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MC-17-573Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Parcel Number /20/20 niicel'-'lie ddition/A statue: APPROVI Expiration: 09/16/2017 Applicant 173 NE 107 Street Miami Shores, FL 1121360070310 Block: Lot: Lauren Rangel Owner Information Address Phone Cell Lauren Rangel 173 NE 107 Street Miami Shores FL 33138- 173 NE 107 Street Miami Shores FL 33138- Contractor(s) SANSONE CORPORATION Phone 954-428-8919 Cell Phone Valuation: Total Sq Feet: $ 1,500.00 100 Tons: Additional Info: MECHANICAL AS PER APPROVED PLANS Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: MECHANICAL AS PER APPROVED P Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.20 $2.00 $2.00 $0.40 $150.00 $3.00 $1.60 $160.20 Pay Date Pay Type Invoice # MC -3-17-63182 03/06/2017 Credit Card 03/20/2017 Credit Card Amt Paid Amt Due $ 50.00 $ 110.20 $ 110.20 $ 0.00 Available Inspections: Inspection Type: Final Rough Duct Review Mechanical Underground 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, PL;;; ING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFID+kVI : at all the foreg information is accurate and that all work will be done in compliance with all applicable laws regulating construction anrmore, I - onze the above-named contractor to do the work stated. March 20, 2017 Autho 3^' er / Applicant / Contractor / Agent Building Department Copy Date March 20, 2017 1 Nit Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION UNE PHONE NUMBER: (305) 7624949 FBC 200 BUILDING Master Permit No. C J Q2,(-4 PERMIT APPLICATION Sub Permit No. f''t C t BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION El RENEWAL ®PLUMBING J MECHANICAL ❑PUBLIC WORKS p CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 173 NE 107 ST City: Miami Shores County: Miami Dade Zip: Falb/Parcel#:11-2136-007-0310 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): ':, t..;ci a 1 Phone#: Address: 173 NE 107 ST city: Miami Shores state: Florida Zip: 33138 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: Sansone Air Conditioning Phone#: 954.428.8919 Address: 590 Goolsby Blvd. city: Deerfield Beach State: FL. Zip: 33442 Qualifier Name: Scott Sansone Phone#: State Certification or Registration #: CMC1249260 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for thls Permit: $ / 'J ° Square/Linear Footage of Work: /t o)ei- Type of Work: 0 Addition Alteration ❑ New 0 Repair/Replace ❑ Demolition Description of Work: s4 3 P - d2 I,ve Specify color of color thru tile: C, �✓ j arab Submittal Fee $ VO Permit Fee $ CCF $ J . 2O CO/CC $ Scanning Fee $ 3 Radon Fee $ 2 DBPR $ 2 Notary $ Technology Fee $ (• 6® Training/Education Fee $ 0 .4 0 Double Fee $ IQ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ 11 0 • 2u (Revisedo2/24/2014) 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. 1 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 val promise in good faith that a copy of the notice of commencement and construction lien law whose property is subject to attachment. Also, a certified copy of the recorded notice of com for the first inspection which occurs seven (7) days after the building permit is issued. inspection will not be approved and a t nspection fee will be charged. Sign / OWNER or AGENT The foregoing ment was acknowledged before me this The foregoing instrument was acknowledged before me this g -2-0 day of (--e t) , 20 l 7 , by 20 day of FEBRUARY , 20 17 by hcL� �z1 is personally known to SCOTT SANSONE , who is personally known to Signature exceeding $2500, the applicant must chu will be delivered to the person nt must be posted at the Job site nce of such posted notice, the CONTRACTOR me or who has produced as me or who has produced identification and who did take NOTARY P Identification and who did take an oath. NOTARY PUBLIC: ` / 41/ .•"�r(1- ffOlf LAURAFARLEY MY COMMISSON I FF 188027 WI IIRES:Marsh 16,2019 INItitilVe04902131 Sobs •*••••••••••••*di**•*•*N• r 1. ••■*•**• APPROVED BY (RevisedO2/24/2014) Sign: Print: ASHLEY DZIE as Seal: ians Examiner Zoning Structural Review Clerk ACORU0 CC0 CERTIFICATE OF LIABILITY INSURANCE DATE (MINDD 12/1/2016 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 POUCIES 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 pollcy(Ies) must be endorsed. If SUBROGATION IS WANED, 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 Iteu of such endorsement(s). PRODUCER Frank H. Furman, Inc. 1314 East Atlantic Blvd. Randi Arnold (954)943-5050 FAX oic. Nok(954)942-6310 ADpR6;randifrltfurmaninaurance.cam P. O. Box 1927 Pompano Beach FL 33061 I JRER(g) AFFORWNG COVERAGE NAIL 9 INsuRERANTational Trust Ins Co 20141 INSURED Sansone LLC alba: Sansone Air Conditioning 590 Goolsby Blvd. Deerfield Beach FL 33442 INSURER a :FOCI Insurance Co 10178 INSURER c:Bridgefislet Employers Inc Co 10701 INSURER D: INSURER E : $ 5,000 INSURERF: COVERAGES CERTIFICATE NUMBER:2016-2017 w/o Endts 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. LTR TYPE OF INSURANCE1141314 =L113413:, POLICY NUMBER 0L00161624 AMA% 12/1/2016 MEM I 12/1/2017 LIMITS EACH OCCURRENCE $ 1,000,000 A I X COMMERCIAL GENERAL LIABILITY CLAOdSMADE X OCCUR MRENTED PRE PREMI ESESS (Es occurrence) $ 100, 000 t DE P(AnyonepecoL $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEMLAGGREGATE LIMITAPPUES POLICY n .7E& 1 OTHER PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP�PAGG $ 2,000,000 $ A AUTOMOBILE X — _AUTOS X UABIUTY AU ANY TO ALL OWNED HIRED AUTOS X SCHEDULED CA001740207 12/1/2016 12/1/2017 COMBINED (Ea accidl INLIMIT $ 1, 000,000 BODILY INJURY (Pr person) $ BODILY INJURY (Per accident) $ PROPERTY$ 0ODAMAGE $ B S UMBRELLA L AB EXCESS LIAB _ OCCUR CLAIMS -MADE 1>1100117257 12/1/2016 12/1/2017$ EACH OCCURRENCE $ 5, 000,000 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 C WORWORKERSC OMPENSATTON AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EICCWDED7 n (Mandatory SINN) 6 yes, describe under DESCRIPTION OF OPERATIONS below N 1 A 083034159 1/1/2017 1/1/2018 H- g ppi�STApp TUTE ER EL EACH ACCIDENT $ 1,000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 EL DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space M required) REI MECHANICAL CONTRACTOR LICENSE 0 CMC1249260 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ACORD 25 (2014101) INS024rm1aml SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZES REPRESENTATIVE Dirk DeJong/RA ®1988-2014ACORD CORPORATION. All rights reserved. The ACORD name and lags are registered marks of ACORD