HC-15-2629 Permit NO. MC-10-15-2..529
`yHonEs°4 Miami Shores Village Permit Type:Mechanical-Residential
10050 N.E.2nd Avenue NE Per
it
Work Classification: New AJC System
Miami Shores,FL 33138-0000 Permit Status:APPROVED
Phone: (305)795-2204
FcoaoA Expiration: 04/18/2016
Issue Date: 10/21/2015
Project Address Parcel Number Applicant
9935 NE 13 Avenue 1132050090470
FABIANO SILVEIRA AGUILAR M
Miami Shores, FL 33138-2634 Block: Lot:
Owner Information Address Phone Cell
FABIANO SILVEIRA AGUILAR MARIANA 9935 NE 13 Avenue
--- MIAMI SHORES FL 33138-2634
9935 NE 13 Avenue
MIAMI SHORES FL 33138-2634
Contractor(s) Phone Cell Phone Valuation: $ 20,200.00
MECHANICAL&AIR CONDITIONING; (305)726-6715 Total Sq Feet: 0
Tons:5 Available Inspections:
Additional Info:NEW A/C UNITS,NEW DUCTS,BATHROOM Inspection Type:
Classification:Residential
Final
Approved: In Review Rough Duct
Comments: Date Approved: : In Review Review Mechanical
Date Denied: Type of Work: Underground
Scanning:3
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $12.60
Invoice# MC-10-15-57446
DBPR Fee $10.61
DCA Fee $10.61 10/21/2015 Credit Card $720.82 $50.00
Education Surcharge $4.20 10/16/2015 Credit Card $50.00 $0.00
Permit Fee $707.00
Scanning Fee $9.00
Technology Fee $16.80
Total: $770.82
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFF I IT: I rtify that II he reg ing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction an zo ing. thermor ,I t rize a above-named contractor to do the work stated.
October 21, 2015
Auth ri d Sig ature:Oner Applicant / Contractor / Agent Date
id r
Building Departm nt Copy
October 21,2015 1
Miami Shores Village 713Y
�.
Building Department s zojs
10050 N.E.2nd Avenue, Miami Shores, Florida 33138Tel:(305)795-2204 Fax:(305)756-8972 -
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 201
BUILDING Master Permit No. �'C l T
PERMIT APPLICATION Sub Permit No. 9 C (S- 26' CI
❑BUILDING ❑ ELECTRIC ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑PLUMBING 14 MECHANICAL F-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
qCONTRACTOR DRAWINGS
JOB ADDRESS: [. N� 3 14-y-r—
City: Miami Shores County: Miami Dade zip:
Folio/Parcel#: O O`�� Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder):T/yjf4 NO ��U�7�i�" Phone#:` T/ 073190,13
Address: 5�.AJ�AIU CT_
%City: _rPrMARAC-, State: FL � Zip:
3. a
Tenant/Lessee Name: Phone#:
Email: FPrbiANoSIL VeiAA A6gAQ(�!,CMgiL .jai'^
N,e_6�fes.1 cvtzp
CONTRACTOR:Company Name: Phone#:3AS ZZiP W(kS
Address: t i3Z <<
City: A41.e.�(n hh State: GL zip: 3301
Qualifier Name: 00VA Phone#: '�S Z?lP Coil t S
State Certification or Registration#:C-MC. 0,5 0 SI ( Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ 20,2Z)0'..4Square/Linear Footage of Work:
Type of Work: ❑ Addition EY Alteration [ New "Repair/Replace ❑ Demolition
Description of Work: eqv Q GUAJI A 1 00 c �¢f ^-� 41
2 Lwlls, s 7 .10d ' 3
Specify color of color thru tile: f
Submittal Fee$ SV 6"
Permit Fee$ _ V � CF$ CO/CC•$
Scanning Fee$ Radon Fee$ DBPR$ Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ Q ZO . E
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES, BOILERS, HEATERS,TANKS,AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with on estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
/-,/
Signature ��''�'"�"�� Signature
OWNER or AGENT 4V CONTR TOR
The f regoing instrumen�w\a\s-ac.,knowledged before me this The foregoing instrument was acknowledged before me this
day of 0���Y ,20 15_ by 04 day of vett U�l 20 15 ,by
Tl-\(XV)DS. OW 1SIC .�vho"is pers own SQ L �10Y�{ who is personally known to
me or who has produced as me or who has produced P L as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign: 4 � INA GEREt
Print: l 1 Print: of u k• 6t Flory
Seal: ;o'""I'`'�:, CARMEN ESTHER JUSINO =;� _ Coinml>affon t FF 164325
Seal �., �N��.•° Bgft�gh,NationalNoWyAssn.
°`t •� MY COMMISSION#FF046931
EXPIRES August 19,2017
0 398.0153 FloridallotaryService.com
****** * *** *************************************************************
1 V
APPROVED BY QPlans Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
'RICK SCOTT,GOVERNOR KEN LAWSON, SECRETARY
STATE OFTLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
P
CMC1250511
The'MECHANICAL CONTRACTOR •�
"Named below IS CERTIFIED
Und&the,pfovisions.of Chapter 489 FS. "
Expitatiori date:-AUG 31, 2016
,-RODRIGUEZ,;OSBEL ��•C.a'-- .
1 - !MECHANICAL&:AIR'CONDIfiONING SERVICES CORP
137 WEST,,IITH-ST,REE7 =. �.. . �,
'r f-'HI�H—=f_.,'FL 3300'- lkN
ISSUED: 10/04/2015 DISPLAY AS REQUIRED BY LAW SEQ# L1510040000670
Local Business Tax Receipt
Miami-Dade County, State of Florida
-THIS IS NDT A BILL-DO NOT PAY
7191837
BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES
&AIR NEW BUSINESS SEPTEMBER 30, 2016
CONDITIONING SERVICES 7473580
CORP Must be displayed at piece of business
137 W 4`ST Pursuant to County Code
HIALEAH, FL 33010 Chapter 8A—Art.s&10
OWNER SEC.TYPE OF BUSINESS
PAYMENT RECEIVED
MECHANICAL&AIR CONDITIONING 196 GENERAL MECHANICAL BY TAX COLLECTOR'
SERVICES CORP CONTRACTOR
C/o RCInpim IF7 ngRFf' 45.00 10/05/2015
Worker(s) 1 CMC1250511 0226-16-000066
This Local Business Tax Receipt only corms payment of the Local Business Tax.The Receipt is not a license,
Permit or a certification of the holder's qualifications,to do business.Holder most comply with any governmental
or nongovernmental regulatory laws and rsquirementswhich apply to the business.
The RECEIPT N0.above must be displayed on all commercial vehicles-Miami-Dade Code Sec ga-276.
MIAM For more information,visit www miamidede,gov/taxcollector
F LIABILITY INSURANCE ! oATE`MMIDDIYYYY)
CERTIFICATE C} 10/08/2015
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 INSU�R(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION IS WAIVED,`,subject to
the terms and conditions of the policy,certain Policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT NAME -- Madelyn Rodriguez I
Simply Insurance Agency Inc PHONE ( �507-0170 FARC No: (�)820-6393
7911 NW 72 Ave Suite 223.8 .MAIL simpyimsurarre®aol.com €
E
DDRESS
Medley,FL 33166 INSURER($)AFFORDING COVERAGE NAIC•
Phone (305)507-0170 Fax 305 820-6393 INSURER A: AMSTRUST NORTH AMERICA
INSURED INSURER B:
MECHANICAL&AIR CONDITIONING SERVICES CORP INSURER C:
INSURER 0.
137 WEST 11TH STREET
-
INSURER E:
HIALEAH,FL 33010
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.
USR POLICY EFF POLICY EXP
ITS TYPE OF INSURANCE POLICY NUMBER MMID (MCEM
LIMITS
® COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000.000.00
AGE TO ED 1 0Q0
❑
CLAIMS-MADE e OCCUR PREMISES jEa occurrence) $_
❑ MED EXP(Arjy one Person) $ 5,000.00
A11 1y OQ63 09118/2015 09/18/2016 PERSONAL a ADV INJURY s 1,000,000.00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000.00
® POLICY ❑ Esc ❑ LOC PRODUCTS jCOMPIOP AGG s 2,000,000.00
❑ OTHER S
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY Ea aecide
❑ ANY AUTO BODILY INJURY(Per per$M) S
❑ ALL OOSWNED ❑ SCHEDULED BODILY INJURY(Per accident) S
AUTOS
NON-OWNED 01Z MAGE $
R.01 n
❑ HIRED AUTOS AUTOS E $
❑ UMBRELLA LU1B C]OCCUR EACH OCCCJRRENCE $
❑ EXCESS LIAS ❑CLAIMS-MADE AGGREGATE $
DED Q RETENTION SS
PER DTH-
MRKERS COMPENSATION STATLE�
AND EMPLOYERS'LIABILITY Y I N
ANY PROPRIETORIPARTNER/EXEC UTKfE—I E.L.EACH ACCIDENT $
OFFICEPJMEMBER EXCLUDED? 9NIA.
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE
R yes,describe under EL.DISEASE.POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
,
t
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H mom$Pace is required)
COMBINED HEATING&AIR CONDITIONING SYSTEMS INSTALATION, SERVICING AND REPAIRS.MECHANICAL CMC-1250511
I
CERTIFICATE HOLDER CANCELLATION
I
SHOULD ANY OF THE ABOVE DESCRIBED,POLICIES BE CANCELLED BEFORE
MIAMI SHORES VILLAGE BLDG DEPT THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
10050 NE 2 AVE
MIAMI SHORES,FL 33138 AUTHORIZED REPRESENT
01988-2014 AC RD C, RATION. All rights reserv0d.
ACORD 26(2014101)OF The ACORD and logo are registered marks of ACORD
_ PS
JEFF ATWATER
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
**CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law.
EFFECTIVE DATE: 10/7/2015 EXPIRATION DATE: 10/6/2017
PERSON: RODRIGUEZ OSBEL
FEIN: 474958431
BUSINESS NAME AND ADDRESS:
MECHANICAL&AIR CONDITIONING SERVICES CORP.
137 W 11 ST
HIALEAH FL 33010
SCOPES OF BUSINESS OR TRADE:
HEATING,VENTILATION,
AIR-COND
Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section
may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only
within the scope of the business or trade 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 shall revoke a
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609
SNoR.93s yrt
eggs J ,,,,,l" Miami Shores Village
Building Department
OR1Dp' 10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees,including the owner,must obtain workers'compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if:
1. The officer owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State,Division of Corporations;and
3. The corporation is registered and listed as active with the Florida Department of
State,Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers'compensation exemption.In these circumstances,Miami Shores Village
does not require verification of workers'compensation insurance coverage from the contractor's company. Therefore,you may be
personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your
insurance carrier since most property insurance policies DO NOT cover this type of liability.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Owner Contractor
n
Print Name: .09/4►to ,`�✓ — Print Namle C"
Signature: Signature:
State of Florida) State of Florid
County of Miami-Dade) Countyof Mia i-Dade)
Sworn to and subscribed before me this <-,O- I Sworn to and subscribed before me this
day of aA V-)-e ,20_1 day of c1j�,20
By B C�cbt�F �oce f��`e Z
CARMEN ESTHER JUSINO
Y-
(SEAL) __ #FF046931 (S
Type of n r o _ T of� ication p6fiEld�GEREI
of
(40�398-0153 FloddallotaryService.com :+ 0 ry U C-state Or
My Comm.Expires Sep 30,2018
=: �,, Commission#FF 164325
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rY Bonded National Not
A
MECANICAL&AIR
CONDITIONING SERVICES CORP.
137 W 4 STREET
HIALEAH,FL 33010
PH: 305 219 1929
,U. CMC 1250511
M & A ' -
i ~`
71
CONDITIONING SERVICES
October 8, 15
STATE OF FLORIDA
COUNTY OF DADE
Before me this day personally appeared Osbel Rodriguez who, being duly sworn, deposes
and says:
That he will be the only person working on the project located at: 9935 NE 13th Ave. Miami
Shores,FL 33138
Sworn to and subscribed before me this 8`h day of October 2015 by
Personally
"�►' JOSEFINA GERE2
Notary Public-State of Florida
• My Comm:Expires Sep 30,tote Or produced Identification
'.�± �F` ••' B
Commission I FF 164325
Nffifflal Wary„
Assn.
Type or Identification Produced Z�