REV-16-2195 A CERTIFICATE OF LIABILITY INSURANCE DATE`MwOO1YYYY'
08123/2016
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 endorsements).
PRODUCER CONTCONTACT
Safe Insurance Group Inc, prlbNe FAx
7901 NW 2nd St. c.No.Emr�os) 4-sa64_..__. ___ TiArc, tjna�2s7 is7s ....___._.
EMAIL sora a afeins rou com
Miami, FL 33126 A> ss __ Y_ .__ __.P�._ _. ..
IN5URE S AFFORDING COVERAGE I
License#:A161532 NAIC k
_......_. -. __.__._ �t.l _ _. . �
_ tNSURERA. . `t7vington..Sf)+PG.)toIty-,InSuraf ce. _... _«... ......._....
INSURED
AIR SYSTEMS A1C,LLC INSURER 8 ...... _._.._ _ _. ....... ..
DBA AIR SYSTEMS A/C INsuceERc-_
7681 NW 169 tern
Miami Lakes,FL 33016 €NSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 000000nn-78163 REVISION NUMBER: 9
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,
INSRL=TYPE OF INSURANCE POLICY EFF POLICY EXP
ITIR1 J POLICY NUMBER LIMITS
AX COMrdERCIALGENERALLIABILITY '
AL000636 GL(BINDER 11)WZ712016 06/27/2017 1 EACH OCCURRENCE 1,000,000
CLAIMS MADE OCCUR i3lAE fO RECO �� 1
_......._ _____�•_ _
MED EXf?(My one persanl E _.._s 000
J PERSONAL 8 ADV INJURY S 1 nuQ 000
..;..................... ....._ .......... ............................... «.._. ......_._..____�___.._._._...._.:_ _,__._.., _
GEN'L AGGREGATE LIMIT APPLIES PER: µGENERAL AGGREGATE, S 2,000,000._
X� COMP/OP l Loc 1 PRODUCTS•Cs 2.000.000
....._..-.__._..._.CO . AGG i ._._._
JE
OTHER:
AUMOBILE LIABILITY { COMBINED SINGLE LIMIT
ANY AUTO ............ .........__.__.
_ € -BODILY INJURY(Per person) J S
_......._—
WN
OEDI SCHEDULED
AUTOS ONLY f AUTOS BODILY INJURY(Per ecddent)j$
HIRED I NON-OWNED _.___.....
_..........
I Y DAMALiE I S
AUTOS ONLY (AUTOS ONLY
1 1s
! )77 UMBRELLA 0 s '
t ( OCCUR TEACH OCCURRENCE 3
._.... EXCESS LIARI CLAIMS-MADE i I AGGREGATE .......... _._
DED RETENTIONS .__—
'WORKERS COMPENSATION _ ! I PER J DTH-
JANDEMPLOYERS'LIABILITY Y1N STATUTE irvR
ANY PROPRIETDRIPARTNERiEXECVTIVE i E _E.L EACH ACCIDENT 15 _ _ .___
OFFICER.'MEMBER EXCLUDED? NlA.
I(Mandatory In NN) _ 'E DISEASE-EA EMPLOYES
P s.oesalbe under ..
I D RIPTION OF OPERATIONS befow J E.C.DISEASE-POLICY LIMIT S
I
� I '
! l
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES(ACORD ibt,Additional Remarks Schedule,may be atmched it mon apace is required)
Subject to policy form,conditions,endorsements,limitations and exclusions
air conditioner sub contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
MIAMI SHORES BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS.
10060 NE 2ND AVE
Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVES
SDH
988-2016 RDC ORATION. All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are r red marks of ACORD
nted by SDH on August 23,2016 at 10:40AM
Miami Shores Village
Building Department AUG
I
10050 N.E.2nd Avenue,Miami Shores, Florida 33138 BY:
Tel:(305)795-2204 Fax:(305)756-8972
INSPECTION LINE PHONE NUMBER:(305)762-4949
FBC 20 � '4
BUILDING Master Permit No.-1a) �is" t6y1
PERMIT APPLICATION Sub Permit No-eV (6- 219 9
❑BUIWING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION RENEWAL
❑PLUMBING `, MECHANICAL ❑PUBLIC WORKS [:] CHANGE OF [:] CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOBADDRESS:
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#: I I. 321' in -&a-I O Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER:Name(Fee Simple Titleholder): J01'n Lnnarrxtr% Phone#:
Address: 333 Ne q S'1Yet+
City: NCja✓y j 154►ores State: F•L Zip: 333 3 8
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR:Company Name: A-e sm;sAcAns LL--," Phone#: 305-USI•1014
Address: 41dR N W 133 f51rc-tor
City: Qp6- Loe-k-a State: r-1, zip:Wit}
Qualifier Name: pnq.A V ;jwc2 Phone#:
State Certification or Registration#: Cm, O?,,�rJ_y�-I Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Re lace
p ❑ Demolition
Description of Work: (L1SL- CIO CV,P(Z L---� SdA,
Specify color of color thru tile:
Submittal Fee$ Permit Fee$ y� CCF$ '-r CO/CC$ ,
Scanning Fee$ 3•y'� Radon Fee$ DBPR$ Notary$_
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
Bonding Company's Name(if applicable)
Bonding Company's Address
City State Zip
Mortgage tender's Name(if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS,
FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC.....
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating construction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING
YOUR NOTICE OF COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which oc seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be appro an Pa reinspection fee will be charged.
Signature Signature
0 or AGENT ONTRACTOR
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
-Lq._day 20 tit by 19 day of_ �X ..20111, by
��h'`i l�tC�L C who is personally known to _Q-fly
who is personally known to
me or who has produced DL pry -Fj•�•C as me or who has produced DL 41"^ gn Q4 as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: Print: q
Seal: !i%�'' • Suyapa T. asquez ,
`''= Commission # FF942611 seal: liA..?�,, Soya I Vasquez
='x ,►_ - '�% Commission I FF942611
Expires:December 9,2019 ="�. , = Expires:December 9 2019
Bonded thru Aaron Notary oFFis '- Bonded thru Aaron Notary
** ***T « ondedtruAaron**a*************
APPROVED BY Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)