwe-Qlie�uF business and law test and means those who are qualified to fabricate and install decorative metal fixtures; such work should be decorative in nature and non - structural in function; the materials used in the manufacturing and installation of said products may be of ferrous or non - ferrous materials. 1.6.3.13. Demolition or Wrecking Contractor requires thirty -six (36) months experience with a passing grade on a4hFe&43+4HW an approved test and a assin p g grade on a business and law test and means those who are qualified to demolish structures such as dwellings, commercial buildings, and foundations and to remove debris. The use of blasting and explosives is not permitted under this category. 1.6.3.14. Dredging Contractor requires thirty -six (36) months experience with a passing grade on thee -0+4- eyf an approved test and a passing grade on a tWe-(2)4+&uf business and law test and means any person who is qualified to operate hydraulic dredging equipment which digs and removes material by pump and which deposits the pumped material at a fill location in one operation. 1.6.3.15. Drywall Contractor requires thirty -six (36) months experience with a passing grade on a thFe (3)"H,m. an approved test and a passing grade on a business and law test and means those who are qualified to install gypsum drywall products to wood and metal studs, wood and steel joists, and metal runners in buildings of unlimited area and height. The scope of work shall include the preparation of the surface over which the drywall product is to be applied, including the placing of metal studs and runners and all necessary ' drywall preparation trim and shall include the placement of fire safing and fire stopping materials as part of the overall drywall contract. 16 Words o4uok4h_ygh are deleted; words underlined are added. opto ARTICLE V. BUILDING TRADES* Page 27 of 36 (i) Any individual who fails to renew his /her certificate of competency prior to December 31 of the year following its expiration shall thereby automatically have a certificate of competency that is null and void. To acquire a valid certificate from the county the individual must pay the then applicable full application fee in accordance with the schedule of fees and charges adopted by resolution pursuant to section 22- 182(a)(4) herein, and must submit an entire. new application. If, as of the date of receipt by the county of said new application, three years have passed since the date of his /her most recent examination that the individual passed to acquire the former certificate, that individual must pass all then applicable testing requirements. If the request is to reactivate a dormant certificate, the re- testing requirement can be waived by staff if the applicant proves that he /she has been active in the trade in another jurisdiction, or has been active as an inspector or investigator in the trade; or for other valid reason that would render such re- testing superfluous. (Ord. No. 90 -105, § 1.4; Ord. No. 92 -61, § 1; Ord. No. 94 -34, § 1; Ord. No. 97 -68, § 1, 10- 28 -97; Ord. No. 9945, § 1.4-- 1.4.9, 6 -8 -99) Secs. 22-192--22-200. Reserved. DIVISION 3. STANDARDS OF CONDUCT AND DISCIPLINE* *State law references: Discipline of contractors, F.S.. §§ 489.129, 489.533. Sec. 22 -201. Misconduct -- Collier County /city certificate of competency. The following actions by a holder of a Collier County /city certificate of competency shall constitute misconduct and grounds for discipline pursuant to section 22 -202: (1) Knowingly combining or conspiring with an unlicensed contractor by allowing one's certificate of competency to be used by an unlicensed contractor with intent to evade the provisions of this article. When a licensed contractor acts as the qualifying agent for any firm without first making application under this article to represent said firm, such act shall constitute prima facie evidence of intent to evade the provisions of this article. When a certificate holder allows his certificate to be used by one or more companies without having any active participation in the operations, management, and control of such companies, such act constitutes prima facie evidence of an intent to evade the provisions of this article. Active participation requires job site supervision, knowledge of and participation in the business operations of the company, including all contractual matters. a. If any individual qualifying any business organization ceases to be affiliated with such business organization, he shall so inform the board. In addition if such individual is the only certified individual affiliated with the business organization, the business organization shall notify the board of the individual's termination and shall have no more than 60 days from the date of termination of the individual's affiliation with the business organization in which to affiliate with another person certified under the provisions of this article. In any event, the business organization shall not enter into any new contracts and may not engage in any new contracting until such time as a qualifying agent is employed. (2) Contracting to do any work outside of the scope of his competency as listed on his ARTICLE V. BUILDING TRADES* Page 28 of 36 competency card and as defined in this article or as restricted by the contractors' licensing board. (3) Abandoning a construction project in which he is engaged or under contract as a contractor. A project may be presumed abandoned if the contractor terminates the project without just cause, or fails to notify the owner in writing of termination of the contract and basis for same, or fails to perform work for 90 consecutive days without just cause and no said notice to the owner. (4) Diverting funds or property received for the execution of a specific contract project or operation or diverting funds earmarked for a specified purpose to any other use whatsoever. (5) Departing from or disregarding in any material respect the plans or specifications of a construction job without the consent of the owner or his duly authorized representative. (6) Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county. (7) Falsifying or misrepresenting any material fact in his application and supporting papers for the purpose of obtaining a certificate of competency under this article. (8) Committing mismanagement or misconduct in the practice of contracting that causes financial harm to -a customer. Financial mismanagement or misconduct includes, but is not limited to, any of the following: a. The contractor fails to fulfill his contractual obligations to a customer because of inability, refusal or neglect to pay all creditors for material furnished or work or services performed in the operation of the business for which he is licensed, under any of the following circumstances: 1. Valid liens have been recorded against the property of a contractor's customer for supplies or services ordered by the contractor for the customer's job; the contractor has received funds from the customer to pay for the _supplies or services; and the contractor has not had the liens removed from the property, by payment or by bond, within 30 days after the date of such liens; 2. The contractor has abandoned a customer's job and the percentage of completion is less than the percentage of the total contract price paid to the contractor as of the time of abandonment, unless the contractor is entitled to retain such funds under the terms of the contract or refunds the excess funds within 30 days after the date the job is abandoned; 3. The contractor's job has been completed, and it is shown that the customer has had to pay more for the contracted job than the original contract price, as adjusted for subsequent change orders, unless such increase in cost was the result of circumstances beyond the control of the contractor, was the result of circumstances caused by the customer, or was otherwise permitted by the terms of the contract between the contractor and the customer. b. The contractor's job been completed, and it is shown that the customer has incurred financial harm by having to seek a variance or other administrative remedy because of actions by the contractor. (9) Performing any act which assists a person or entity in engaging in the prohibited unlicensed .practice of contracting, if the licensed contractor knows or should have `known that the person or entity was unlicensed. E y2 Statutes & Constitution :View Statutes :- >2007- >Ch0440- >Section 10 : Online Sunshine A Select Year: 2007. .Gg; The 2007 Florida Statutes Title XXXI Chapter 440 View Entire Chapter LABOR WORKERS' COMPENSATION 440.10 Liability for compensation. -- Page 1 of 2 (1)(a) Every employer coming within the provisions of this chapter shall be liable for, and shall secure, the payment to his or her employees, or any physician, surgeon, or pharmacist providing services under the provisions of s. 440.13, of the compensation payable under ss. 440.13, 440.15, and 440.16. Any contractor or subcontractor who engages in any public or private construction in the state shall secure and maintain compensation for his or her employees under this chapter as provided in s. 440.38. (b) In case a contractor sublets any part or parts of his or her contract work to a subcontractor or subcontractors, all of the employees of such contractor and subcontractor or subcontractors engaged on such contract work shall be deemed to be employed in one and the same business or establishment, and the contractor shall be liable for, and shall secure, the'payment of compensation to all such employees, except to employees of a subcontractor who has secured such payment. (c) A contractor shall require a subcontractor to provide evidence of workers' compensation insurance. A subcontractor who is a corporation and has an officer who elects to be exempt as permitted under this chapter shall provide a copy of his or her certificate of exemption to the contractor. (d)1. If a contractor becomes liable for the payment of compensation to the employees of a subcontractor who has failed to secure such payment in violation of s. 440.38, the contractor or other third -party payor shall be entitled to recover from the subcontractor all benefits paid or payable plus interest unless the contractor and subcontractor have agreed in writing that the contractor will provide coverage. 2. If a contractor or third -party payor becomes liable for the payment of compensation to the corporate officer of a subcontractor who is engaged in the construction industry and has elected to be exempt from the provisions of this chapter, but whose election is invalid, the contractor or third -party payor may recover from the claimant or corporation all benefits paid or payable plus interest, unless the contractor and the subcontractor have agreed in writing that the contractor will provide coverage. (e) A subcontractor providing services in conjunction with a contractor on the same project or contract work is not liable for the payment of compensation to the employees of another subcontractor or the contractor on such contract work and is protected by the exclusiveness -of- liability provisions of s. 440.11 from any action at law or in admiralty on account of injury to an employee of another subcontractor, or of the contractor, provided that: Z Details Collier County Tax Collector 3291 East Tamiami Trail Naples, FL 34112 -5758 Collier County Business Tax Receipt Tax Year Info: 2012 Prev Record BUSINESS INFORMATION II License #11993399 1 I Name:IIKC TILES & MARBLE, INC I I DBA:II I Location: 3773 ARNOLD AVE Zoned: INDUSTRIAL Mail 1: 3773 ARNOLD AVE Page 1 of 1 Next Record OWNER INFORMATION Na IRODRIGUEZ, MARIO Name 2: Addres 13799 WHITE BLVD Address 2: City, Stat 134117 Phone: 304 -0960 Mail 2: City, State, NAPLES , FL 34104 Phone: 435 -0702 Open Date: 00 -00 -99 Code: 02101001 Description: CONTRACTOR Changed Date: 08 -07 -08 Paid 109-26-12 Closed Date: 00 -00 -00 1-10 State Lic: Class: MASONRY CONTRACTOR DCounty Lic: 21273 Category: 1 -10 EMPLOYEES City Lic: � Preq: COLLIER CTY COMP CARD Prev Record ** LICENSE IS PAID ** ** LICENSE IS Open ** New Search Back To List _Next Record 2005 Tax 2006 Tax 2007 Tax 2008 Tax 2009 Tax 2010 Tax 2011 Tax Information Information Information Information Information Information Information 614 http://colliertax.com/search/ols—details.php?ID=37951479&page=l 6/27/2013 STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION EMPLOYER NAME: K. C. TILES & MARBLE, INC. STOP -WORK ORDER No.: 13- 172 -D7 FEIN: 650712052 ISSUANCE DATE: 7/12/2013 EMPLOYER ADDRESS: 3773 ARNOLD AVE CITY: NAPLES STATE: FL ZIP: 341043367 WORKSITE POSTING ADDRESS: 1365 47TH AVE NE CITY: NAPLES STATE: FL ZIP: 34120 INDUSTRY OF EMPLOYER: 9 Construction 0 Non - Construction 0 Agriculture STOP -WORK ORDER Pursuant to Section 440.107, F.S., the above - referenced Employer is hereby ORDERED TO CEASE ALL BUSINESS OPERATIONS FOR ALL WORKSITES IN THE STATE based on the following violation(s): Failure to secure the payment of workers' compensation in violation of sections 440.10(1), 440.38(1), and 440.107(2) F. S., by: F,/] failing to obtain coverage that meets the requirements of Chapter 440, F. S., and the Insurance Code; materially understating or concealing payroll; ❑ materially misrepresenting or concealing employee duties so as to avoid proper classification for premium calculations; materially misrepresenting or concealing information pertinent to the computation and application of an experience rating modification factor. Failure to produce required business records within 5 business days in violation of section 440.107(7)(a), F.S. F] Failure to produce required documents within 3 business days in violation of section 440.05(11), F.S. THIS STOP -WORK ORDER MAY BE AMENDED TO INCLUDE ADDITIONAL VIOLATIONS AND SHALL REMAIN IN EFFECT UNTIL THE DIVISION ISSUES AN ORDER RELEASING THE STOP -WORK ORDER FOR ALL WORKSITES. CONDUCTING ANY BUSINESS OPERATIONS IN VIOLATION OF THIS STOP -WORK ORDER CONSTITUTES A FELONY OF THE THIRD DEGREE AND A PENALTY OF $1,000.00 PER DAY FOR EACH DAY OF VIOLATION SHALL BE ASSESSED. ORDER OF PENALTY ASSESSMENT A penalty against the Employer is hereby ORDERED in an amount: aEqual to 1.5 times the amount the employer would have paid in premium when applying approved manual rates to the employer's payroll during periods for which it failed to secure the payment of workers' compensation required by this chapter within the preceding 3-year period, or $1,000, whichever is greater. Section 440.107(7)(d), F.S. Up to $5,000 for each employee who the Employer misclassified as an independent contractor. Sections 440.10(1)(f) and 440.107(7)(0, F. S. The Stop -Work Order in this case shall remain in eff�:t until the Division either (a), issues an order releasing the Stop -Work Order upon finding the employer has come into compliance with the coverage requirements of the Workers' Compensation law and paid the total penalty in full, or (b), issues an Order of Conditional Release from Stop -Work Order pursuant to the employer coming into compliance with the coverage requirements of the Workers' Compensation law and entering into a Payment Agreement Schedule For Periodic Payment of Penalty. Please see the Notice of Rights on the reserve side that pertains to your rights regarding this action. CERTIFICATE OF SERVICE Pursuant to section 440.107(4), F.S., JACK GUMPH served a true copy of this Stop -Work Order: 1-1 By posting at the Worksite: DATE: TIME: OBy hand delivery: DATE: TIME: �y certified mail: DATE: O/ TIME: SERVER: SERVER: ARTICLE: Rev 09/19/2012 r* � Colfw9; �j CoIGer County Arrests x C' fi wwv2 .coiliersherifforwarrestsearc ^ii in iRWILLO,JOEL 12!2811969 NAPLES, FL 34117 6Z10 Wednesday, Nov 06, 2013 07:41 AM m a -- * �` s 62.1 JCR Investigative & Adjusting Services, Inc. 8930 SR 84, Ste 226 Davie, Florida 33324 Tel: (954) 818 -4246 November 26, 2013 INFORMATION REQUEST Reggie Smith Collier County Contractor Licensing Division 2800 North Horseshoe Drive Naples, Florida 34104 Re: JCR File Insurance Co Insured Subject Date of loss Dear Mr. Smith: :1311191 : Granada Insurance : KC Tiles and Marble : Robert Wiley : 6126/2013 Our office has been retained by the noted insurance company to investigate the captioned loss. We are in receipt of your Compliance Case 2013009146 notes and the photographs forwarded via email. As part of our investigation, a request is hereby made to obtain any and all additional information you might have at this date pertaining to the electrocution, (lightning strike) to Mr. Robert Wiley, at 1365 47th Avenue NE at the Golden Gates Estates, Naples, Florida, an employee of KC Tiles and Marble. Please forward all reports, photos, and any information on the above, to us as soon as available. You may contact me at 954 - 818 -4246 or by email to: jcrpi @bellsouth.net Sincerely, C-) f t"I- L--c, a�C? coo Lourdes Bedgood J e . . �i %,, DBPR - GONZALEZ, ARIEL; Doing Business As: ASH -ANN HOMES INC, Certified ... Page I of 1 4:26:52 PM 6/27/2013 Licensee Details Licensee Information Name: GONZALEZ, ARIEL (Primary Name) ASH -ANN HOMES INC (DBA Name) Main Address: 3906 ENTERPRISE AVENUE NAPLES Florida 34104 County: COLLIER License Mailing: 3906 ENTERPRISE AVENUE NAPLES FL 34104 County: COLLIER LicenseLocation: 3906 ENTERPRISE AVENUE NAPLES FL 34104 County: COLLIER License Information License Type: Rank: License Number: Status: Licensure Date: Expires: Certified General Contractor Cert General CGC1510731 Current,Active 03/01/2006 08/31/2014 Special Qualifications Qualification Effective Construction Business 03/01/2006 View Related License Information View License Complaint 1940 North Monroe Street, Tallahassee FL 32399 :: Email: Customer Contact Center :: Customer Contact Center: 850.487.1395 The State of Florida is an AA /EEO employer. Copyright 2007 -2010 State of Florida. Privacy Statement Under Florida law, email addresses are public records. If you do not want your email address released In response to a public - records request, do not send electronic mail to this entity. Instead, contact the office by phone or by traditional mail. If you have any questions, please contact 850.487.1395 (@. - Pursuant to Section 455.275(1), Florida Statutes, effective October 1, 2012, licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one. The emails provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish to supply a personal address, please provide the Department with an email address which can be made available to the public. Please see our Chapter 455 page to determine if you are affected by this change. 630 httns: / /www_mvfl oridalicense. com/LicenseDetail.asD ?SID= &id= 4047E5 CF0077069D34C... 6/27/2013 Proof of Coverage Page 1 of 1 � JEFF ATWATER,' CHIEF FINANCIAL OFFICER FLORIDA DEPARTMENT OF FINANCIAL SERVICES WC Home WC Databases CFO home Employer Detail Page Carrier Location information Return to Search Pa e Employer information *Represents the Governing Class Code associated with the Named Insured on the policy, as reported by the Insurance Carrier, and is not validated as correct. Exemption Listings Exemption Holder Name ARIEL GONZALEZ Owner Election Listings jNo Owner Election of Coverage Listings Employer Name History Employer Name Name Type Change Date IASH ANN HOMES INC I Legal Current 1ASH -ANN HOMES, INC. Also Known As N/A Return to Search Page E3\ Employer Name Employer Type NAICS Code I ASH ANN HOMES INC CORPORATION 236118 Coverage History Governing Effective Cancellation Wrap Locations Class Code Date Effective at 12:01 Carrier Office Policy Number Up A.M. View 05606 Apr 5 2012 Dec 25 2012 FLORIDA WC JOINT UNDERWRITING ASSOC 6FR13UB2847C38312 NO Locations View 05606 May 18 Nov 18 2011 AMERISURE MUTUAL WC207017401 NO Locations 2011 INSURANCE COMPANY View 05606 May 18 May 18 2011 AMERISURE MUTUAL WC207017400 NO Locations 2010 INSURANCE COMPANY *Represents the Governing Class Code associated with the Named Insured on the policy, as reported by the Insurance Carrier, and is not validated as correct. Exemption Listings Exemption Holder Name ARIEL GONZALEZ Owner Election Listings jNo Owner Election of Coverage Listings Employer Name History Employer Name Name Type Change Date IASH ANN HOMES INC I Legal Current 1ASH -ANN HOMES, INC. Also Known As N/A Return to Search Page E3\ i ,�� F � i( i �: t •'� .. { �< �� J ,77 W-Mv lot „-A . � � \ \ \d \ �y \� � :� ��. �� »; � . � �. .� �y�� .� y�� y\ /y� �� . \� � ' � � � � ^ � : � q can, $0011g, .pl &KYS' 11 A i to, its �AN M All WW�mm F4 1 4 1 fX WW�mm y7 M 2« »a. . z , »�\ ��y Employer Name: KX. TILES & MARBLE, INC. Case Type: SWO i ► Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page i of 32 Section 1 JACK CUMPH Initial: 6/281201312:56 :10 Modred: 7/12/201311:01;21 06/27/2013 JM Gumph Investigation of accidental death on construction site... As per Investigation Manager William Dorney, Bureau of Compliance, a Request for Business Records was issued. (NOTE: Please refer to complete narrative to follow) Section 2 JACK GUMPH Initial: 71121201311:02:34 Modified: 71121201311:03:36 07/10/2013 J.M. Gumph BUSINESS RECORDS RECEIPT On the date of Tuesday, July 9, 2013, 1(investigator Jack Gumph) did receive certain business records pursuant to the Division of Workers' Compensation, Request for Production of Business Records # 1 issued to the business entity of K. C. Tiles & Marble, Inc. on June 28, 2013- These records were received electronically via email to my Division of Workers' Compensation email account, On the date of Wednesday, July 10, 2013, 1 did review all business records submitted by K. C. Tiles & Marble, Inc., more specifically Yvetva ML- Trujillo, Administrator. I did send reply emails to Yvette ML- Trujillo requesting clarification of certain records submitted. I subsequently received clarifying response from Yvette ML- Trujillo. 651 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE i City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 2 of 32 Section 3 JACK GUMPH Initial 7/121201311:55:10 Modified: 7112/201311:55 :10 07/12/2013 J.M. Gumph On the date of Friday, July 12, 2013, 1(investigator Jack Gumph) was contacted by Division of Workers' Compensation, District 7 Supervisor Maria Seidler, Supervisor M. Seidler provided authorization for the issuance of a Stop Work Order to the business entity of" K. C. Tiles & Marble, Inc. for violation of Chapter 440.107 F.S. for the failure to provide workers' compensation coverage for workers Jose Cruz and Robert Wiley. i (Inv Gumph) issued SWO 13- 172 -177 to K. C. Tiles &.Marble, Inc. The case now was converted from a Request for Production of Business Records (# 1 ) to Stop Work, Order on 7/12/2013. Section 4 Initial: 71121201311:56:51 Modified: 7112!201311:56:51 This Case Was Converted From Type BRR to SWO on 7/12/2013. 634 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 . . .......... _. NARRATIVE Section 5 JACK GUMPH Initial: 7/1.2/201312:22 :27 07/03/2013 J.M. Gumph Case Number: 13- 172 -D7 Page 3 of 32 Modified! 7/12/201312:30 :32 NARRATIVE FOR INVESTIGATION OF JOBSITE LISTED AS 1365 47th AVE NE, NAPLES, FL 34120 On the date of Thursday, 06127/2013, at approximately 10:20 AM, I (Investigator Jack Gumph) received ,a telephone request to assist investigator Aysia Snodgrass, Division of Workers' Compensation, Bureau of Compliance who was Investigating an accidental death at a construction site in unincorporated Collier County (Naples), FL. I traveled to the construction site arriving at approximately 11:10 AM. From the Permit Board, the construction site was properly addressed as 136547th Ave NE, Naples, FL 34120 (hereafter referred to as "the site ), The site was observed to be a rural location, a single family residential structure under construction. The construction to date included site prep, slab poured, cement block walls complete and current "forming" for cement poured beams. At the site; i was met by Investigator Aysia Snodgrass. Inv. Snodgrass briefed me as to the investigation status. Inv. Snodgrass stated she had arrived on the site at approximately 9:45 AM. Inv. Snodgrass did make contact with Investigators of the Occupational Safety & Health Administration (OSHA) who were on the site conducting their investigation. The Investigators were identified as Greg Rodgers & Jossie Aviles. inv. Snodgrass proceeded to gain knowledge of the investigation. Inv. Snodgrass gave me a brief summery as follows: This was an accidental death investigation site whereby on the previous day (Wednesday, June 26, 2013) at approximately 1:30 PM, two construction workers were working up on scaffolding installing wooden "forming" for a concrete beam to be poured (cement). There was an electrical storm in the area. Lightening struck the top of the scaffolding, one worker was struck and killed (NOTE: The scaffolding had been taken down prior to Inv. Snodgrass' arrival at the jobsite). The other worker was thrown to the ground with unknown injuries. The struck/deceased worker was identified as Robert Wiley. The 2nd worker on the scaffolding was identified as Jose Cruz. Jose Cruz had signed a "waiver" for. Paramedics on the scene and was not transported to the hospital. There was a: third worker present who was identified as Arturo Vallejo who was not injured. The General Contractor of the site was identified as.Ash -Ann Homes, inc, (hereafter referred to as Ash -Ann). The subcontractor who's employees were doing the "forming" was said to be K.C. TILES & MARBLE, INC. (hereafter referred to as KC) Inv. Snodgrass researched the Division of Workers' Compensation, Coverage and Compliance Automated System (CCAS), Proof of Compliance Subsection (OCAS), which revealed KC to be covered under a Personnel Employee Qrganization /Leasing Company (PEO /Leasing Co), identified as South East Personnel Leasing, Inc (SE Leasing). inv. Snodgrass requested a current/active roster from SE Leasing for KC. Inv. Snodgrass received the roster at 10:58 AM (06/27/2013), which documented that the name of the deceased (Robert Wiley) as well as the 2nd worker on scaffold (Jose Cruz) WERE NOT listed as currentlactive on the roster. The 3rd worker, Arturo Vallejo was listed on the roster. Inv. Snodgrass researched the CCAS, Proof of Compliance Subsection for Ash -Ann Homes, which revealed Ash -Ann had no Proof of Coverage. Inv. Snodgrass researched the CCAS, Exemption Subsection for Ash -Ann Homes and found only an active Exemption in the name of owner, Ariel Gonzalez. inv. Snodgrass stated that she took photographs of the site. Inv. Snodgrass stated that the OSHA Investigators were interviewing several persons who were on the site. Inv Snodgrass identified these persons as: Mario Rodriguez: the Registered Agent[Vice President of KC Filemon Cendejas: Supervisor for KC ,640 Employer Name: K. C. TILES St MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Case Number: 13- 172 -D7 _.... __ . ..._..__ , NARRATIVE Page 4 of 32 tv Luiu vanejV. vv (it rei tci nt, (wilu was U1 tuwiite ti ,u Ntuviuus udy) I directed Inv. Snodgrass to initiate interviews with all parties and obtain written statements from all parties located on the site. I was subsequently briefed as to these interviews and written statements by Inv. Snodgrass: Filemon Cendejas: He (Filemon) works for KC. He (Filemon) has worked for KC for about two months. He (Filemon) was hired by KC as Supervisor of Masonry. He (Filemon) can hire workers (on behalf of KC). Robert Wiley (the deceased) came to the jobsite on Monday (06/24/2013) looking for work. Filemon told hint he would hire him, but to go to the KC office to fill out an application. He (Filemon) returned to the site in the afternoon hours. Robert Witeywas working on the jobsite, so he thought Robert had filled out the application at the KC office and all was OK. Robert worked on the site again on Tuesday (06/25/2013) and Wednesday (06/26/2013) till the lightning strike. He (Filemon) was advised of the accident by phone (from Jose Cruz). He (Filemon) immediately went to the office of KC. about 2 PM to report the accident and was told by Yvette (Trujillo) that Robert Wiley had not come into the office to fill out the application Jose Cruz had filled out an application that he got from the KC office and gave it to him (Filerrion) on Thursday (0612112013). He (Filemon)put the application in his. truck to take to the KC office on Friday (06122/2013), because he goes to pick up the paychecks. On Friday (06/22/2013), he (Filemon) went to the KC offices and picked up the pay checks, but he forgot to submit the application for Jose Cruz which remained in his truck. He (Filemon) forgot about the application (for Jose Cruz) and Jose Cruz began work on Monday (06/24/2013). Jose Cruz worked on the site on Tuesday (06/2512013) and Wednesday (0612612013) till the lightning strike knocked him off the scaffolding. He (Filemon) went to the office of KC about 2 PM to report the accident and at that time submitted Jose Cruz's application to Yvette who "sent in" the application to the Leasing Company. Arturo Vallejo: He (Arturo) works for KC and has worked for KC for about two months and Filemon is his supervisor. He (Arturo) was working on the site on Wednesday (06126/2013) with two other workers, he identified as Alejandro (Jose Cruz) and Robert. (Wiley). He (Arturo) was working on the back of the house (up on the scaffolding) and the two other workers in the front of the house about 12 feet up on scaffolding. It began to rain; He (Arturo) got down walked to the front of the house and told Alejandro (Jose Cruz) and Robert (Wiley) to get down. As Alejandro (Jose Cruz) began to climb down, the lightning struck and knocked both men to the ground. He (Arturo) then called 911 on his cell phone. Mario Rodriguez: He (Mario Rodriguez) was aware that Robert Wiley had come to the jobsite on Monday (06/24/2013) looking for work. The Foreman for KC was Filemon Cendejas. Filemon agreed to hire him (Robert) and asked him (Robert) to go to the KC office to fill out an application. When the Foreman (Filemon) came back to the job on Monday (06/2412013) afternoon, Robert Wiley was working. The Foreman (Filemon) told him (Mario Rodriguez) that he (Filemon) assumed Wiley had gone to the office and filled out the application, and all was OK. That Filemon did not know there had not been an application filled out by Wiley until he went to the KC offices to report the accident and was told by Yvette (Trujullo). At approximately 11:55 AM, I was approached on the site by a man who said he was the General Contractor for this construction site. This man identified himself Ariel Gonzalez, owner of Ash -Ann Homes, Inc. I identified myself and provided a business card to Ariel Gonzalez. I then requested information from Ariel Gonzalez as to this investigation of the site. Ariel Gonzalez did provide the following information: Ariel Gonzalez said that Filemon Cendejas was known to him for many years and Ariel knows he (Filemon) has worked with various contractors in Naples area. He (Ariel Gonzalez) knows Filemon to be a very good masonry contractor. About two (2) months ago, he was preparing to start construction on a separate house (hereafter referred to as the "18th St. house "). He ( Ariel Gonzalez) had come in contact with Filemon who had told him that he now runs the masonry for a company named KC. He tells Filemon about the project and asks if he Is interested in the "18th St. house" project. 0 �' He ( Ariel Gonzalez) tells Filemon that he. is going to do construction on three houses. Filemon says yes, that he is interested. Filemon tells him to contact the offices of KC and that will prepare an "estimate ". e; Employer Name: K. C. TILES & MARBLE, INC. _ Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 ` Page 5 of 32 He ( Ariel Gonzalez) telephones the KC offices and speaks to a woman (subsequently identified as Yvette TRUJILLO, wife of KC owner, Joel TRUJILLO). Adel Gonzafeztells her he's been speaking to Filemon about a job and requests a written estimate for the subcontracting of the masonry to KC, as well as insurance paperwork (for the 18th St project only). The woman says she will prepare and sent to him via email. He subsequently receives the email from KC with and attachment that includes a written estimate. He believes-that at this time, he also received the insurance paperwork. He subsequently met with Filemon on the "18th St" house site and then spoken with a man (unknown name) in the KC office by telephone and said he would hire KC as subcontractors. Filemon indicated to Ariel Gonzalez that he (Filemon) would be the sole contact person for all details as he runs all the masonry jobs.. Filemon and his crew arrived on the "18th St. house" site and commenced the masonry of slab, block, beam etc (approximately six weeks ago). He ( Ariel Gonzalez) paid KC with an Ash -Ann Homes check during this time. As the masonry part of the job was winding down, he spoke. to Filemon about the second .house he was about to "break ground" on. He ( Ariel Gonzalez) said that he & Filemon made a deal that since the 2nd house was very similar (to the 1 st house - "18 St house").; that he would pay KC at the conclusion of the masonry using the square footage as price point {just like the 1 st house- $1.20 per sq. ft.). Since he ( Ariel Gonzalez) had already paid KC for the first house, Filemon agreed to this verbal agreement. About 3 weeks ago, Filemon and his crew initiated the masonry on the second house, which was the jobsite under investigation (1 -365 47th Ave NE, Naples, FL 34120). Filemon and his crew worked the job where there were always 2 or three workers besides Filemon on the jobsite. Yesterday (06126/201.3), in the afternoon hours, he was called by Filemon telling him about the lightning strike. I did have Adel Gonzalez complete a written statement. Adel Gonzalez indicated that he would be more comfortable writing the statement in Spanish. Since Inv. Snodgrass could interpret the written statement, I agreed that it could be written in Spanish. 1 did subsequently personally speak to the person identified at Mario Rodriguez, Registered Agent(Vice President of KC. I did request information relating to his status as officer of the corporation. Mario Rodriguez did advise me that he was previously the President of KC, however due to the decline of the economy in 2007; he had to secure employment elsewhere. He (Mario Rodriguez) therefore resigned as President of the corporation and Joel Trujillo became President (Joel Trujillo was Vice President previously). Mario Rodriguez remained as Registered Agent of KC and is a Vice President in name only (not listed on KC Corporation). Mario Rodriguez stated he remains involved in the KC business. I did request information of Mario Rodriguez in reference to employee Filemon Cendejas. Mario Rodriguez stated to me that Filemon was Project Manager /Foreman for KC and had been so employed for several months. Mario Rodriguez said that Filemon "runs" the masonry jobs. Further, that Filemon has the authority to hire and fire employees on behave of KC. I had observed a large "utility truck" and trailer stacked with scaffolding parked next to the house. I inquired of Mario Rodriguez if the work truck vehicle and equipment now at the jobsite belonged to KC. Mario Rodriguez said they belong to Filemon Cendejas. I did request of Mario Rodriguez that investigators would need to speak directly with documented officer of KC, Joel Trujillo as soon as possible. Mario Rodriguez advised that Joel Trujillo was now at the offices of KC and was awaiting our arrival. I subsequently searched the Florida Division of Corporations, which showed K.C. TILES & MARBLE, INC., FEIN: 650712052, Date Filed: 12/04/1996, ACTIVE, with Registered Agent: RODRIGUEZ, MARIO, Officer /Director: TRUJiLLO, JOEL, (Title- P). The address of the corporation is listed as 3773 ARNOLD AVE, NAPLES, FL 34104. It should be noted that while on the site,.I did place a telephone call to the State of Florida, Department of Financial Services, Division of Insurance Fraud, Fort Myers Field Office. At that time, I made phone contact with Lieutenant Mark Fritz. I explained to Lieutenant Fritz the circumstances of the investigation at the site and made an official "referral" at that time. Lieutenant Fritz advised that he would be responding to the site for investigative purposes. Employer Name: K. C. TILES & MARBLE, INC. ~ rt Case Type: SWO Case Number: 13- 172 -D7I Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page 6 of 32 .Lieutenant rntz oia suDsequently arrive at me site along min Qeiective maipn uuarniero. mi inat time Lieutenant Fritz and Detective Ralph Guarniero did initiate an official Division of Insurance Fraud investigation. Lieutenant Fritz and Detective Ralph Guarniero did .complete tape recorded interviews of all pertinent persons on the site. to include: Mario Rodriguez: the Registered AgentlVice President of KC. Filemon Cendejas: Supervisor for KC Arturo. Vallejo: Worker for KC (who was on jobsite the previous day) Ariel Gonzalez: Owner of Ash -Ann Homes and General Contractor of the site. At approximately 1:45 PM, I received a telephone call from Investigator Greg Rodgers, OSHA. Mr. Rodgers had completed his investigation at the site and had left to attempt an interview with KC worker, Jose Cruz (worker who was on scaffold when struck by the lightning). Greg Rodgers advised me that he was in phone contact with Jose Cruz and was in route to interview Cruz at his home. I advised Rodgers that we also needed to contact and interview Jose Cruz. Rodgers supplied the address to me in Naples.. *** CONTINUED NEXT PAGE — SECTION SIX ` 6 4 3 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 i I Address 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 7 of 32 Section: 6 JACK GUMPH Initial: 71121201312:23:43 Modified: 71121201312:31:37 07/0312013 J.M. Gumph -- CONTINUATION -- NARRATIVE FOR INVESTIGATION OF JOBSITE LISTED AS 1365 47th AVE NE, NAPLES, FL 34120 Myself and Investigator Snodgrass had completed our investigation on the site. At approximately 2:01 PM, we departed the jobsite (1365 47th Ave NE, Naples, FL 34120) and traveled to the home address of KC worker, Jose Cruz. At approximately 2 :47 PM, we arrived at the address of 4019 Mindi Ave., Naples, Florida at which time; we met Investigator Greg Rodgers, OSHA. Greg Rodgers introduced me to Mr. Jose Cruz, who was the worker of KC that was thrown off the scaffolding when the lightning struck Robert Wiley. Myself and Investigator Snodgrass initiated an interview with Mr. Cruz. I did request identification and Mr. Cruz supplied a Florida Drivers License: Jose Kenn Alexi Cruz Villamar 4019 Mindi Ave,. Naples, FL 34112 -6787 DOB: 04/20/1992, Male, 609" D L# C621- 431 -92 -140-0 (SS# 800 -57 -2686) During this interview, Jose Cruz supplied the following information: He personally knows Filemon Cendejas as he is currently dating his daughter. Cruz said that several weeks ago, he (Jose Cruz) and Filemon spoke about him (Jose Cruz) coming to work for KC_ Filemon told him (Jose Cruz) to go to the KC office and fill out an application. He went to the KC office and met a woman (subsequently identified as Yvette Trujillo). He filled out an application and the woman said she would "send it in ". He (Jose Cruz) said that he was later told by Filemon that the application had been rejected by the insurance company because the social security number was wrong. Cruz said that he "got new papers" and last week returned to the office of KC. He again contacted the same woman in the office and she requested he fill out a new application. She provided the application to him and he took it home and filled it out. Cruz said that last Thursday (06/2012013), he provided the completed second application. He (Jose Cruz) then personally gave the second application to Filemon who told him (Cruz) he would take it to the KC offices and turn it in the next day (Friday, 06/21/2013). Cruz said that he was subsequently told by Filemon to start work the following Monday (06/24/2013) so he believed the application had been accepted by KC. Cruz said that Filemon told him he would be paid $10.00 per hour. Cruz said that on Monday (06/24/2013) at approximately 7:30 AM, he went to Filemon's house, picked up the work truck, and drove it to the site on 47th Avenue. He (Jose Cruz) began working at the site with Arturo (Vallejo) who was already there working. At about 8:00 AM, Robert Wiley walked onto the site and asked if any work? Jose Cruz said that Robert Wiley said that a "Jenny' told him to come to the site to see if they needed help. He (Jose) called Filemon (who was not on the site yet). Filemon then came to the site at about 8:30 AM, spoke to Robert Wiley. Cruz said that Filemon did some work on the site, then left the site. Cruz said that Robert Wiley never left the site and began working with him and Arturo (Vallejo). That Filemon returned to the site at about 4:30 PM where he (Jose Cruz), Robert Wiley and Arturo were still working. 6044 Jose Cruz stated that he worked on the site on Tuesday (06/2512013), again driving the truck from Filemon's house. On Tuesday, he worked with Arturo (Vallejo) and Robert (Wiley) all day. 1 -..... /-- — ..1...4 —A 4&. -i -- to J...1 —.t, -.., inc Inc Inn n� lJ- ..... -:- A........ 1L-- 4- ....1. L.. 14- :.. L..:1. l - lAl....l «.......J.... i... Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 8 of 32 .1uJG c,IUG stateu u)at VII VVuunebuay tua/zal/w 10). ntl dgU111 ulUYC u1C LIQAA U3 Ule juMte. VII yyeutlesudy, IIC worked with Arturo (Vallejo) and Robert (Wiley). Cruz said that Filemon was on the site early in the morning, then left. The lightning struck him (Cruz) and Robert about 2:00 PM where he was knocked to the. ground_ Cruz said the first thing he did was to telephone Filemon and tell him about the lightning strike. He (Cruz) then called 911. Cruz said that Filemon never did come to the site that day (Wednesday) while he was there. Cruz said that Ariel Gonzalez.did come to the site that afternoon. Jose Cruz said that although he was hired by Filemon, he knew he worked for KC. He had gone to the KC two times and completed applications. The first application to the office was rejected. The second application for KC was filled out and given to KC supervisor Filemon Cendejas who told him the application would be submitted to KC office the nextday. It should be noted that Division of Insurance Fraud investigators, Lieutenant Fritz and Detective Ralph Guarniero did complete tape recorded interview of Jose Cruz at this location. Myself and Investigator Aysia Snodgrass did then travel to the office of K.C. Tiles & Marble, Inc. located at 3773 Arnold Ave, Naples, FL 34104. At the location, we did contact with the following persons: Mario Rodriguez: the Registered Agent/Vice President of KC Joel Trujillo: Officer /Director of KC (Title -P) Yvette Trujillo: Office Manager of KC (wife of Joel Trujillo) Filemon Cendejas: Project Manager of KC (who arrived after the interview started) An interview was completed with these persons whereby they related the following: Filemon Cendejas was hired by KC about two months ago. Mario Rodriguez has known Filemon for about 20 years. Mario Rodriguez also stated that Filemon and Ariel Gonzalez (owner of Ash -Ann) know each other for many years. KC is basically a fabricating facility; however they carry a masonry license in Collier County (qualified by Mario Rodriguez). Since Filemon was an experienced masonry contractor, they decided to hire Filemon to make use of the Masonry License. They set up what was termed a Masonry or Concrete Division and made Filemon Cendejas the. Project Manager. Filemon's responsibilities were to deal directly with the contractors in the field setting up jobs, hiring workers (Yvette Trujillo said the KC office does not deal with them - contractors). Filemon's responsibility to KC was that the jobs are made known to KC and the workers hired go through the KC PE011-easing Company. Filemon puts in the hours for himself and his workers each week to Yvette (Trujillo) and KC pays them through South East Personnel Leasing. Joel (Trujillo) indicated that he is aware that some time ago, KC did subcontract a job from Ash -Ann Homes for a location described as "18th Street' in Naples. Joel said that there was a written estimate and work was performed on that project by KC workers with Filemon fully in charge of the project. Filemon did provide the hours to KC (Yvette) each week. and Filemon (and workers) paid by KC (SE Leasing). Filemon came into the office on the previous day (Wednesday, 06126/2013) in the afternoon hours and advised Joel Trujillo of the lightning strike accident on the jobsite at 47th Avenue (1368 47th Ave NE, Naples, FL 34120). Joel said that Filemon told him that "Robert" died. Joel then asked "Who is Robert ?" That is when Filemon told them he had sent Robert Wiley to the office on Monday (06124/2013) to fill out the application. They realized that he (Robert Wiley) never came in to the KC office to fill out an application. Joel Trujillo stated that this was the first time he ever heard of the project on 47th Avenue. That he believed Filemon was still working for Ash -Ann on the 18th St project. He (Joel Trujillo) believed that Filemon Cendejas must have made a separate agreement with Ash -Ann Homes (Ariel Gonzalez) to work outside of KC's knowledge. Yvette Trujillo stated that on the previous date (Wednesday, 06/26/2013), in the afternoon hours, Filemon had advised her that he had placed the revised (new) application of Jose Cruz on her desk for submission to South East Personnel Leasing. She (Yvette) knowing this individual from his coming into the office twice to fill out applications for KC, did in turn submit the application to South East Personnel Leasinq on Wednesday Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE { City, State, Zip: NAPLES, FL 34/043367 I i Page 9 of 32 (66/26/2013). Sole Officer /Director Joel Trujillo made several references to "she takes care of all that" (his wife Yvette Trujillo) in referring to the bookkeeping and office records questions. Yvette Trujillo stated she works in the office taking care of the payroll and all other office record. keeping. NOTE: Yvette Trujillo was not listed on the official SE Leasing Roster for KC Tiles. Yvette was asked if she received remuneration from KC for her duties running the. KG office, and she said that she did not. Filemon Cendejas entered the interview and. related that Ariel Gonzalez of Ash -Ann Homes had spoken to him about the three projects. That they have known each other a long time and he trusts Adel. The 1 st house on 18th Street was the one that Yvette provided the written estimate (documented on May 1, 2013). Filemon and his workers worked on the 18th Street project and completed about six weeks ago. He (Filemon) ran all payrolls through KC (Yvette). Filemon stated that Ariel Gonzalez again spoke to him about starting. the 47th Avenue project. Filemon stated that he and Ariel talked about the fact that the houses would be similar and since the 18th Street project was "piece work" anyway, that Ariel would pay KC upon completion whereby they would both figure the square footage of work completed for "piece work" rate. They both agreed and Filemon (and his workers) began work on the 47th Avenue project about 5 weeks ago. He (Filemon) ran all payrolls through KC (Yvette). Filemon stated that the work is for "labor ".only and that Ariel (Ash -Ann) pays for all materials. Filemon related he did not advise either Yvette or Joel about the 47th job, just stating "My mistake for not telling them ". Yvette Trujillo stated that Ash -Ann only paid KC a "deposit" for the 18th Street project and the balance remains open. Yvette Trujillo then confirmed that Filemon and Arturo Vallejo had. been receiving payroll checks from KC continuously since the inception of the 18th Street project. Yvette said that Filemon gives her the hours and he doesn't have to tell her what the workers are working on. Further, that Filemon had responsibility in that area, and they don't question the work hours that he puts in for his workers. I then inquired of a person named "Jenny" or Jennifer Caudillo, who was a person listed on the KC Leasing Roster with South East Personnel Leasing. (Note: "Jenny" was the name provided by Robert Wiley as telling him to go to the jobsite). Yvette related that Jennifer Caudillo was hired as a personal assistant for Filemon in the Masonry Division helping with blueprints, paperwork, materials etc. Yvette again explained that Filemon runs the masenry field work while she and Joel have the "fabricating side ". I did request from Yvette Trujillo, all applications for workers under the supervision of Filemon Cendejas. Yvette provided me the following applications: Filemon Cendejas, dated 04/2912013 Jose Cruz, dated 04/29/2013 (old application) Arturo Vallejo, dated 05/02120.13 Jose Cruz, dated 06/19/2013 (new application) The interviews were then concluded with all parties at the KC offices. It should be noted that Division of Insurance Fraud investigator, Lieutenant Mark Fritz did complete tape recorded interviews of KC personnel at this location. On the date of Friday, June 28, 2013, 1 (Investigator Jack Gumph) did again interview Mr. Ariel Gonzalez, owner of Ash -Ann Homes. Ariel Gonzalez was accompanied by a man named Mario E. Rodriguez. Mario E. Rodriguez was the representative of the homeowner at 1365 47th Ave NE, Naples, FL 34120 (listed as his brother -in -law, Yancey 646 Mayor DeLeon), who lives in California (NOTE: It should be noted that this Mario E. Rodriguez is not the same Mario Rodriguez who is the Registered agent/VP of KC Tiles). Adel stated the contract (written estimate) with KC .t_..__- Ani!_ ( _ -i _--_- _a._. -_ -L-..L n • .____a!_- - _. - l f -., .1-- L - J t -!a T'!_.___._ — ___f -, -- L- L - J n !__..- -- Employer Name: K. C. TILES & MARBLE, INC. ' Case Type: SWO Case Number: 13- 172 -D7 I , Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page 10 of Tor Ine -i mn Jireel project was aDDui d -4 monins ago. rte (/-lnei) nao toio miemon Venuejas ne nao S nouses coming up. They ( Ariel & Filemon) agreed on "piece rate ", $1.20, per sq. ft labor only for the masonry work. Ash -Ann would provide for all materials. Ariel again reiterated that he only spoke to the KC office one time with a Women (for the written estimate for 18th Street) and then his sole contact was with Filemon. Ariel spoke to Filemon about the 47th Avenue project and they agreed to do the same "piece rate" and he ( Ariel) would pay KC upon completion. He ( Ariel Gonzalez) had already paid a business check (Ash -Ann Homes) to KC for the 48th St. project. Filemon and his workers began on 47th Avenue project about 3-4 weeks ago. During this meeting, Ariel provided copy of an "Estimate" (## 2566), dated May 1, 2013, KC Tiles & Marble, Inc. to Ash -Ann Homes for work on job name: Rodriguez Residence_ The estimate was totaled at $9,815.20. Ariel also provided a copy of an Ash -Anh Homes check (#1013), dated 05/06/2013 made out to KC Tiles & Marble, Inc for $5,869,20. Ariel related that this was for "full payment" on the 18th Street project. Ariel explained this by saying the cement company would not deliver the cement because KC owed them money. So he had to payoff the KC debt to the cement company, therefore deducted from the money owed to KC. Ariel Gonzalez stated that he could find no written documentation from KC indicating their proof of worker's compensation coverage prior to the commencement of the 18th Street project. He ( Ariel) also re- confirmed that his. agreement on the 47th Avenue project was "verbal" only with Filemon, but with the understanding and knowledge that Filemon works for KC and is their representative in the field working on masonry projects. As he had done with the 18th Street project, he had every intention of paying KC by check at the conclusion of work on 47th Avenue project by Filemon and his workers. Ariel reasoned that he could not ever pay Filemon directly because Filemon did not carry a valid contractor's license in Collier County and the license was held by KC in Collier County. The interview was then concluded with Adel Gonzalez, Ash -Ann Homes. On the date of Friday, June 28, 2013, 1 (Investigator Jack Gumph) did again interview Mr. Mario Rodriguez, Registered Agent/ VP of KC Tiles. During the course of the interview, I did inquire of Mr. Rodriguez if he received any remuneration for his duties as VP of KC Tiles. Mario Rodriguez stated that he received no monies for his work with KC Tiles. On the date of Friday, June 28, 2013, 1 (investigator Jack Gum ph) did have a .telephone conference call with Bureau of Compliance, Investigations Manager, liliam Dorney and Michael T. McGuckin, Managing Attorney, Workers' Compensation Compliance, Division of Legal Services. At that time, Manager Domey authorized the issuance of a Division of Workers' Compensation, Request for Production of Business Records (BRR #1)to the General Contractor, Ash -Ann Homes and the subcontractor, K.C. Tiles & Marble, Inc. I contacted Investigator Aysia Snodgrass and advised her to issue the Records Request to Ash -Ann Homes. I was subsequently advised by Investigator Aysia Snodgrass that she had provided personal service of the Records Request to Officer/Director Ariel Gonzalez on this date of June 28, 2013. I subsequently received a telephone call from an attorney who identified himself as Hugo Rodriguez, representing KC Tiles, who requested .I refrain from any further contact of KC management. I advised the attorney that I was required to serve the "Records Request ". An agreement was made that I could meet the Registered Agent, Mario Rodriguez for service. On this same date of Friday, June 28, 2013 at approximately 3:10 PM, I did personally meet with Registered Agent, Mario Rodriguez at the Publix Parking lot, Collier Blvd & Pine Ridge Rd, Naples, FL. At that time (documented as +>� 3:13 PM), I did personally serve Mario Rodriguez with the Request for Production of Business Records for K.C. Tiles & Marble, Inc. 10 14 * ** CONTINUED NEXT PAGE - -- SECTION. 7 *** Employer Name: K. C. TILES & MARBLE, INC. j i Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 11 of 32 64% Employer Name: K: C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -137 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 12 of 32 Section 7 JACK GUMPH 07/03/2013 -- -- CONTINUATION — Initial: 7112/201312:30:57 J.M. Gumph Modified: 7/12/201313:04:55 NARRATIVE FOR INVESTIGATION OF JOBSITE LISTED AS 1365 47th AVE NE, NAPLES, FL 34120 On the date of Tuesday, July 2, 2013, 1 (investigator Jack Gumph) received communication from Ash -Ann owner; Ariel. Gonzalez that he had compiled the requested records pursuant the issued "Records Request" from the Division of Workers' Compensation. At 8:30 AM, I subsequently met with Mr. Ariel Gonzalez at the Collier County Contractor Licensing .Offices, 2800 Horseshoe Drive, Naples, FL. At that time, Mr. Ariel Gonzalez did turn over top me certain records pursuant the issued records request. A standard "STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES, Division of Workers' Compensation, Bureau of Compliance, DOCUMENT IDENTIFICATION FORM" was completed for these documents. I took possession of these records to be transported to the Fort Myers Field Offices These records were itemized as follows:. 1. Collier County Building Permit for 1365 47th Ave NE, Naples, FL 34120 2. Collier County Building Permit for 482518th St NE, Naples, FL 34120 3. Wells Fargo Account #.-.8865, bank statement & check copies. 4. Wells Fargo Account # ...31:14, bank statement & check copies 5. Wells Fargo Account # ...1075, bank statement & check copies 6. Wells Fargo Account # ...6765, bank statement & check copies 7. 1st National Bank of Naples Account # ...5543, bank statement & check copies 8. QuickBooks Ledger for account # ...5543 (1st National Bank of Naples) 9. Ash -Ann Homes contract with homeowner for 1365 47th Ave NE, Naples, FL 34120 10. Letter explaining Check # 1049 for account # ... 1075 (Wells Fargo) At approximately 1.0:30 PM, I did receive a. telephone call from Supervisor Maria Seidler in the Fort Myers Field Office. At that time, I was advised by Spv. Seidler that it had been authorized to issue a Stop Work Order (Site Specific) to the General Contractor in this case, Ash -Ann Homes. Investigator Snodgrass subsequently issued the Stop Work Order # 13- 159 -D7 to ASH -ANN HOMES, INC. On this same date of July 2, 2013, at 12:22 PM,. I did again meet with Ash -Ann Homes owner, Mr. Ariel Gonzalez. At this time, I did personally serve Officer /Director Ariel Gonzalez with Stop Work Order # 13- 159 -D7 (documented at 12:40 PM) issued to ASH -ANN HOMES, INC. Mr. Gonzalez was also issued the Request for Production of Business Records (BRR #2), for the audit period of 07/03/2010 to 07/02/2013. Also issued the "State of Florida, Department of Financial Services, Division of Legal Services, ELECTION OF PROCEEDING ". Mr. Ariel Gonzalez informed me that he was leaving the, country, traveling to Cuba on Monday, July 8, 2013. He would return in 3 weeks at which time he would compile the additional records and re- contact me. –=-------------------------------------- During the course of this investigation, I (Investigator Jack Gum ph) did have the occasion to contact Mr. Scott v_.'--- i .... tie_. -_ --- t :_ i - - � - is ...� r._....a I a-...N nt_ Employer Name: K. C. TILES & MARBLE, INC. Ease Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE I City, State, Zip: NAPLES, FL. 341043367 (f NARRATIVE Page 13 of 32 muyser, Musa uurtvvuketuncdte iwandyet, uun to ,iutaitce L.u111Pa11y kotiuui r-ast retacrmet Ledbrnylnc1, rn 727 - 682 -0136. During the course of this contact, I did inquire of Mr. Keyser, if his company had received any application from KC Tiles in the name of a worker named Jose Cruz. Mr. Keyser did confirm that his company did receive an electronic application which was time stamped at 6:46 PM, Wednesday, June 26, 2013. This confirms the statements by both Filemon Cendejas that he took the application of Jose Cruz to the KC offices on that date and also Yvette Trujillo of KC that she accepted the application of Jose Cruz and submitted to South East Leasing on that date (which was at five plus hours after the lightning strike). Mr. Scott Keyser, Loss Control /Certificate Manager, was also requested to research the files of South East Personnel Leasing Inc to ascertain payroll_ records of KG Tiles for the previous 3-4 weeks. (This is the time period of work being completed on the 47th Ave project). Mr. Scott Keyser provided written documentation of payroll for KC Tiles employees, Filemon Cendejas, Arturo Vallejo and Jennifer Caudillo for the period of "Week ending June 14, 2013" to "Week ending June 28, 2013 ". This document confirmed that KC "Masonry Division" workers were constantly paid for the time period working on the 47th Ave project. NOTE: It should be noted that the wage hours document supplied by KC Tiles (Yvette Trujillo) to SE Leasing clearly designate two separate divisions with the KC Tiles company. One division was listed as "Pre- cast" with the names of Joel Trujillo and Lazaro Lugo, The second division was listed as "Masonry' with the names of Filemon Cendejas,. Arturo (Vallejo) and Jennifer (Caudillo). On the date of Tuesday, July 2, 2013, 1 did go the Collier County Sheriff's Office. in Naples, Fl. At that time, I did request an official record of the investigation of the lightning strike at 1365 47th Ave NE, maples, FL 34120,1 personally received a copy of report # 1300015822, dated 06/26/2013 for the location of 1365 47th Ave NE, Naples, FL 34120.1 reviewed the report (Officer Eric Grundeman, # 1842) which confirmed the presence on the site of Jose Cruz, Arturo Vallejo and victim Robert Wiley on 06/26/2013. On the date of Wednesday, July 3, 2013, 1 received a telephone call from Jose Cruz. Mr. Cruz now told me that when he was knocked from the scaffold, he injured his back. He has gone to see a doctor about the injury and will have a follow up in a few days. During this conversation, I did again ask Jose Cruz who he believed he worked for on the jobsite (47th Ave project). Jose Cruz told me that there was no doubt in his mind that he worked for KC Tiles. Jose Cruz again said he filled out two separate applications for KC and had been to the office twice. He gave the second application to Filemon Cendejas who told him (Cmz) it would be taken to the KC office. Cruz said that Filemon told him he would be paid. $10.00 an hour to start. INCIDENT / JOBSITE SUMMARY * On the date of 06/26/2013, the jobsite addressed as 1365 47th Ave NE, Naples, FL 34120 did properly list the General Contractor of record to be Ash -Ann Homes, Inc., with sole Officer /Director being Ariel Gonzalez- * On the date of 06/26/2013, the jobsite addressed as 1365 47th Ave NE, Naples, FL 34120 did O have masonry "forming" construction being completed (and no other construction work). * The masonry forming was under the control and supervision of Filemon Cendeias. Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE l City, State, Zip: NAPLES, FL 341043367 Page 14 of 32 * The forming work was being completed by workers, Arturo Vallejo, Jose Cruz and Robert Wiley, * The Work came to a halt when a lightning strike resulted in the. death of worker Robert Wiley and injury to worker Jose Cruz. Arturo Vallejo was not injured. * Surviving workers Jose Cruz and Arturo Vallejo made verbal statements that they worked for KC Tiles & Marble Inc. under the direct supervision of Filemon Cendejas. * Filemon Cendejas made a verbal statement that he worked for KC Tiles & Marble Inc. as Supervisor of Masonry and supervised Arturo Vallejo, Jose Cruz and Robert Wiley at the 47th Ave jobsite. * The General Contractor of record, Ash -Ann Homes, Inc., Officer /Director Ariel Gonzalez made a verbal statement that he subcontracted the masonry forming to KC Tiles & Marble Inc. through Filemon Cendejas, who he knew worked for KC Tiles. * KC Tiles & Marble Inc. was found to carry workers' compensation in the form of a PEO /Leasing Company, identified as South East Personnel Leasing. * An Active / Current Roster of South East Personnel Leasing on 06127/2x13 (day after accident) showed no listing of KC workers, Jose Cruz and Robert Wiley. The Active / Current Roster of South East Personnel Leasing on 06/27/2013 did show a listing of KC workers, Filemon Cendejas and Arturo Vallejo. * That Filemon Cendejas and Arturo Vallejo were pay rolled employees of KC Tile and were insured for their workers' compensation insurance through KC Tile (through South East Personnel Leasing). KC Tiles & Marble, Inc— Position Statements * KC Tile sole Officer/ Director Joel Trujillo (Title President) did contend that KC Tile had no responsibility for the two workers (Jose Cruz & Robert Wiley) because: - Jose Cruz and Robert Wiley had no applications on file with KC Tile. - That he (Joel Trujillo) was unaware of the jobsite (1366 47th Ave NE, Naples, FL 34120) and was never told about the verbal agreement between his supervisor Filemon Cendejas and Ash -Ann owner Ariel Gonzalez to complete work on the site. * Officer / Director Joel Trujillo (KC Tiles) contention is that Filemon Cendejas and Ariel Gonzalez (Ash -Ann Homes) surreptitiously made an agreement outside the knowledge of KC Tiles. INVESTIGATIVE FINDINGS * KC Tile has a management team of sole Officer / Director Joel Trujillo (President), his wife Yvette Trujillo (Office Manager) and Registered Agent/ VP Mario Rodriguez. * KC Tile hired Filemon Cendejas on April 29, 2013 as Project Manager / Supervisor and established a new Masonry - Cement Division for him to operate. &5I Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES; FL 341043367 Case Number: I 1.3- 172 -D7 Page 15 of 32 * Filemon Cendejas was given full responsibility and authority to work in the field with all contractors in making agreements, hiring workers and all necessary contacts. * KC Tile hired a speck Clerical Assistant, Jennifer Caudillo to specifically assist Masonry Division Project Manager Filemon Cendejas with all clerical duties for the division such as material orders, blueprinting, etc. * Filemon Cendejas had the sole responsibility to submit the hours Division workers. worked for the KC, Masonry * Filemon Cendejas continuously from his date of hire "(04/29/2013) submitted consistent payroll hours for workers up to and including the date in question (06/2612013). * KC Tile worker Arturo Vallejo (who was working on the site on 06/26/2013) was one of the payrolled employees who" received consistent payroll hours since his hire date of May 2, 2013. Worker Jose Cruz first went to the offices of KC Tile in April, 2013, whereby met Office Manager, Yvette Trujillo, and completed an application for KC Tile. * After the first application was rejected by the Leasing Company, worker Jose Cruz went to the offices of KC Tile a second time the week of June 17, 2013,where6y met with Office Manager, Yvette Trujillo. Jose Cruz was issued a new application by Yvette Trujillo to complete for employment. * Jose Cruz subsequently completed the 2nd application and submitted to Supervisor Filemon Cendejas on June 20,. 2013, and in good faith was told (by Filemon Cendejas) to report for work the following Monday (06124/2013), as Filemon said he would submit the application the following day (Friday, 06/2112013) to the KC office. * Supervisor Filemon Cendejas forgot to submit the application of Jose Cruz when he went to the KC Tile Offices on June 21, 2013 to pick up payroll checks for workers. * Worker Robert Wiley had been instructed by Supervisor Filemon Cendejas to report to the KC Tile offices to complete the application process. on the morning of June 24, 2013. * Filemon Cendejas assumed Robert Wiley had gone to the KC Offices and completed the application process. Robert Wiley was allowed to work at the site by the Supervisor of KC Tiie (Filemon Cendejas) who was in control and supervision of the" site. * Ash -Ann Homes owner, Ariel Gonzalez did enter into a written agreement with KC for a first subcontracted masonry job in May, 2013 and entered a second verbal agreement with Project Manager / Supervisor Filemon Cendejas for the masonry work on the 47th Avenue project. * Ash -Ann Homes owner, Ariel Gonzalez did believe that KC Tiles, Project Manager / Supervisor Filemon Cendejas had full authority to commit to any agreements, written or verbal. * KC Tiles, Project Manager / Supervisor Filemon Cendejas believed he (Cendejas) had the full authority from KC Tiles management to commit to any agreements, with any contractors in the field for the Masonry Division of KC. CONCLUSION 1. Asper statements of KC Tiles management (Joel Trujillo & Yvette Trujillo),. Filemon Cendejas had the responsibility and authority to make agreements in the field with contractors for the Masonry Division of KC Tiles. Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 I Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page 16 of 32 2. That Ariel Gonzalez (Asti -Ann Homes) had no deceptive-or unethical intent when he made the verbal agreement with Filemon Cendejas, because he believed that Filemon Cendejas was authorized to make any such agreements for KC Tiles. 3. That Filemon Cendejas (KC Tiles) had no deceptive or unethical intent when he made the verbal agreement with Ariel Gonzalez, because he believed he was authorized to do so by KC Tiles. 4. That Filemon had authority, control and supervision of KC workers. at the 47th Ave project for the past 3 -4 weeks and was paid by KC Tiles for doing so. 5. That a continuous employer- employee relationship existed between Filemon Cendejas and KC Tiles since his hiring as Masonry Division Project Manger on 04/29/2013. 6. That an employer - employee relationship existed between Jose Cruz and KC Tiles in that Jose Cruz had gone twice to KC office, filled out two applications, had personal contact with Yvette Trujillo and gave the application in good faith to Filemon Cendejas who was to take to KC office. 7. That Yvette Trujillo knowingly accepted the Jose Cruz application on the date in question (06/26/2013), and submitted the application to SE Leasing to insure Jose Cruz as an employee of KC Tiles. Based on the foregoing information, it is believed that clear and convincing evidence exists that KC Tiles & Marble, Inc was in violation of Chapter 440 F.S. for failure to provide workers' compensation insurance to workers Jose Cruz and Robert Wiley on the jobsite documented as 1365 47th Ave NE, Naples, FL 34120. Sedtion 8 JACK GUMPH Initial: 7112/201313:16:53 Modified: 7!15/2013 08:53:35 Business: K. C. TILES & MARBLE, INC. Date of Violation: 06/26/2013 Audit/Review Period: 0 7/1 31201 0 to 07112/2013 Corp Filed: 12/04/1996 Corp Officer: Officer /Director: TRUJILLO, JOEL (Title - P) Exemption: NONE Insurance Policy or Employee Leasing: South East Personnel Leasing Inc, Policy # WC71949, 04101/2013 to 04/01/14 Scope of Work: Forming for concrete pouring for cement beams on single family residence - new construction. On site employee(s) in violation: Jose Cruz, Robert Wiley and Yvette Trujillo ES') Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number:. 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 17 of 32 Section 9 AYSIA SNODGRASS Initial. 71121201313:39:55 Modified: 7/12/201313:39:55 Sunbiz - Florida Department of State, Division of Corporations CCAS _ Coverage and Compliance Automated System NCCI - National Council on Compensation Insurance WC - Workers' Compensation BRR - Business Records Request SWO - Stop Work Order OPA - Order of Penalty Assessment AOPA - Amended Order of Penalty Assessment PPA - Penalty Payment Agreement FEIN - Federal Identification Number On June 27th, 2013, at approximately.9:45am, I .Inv Snodgrass conducted a Worker's Compensation . compliance check at 1.365 47th Ave NE in response to a news article found in the Naples Daily News; a new residential home under construction. The news article had said that a worker was killed at the site on June 26th as the result of a lightning strike. The worker that was killed was Robert Wiley had started working for KC Tiles & Marble on June 24th, 2013. Upon my arrival onsite; there were two men interviewing Filemon Cendejas and Mario Rodriguez. One of the. men . provided me with a business card that identified him as Greg Rodgers, an OSHA Compliance Safety & Health officer, and the other was a new trainee from Puerto Rico.. Mario Rodriguez is the registered agent listed on Sunbiz for K.C. Tiles & Marble, and Filemon who indicated to me that he was the jobsite supervisor for K.G. Tiles, Marble. I exp €ained to all four men that I was looking into how the employers of the deceased were providing workers` compensation coverage for their employees. I was advised by Filemon that Payroll was run through SE Personnel Leasing. I inquired how many men were working on the jobsite on the 26th, and was told three. In addition to Robert Wiley, Jose Cruz and Arturo Valejo were also working that day. The general contractor (GC) on the, job site is Ash -Ann Homes; Inc. I asked Filemon if he had a number for the GC whom he identified as Ariel Gonzalez. I was provided (239) 207 -4802. 1 contacted Ariel and inquired who he had hired to complete the form work on the home, and he identified K.0 Tiles & Marble. I asked Ariel what exactly the men were doing onsite on the 26th of June, and he advised me that the men were working on, cement work i.e. slab and tie beams etc. I then asked Ariel what he had received as proof of insurance from KC, Tiles &Marble, and he told me he had received a certificate of insurance from the company. I asked him to supply me with that proof of coverage, and he informed me that he would try to locate the certificate, but his office manager was not currently in the office. At this time, Senior Investigator Jack Gum ph arrived I. site to assist with the investigation. I contacted Scott Keyser from SE Personnel leasing via e-mail to verify the employee roster for K.C. Tiles & Marble, Inc. The roster did not show active coverage for Jose Cruz or Robert Wiley. I returned to speak with Filemon about the two men. Filemon informed me that Robert Wiley had come to the job site on Monday 6124/2013 inquiring about work opportunities. One of the workers onsite contacted Filemon, and the phone was given to Robert. Filemon explained that the company was hiring, and that if Robert wanted to work, he needed to go down to the office and fill out all the employment forms. According to Filemon when he returned to the site later that afternoon, he found Robert working with the other men onsite, and assumed he had filled out the required paperwork but never inquired. Filemon explained that Jose Cruz had filled out the required paperwork, but Filemon had forgotten to turn the paperwork into the office on the 21st for approval. Filemon advised the OSHA investigators that Jose Cruz was thrown, off the scaffolding when the lightning struck, but was not reporting any injuries. I was given Jose Cruz's number by the OSHA investigators and was told that a meeting was going to be set up.to speak with Jose regarding the accident-.Jose's number is 239 - 298 -2650. 65 4 During this time the GC Ariel came to the site to check on the progress of the investigation. Investigator Jack Gumph spoke to Ariel and a written statement was collected in Spanish from Ariel regarding email 44t_ I/ n T:1 -- » »J A -" A »» t 1......-- IAt -:aa .... -1— -....11,. «c...J t,..,,.,.. A'1....« ��J Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page 18 of 32 tsuininuravauuris wnr� n.e,. i ne5 U1 1U HSn -tilts nwnes. VVIatell 6Ldle111e1lt5 Wet a15u uvrim;wu 11U111 I-V Luf U aiIu Filemon, also in Spanish, regarding the employment of the two workers not covered and of the accident that took place on the 25th. A Synopsis of written statements will follow at the end of this narrative. Senior Inv Gumph and I left the site at about 1 pm and proceeded to the interview set up by the OSHA investigators with Jose Cruz. Jose informed us that he had initially applied to work with K.C. Tiles about two weeks ago, but the application was rejected. After getting the correct documentation, Jose picked up a second application at K.C. Tiles office and returned the completed application to Filemon on June 20th. That weekend, Filemon called Jose, and authorized him to report to. work on the 24th. He was to report to Filemon's house to pick up the truck and then report to the jobsite on 47th Ave NE. Jose told us. that he arrived onsite at about 7:30am on the 24th, and Robert Wiley arrived on the jobsite at about 8am. Robert began asking about work, and he was put in contact with Filemon at that time. Jose said that during conversation with Robert, Robert had said that "Jenny' had told him to go to the jobsite to look for work. Jose continued to work the week of the 24th, every day driving the truck to the site and working the remainder of the day onsite. After speaking with Jose, Inv Gumph and I went to K.C. Tiles office to speak with the owner Joel Trujillo. Joel informed us that Filemon has been working for K.0 Tiles for approximately two months. At the time that Filemon was hired, he immediately informed K.C. Tiles of possible contracts for work from Ash -Ann Homes. Joel told us that Filemon and Ariel had known each other prior to being contracted for work. Joel informed us that he did not have a contract or any other knowledge of the job on 47th Ave,. and was only aware of a job that was bid on for 18th St. Joel stated that he was not made aware of any jobsite on 47th until 7:30pm on the night of the 26th, after the accident had occurred: Also in attendance at this meeting was Joel's wife Yvette, the office manager and Mario Rodriguez the Registered Agent for K.G. Tiles. Yvette said that she was not aware_ that Filemon had hired a new person, and no paperwork had been received for that employee. At this time we advised Joel to contact Filemon fo come into the office. When Filemon arrived, he advised us. that Ariel had approached him about the contracts for work. He had advised Filemon that he had three projects that he would need work done on. According. to Filemon, the job that was bid by K.C. Tiles was completed approximately 6 weeks ago, and he started work on the house at 47th Ave 5 weeks ago. We were advised that Ariel pays K.C. Tiles for Labor only, and that all the materials for the jobs are paid for by Ash -Ann Homes. According to K.C. Tiles, the invoice for the job contracted on 18th St is still open, and has not been paid off by Ash -Ann Homes. At this time, K.C. provided some conflicting information stating that Filemon is only a "Piecework' employee. I asked Yvette for what job the worker's were being paid for during the last 5 weeks of payroll if the job on 18th St had been completed. Yvette informed me that they do not require their employees to list what job they are working on, only the number of hours worked. I tried to then confirm how the office knew the men were working if there was no communication between the office and the field, but was told it was never an issue, and they trusted their employees. When I began to inquire about the timeline of events and jobs, Yvette asked me if I knew anything about construction, and how long these jobs took. Finally I inquired about their employee Jenny and were told that Jenny is Filemon's assistant. Yvette also indicated that she and Joel worked primarily with the precast concrete side of the business, while Filemon essentially ran the field portion of the business separately. On June 27th, Inv Gumph and I met with Ariel Gonzalez and Mario E. Rodriguez (the property owner). Ariel informed us that the contract that was made with K.C. Tiles was made approximately 3 -4 months ago. Ariel had advised K.C. that he had 3 properties that he needed work done on. Ariel stated that since the houses were the same square footage, that he was under the impression that the quote for the job on 18th would be the same for the other two properties. After the job. on 18th St was completed, Ariel contacted Filemon verbally to initiate the work on the 47th Ave property. We asked Anel if he had paid the open invoice to K.C. Tiles for the job on 18th St, and he advised us that he had. Ariel explained that K.C. Tiles had an open invoice with the concrete company that was to be used for the jobs in the amount of about $4000.00. Adel stated that he paid the balance on the concrete account, and then paid the remaining balance of the invoice (minus the $4,000) to K.C. Tiles for the job on 18th St. At the conclusion of the meeting,.Ariel .stated that after the accident occurred he spoke with Yvette in the office regarding Jose and Yvette advised him that they were going to submit the paperwork to the leasing company. Statement #1 from Filemon: In Spanish This statement contains information regarding Robert Wiley looking for work on 6/24/2013 and the conversation that Filemon had with Robert. Statement #2 from Filemon: In Spanish This statement contains information regardinq the employment of Jose Cruz, and his start date with K.C. Tiles. 6�� Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Case Number: 13- 172 -D7' Page 19 of 32 Statement from Arlel Gonzalez: In Spanish This statement contains information regarding a -mails between Aries and Filemon regarding jobs for K.C. Tile Marble. Statement from Arturo Valejo: In Spanish This statement contains information regarding the events that occurred on 6/25/22013 and the accident itself. Statement from Mario Rodriguez: In English This statement contains information regarding the accident, and about how Robert came to be working on the jobsite. Section 10 JACK GUMPH Initial: 7112/201314 :23:11 Modified: 711512013 11:16:24 07/12/2013 JM Gumph On this date of 07/12/2013, f (Inv Gumph) did prepare a certified mailing (Article #7100 3500 0001 6989 3674) for the Stop Work Order, Request for Production of Business Records # 2 and Election of Proceediing and sent to. attorney of record, Mr. Hugo A Rodriguez, Esq, The Law Offices of H.A. Rodriguez, P.A. 888 S. Andrews Avenue, Suite 203, Ft. Lauderdale, FL 33316 &ecLp Employer Name: K. C. TILES & MARBLE, INC. l I 1 Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 3410143367 1 NARRATIVE Page 20 of 32 Section 11 JACK GUMPH Initial: 7/16 /2013 08:49:07 Modified: 7/1612013 08 :51:19 07/15/2013 JM Gumph On this date of 07/15/2013, 1(investigator Jack Gumph) did receive a. telephone calf from Attorney Hugo Rodriguez, who is the attorney of record for KC Tiles & Marble. At that time, Mr. Rodriguez did confirm receipt via certified mail of the Stop Work Order, Request for Production of Business Records # 2 and Election of Proceedling. Mr. Rodriguez advised he will speak to his clients reference the Request for Production of Business Records and submission of the records. Section 15 JACK GUMPH 07/16/2013 Initial: 711 812013 10:42:18 JM Gumph Modified* 7118/201310:42:18 On the date of Tuesday, July 16, 2013, 1 did personally meet with Supervisor Michael Ossorio and Compliance Officer Reggie Smith, Collier County Contractor's Licensing Authority; 2800 Horseshoe Dr, Naples, FL, 34104: At that time, I did have a discussion with Spv. Ossorio reference his agency's investigation of K. C.. Tiles & Marble, Inc (KC) in regards to the incident (of the lightning strike) at 1365 47TH Ave NE, Naples, FL 34120 on 06/26/2013. Spv. Ossorio and Officer Reggie Smith related to me that Collier County Contractor Licensing, Compliance. Officer Reggie Smith had responded to the location of at 1365 47TH AVE NE, Naples, FL 34120 on 0712712013. Officer Smith said that after interviewing the Contractor License "Qualifier" for KC, a Mr. Mario Rodriguez; he was authorized by Spv.. Ossorio to issue a .Citation to KC for "Unlicensed Contractor ". Spv. Ossorio also stated that this is an on -going investigation and it is possible that additional citations will be issued. Spv. Ossorio also related that on the date of 07103/2013, he ( Ossorio) was met at the Collier County Contractor's Licensing Authority (2800 Horseshoe Dr, Naples, FL, 34104) by the KC "License Qualifier ", Mr: Mario Rodriguez. At that time, Mr. Rodriguez was accompanied by a female who was introduced to him ( Ossorio) as Yvette Trujillo of "KC Tiles & Marble ". At this time, Mario Rodriguez advised Ossorio that they (Mario Rodriguez & Yvette Trujillo) were there to pay the Citation issued to KC for the "Unlicensed Contractor". Spv. Ossorio did observe that it was Yvette Trujillo of KC who carried the KC checking book and was the person who wrote out and signed the KC check for the payment of the Citation, I was provided a copy of a "Receipt of Payment ", Collier County, Growth Management Division, dated 07/03/2013 to KC Tiles & Marble Inc. The receipt detailed payment method - check, amount paid - $300.00, check number - 10001. �S1 Employer Name: K. C. TILES & MARBLE, INC. i Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE i City, State, Zip: NAPLES, FL 349043367 NARRATIVE Page 21 of 32y Section 16 JACK GUMPH Initial: 7/18/201313:05:07 Modified: 7/181201313:05:07 07/1612013 JM Gumph On the date of Tuesday, July 16, 2013, 1 did personally meet with K. C. Tiles & Marble, Inc (KC), Project .Manager /Supervisor, Filemon Cendejas. At that time,, I did complete an interview with Mr. Cendejas reference his employment with KC. During the interview, Mr. Cendejas provided the following information: He (Cendejas) was hired by KC in April of this year (2013) and was told by Mario Rodriguez and Joel. Trujillo that he would "run" the Masonry Division. He. believed this to mean that he would have full. authority to do all the job estimates with contractors, hiring (& firing), materials etc. He immediately, contacted Ash -Ann Homes owner Ariel Gonzalez and told Joel Trujillo (KC) about the upcoming job at the 18th Street location. That he (Cendejas) then hired Arturo Vallejo, Jose Cruz (whose application was turned down) and Jennifer Caudillo (as his clerical assistant)as KC employees. He was told to have all persons fill out applications with Yvette (Trujillo) at the KC offices and to submit all payroll to Yvette (Trujillo) at the KC offices. He went to work on the 18th Street project (for Ash -Ann Homes). When the job was nearing completion, he and Ariel Gonzalez (Ash -Ann Homes) calculated the costs. He then turned the costs into Yvette Trujillo in the office who prepared the written estimate for payment and the check was subsequently provided by Adel (Ash -Ann Homes). Cendejas stated he and Ariel Gonzalez (Ash -Ann Homes) then spoke about the upcoming job on 47th Ave (jobsite in question); they decided to work it the same manner as the previous (on 18th Street). On the 18th Street, they (Cendejas & crew) had completed the job before the written estimate was provided to /by Yvette (Trujillo) of KC, whereby paid by Ariel Gonzalez (of Ash -Ann Homes). The 47th Ave project was to be no different. They (Cendejas & crew) would complete the job, whereby calculate the costs, turn into Yvette at. KC for the written estimate and subsequent payment by Ariel Gonzalez (Ash -Ann Homes). Cendejas said that the only thing he failed to. do this time (on the 47th Ave project) was to let Joel Trujillo or Yvette Trujillo know they had` switched over to the 47th Ave job. He (Cendejas) explained this as saying "I forgot to tell them ". He (Cendejas) never thought anything about it because he. and Ariel had worked the same way the previous job so he knew Ariel would be (responsible) and pay KC upon completion (just as Ariel had done on the 18th St project). NOTE: It should be noted that I (Investigator Jack Gumph) did research the records I had previously received from Adel Gonzalez (Ash -Ann Homes) reference the 18th St project. This record, from the Collier County Building Department confirmed masonry work was completed on the 18th St project prior to the written estimate by Yvette Trujillo of KC and payment by Ash -Ann Homes. Cendejas went on to explain that Jose Cruz' application was initially rejected by the "Leasing" company for KC. He was informed by Yvette to have Jose Cruz return to the KC office with accurate information and till out. another application. He informed Jose Cruz of the information. He knew that Jose Cruz went back to the KC office (the week of June 17th, 2013) where Cruz again met Yvette and received a new application. Cruz took the application home, filled out the application and gave it to him that Thursday (June 20, 2013). He told Cruz he could start work on.Monday (June 24, 2013) because he (Cendejas) would submit the application to Yvette the following day (Friday, June 21, 2013) when he goes to the KC offices to pick up payroll checks for his workers. He went to the KC offices on Friday, (June 21, 2013) and picked up the payroll checks from Yvette.. He forgot to give Yvette the Cruz application at the time and left it in his truck. When he left the KC offices, he was driving back out to the jobsite; he saw the application on the seat (of his truck). He (Cendejas) then telephoned the KC office and spoke to Yvette. He told Yvette that he had the completed Cruz application in his truck and had forgotten to give it to her when he picked up the payroll checks. Cendejas said that Yvette told him to make sure he got it (the application) into the KC office by Monday (June 24, 2013). He told her he would, but forgot it was on the seat until the lightning strike (on Wednesday, June 26, 2013). After the lightning strike, he (Cendejas) then immediately took the Cruz application (on Wednesday, ,tune 26, 2013) to the KC office and turned it in to Yvette. He said that he was told later by Yvette that she had submitted the Cruz application to the "Leasing" company. Cendejas completed the interview by advising he and Ariel Gonzalez (Ash -Ann Homes) had not entered into any separate agreement outside the scope of his employer, KC, and there was never any intent to deceive KC in any manner. Further, that the 47th Ave project was being completed in the same manner as the previous 18th St project was with Ariel Gonzalez (Ash -Ann Homes). The work was completed first and payment upon completion. That the only thing he failed to do was tell KC that they had moved on to the second project (can 47th Ave). He always put in the time for payroll to Yvette up and including the week of the incident. He said that on Friday, June na nn4 o "...,..... 11-A :-I- IL,- ..K: --- ..t vi- ..,i, .. -_ "_ _-, i__i /r_. .;-.I -._.A v....u_ ir_..:n I_N I J_ a_is a". Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D71 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Page 22 of 32 /-0, --4V 1-5, 118 WdtS Vdill:U IIILU Llle Ullluus Ul rm,i Wl lei e Ile IIlet Juel ( I IUjI110) allu T VeLle ( I iupiu). ne was LUIU LlJdL the insurance company (for KC) had cancelled the KC insurance, thus he and all the masonry workers. (himself, Arturo Vallejo, Jennifer Caudillo & Jose Cruz) would be "let go ". He (Cendejas) and the other workers were never paid by KC for their work on that last week (June 24th through June 28, 2013). NOTE: It should be noted: that i (Inv. Gumph) did subsequently have contact with the insurance company (South East Leasing), whereby was advised that the notification of cancellation was sent to KC documenting the forthcoming a cancellation (45 days of notification), so KC was currently insured .on June 28, 2013 when they told Filemon Cendejas of the cancelled insurance. Section 17 JACK GUMPH Initial: 7/18/20131.3:40:08 Modified: 7/18/201313:40:08 07/16/2013 JM Gumph On the date of Tuesday, July 16, 2043; 1 did personally meet with Jose Cruz, the worker who was on the scaffold when the lightning struck, and was thrown to the ground resulting in injury to his back. At that time, I did complete an interview with Mr. Cruz reference his employment with KC. During the interview, Mr. Cruz provided the following information: He first went to the offices of K. C. Tiles & Marble, Inc (KC) in April (2013). He contacted the woman in the office (subsequently identified as Yvette Trujillo). She provided him an application for KC. He sat down in the office and completed the application. He gave the completed application to the woman and the woman then took copies of his Identification cards. He was later told by Filemon Cendejas that the application was turned down for a wrong social security number. He (Cruz) went back a second time to the KC office in June (the week of June 17th, 2(]13). At the KC office, he again talked to the same woman (Yvette Trujillo) who gave him a second application. She again took copies of his identifications and kept the copies. He took the application home and filled it out. He gave the completed application to Filemon Cendejas on that Thursday (June 20, 2013). Filemon told him he would turn it in to the KC office on Friday (June 21, 2013) and he could start work on Monday (June 24, 2013). He started work on Monday (June 24, 2013) and worked till Wednesday (June 26, 2013) when the scaffold, he was working was hit by the lightning. He was thrown to the ground. He initially refused medical treatment from the paramedics on the scene. The next day, he began to have back pain and went to the doctor who initialized a treatment plan. NOTE: It should be noted that 1 did request/receive the Paramedic's report of the accident scene, which documents the signature of Jose Cruz signing a "waiver of treatment'. The copy is included in this case file for reference. During this interview, 1 did ask Jose Cruz two follow up questions: Question: What company did Filemon say you would be working for? Answer: K.C. Tile and Marble Question: What company did you believe you were working for when the lightning struck the house on 47th Avenue? Answer: K-C. Tile and Marble I did have Jose Cruz complete a written statement reference this interview and is included in this case file for reference. 6604 Employer Name: K C. TILES &MARBLE, INC. Case Type: SWO Case Number: 13- 172 -D7 Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 3410433$7 Page 23 of 32 Section 18 JACK GUMPH Initial: 71x3/241312:31:12 Modified: 812012013 08:52:28 07/23/2013 JM Gumph On the date of 07/19/2013, 1(JM Gumph) did receive a letter of representation from the law firm of Kelley Kronenberg that they would now be the attorneys of record for KC Tiles & Marble. On the date of 07/23/2013,.l did speak by telephone to Attorney, Jason Stewart, from the law firm of Kelley Kronenberg. Mr. Stewart stated he would be handling the KC Tiles case for the law firm. Mr. Stewart stated it would be the intention to file the Election of Proceeding in this case. Section 19 Initial: 71301201311:29:44 Modified: 71301201311:29:44 Petition filed with the Div, of Legal Services on 07 -30 -2014. 6 bO Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO I Address: 3773 ARNOLD AVE City, State,. Zip: NAPLES, FL 341043367 I Case Number: 13- 172 -D7 I 1 Page 24 of 32 Section 20 JACK GUMPH Initial: 8111201311:43 :58 Modified: 8/1/201311:43:58 08/01/2013 JM Gumph I (investigator Jack Gumph) reviewed case file information on this date. No records have been submitted reference the Business Records Request (BRR.#f2) issued for the Stop Work Order. There was however, partial records from the Business Records Request (BRR #1) initially issued in this case (dated 12/27/12 -06 /27/13)..1 have set the penalty for impute. All necessary email directed to Examiner Eileen Almas for Penalty Audit.section including the "new" Imputation Request Form. Section 21 NICHOLAS THOMAS initial: 8/2/2013 10:03:38 Modified:. 8/2/201310:03 :38 Assigned 8/2/13 @ 9:30 to Nicholas Thomas for penalty calculation 6 k91 Employer Name: K. C. TILES .& MARBLE, INC. Case Type: SWO Case Number: Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Section 22 NICHOLAS THOMAS Assigned: 8/2/13 completed: 8/2/13 Audit. period. 7/13/10-7/12113 Period of non-com pliance :111/13 - 7112[13 Florida Profit Corp. Class code: 5215,5506 Corp. date filed: 12/4/96 Corp officers: joel trujiilo I 13- 172 -D7 i Page 25 of 32 Initial: 812/201312:08:06 Modified: 9/9/2013 09:59:31 Records received: bank statements & coverage certificates Employees identified on site: Robert whiley, jose Cruz, Arturo vallejo Insufficient records were given for the period of non - compliance. Due to the nature of this case one employee is imputed up to and including the date of the incident which began the investigation. The business was covered via a policy up to 1/1/13 and then switched to employee leasing and the people that were not on the roster are imputed for. Penalty: 24,290.32 Section 23 JORDAN RIMERT Initial: 815/2013 12:58:28 APO approved by Jordan Rimert 8/5/1312:58 pm Modified: 8/5/201312:58 :28 6%;� Employer Name: K. C. TILES & MARBLE, INC. I Case Type: SWO Case Number: 13- 172 -D7' Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 27 of 32 Section 26 initial: 81191201310 :09.:19 Modified: 8/19/2013 10:09:19 Petition filed with the Div, of Legal Services on 08 -16 -2013. Section 27 JACK GUMPH Initial: 8/20/2013 08 :51 :33 Modified: 8/20/2013 08:51 :33 08/20/2013 J.M. Gumph On the date of August 20, 2013,1 (Investigator Jack Gumph) did receive the USPS receipted "GREEN CARD" for the Certified Mailing to Steven H. Osber, Jason S. Stewart, C/O Kelley Kronenberg, Attorneys at Law, The mailing was for the service of the original Amended Order of Penalty Assessment ( #13- 172 -D7). Issued also were the "State of Florida, Department of Financial Services, Division of Legal Services, ELECTION OF PROCEEDING'' and Division of Workers' Compensation Lien Card. The receipt indicated a service date of 08/12/2013. 6104 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13- 172 -07 Address: 3773 ARNOLD AVE 1 City, State, Zip: NAPLES, PL 341043387 NARRATIVE Page 28 of 32 Section 28 NICHOLAS THOMAS initial: 8/291201310:17:11 Modified; 8!29/201310:17:40 8/28113 additional records revived penalty auditor nicholas thomas reviewed additional records The records consisted of bank statements d. ated 1/1/11- 6/30/11 These are records are insufficient because the period of non- complaince is 1/1113-7/12113. penalty remains un- changed Section 29 JACK GUMPH Initial: 915/2013 08 :59:03 Modified: 9/512013 08:59:03 08/2812013 JM Gumph From the dates of August 26 to 28, 2013, 1(Jack Gumph) did receive records from Attorney of Record, Mr. Jason S. Stewart. These records were subsequently uploaded to the penalty queue for consideration. 6 �5 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 Section 30 JACK GUMPH initial: 915/2013 09 :00:47 b9/05/2013 JM Gumph Case Number: 13- 172 -D7 i _r~ Page 29 of 32 Modified: 9/5/2013 09:00:47 From the date of September 4, 2013,1(Jack Gumph) did receive additional records from Attorney of Record, Mr. Jason S. Stewart. These records were subsequently uploaded to the penalty queue for consideration. Section 31 NICHOLAS THOMAS Initial: 9/51201316:49:13 Modified: 919/2013 09:59.14 additional records reviewed by nicholas thomas The additional records consisted of: 1: bank statements(2010 -2013) 2 :1easing records 3: Insurance documents The imputations were removed and the following changes were made. 1:all withdrawals, atm withdrawals and blank check were attributed to the corp officer. 2., the two workers on site were imputed for. 3: the bank statements and general ledger were also used to calculate a penalty. penalty: 7,689.24 6610 Employer Name: K. C. TILES & MARBLE, INC. Case Type: SWO Case Number: 13-172 -D7 Address: 3773 ARNOLD AVE I City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 30 of 32 Section 32 JORDAN RiMERT Initial: 91912013 10:09:15 Modified: 9191201310:09:15 APO. approved by Jordan Rmert 9/9/1310:09am Section 33 JACK GUMPH 09/30/2013 Initial: 9/30/201314 :53 :40 JM Gumph Modified: 9/30/201314:53:40 On the date of September 9, 2013, 1 (Investigator Jack Gumph) received the approved 2nd Amended Order of Penalty Assessment (AOPA) penalty calculation from Audit Department. I (Inv. Gumph) issued the Amended Order of Penalty Assessment in the amount of $7,689.24to K. C. Tiles & Marble, Inc. On the date of September 30, 2013, 1(investigator Jack Gumph) did issue the approved 2nd Amended Order of Penalty Assessment (AOPA) penalty calculation. I then sent the documents to Buff Miller, Legal Division for Service to the attorney of record for K. C. Tiles & Marble, Inc. Employer Name: K. C. TILES & MARBLE, INC. I Case Type: SWO Case Number: 13- 172 -D7; Address: 3773 ARNOLD AVE City, State, Zip: NAPLES, FL 341043367 NARRATIVE Page 31 of 32 Section 34 JACK GUMPH Initial: 11/5!201312 :18`:13 Modified.: 11 /5/201316:01 :46 11/05/2013 J.M. Gumph NARRATIVE FOR A "WORKING IN VIOLATION" CONTACT OF K. C. TILES & MARBLE, INC., IN NAPLES, FLORIDA ON November 5, 2013. On the date of Tuesday, November 05, 2013, 1(Investigator Jack Gumph) did travel to the address of 3773 Arnold Ave, Naples, FL 34104, which is described :as the offices and workshop of K. C. Tiles & Marble, fnc (KC Tiles). It should be noted that I was personally aware that KC Tiles was currently under an active Stop Work Order # 13- 172 -D7. I was accompanied by Division of Insurance Fraud (DIF), Lt. Mark Fritz and Detective Ralph Guarniero. I approached the building from a west side gate which was open and unlocked. I immediately observed an open garage "bay" door on the west side of the building. I entered the "bay" door into the interior of the building. I observed this to be a large "Foundry' work area. To my right, I immediately observed a man personally known to me as Joel Trujillo, owner of KC Tiles. Mr. Trujillo was working on a "mold" frame on a table. I immediately contacted Mr. Trujillo. Mr. Trujillo was advised by me that his company was under a Stop Work Order and was not supposed to be working. Mr. Trujillo immediately exclaimed that he had to work to pay the bills, Mr. Trujillo was advised that he was working in violation of the Stop Work Order and was asked if there were any other persons working at the shop (it should be noted that while speaking to Mr. Trujillo, two men walked from the back of the shop area out the front. gate). Mr. Trujillo said that these men were "just looking at equipment" and he had no one else working at the shop. then exited the garage "bay" door and walked to the rear of the shop where.1 found a second garage "bay" door. I entered this door area and immediately observed a mate worker pouring cement into a "mold" frame. I approached this man and asked him his name (in Spanish, as he only spoke Spanish). He told me his name was Lazaro Lugo. I had him write his name in my notebook for confirmation. Mr. Lugo stated that he worked for KC Tiles. With the assistance of Lt. Fritz (Spanish interpretation), I did obtain the following information: That Lazaro Lugo worked for KC Tiles. He (Lugo) arrived for work this morning at 7:00 AM and was scheduled to work until 3:30 PM working in the shop. Lugo said that he has worked for KC Tiles for five years and that he continually works 5 days a week and gets paid $11.00 per hour. I returned to Officer/Director Joel Trujillo and informed him that the work must cease and that worker Lazaro Lugo needs to vacate.. Mr. Trujillo spoke to Lazaro Lugo and advised to commence clean up and close up the shop. It should be noted that f was. unable to serve Officer /Director Joel Trujillo with the Amended Order of Penalty Assessment for the Working in Violation because he was placed under arrest by DIF Detectives and driven from the location (service to be completed by Legal Division as this case is assigned). 1 did complate a Division of Fraud Referral for the "Working in Violation" (The CCAS system would not allow for a subsequent entry in the "referral" section). %5 Employer Name: K. C. TILES & MARBLE, INC. Case Type: Swo Address: 3773 ARNOLD AVE City, State, Zap: NAPLES, FL 341043367 Section 35 MARIA SEIDLER Initial: 11/5/201316:55:53 11/05/2013 1 approved the working in violation penalty. Case Number: 13-172-D7 Page 32 of 32 Modified: 11 /5120-13'15:56:53 6 1., k COLLIER COUNTY CONTRACTORS' LICENSING BOARD COLLIER COUNTY, FLORIDA COLLIER COUNTY, apolitical subdivision of the State of Florida, VS. K.0 Tiles& Marble, Inc Mario Rodriguez To: Ariel Gonzalez Ash -Ann Homes, Inc Petitioner, Respondent. CASE NO.'S f` % WITNESS SUBPOENA YOU ARE HEREBY COMMANDED, pursuant to Section 162.08, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, to be and appear before the Contractors' Licensing Board of Collier County, Florida, located at the Commission Meeting Room, 3301 East Tamiami Trail, Administration Building, Third Floor, Naples orida, on the _15th_ day of January_____________, 9am , at M, to give testimony regarding an alleged violation of Ordinance 90 -105, as amended, of Collier County Florida. You are being subpoenaed by the person whose name appears below on this left side of this subpoena and, unless excused from this subpoena by that person, you shall respond to this subpoena as directed. IF YOU FAIL TO APPEAR, YOU MAY BE IN CONTEMPT OF COURT. Dated this -L.., day of�-' Respondent or Attorney / Address:t�r' Tele. No.�;, r, CONTRACTORS' LICENSING BOARD, COLLIER COUNTY, FLORIDA Chairman 1 COLLIER COUNTY CONTRACTORS' LICENSING BOARD COLLIER COUNTY, FLORIDA COLLIER COUNTY, apolitical subdivision of the State of Florida, VS. K.0 Tiles& Marble, Inc Mario Rodriguez Petitioner, Respondent. CASE NO. WITNESS SUBPOENA To: Sr. Investigator Jack Gumph Florida Department of Financial Services Division of Workers' Compensation Bureau of Compliance YOU ARE HEREBY COMMANDED, pursuant to Section 162.08, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, to be and appear before the Contractors' Licensing Board of Collier County, Florida, located at the Commission Meeting Room, 3301 East Tamiami Trail, Administration Building, Third Floor, Naples, Florida, on the _15th_ day of January , _9am at _ zy M, to give testimony regarding an alleged violation of Ordinance 90 -105, as amended, of Co lier County Florida. You are being subpoenaed by the person whose name appears below on this left side of this subpoena and, unless excused from this subpoena by that person, you shall respond to this subpoena as directed. IF YOU FAIL TO APPEAR, YOU MAY BE IN CONTEMPT OF COURT. Dated this Z— day of " Respondent or Attorney Address: J CONTRACTORS' LICENSING BOARD, COLLIER COUNTY, FLORIDA f ' / 1 ii G= ftf,� I , Chairman 611 Ville BEFORE THE COLLIER COUNTY CONTRACTORS' LICENSING BOARD BOARD OF COUNTY COMMISSIONERS, COLLIER COUNTY, FLORIDA, CONTRACTORS' LICENSING BOARD Petitioner, V. Seth B. Hollander D /B /A — Hollander Construction Company, Inc Respondent. Case Number: 2014 -02 License Number: 201300000579 ADMINISTRATIVE COMPLAINT Collier County (County) files the Administrative Complaint against Seth B. Hollander ( Respondent), a Collier County licensed Excavation Contractor ( license # 201300000579), and states the following facts and allegations in support of the cited violations below: 1. The Respondent is currently suspended due to a violation of the probationary set forth by the Collier County Contractors Licensing Board on October 16th, 2013 2. Under the provisions of Collier County Ordinance 90 -105, as amended, Section 22 -201, the following actions by a holder of a Collier County / City Certificate of competency shall constitute misconduct and grounds for discipline pursuant to Section 22 -202. a. On December 20th, 2013, it was discovered that, at a active construction jobsite at 12823 Valewood Dr, Seth B. Hollander, qualifier of Hollander Construction Company, Inc, had two employees, Wayne Boswell and Hugh Campbell, performing construction without workers' compensation coverage, as required pursuant to Florida State Statute 440.10(1)(a). Said violation of the Florida State Workers' Compensation Statute constitutes a violation of Collier County Ordinance 90 -15, as amended, Section 22.201(6) b. Thereafter, pursuant to Collier County Ordinance 90 -105, as amended, Section 22 -202 (b) and Section 22 -202 (c), the complaint was investigated and found sufficient cause to file formal charges pursuant to the order of the Collier County Contractors Licensing Board dated October 16th, 2013 3. Collier County brings the following charge in this formal complaint against the Respondent. COUNT 4. Collier County Ordinance 90 -105, as amended, Section 22.201(6) states "Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county " WHEREFORE, the Petitioner asserts the above facts and charges are grounds for disciplinary action under Section 22 -201 of Collier County Ordinance 90 -105, as amended, and WHEREFORE, in consideration of the foregoing, the Petitioner respectfully requests the Collier County Contractors' Licensing Board to find the Respondent guilty of the violations charged. Dated: January 6, 2014 Signed: Collier Coun-ty-C-eiqtfactors' Licensing Supervisor or Designee Seth B. Hollander- D /B /A– Hollander Construction Company, Inc C.L.B. Case# 2014 -02 Table of Contents E -1 through E -3 – Case Detail Report E -4 through E- 6— Formal Complaint E -7- Notice of Hearing E -8 through E -9- Corporation Detail E -10- Collier County Certificate of Competency E -11- Workers' Compensation policy #10652685 Termination /Cancellation Notice E -12- Workers' Compensation Coverage History / Employer Detail Page E -13- through E14- Email E -15 – State of Florida, Department of Financial Services, Division of Workers' Compensation Stop -Work Order E -16 through E -17- Florida Statute 440.10(1)(a) Liability for Compensation E -18 through E -21- Collier County Ordinance 90 -105, as amended, Section 22.201(6) E -22 through E -29- Order of the Contractors Licensing Board for Case #2013 -09 E -30 through E32- December 20th, 2013 jobsite photos CAergov.net Report Title: Code Case Details Date: 1/6/2014 10:19:39 AM Case Number: CEMIS20130019332 Case Number: CEMIS20130019332 Case Type: Misconduct Priority: Normal Inspector: ThomasKeegan Jurisdiction: Contractor's Licensing Origin: Complaint Detail Description: 1w/c violation - Hollander, Seth Hollander Construction Company, Inc Location Comments: 112823 Valewood Property 68592760007 Complainant Palermo Pavers, Inc Violator Hollander Construction Company, Inc. Business Management & Budget Office Status: Refer to CL13 Date & Time Entered: 12/20/2013 2:09:39 PM Entered By: ThomasKeegan Case Disposition: Case Pending 1 Code Case Details Execution Date 1/6/2014 10:19:39 AM Desc Assigned Required Completed Outcome Comments Preliminary Investigation ThomasKeega 12/20/2013 1/2/2014 Needs 12/20/2013- received call from MGO in n Investigatio regards to a call in complaint made by n Palermo Pavers, Inc in regards to Hollander Construction Company Inc installing pavers at location - made site visit - observed excavating of driveway being performed by two men - made contact with them stated their names were Wayne Boswell and Hugh Campbell - stated they are employees for Seth Hollander and they just started working for him on Monday - which would of been December 16th, 2013. 1 asked them if they filled out any applications for the company and they stated no. While on site I researched insurance for Hollander Construction, Inc which showed workers comp policy was cancelled on 10/5/13. 1 proceeded to call Seth Hollander who did claim the two men as employees and he stated he had insurance for them. I advised his policy was cancelled and that we needed to meet on the jobsite. I spoke to the homeowner Philip Jason who advised that he hired The Construction Managers (CGC) - qualifier John Varsames - I called Mr. Varsames who did state that he subcontracted the excavation part of the job to Seth Hollander. I advised that there is a issue with the sub concerning workers compensation and that I will be in touch with him. I then proceeded to call Workers Compensation Sr. Investigator Jack Gumph for more info on Mr. Hollander's cancelled policy - Mr. Gumph met me on site in which he advised that policy #10652685 - Carrier Name : Florida Citrus, Business & Industries Fund was cancelled on 10/5/13 for non payment of premium. Mr. Gumph and I met with Mr. Hollander on site in which I advised Mr. Hollander that his end of the job would be shut down as his company is in violation due to lack of workers compensation for the two employees and to meet me in my office later in the afternoon. Called GC - John Varsames and advised and aslo advised homeowner Mr. Philips of issue. Later that afternoon a meeting was held between Michael Ossorio, Mr. Hollander, Mr. Gumph and myself in which Mr. Hollander admitted to not having workers compensation for his employees for months and was served a Notice of Hearing for the January 15th, 2014 for the Contractor Licensing Board for violating the probation set by the board on October 16th, 2013. Certificate was also suspended by MGO. Business Management & Budget Office 2 Code Case Details Execution Date 1/6/2014 10:19:39 AM Desc Assigned Required Completed Outcome Comments Investigation ThomasKeega 1/2/2014 1/2/2014 Refer to n CLB Schedule for CLB michaelossori 1/2/2014 1/2/2014 Complete 0 CE Staff Review ThomasKeega 1/2/2014 1/2/2014 Complete State Stop Work Order issued on 12/20/2013 n for failure to obtain workers compensation coverage. Generate CLB Notice of Hearing JenniferBlanc 1/2/2014 1/2/2014 Complete 0 Enter Hearing Results michaelossori 1/16/2014 Pending 0 Violation Description Status Entered Corrected Amount Comments Worker's Compensation Violation Open 1/2/2014 $0 Title Reason Result Compliance Fine /Day Condition Business Management & Budget Office 3 Contractors' Licensing Board 2800 North Horseshoe Drive Naples, Fl. 34014 Complaint Number: 2014 -02 Complainant: Any person that believes that a Contractor holding a State Certification or Certificate of competency has violated Collier County Ordinance 90 -105, as amended, may submit a sworn complaint to the Contractor Licensing Supervisor, or his / her designee. The complaint shall be in substantially the form prescribed by the Contractor Licensing Supervisor. The complainant shall pay a fee of $50.00 to defray the costs of administering the complaint, at the time of filing the complaint. The complaining party shall state with particularity which section(s) of this Ordinance he or she believes has been violated by the contractor and the essential facts in support thereof. Complaint: Please print or type and return signed copied of the complaint. Date: January 6th, 2014 Against: Contractor's name: Seth B. Hollander Phone: 239 - 253 -1406 Business name: Hollander Construction Company, Inc License number if known: 201300000579 Collier County Competency number: 201300000579 Contractor's business address: 1239 Nottingham Dr. Naples, FL 34109 Filed By: Name: Collier County Contractors' Licensing / Thomas Keegan Address: 2800 North Horseshoe Dr Naples, FL 34104 Business phone: 239 - 252 -2468 Address where work done: 12823 Valewood Dr County: Collier Date of contract: N/A Date job started: N/A �: 7 Date job completed or new home occupied: N/A Were there plans and specifications? N/A Is there a written contract? N/A If yes, amount of Contract? N/A Has Contractor been paid in full? N/A If Contractor has NOT been paid in full, what amount is paid? N/A Was a Building Permit obtained? N/A Building Permit number if known: N/A Have you communicated by letter with the licensee? yes Date: December 20th, 2013 Do you have a reply? Please attach to this form all copies of the purchase agreement, building contract, home improvement contract, copies of receipts and / or cancelled checks available and any additional evidence to substantiate your allegations. List any subsections of Section 4 of Collier County Ordinance number 90- 105, as amended, which, in your opinion, have been violated by the contractor which is the subject of this complaint, (list subsection): Section 22.201(6). Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county. Please state the facts which you believe substantiate your charge of misconduct against the subject contractor. List facts separately for each subsection number above: On December 20th, 2013, it was discovered that, at a active construction jobsite at 12823 Valewood Dr, Seth B. Hollander, qualifier of Hollander Construction Company, Inc, had two employees, Wayne Boswell and Hugh Campbell, performing construction without workers' compensation coverage, as required pursuant to Florida State Statute 440.10(1)(a). Said violation of the Florida State Workers' Compensation Statute constitutes a violation of Collier County Ordinance 90 -15, as amended, Section 22.201(6) (complainant's sign �r State of: flnr..Na County of: C6 Sworn to (or affirmed) and subscribed before me this ID'" day of l 201N H. . By (signature of person making statement). (signature of Notary Public) " . JOANN GREENBERG * 4Y COMMISSION # EE 066562 Print, type or stamp name of Notary Public: EXPIRES: April 6,2015 -- gairded mro Budget -t +OWY 8eM ft tilCrtn Personally known or produced identification. e- c- Collier County Growth Management Division / Planning and Regulation Operations Department / Licensing Section CERTIFIED MAIL # RETURN RECEIPT REQUESTED Date: December 20, 2013 RE: Complaint filed against you by Collier County Contractor Licensing regarding a violation of failing to provide workers compensation insurance for employees on December 20, 2013 Dear: Hollander, Seth Hollander Construction Company, Inc • complaint has been filed against you by the above referenced individual. • hearing of this complaint will be held by the Contractors' Licensing Board on January 15t', 2013 at 9:00 AM in the Board of County Commissioner's Room, Third Floor, Administration Building (W. Harmon Turner Bldg.), at 3301 East Tamiami Trail, Naples, Florida. Your presence before the Contractors' Licensing Board is required at this time. The packet you will receive marked composite exhibit "A" will be delivered to the members of the Contractors' Licensing Board one week prior to the hearing. If you wish to prepare a defense packet and have it delivered in conjunction with composite exhibit "A ", you must make fifteen copies and have them in our office by 8:00 AM on Wednesday, one week prior to the hearing. In your packet, you may give a summary of events. At this meeting, you may present evidence and be represented by an attorney of your choice. In the event the Contractors' Licensing Board finds you in violation of Section number(s)4.1.11 of Ordinance # 2006 -46, as amended, the range of disciplinary sanctions which may be imposed are from an oval reprimand to a suspension or revocation of your Collier County Certificate 201300000579 and/or suspension or revocation of your permit privileges against your state license # . Sincerely, Thomas _5 an Licensin ompliance Officer ph /n 6-7 1/6/14 Detail by Entity Name Florida Profit Corporation Detail by Entity Name HOLLANDER CONSTRUCTION COMPANY, INC. Filing Information Document Number FEI /EIN Number Date Filed State Status Last Event Event Date Filed Event Effective Date Principal Address 2681 Airport Road South Suite 103 NAPLES, FL 34112 Changed: 02/25/2013 Mailing Address 2681 Airport Road South suite 103 NAPLES, FL 34112 Changed: 02/25/2013 P06000047957 204543956 04/04/2006 FL ACTIVE REINSTATEMENT 02/06/2012 NONE Registered Agent Name & Address HOLLANDER, SETH B 1239 NOTTINGHAM DR NAPLES, FL 34109 Address Changed: 10/30/2009 Officer /Director Detail Name & Address Title P search. sunbiz. org / Inquiry/ CorporationSearc [VSearchResu[tDetail /Entit Namet dome- p06000047957- 1797a06e- 2f7b- 4ef4- b4dd- b1108654c6balhollander construc... 1/2 1/6/14 HOLLANDER, SETH B 1239 NOTTINGHAM DRIVE NAPLES, FL 34109 Annual Reports Report Year 2012 2013 Document Images Filed Date 02/06/2012 02/25/2013 02/25/2013 --ANNUAL REPORT 02/06/2012 -- REINSTATEMENT 10/30/2009 -- REINSTATEMENT 01/08/2008 -- ANNUAL REPORT 11/07/2007 -- REINSTATEMENT 04/04/2006 -- Domestic Profit Detail by Ent tyName View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format Ccwvr.'l ., <. .d Pr racv aj'_!c:s State. of Florida, Department S*a °_ fi ct search. sunbiz. org / Inquiry /C orporationSearch/ SearchResultDetaiI/ EntityName/ domlr p06o00047957- 1797a06e- 2f7b- 4ef4- b4dd- b1108654c6ba/holIander construc... 2/2 COLLIER COUNTY CERTIFICATE OF COMPETENCY CERTIFICATION INFORMATION LCC20120002910 Certification Information Collier County Board of County Commissioners DBA: Hollander Construction Company, Inc. ADDRESS: 1239 Nottingham Drive Naples, FL 34109 PHONE: 2392531406 CELL: FAX: LICENSEE NBR: LCC20120002910 INSURANCE: General Liability April 01, 2014 Worker's Comp Exemption March 01, 2014 Date: December 23, 2013 LICENSE STATUS: SUSPENDED QUALIFIER: SETH B. HOLLANDER TYPE: EXCAVATION CONTR. CLASS 4150 CODE: ISSUANCE 201300000579 NBR: ORIG ISSD: October 11, 2013 EXPIRATION: September 30, 2014 NOTE: It is the Qualifier's responsibility to keep all business, licensing and requirements current and to provide up to date copies for Collier county files. This includes all insurance certificates and any change of address information. Collier County * City of Marco * City of Na les Contractor Licensing EXCAVATION CONT . Cert Nbr: Exp: Status: LCC20120002910 09/30/201 SUSPENDED Hollander Construction Compa Inc. SETH B. HOLLANDER 1239 Nottingham Drive Naples, FL 34109 Signed: C-/ C POLICY TERMINATION /CANCELLATION /REINSTATEMENT NOTICE POLICY TERMINATION /CANCELLATION /REINSTATEMENT NOTICE Carrier Name /NCCI Carrier Code Insured's Name Federal ID No. Insured's Address Policy Number 10652685 WC 89 06 09C FLORIDA CITRUS,BUSINESS & INDUSTRIES FUND / 31259 HOLLANDER CONSTRUCTION COMPANY, INC. 204543956 2681 AIRPORT RD S, 103 NAPLES, FL 34112 Policy Effective Date 07/16/13 X Termination /Cancellation /Nonrenewal Policy Expiration Date 10/05/13 The coverage provided by the policy number shown above is being nonrenewed or X terminated /cancelled, flat, pro rata, or short rate, effective 10/05/13 12:01 a.m. standard time at the insured's mailing address for the following reason(s): Nonpayment of Premium Reinstatement The coverage provided by the policy number shown above and previously nonrenewed, cancelled or scheduled for cancellation is being reinstated effective/ / 12:01 a.m. standard time at the insured's mailing address. Issue Date Issuing office Producer's Name Date Stamp (for NCCI use only): 10652685 09/24/13 Tallahassee Weems Insurance of Naples 2661 Airport Rd S, Ste B105 Naples, FL 34112 (239) 775 -8705 HOLLANDER CONSTRUCTION COMPANY, INC. 2681 AIRPORT RD S, 103 NAPLES, FL 34112 © Copyright 2009 National Council on Compensation Insurance, Inc. All Rights Reserved. 12/20/13 Proof of Co\erag e JEFF ATWATER, CHIEF FINANCIAL OFFICER I4R FLORIDA.. DEPARTMENT OF FINANCIAL SERVICES WC Home WC Databases CFO Home Employer Detail Page Carrier Location information Return to Search Page Employer information Employer Name Employer Type �CS Code HOLLANDER CONSTRUCTION CO INC 'CORPORATION 237310 Coverage History Governing jEffective Cancellation Effective _.__._T. Wrap Locations Class Carrier Office Policy Number U µ ClassCode'w___.)_Date at 12:01 A M _- tvp.. iMew Jul FLORIDA CITRUS BUSINESS& a I i 06217 t Oct 5 2013 10652685 'NO Locations 1 2013 BJDl1STRIES View 05506 p 23 Oct 222010 GUARANTEE INSURA WE Co 'GWIC301000968110'NO ?Locations i 2010 Uew 05506 Sep 23 Sep 232010 "GUARANTEEINSURANCECO GWIC301000968109 NO Locatons 2009 mew Dec 15 FIRSTCOMMERCIAL 05506 Sep 23 2009 328410 NO Locations 2008 INSURANCE COMPANY *Represents the Governing Class Code associated with the Named insured on the policy, as reported by the insurance Carrier, and is not validated as correct. Exemption Listings I (No Officer Exemption of Coverage Listings 1 0 %,,finer Eie tints � _stings 1 (No Owner Election of Coverage Listings !Employer Name History � .Employer Name #Name Type Change Date HOLLANDER CONSTRUCTION CO INC 1Legal Dec 182008 Return to Search Page https:/ /apps8.fldfs.corrVproofofco\,erag e/EmployerDetai l.asp)OEmplD= EO1055311 1/1 KeeaanThomas From: Gumph, Jack M [Jack.Gumph @myfloridacfo.com] Sent: Friday, December 20, 2013 11:52 AM To: KeeganThomas Subject: RE: anything on this company Policy Carrier Reports Cancellations Reinstatements / Non - Renewals FLORIDA Back to Search Results Policy &Carrier s fumes &Addresses ; Names Addresses '; State Exposure Canc /Reins Policy Nbr 10652685 Carrier Code 31259 Primary Insured Name HOLLANDER CONSTRUCT-ION CO INC Cancellation Notice C /R /N Received Date � C /R /N Effective Date Mail Date Reason for Reinstatf 171 Iv 09/24/2013 10/05/2013 09/24/2013 i Jack Gumph Sr. Investigator Florida Department of Financial Services Division of Workers' Compensation Bureau of Compliance 2295 Victoria Avenue, Suite 284 Ft. Myers, FL 33901 Tel: 239 - 461 -4087 Cell: 239- 633 -3710 Fax: 239 - 338 -2786 VOIP: 74087 From: KeeganThomas [ mailto :ThomasKeegan(cbcolliergov.net] Sent: Friday, December 20, 2013 11:02 AM To: Gumph, Jack M Subject: anything on this company 1 Prvaf Cf C'o'verage X PPS8.ff fs ton-, . fc fotcovera e 1-otati(1f1sDeTail c;li(YfD= 106526M, EFF A?"' ATEFt, CHIE 4 F FINANCIAL —._ FLOk'DA DEPAR -rMENT OF FiNAN A SF Locations Dt This database was last updated ,Prude.; L Rat! to iEmptQy WV51 AIRPORT ,, eAre of tiue total 1"Mmr csf crri '"carmra,@re nG, rcgUitcrl tb rP �S f @isnr[Ct! dY the irlgiiT lx+rx tir,_• ta%i nurr`6�r crf+�mpiby�£ r-- __ - -_ _ Return to featch Thomas Keegan Growth Management Division Planning & Regulation Contractor Licensing 2800 N. Horseshoe Dr Naples, FL 34104 Office- 239 - 252 -2468 Cell - 239- 438 -5195 15 - ! q. W STATE OF FLORIDA, DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION EMPLOYER NAME: HOLLANDER CONSTRUCTION COMPANY, INC. STOP -WORK ORDER No.: 13- 327 -D7 FEIN: 204543956 ISSUANCE DATE: 12/20/2013 EMPLOYER ADDRESS: 2681 AIRPORT ROAD SOUTH SUITE 103 CITY. NAPLES STATE: FL ZIP: 34112 WORKSITE POSTING ADDRESS: 12823 VALEWOOD CITY: NAPLES STATE: FL ZIP: 34119 Id INDUSTRY OF EMP YER: *Construction O Non- Construction t, O Agriculture STOP -WORK ORDER A rs nt to Section 440.107, F.S., the above - referenced Employer is hereby ORDERED TO CEASE ALL BUSINESS OPERATIONS LL WORKSITES IN THE STATE based on the following violation(s): Failure to secure the payment of workers' compensation in violation of sections 440.10(1), 440.38(1), and 440.107(2) F. S., by: failing to obtain coverage that meets the requirements of Chapter 440, F. S., and the Insurance Code; ❑ materially understating or concealing payroll; ❑ materially misrepresenting or concealing employee duties so as to avoid proper classification for premium calculations; ❑materially misrepresenting or concealing information pertinent to the computation and application of an experience rating modification factor. ❑ Failure to produce required business records within 5 business ❑ Failure to produce required documents within 3 business dail THIS STOP -WORK ORDER MAY BE AMENDED TO I E THE DIVISION ISSUES AN ORDER RELEASING T ion of section 440.107(7)(a), F.S. section 440.05(11), F.S. 11OLATIONS AND SHALL REMAIN IN EFFECT UNTIL FOR ALL WORKSITES. CONDUCTING ANY BUSINESS OPERATIONS IN VIMTION OF THIS STOP -WORK ORDER CONSTITUTES A FELONY OF THE THIRD DEGREE AND A PENALTY OF $1,000.00 PER DAY FOR EACH DAY OF VIOLATION SHALL BE ASSESSED. ORDER OF PENALTY ASSESSMENT A penalty against the Employer is hereby ORDERED in an amount: Equal to 1.5 times the amount the employer would have paid in premium when applying approved manual rates to the employer's payroll during periods for which it failed to secure the payment of workers' compensation required by this chapter within the preceding 3 -year period, or $1,000, whichever is greater. Section 440.107(7)(d), F.S. ❑ Up to $5,000 for each employee who the Employer misclassified as an independent contractor. Sections 440.10(1)(0 and 440.107(7)(f), F. S. The Stop -Work Order in this case shall remain in effect until the Division either (a), issues an order Order upon finding the employer has come into compliance with the coverage requirements of the law and paid the total penalty Bull, or (b), issues an Order of Conditional Release from Stop - employer coming into compliance with the coverage requirements of the Workers' Compensa Mn' Payment Agreement Schedule For Periodic Payment of Penalty. Stop -Work pursuant to the entering into a Please see the l.otice of Rig hts on the reserve side that pertains to your righ garding this action CERTIFICATE OF SERVICE Pursuant to section 440.107(4), F.S., JACK GUMPH served a true copy of this Stop -Work Order: F-1 By posting at the Worksite: DATE:_ TIME: SERVER: By hand delivery: DATE: 12/26/2013 TIME: 10:05 AM SERVER: J.M. Gum ❑By certified mail: DATE: TIME: ARTICLE: Rev 09/19/2012 Statutes & Constitution :View Statutes : Online Sunshine Select Year: 2012 :Go The 2012 Florida Statutes Title XXXI Chapter 440 View Entire Chapter LABOR WORKERS' COMPENSATION Pa (le 1 of 2 440.10 Liability for compensation. — (1)(a) Every employer coming within the provisions of this chapter shalt be liable for, and shall secure, the payment to his or her employees, or any physician, surgeon, or pharmacist providing services under the provisions of s. 440.13, of the compensation payable under ss. 440.13, 440.15, and 440.16. Any contractor or subcontractor who engages in any public or private construction in the state shalt secure and maintain compensation for his or her employees under this chapter as provided in s. 440.38. (b) In case a contractor sublets any part or parts of his or her contract work to a subcontractor or subcontractors, all of the employees of such contractor and subcontractor or subcontractors engaged on such contract work shalt be deemed to be employed in one and the same business or establishment, and the contractor shalt be liable for, and shall secure, the payment of compensation to at[ such employees, except to employees of a subcontractor who has secured such payment. (c) A contractor shalt require a subcontractor to provide evidence of workers' compensation insurance. A subcontractor who is a corporation and has an officer who elects to be exempt as permitted under this chapter shalt provide a copy of his or her certificate of exemption to the contractor. (d)1. If a contractor becomes liable for the payment of compensation to the employees of a subcontractor who has failed to secure such payment in violation of s. 440.38, the contractor or other third -party payor shall be entitled to recover from the subcontractor all benefits paid or payable plus interest unless the contractor and subcontractor have agreed in writing that the contractor wilt provide coverage. 2. If a contractor or third -party payor becomes liable for the payment of compensation to the corporate officer of a subcontractor who is engaged in the construction industry and has elected to be exempt from the provisions of this chapter, but whose election is invalid, the contractor or third -party payor may recover from the claimant or corporation all benefits paid or payable plus interest, unless the contractor and the subcontractor have agreed in writing that the contractor wilt provide coverage. (e) A subcontractor providing services in conjunction with a contractor on the same project or contract work is not liable for the payment of compensation to the employees -of another subcontractor or the contractor on such contract work and is protected by the exclusiveness -of- liability provisions of s. 440.11 from any action at law or in admiralty on account of injury to an employee of another subcontractor, or of the contractor, provided that: 1. The subcontractor has secured workers' compensation insurance for its employees or the contractor has secured such insurance on behalf of the subcontractor and its employees in accordance with paragraph (b); and 2. The subcontractor's own gross negligence was not the major contributing cause of the injury. (f) If an employer fails to secure compensation as required by this chapter, the department shalt assess against the employer a penalty not to exceed $5,000 for each employee of that employer who is `V htt-o: / /www.leii. state .fl.us /Statutes /index.cfm ?Apn mode = Dismay Statute &Search String =... 3/5/2013 ARTICLE V. BUILDING TRADES* Page 28 of 36 competency card and as defined in this article or as restricted by the contractors' licensing board. (3) Abandoning a construction project in which he is engaged or under contract as a contractor. A project may be presumed abandoned if the contractor terminates the project without just cause, or fails to notify the owner in writing of termination of the contract and basis for same, or fails to perform work for 90 consecutive days without just cause and no said notice to the owner. (4) Diverting funds or property received for the execution of a specific contract project or operation or diverting funds earmarked for a specified purpose to any other use whatsoever. (5) Departing from or disregarding in any material respect the plans or specifications of a construction job without the consent of the owner or his duly authorized representative. (6) Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation taws of the state or ordinances of this county. (7) Falsifying or misrepresenting any material fact in his application and supporting papers for the purpose of obtaining a certificate of competency under this article. (8) Committing mismanagement or misconduct in the practice of contracting that causes financial harm to a customer. Financial mismanagement or misconduct includes, but is not limited to, any of the following: a. The contractor fails to fulfill his contractual obligations to a customer because of inability, refusal or neglect to pay all creditors for material furnished or work or services performed in the operation of the business for which he is licensed, under any of the following circurirstarrues: 1. Valid liens have been recorded against the property of a contractor's customer for supplies or services ordered by the contractor for the customer's job; the contractor has received funds from the customer to pay for the supplies or services; and the controilo, hi,:; not had the liens removed from the property, by payment or by bond, within 30 days after the date of such liens; 2. The contractor has abandoned a custunier's job and the percentage of completion is less than the percentage of the total contract price paid to the contractor as of the time of abandonment, unless the contractor is entitled to retain such funds under the terms of the contract or refunds the excess funds within 30 days after the date the job is abandoned; 3. The contractor's job has been completed, and it is shown that the customer has had to pay more for the contracted job than the original contract price, as adjusted for subsequent change orders, unless such increase In cost was the result of circumstances beyond the control of the contractor, was the result of circumstances caused by the customer, or was otherwise permitted by the terms of the contract between the contractor and the customer. b. The contractor's job been completed, and it is shown that the customer has incurred financial harm by having to seek a variance or other 'administrative remedy because of actions by the contractor. (9) Performing any act which assists a person or entity in engaging in the prohibited unlicensed practice of contracting, if the licensed contractor knows or should have known that the person or entity was unlicensed. ... /1AC70 /I M CIAIOL:7:a _fnAlf ec. , 1, min nn ARTICLE V. BUILDING TRADES* ARTICLE V. BUILDING TRADES* *Cross references: Businesses, ch. 26. Page 1 of 36 : State law references: Authority to adopt business regulations, F.S. § 125.01(1)(h); contractors generally, F.S. ch. 489; preservation of certain powers of counties, F.S. §§ 489.131, 489.537. DIVISION 1. GENERALLY Sec. 22 -161. Title and citation. This article shall be entitled and may be cited as the "Collier County Contractors' Licensing Board Ordinance." (Ord. No. 90 -105, § 6.1) Sec. 22 -162. Definitions and contractor qualifications The following words, terms and phrases, when used in this article, shall have the meanings ascribed to them in this section, except where the context clearly indicates a different meaning: Business organization means any partnership, corporation, business trust, joint venture, or other legal entity which engages or offers to engage in the business of contracting or acts as a contractor as defined in this section. Contracting means, except as exempted in this part, engaging in business as a contractor and includes, but is not limited to, performance of any of the acts as set forth in subsection (3) which define types of contractors. The attempted sale of contracting services and the negotiation or bid for a contract on these services also constitutes contracting. If the services offered require licensure or agent qualification, the offering, negotiation for a bid, or attempted sale of these services requires the corresponding licensure. However, the term "contracting" shall not extend to an individual, partnership, corporation, trust, or other legal entity that offers to sell or sells completed residences on property on which the individual or business entity has any legal or equitable interest, if the services of a qualified contractor certified or registered pursuant to the requirements of this chapter have been or will be retained for the purpose of constructing such residences. Contractor means the person who is qualified for and responsible for the entire project contracted for and, except for those herein exempted, the person who, for compensation, undertakes to, or submits a bid to, or does himself or by others, any or all of the following construct, repair, alter, remodel, add to, demolish, subtract from, or improve any building or structure, including related improvements to real estate, for others, or for resale to others, as hereinafter defined in this section. (1) General contractor requires 48 months experience with a passing grade on an approved test and a business and law test and means a contractor whose services are unlimited as to the type of work which he may do, except as provided in this article or in the Florida Statutes. (See also the definition of subcontractors.) (2) Building contractor requires 48 months experience with a passing grade on an http:// library2 .municode.com/default/DocView /105 -/8 /l/36/41 ?hilite =2006 46; 1/16/2009 AKHC;LE V. BUILDING TRADES* Page 27 of 36 (i) Any individual who fails to renew his /her certificate of competency prior to December 31 of the year following its expiration shall thereby automatically have a certificate of competency that is null and void. To acquire a valid certificate from the county the individual must pay the then applicable full application fee in accordance with the schedule of fees and charges adopted by resolution pursuant to section 22- 182(x)(4) herein, and must submit an entire new application. If, as of the date of receipt by the county of said new application, three years have passed since the date of his /her most recent examination that the individual passed to acquire the former certificate, that individual must pass all then applicable testing requirements. If the request is to reactivate a dormant certificate, the re- testing requirement can be waived by staff if the applicant proves that he /she has been active in the trade in another jurisdiction, or has been active as an inspector or investigator in the trade; or for other valid reason that would render such re- testing superfluous. (Ord. No. 90 -105, § 1.4; Ord. No. 92 -61, § 1; Ord. No. 94 -34, § 1; Ord. No. 97 -68, § 1, 10- 28 -97; Ord. No. 99 -45, § 1.4 -- 1.4.9, 6 -8 -99) Secs. 22-192--22-200. Reserved. DIVISION 3. STANDARDS OF CONDUCT AND DISCIPLINE* *State law references: Discipline of contractors, F.S. §§ 489.129, 489.533. Sec. 22 -201. Misconduct -- Collier County /city certificate of competency. The following actions by a holder of a Collier County /city certificate of competency shall constitute misconduct and grounds for discipline pursuant to section 22 -202: (1) Knowingly combining or conspiring with an unlicensed contractor by allowing one's certificate of competency to be used by an unlicensed contractor with intent to evade the provisions of this article. When a licensed contractor acts as the qualifying agent for any firm without first making application under this article to represent said firm, such act shall constitute prima facie evidence of intent to evade the provisions of this article. When a certificate holder allows his certificate to be used by one or more companies without having any active participation in the operations, management, and control of such companies, such act constitutes prima facie evidence of an intent to evade the provisions of this article. Active participation requires job site supervision, knowledge of and participation in the business operations of the company, including all contractual matters. a. If any individual qualifying any business organization ceases to be affiliated with such business organization, he shall so inform the board. In addition if such individual is the only certified individual affiliated with the business organization, the business organization shall notify the board of the individual's termination and shall have no more than 60 days from the date of termination of the individual's affiliation with the business organization in which to affiliate with another person certified under the provisions of this article. In any event, the business organization shall not enter into any new contracts and may not engage in any new contracting until such time as a qualifying agent is employed. (2) Contracting to do any work outside of the scope of his competency as listed on his 2�° /% http: / /Iibrary2.municode.com/ default /DocView /10578/l/36/41 ?hilite =2006 46; 1/16/2009 ARTICLE V. BUILDING TRADES* Page 28 of 36 competency card and as defined in this article or as restricted by the contractors' licensing board. (3) Abandoning a construction project in which he is engaged or under contract as a contractor. A project may be presumed abandoned if the contractor terminates the project without just cause, or fails to notify the owner in writing of termination of the contract and basis for same, or fails to perform work for 90 consecutive days without just cause and no said notice to the owner. (4) Diverting funds or property received for the execution of a specific contract project or operation or diverting funds earmarked for a specified purpose to any other use whatsoever. (5) Departing from or disregarding in any material respect the plans or specifications of a construction job without the consent of the owner or his duly authorized representative. (6) Disregards or violates, in the performance of his contracting business in the county, any of the building, safety, health, insurance or workers' compensation laws of the state or ordinances of this county. (7) Falsifying or misrepresenting any material fact in his application and supporting papers for the purpose of obtaining a certificate of competency under this article. (8) Committing mismanagement or misconduct in the practice of contracting that causes financial harm to a customer. Financial mismanagement or misconduct includes, but is not limited to, any of the following: a. The contractor fails to fulfill his contractual obligations to a customer because of inability, refusal or neglect to pay all creditors for material furnished or work or services performed in the operation of the business for which he is licensed, under any of the following circumstances: 1. Valid liens have been recorded against the property of a contractor's customer for supplies or services ordered by the contractor for the customer's job; the contractor has received funds from the customer to pay for the supplies or services; and the contractor has not had the liens removed from the property, by payment or by bond, within 30 days after the date of such liens; 2. The contractor has abandoned a customer's job and the percentage of completion is less than the percentage of the total contract price paid to the contractor as of the time of abandonment, unless the contractor is entitled to retain such funds under the terms of the contract or refunds the excess funds within 30 days after the date the job is abandoned; 3. The contractor's job has been completed, and it is shown that the customer has had to pay more for the contracted job than the original contract price, as adjusted for subsequent change orders, unless such increase in cost was the result of circumstances beyond the control of the contractor, was the result of circumstances caused by the customer, or was otherwise permitted by the terms of the contract between the contractor and the customer. b. The contractor's job been completed, and it is shown that the customer has incurred financial harm by having to seek a variance or other administrative remedy because of actions by the contractor. (9) Performing any act which assists a person or entity in engaging in the prohibited unlicensed practice of contracting, if the licensed contractor knows or should have known that the person or entity was unlicensed. a ARTICLE V. BUILDING TRADES* Page 29 of 36 (10) Failing to promptly correct faulty workmanship or promptly replace faulty materials installed contrary to the provisions of the construction contract. Faulty workmanship means work that is not commenced, not continued, or not completed in accordance with all specifications of the applicable written agreement. Faulty workmanship includes any material flaw(s) in the quality and /or quantity of the unfinished work product, including any item that does not function properly as a part of the entire project. If there is no written agreement provision regarding the specific faulty workmanship issue, faulty workmanship exists if the work, process, product or part thereof does not meet generally accepted standards in Collier County in relation to the entire project. Faulty workmanship does not include matters of aesthetics unless the aesthetically related item clearly violates a written contract specification directly related thereto. (11) Failure to maintain at all times, with an insurance company authorized to do business in the state, the limits of liability and other categories of insurance as required by this article. (12) Failing to claim or refusing to accept certified mail directed to the contractor by the contractors' licensing board, or its designee. (13) Failing to maintain a current mailing address. (14) Failing to appear in person or through a duly authorized representative at any scheduled hearing on a complaint filed against the contractor. (15) Being convicted or found guilty, regardless of adjudication, of a crime in the county which directly relates to the practice of contracting or the ability to practice contracting. (16) Allowing another to take a qualifying examination on the applicant's behalf. (17) Engaging in contracting business in the county or the city when prohibited from doing so by the contractors' licensing board. (18) Proceeding on any job without obtaining applicable permits or inspections from the city building and zoning division or the county building review and permitting department. (19) Failing in any material respect to comply with the provisions of this article as a contractor or as a qualifying agent for a business entity engaging in contracting. (20) Signing a statement with respect to a project or contract falsely indicating that the work is bonded; falsely indicating that payment has been made for subcontracted work, labor, or materials which results in a financial loss to the owner, purchaser, or contractor; or falsely indicating that workers' compensation and public liability insurance are provided. (21) Failure of a qualifying agent for a firm /legal business entity to comply with the requirements set forth in F.S. §§ 489.119 and 489.1195. (22) Falsifying or misrepresenting any material fact to another person with the intent or for the purpose of engaging in the contracting business, providing materials or services, or soliciting business for an employer, as a contractor, or as an employee, regardless of any financial consideration. (23) Failing or refusing to provide proof of public liability and property damage insurance coverage and workers compensation insurance coverage. (24) Misconduct in the practice of contracting (see section 22 -201.1 below). (Ord. No. 90 -105, § 4.1; Ord. No. 92 -61, § 4; Ord. No. 94 -34, § 4; Ord. No. 97 -68, § 1, 10- 28 -97; Ord. No. 99 -45, § 4.1 -- 4.1.24, 6 -8 -99) htti):// Iibrarv2 .municode.com/default/DoeView /10578/1 /36/41 %iliie =7006 46• 1 A A19nn4 CONTRACTORS LICENSING BOARD COLLIER COUNTY, FLORIDA BOARD OF COUNTY COMMISSIONERS ) COLLIER COUNTY, FLORIDA ) Petitioner, ) Case No: 2013 -09 vs. ) License No. 201300000579 Seth B. Hollander ) d /b /a Hollander Construction Company, ) Inc., Respondent(s) ) • -r THIS CAUSE came on for public hearing before the Contractors' Licensing Board (hereafter Board) on October 16, 2013 for consideration of the Administrative Complaint filed against Seth B. Hollander d /b /a Hollander Construction Company, Inc. Service of the Complaint was made in accordance with Collier County Ordinance 90 -105 as amended. The Board made a finding of fact that the service conformed with the requirements of Ordinance 90 -105, as amended. The Board having at said hearing heard testimony under oath, received evidence, and heard arguments respective to all appropriate matters, thereupon issues its Findings of Fact, Conclusions of Law and Order of the Board as follows: F- C;�D 316444.2 10/31/2013 FINDINGS OF FACT 1. That Seth B. Hollander is the holder of record of License Number 201300000579. 2. That the Board of County Commissioners of Collier County, Florida is the complainant in this matter. 3. That the Board has jurisdiction of the person of the Respondent and that Seth B. Hollander was present at the public hearing and was represented by counsel at the hearing on October 16, 2013. 4. All notices required by Collier County Ordinance No. 90 -105, as amended, have been properly issued, hand delivered and delivered by certified mail in accordance with Collier County Ordinance 90 -105, as amended. 5. The evidence presented and testimony given established that the Respondent acted in a manner that is in violation of Collier County Ordinances as follows: (1) engaging in contracting to do work outside of his scope of competency as listed on his competency card (Ordinance 90 -105, as amended, Section 22- 201(2)), and is the one who committed the acts. 6. That the Contractors' Licensing Supervisor presented sworn testimony and the administrative complaint and exhibits thereto were admitted into evidence. The Respondent was afforded an opportunity to present sworn testimony, exhibits, and to cross examine the Contractors' Licensing Supervisor's witness. The Board was afforded an opportunity to ask questions of the Respondent and witnesses. The Board determined that the allegations of fact as set forth in the Administrative Complaint, as to a✓ 316444.2 10/31/2013 Count I, Section 22- 201(2) of the Collier County Ordinance 90 -105, as amended, are true and therefore such facts are hereby found to be supported by the evidence presented at the hearing. CONCLUSIONS OF LAW 1. The Conclusions of Law alleged and set forth in the Administrative Complaint as to Counts 1 were supported by the evidence presented at the hearing on October 16, 2013 and said conclusions of law are hereby approved, adopted and incorporated herein, to wit, the Respondent violated Sections 22- 201(2) of Collier County Ordinance 90 -105, as amended, in the performance of his contracting business in Collier County by acting in violation of the sections set out above with particularity. 2. Collier County has jurisdiction over this contractor pursuant to Collier County Ordinance 90 -105, as amended. ORDER OF THE BOARD Based upon the foregoing Findings of Fact and Conclusions of Law, and pursuant to the authority granted in Chapter 489, Florida Statutes, and Collier County Ordinance No. 90 -105, as amended, by a vote of 8 in favor and 0 opposed, a majority vote of the Board members present, the Respondent has been found in violation as set out above. Further, it is hereby ORDERED, by a vote of 8 in favor and 0 opposed, a majority vote of the Board members present that the following disciplinary sanction(s) and 6' <9, C] 316444.2 10/31/2013 related order are hereby imposed upon the holder of Contractors' License Number 201300000579: 1. Probation for a period of twenty four (24) months whereby the Respondent will perform his contracting activities under the supervision of the Board. During which time, should the Respondent violate the Ordinance in any respect which results in charges being brought against him pursuant to the Ordinance, his permit pulling privileges on his license will be immediately suspended and a hearing on the suspension and violation shall be held at the next regularly scheduled Board hearing. 2. A fine in the amount of two thousand five hundred dollars ($2,500.00) to be paid as follows: $500.00 on December 1, 2013 and thereafter in Installments of $500.00 each on the 1St business day of each ensuing month until paid in full. There is no pre - payment penalty. If the Respondent fails to make any payment as set forth herein, his license will be suspended the day after payment was due and a hearing on the suspension shall be held at the next regularly scheduled Board hearing. 3. Administrative and investigative costs in the amount of $620.00 to be paid on or before November 1, 2013. 4. Respondent is to retake and pass the Business Procedures Examination within six (6) months of the date of this hearing. ac 316444.2 10/31/2013 5. Respondent is to provide evidence to the Board that the Owner of the subject property suffered no net loss as a result of the Respondent's actions. The parties hereto are hereby notified that the Respondent has a right to request a rehearing of this matter. A request for rehearing shall be made in writing and shall be filed with the Clerk to the Collier County Board of County Commissioners, and served on any other parties, within twenty (20) days from the date of mailing of the Board's written decision under Section 4.3.4.9 and 4.3.4.10 of Ordinance 90 -105, as amended. A request for rehearing shall be based only on the ground that the decision was contrary to the evidence or that the hearing involved an error on a ruling of law which was fundamental to the decision of the Board. The written request for rehearing shall specify the precise reasons therefore. The decision of the Board which is the subject of the rehearing request shall remain in effect throughout the rehearing procedure unless the Board orders otherwise. The Board shall make a determination as to whether or not to rehear the matter and its decision shall be made at a public meeting, reduced to writing and mailed to the interested parties within 21 days after the decision is made. If the Contractors' Licensing Board determines it will grant a rehearing, it may: a. Schedule a hearing where the parties will be given the opportunity of presenting evidence or argument limited by the Board to the specific reasons for which the rehearing was granted; or ,6 e---) a&- 316444.2 10/31/2013 b. Modify or reverse its prior decision, without receiving further evidence, providing that the change is based on a finding that the prior decision of the Board resulted from a ruling on a question of law which the Board has been informed by its counsel was an erroneous ruling and which ruling could affect the substantive decision. The parties are further notified that upon the timely filing of a Notice of Appeal within thirty (30) days you may have the decision of the Board reviewed pursuant to the procedure set out herein. The contractor found to be in violation may appeal a decision of the Board to the Collier County Circuit Court. Such an appeal shall not be a hearing de novo but shall be limited to appellate review of the record created before the Board. Any appeal shall be filed with the Circuit Court and served on the parties within thirty (30) days of the mailing of the decision of the Board under Sections 4.3.4.9 and 4.3.4.10 of Ordinance 90 -105, as amended. If there has been a re- hearing request, the appeal shall be filed with the Circuit Court and served on the parties within thirty (30) days of the mailing of the re- hearing decision under Section 5.1.2 of Ordinance 90 -105, as amended. In the event that the contractor found to be in violation should elect to appeal, a verbatim record and transcript of the proceedings will be necessary. It shall be the sole responsibility of said party to ensure that a record is made from which a transcript may be prepared which includes the testimony upon which an appeal may be taken. Neither Collier County nor the Board shall have any responsibility to provide a verbatim record transcript of the proceedings. 316444.2 10/31/2013 FURTHER, the Board hereby makes a recommendation to the Florida Construction Industry Licensing Board for a full investigation. In accordance with Chapter 489.131(7) (c) and (d), Florida Statutes, the disciplined contractor, the complainant, or the Department of Business and Professional Regulation may challenge the local jurisdiction enforcement body's recommended penalty for Board action to the State Construction Industry Licensing Board. A challenge must be filed within sixty (60) days of the issuance of the recommended penalty to the State Construction Industry Licensing Board in Tallahassee, Florida. If challenged, there is a presumptive finding of probable cause and the case may proceed before the State Board without the need for a probable cause hearing. Failure of the disciplined contractor, the complainant, or the Department of Business and Professional Regulation to challenge the local jurisdiction's recommended penalty within the time period set forth herein shall constitute a waiver of the right to a hearing before the State Construction Industry Licensing Board. A waiver of the right to a hearing before the State Board shall be deemed an admission of the violation, and the penalty recommended shall become a final order according to the procedures developed by State Board rule without further State Board action. Pursuant to Section' 120.59, Florida Statutes, the parties are hereby notified that they may appeal the Final Order of the State Board by filing one copy of a Notice of Appeal with the Clerk of the Department of Business and Professional Regulation, Northwood Centre, 1940 Monroe Street, Tallahassee, Florida 32399 -0792, and by filing 316444.2 10/31/2013 the filing fee and one copy of the Notice of Appeal with the District Court of Appeal within thirty (30) days of the effective date of said Order. ORDERED by the Contractors Licensing Board effective the 16th day October, 20 Richard Joslin, Chairman Contractors' Licensing Board I HEREBY CERTIFY that a true and correct copy of the above and foregoing Findings of Fact, Conclusions of Law, and Order of the Board has been furnished the Respondent; and Michael Ossorio, Licensing Compliance Supervisor, 2800 North Horseshoe Drive, Naples, FL 34103 on this--�( day o ber, 2013. Secretary Contractor's Licensing Board 6-aq 31644 4.2 10/31/2013 J cl/ 4