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MC-17-340 Permit NO. MC- -17-340 �sK°REs LT Miami Shores Village Permit Type:Mechanical-Commercial 10050 N.E.2nd Avenue Work Classification Addition/Alteration Miami Shores,FL 33138-0000 Pen ot Permit Staters:APPROVED Phone: (305)795-2204 F<ORiDp` Issue Date:3/2/2017 Expiration: 08/29/2017 Project Address Parcel Number Applicant 1132060132480 MIAMI SHORES VILLAGE Miami Shores, FL Block: Lot: Owner Information Address Phone Cell MIAMI SHORES VILLAGE Contractor(s) Phone Cell Phone Valuation: $ 5,300.00 JORDA MECHANICAL (305)262-0095 Total Sq Feet: 0 Tons: Available Inspections: Additional Info:mechanical work at Pump station gen Inspection Type: Classification:Commercial Ventilation Approved:In Review Final Comments: Date Approved: : In Review Rough Date Denied: Type of Work:mechanical work at Pump station gen Rough Duct Scanning:2 Duct Detector Test Review Mechanical Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $3.60 Invoice# MC-2-17-62893 DBPR Fee $2.39 03/02/2017 Credit Card $ 179.38 $0.00 DCA Fee $2.39 Education Surcharge $1.20 Permit Fee $159.00 Scanning Fee $6.00 Technology Fee $4.80 Total: $179.38 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoni r I authorize the above-named contractor to do the work stated. March 02, 2017 A rized Signat .Owner / Applicant / Contractor / Agent Date Building Department Copy March 02, 2017 1 w Miami Shores Village RF'C"'1177 1N7VD Building Department FEB x20,1 10050 N.E.2nd Avenue, Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 BY:— INSPECTION LINE PHONE NUMBER:(305)762-4949 FRC 20) h BUILDING Master Permit No.PW-2-16-323 PERMIT APPLICATION Sub Permit No. M C ❑BUILDING ❑ ELECTRIC ❑ ROOFING REVISION EXTENSION [:]RENEWAL PLUMBING Q MECHANICAL ❑PUBLIC WORKS CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 135 NE 97th Street City: Miami Shores County: Miami Dade Zip: 33138 Folio/Parcel#: 1132060132480 Is the Building Historically Designated:Yes NO X Occupancy Type: N/A Load: N/A Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):Village of Miami Shores Phone#:305-795-4857 Address: 10050 NE 2nd Ave City: Miami Shores State: FL Zip: 33138 Tenant/Lessee Name: Tom Benton (Village Manager) Phone#:305-795-4857 Email: bentont@miamishoresvillage.com CONTRACTOR:Company Name: Jorda Mechanical Contractor Phone#: 305-262-0095 Address: 1510 NW 79th Avenue City: Doral State: FL Zip: 33126 Qualifier Name: Jorge Guisasola Phone#: 305-262-0095 State Certification or Registration#: Certificate of Competency#: DESIGNER:Architect/Engineer: CPH, Inc. Phone#: 305-274-4805 Address: 1992 SW 1 st Street city. Miami State: FL Zip: 33135 Value of Work for this Permit:$5,300 Square/Linear Footage of Work: N/A Type of Work: ❑ Addition ❑ Alteration ❑■ New ❑ Repair/Replace ❑ Demolition Description of Work: mechanical work at Pump Station Generator House Specify color of color thru tile: n Submittal Fee$ Permit Fee$ CCF$ x"77 CO/CC$ Scanning Fee$ Q Radon Fee$ DBPR$ L • Notary$ Technology Fee$ ' vo Training/Education Fee$ Double Fee$ ----- Structural Reviews$ Bond$ TOTAL FEE NOW DUE$ � � 3� • (Revised02/24/2014) Bonding Company's Name(if applicable) N/A 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 ;J1 OWNER or AGENT CONTRA OR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this -C?44N day of F&LL40,A 20 by QV5- day of -Tk?)pUAQ& 20 1 by To v.,,--6 0A V1 who is personally known to , R 1 t_SC� Cc who is personally known to me or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: ' NOTARY PUBLIC: Sign: (moi , Sign: Print: Print: 0 (1PZ Seal: r„r, Seal: MIRNACORTEZ IN's ry, y BARBARA A ESTEP = '''-Commission t FF 986098 MY COMMISSION Y FF 073975 '*� ' .• ,� EXPIRES:March 29,2018 =� Expires Mty2,2020 APPROVED BY �V `Plates Examiner Zoning Structural Review Clerk (Revised02/24/2014) ,SNORES G,! •••. gig,s .....�+ Miami shores Village Building Department �LoRIDp' 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. BUSINESS NAME: 7-mb 1 Ewai gyses� l No. lb�A : -' )C)n�Q 00ntccacbr BUSINESS ADDRESS: I510 NW 1-°li" AVE'IWP- CITY STATE FL ZIP_aa12a BUSINESS PHONE: ( a::j 1 J°t-1 -7020 FAX NUMBER(395 ) 5q-1- X04() CELL PHONE (,1723'8 " 9 96 5 QUALIFIER'S NAME: 30rcae C ui iso b, QUALIFIER'S LIC NUMBER: CMC Oog(Aqc) 000895 Local Business Tax Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-'DO NOT PAY 1183367 JBT BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES JORDA MECHANICAL CONTRACTOR RENEWAL SEPTEMBER 30, 2017 1510 NW 79 AVE 1183367 Must be displayed at place of business DORAL FL 33126 Pursuant to County Code i Chapter 8A—Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED 10RDA ENTERPRISES INC' 198 GENERAL MECHANICAL CONTRACTOR sy TAX COLLECTOR Worker(s)JJORGE GUISASOLA PRES CMC008499` $171.00 07/15/2016 CREDITCARD-1 6-041143 This focal Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,or a certification of the hold r'sqqualifictions, to do business.'Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles=Miami—Dade Code Sec 8a-716. For more information,visit wwwmiamidade.govftexcollector 000314 4 Local Business Tac Receipt Miami-Dade County, State of Florida -THIS IS NOT A BILL-DO NOT PAY 459065 �ILBT BUSINESS NAMEILOCATION RECEIPT NO. EXPIRES GUISASOLA JORGE'PE RENEWAL SEPTEMBER 30, 2017 1510 NW 79 AVE 459665 Must be displayed at-place of business DORAL FL 33126 Pursuant to County Code Chapter 8A-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED GUISASOLA JORGE PE 212 PROFESSIONAL BY TAX COLLECTOR PE0012743 $60.00 07/15/2016 CREDITCARD-16-041143 This focal Business Tax Receipt only confirms payment of the Local Business Tax.The Receipt is not a license, permit,ora certification of the hoider'squalifications,to do business..Holder must eomply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0.above must be displayed on all commercial vehicles—Miami—Dade Code Sec 8a-276. For more information,visit www.mismidade.govitexcol lector i i • Y 3 RICK SCOTT, GOVERNOR KEN LAWSON,SECRETARY 77 STATE,OF. FLORIDA _ "DEPARTMENT OF BUSINESS--AND pkOOtSSION'AL RIEGULATION` , " C;ONSTRUCTION:INDUSTRY LICENSING'BOACD n 3 The�MECHANICAL�CONTRACTOR Undr thetovisionS°af Capfer489 FS Exp ratk ,d' At�G 31, 2018 {u,, r✓' a'" tea�^i mo�rr �+� a� y UIQASOLA, JCiR4Jl= x �. •.+ •,. ..... "� t._ ^. k .,'�' ,?4` ,.,.v tt,�.' • R �'JOF2Df�MO /I�W�Iry{ryCH�l1({1�GL Ct��IaiTI7ACTOR _ ___ r -� /V'79Ti�n�✓�Nt�.l� *.IvD K .,w �. .'W. lww,��^h��,�,iM„' �' :,fin Y... t :,.Pr b �,�' 4,•t� i S� �F- ..3 F 'k"' �y^ an'JM,�S^�"�r 'YM"_ "' '�WIiP.,sue. � .+r,v���,�.' .3.� �^��14.ti..'+��•�L•3�,•'� W4.,�L 'A ISSUED: 06/28/2016 DISPLAYAS REQUIRED BY LAW SEQ# L1606280000653 'A`� CERTIFICATE OF LIABILITY INSURANCE 2/7/2017 THIS 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 policy(ies)must have ADDITIONAL INSURED provisions or 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 CONTACT NAME: Stephanie Wilkinson Brown&Brown of FL, Inc. -Fort Myers 6611 Orion Dr. PHONE 239-274-1430 FAX 239-278-5306 Suite 201 &NIHIL .swilkinson@bbftmyers.com Fort Myershttps://wwm.i-csr.net/Voy FL 33912 INSURERS AFFORDING COVERAGE NAIC# INSURER A:National Trust Ins Co* 20141 INSURED INSURERB:FCCI Insurance Company* 10178 Jorda Enterprises, Inc. INSURER C: DBA Jorda Mechanical Contractor Buck Investments INSURER D: 1510 NW 79th Ave. INSURER E: Doral FL 33126 INSURER F: COVERAGES CERTIFICATE NUMBER:699614336 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDY/YYYY MMIDD/YYLICY YY LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y GL00096728 12/31/2016 12/31/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X�OCCUR DAMAGE RENTED PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY ECT F LOC PRODUCTS-COMP/OP AGG $2,000,000 PRO- OTHER: $ A AUTOMOBILE LIABILITY Y Y CA10000916301 12/31/2016 12/31/2017 COMSINGLE LIMIT Eaaccident $1,000,000 AINY AUTO BODILY INJURY(Per person) $ AUTOS AUTOSULED BODILY INJURY(Per accident) $ HIRED NON-OWNED PR TY DAMA E X AUTOS ONLY X AUTOS ONLY Per accident $ X A X UMBRELLA LIAB X OCCUR Y Y UMB00099908 12/31/2016 12/31/2017 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X I RETENTION$10,000 $ B WORKERS COMPENSATION Y 001WC16A71535 12/31/2016 12/31/2017X POTH- AND EMPLOYERS'LIABILITY Y/N STAER TUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $500,000 OFFICERIMEMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 30 days notice of cancellation except 10 days notice for non-payment Contractor's License#CMC008499 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village Building&Zoning THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores FL 33138-2304 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD