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MC-16-2045Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING FBC 20 14 s Master Permit No. RC ----1 9.0 E Sub Permit No. nlC 9b45 0 REVISION ❑ EXTENSION ❑ RENEWAL ❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS': 72 G A✓ City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: l I p'�• ' -0 S `' 0 9'x-1 0 ®C %2 OIs the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFE: OWNER: Warne (Fee Simple Titleholder): /4e.+ r Lei r,0e- Address: 7 2 6 A/s 92 3i Ara 9/L. City: AA I Cu.1 S lllC�' .` t: ; State: /��-- e- Tenant/Lessee Name: Email: hi /ape -z. 7g J (.A(..:; % GQ I r Cocici I149r~ratl i iie#: 7g6 -23 - 2 7/ 1 zrg4/ NO V` FFE: Phone#: J52— S-49 - -5 2 Zip: r.3 /e Phone#: CONTRACTOR: Company Name: Address: 20q7(J SW City: Howe.,S/-Ptcd State: /'joi/oa A/� "��� Zip: .� 30 j-/ f /14 Qualifier Name: Gni i14 1< f C.d eke..r Phone#: 7g6 -2 &J 2 7// State Certification or Registration #: C A C / l 75 Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $_/®1) Square/Linear Footage of Work: Type of Work: ❑ Addition ❑t Alteration Description of Work: T)U c t -I esS New ❑ Repair/Replace 0 Demolition Sp/17- io Zoeie. Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) Permit Fee $ Lt(- 6 v CCF $ Radon Fee $ DBPR $ Training/Education Fee $ CO/CC $ Notary $ Double Fee $ Bond $ � �r TOTAL FEE NOW DUE $ t`Cn - 50 ' 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 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 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 7 Signature WNER or AGENT The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before this' 2/ day of "7 , 20 / , by Z day of �� , 20 1 cd , by OCe7#4- re l ' who is sonally knoto ilk , who is personally known to PL - me me or who has produced as me or who has produced as identification and who did take an oath. NOTARY PUBLIC Sign: 18 r�-nt: 4 Seal: .1 Notary Public - State of Florida ,,I Commission 0 FF 197603 Agg•r My Comm. Expires Feb 9, 2019 ************s******s*************f ******* *** APPROVED BY (Revised02/24/2014) identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Seal: AAA' MY COMMISSION#FF086857 .j EXPIRES: FEB 28, 2018 Bonded through 1st State Insurance lans Examiner Zoning Structural Review Clerk STATE FLORIDA ;7E -S. USINESS AND f' OF L. GULATION CA6151-84 f 6112/2016 CERTIFIEDAIR GOND CON l KL-EFEKERF MATT'THOMAS . AIR CONDITIONING -AND REFRIGER • AS �3,43�R�1°EB under tfier"vlsl�rrs—ntsakt48,Fg, 6orrdate.,"A.UW312018 -L1 608-02090 003699 Local Business Tax Receipt Miami—Dade County, State of Florida THIS IS NOTA BILL - DO NOT PAY 6256432 BUSINESS NAME/LOCATION KING AIR CONDITIONING AND REFRIGERATION OPERATING IN DADE COUNTY OWNER KING AIR CONDITI & REFRIGET LLC Employee(s) 1 RECEIPT NO. RENEWAL 6521000 SEC. TYPE OF BUSINESS 213 SERVICE BUSINESS LBT EXPIRES SEPTEMBER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 07/28/2015 CREDITCARD-15-038621 Not a Contractor Receipt This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permitor a certification of the holder's qualifications, to do business. Holder must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT NO. above must he displayed on all commercial vehicles - Miami -Dade Code Sec Ba -276. For more information, visit www.miamidade.gov/taxceliector A �Rbr CERTIFICATE OF LIABILITY INSURANCE DATE E(� DD 6 Y) THIS CERTIFICATE 15 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 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 Amco Insurance Corporation 208 NE 8th StreetRDRRESS: Homestead, FL 33030 Phone (786) 243-9222 Fax (786) 243-9122 CONTACT E H NNo Elm. (786) 243-9222 FAX No): (786) 243-9122 homestead(damcoallinsurance.com INSURERS) AFFORDING COVERAGE NAIC # INSURERA: ASCENDANT COMMERCIAL INSURANCE CO. Y INSURED KING AIR CONDITIONING AND REFRIGIRATION 20470 SW 344 ST ' HOMESTEAD FL 33030 INSURER B : 02/02(2016 INSURER C : EACH OCCURRENCE INSURER D : DAMAGE TO PREMISES (EaENTED occrurence) INSURER E : MED EXP (My one person) 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. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR VD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) V Mn5 A n COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE ❑ OCCUR ❑ Y GL -51065-0 02/02(2016 02/02/2017 EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO PREMISES (EaENTED occrurence) $ 100,000.00 MED EXP (My one person) $ 5,000.00 ❑ PERSONAL &ADV INJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ JECT ❑ LOC ❑ OTHER GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 1,000,000.00 $ AUTOMOBILE UABIUTY ❑ ANY AUTO ❑ ALL OWNED ❑ SSC�H LED HIRED AUTOS NON -OWNED ❑ ❑ AUTOS ❑ ❑ COMBINED O eBIINEDISINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA UAB ❑ OCCUR ❑ EXCESS UAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVrI OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N 1 A ❑PER STATUTE ❑ 0R E.L EACH ACCENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space Is required) AIR CONDITIONING AND REFRIGERATION CERTIFICATE HOLDER CANCELLATION I MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2 AVE MIAMI SHORES,FLORIDA 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE04 eriaz 4 lA ACORD 25 (2014101) QF © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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: 2/2/2016 EXPIRATION DATE: 2/1/2018 PERSON: KLEFEKER MATT T FEIN: 371566687 BUSINESS NAME AND ADDRESS: KING AIR CONDITIONING AND REFRIGERATION LLC 20470 SW 344 STREET HOMESTEAD FL 33034 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 firing a certiticate 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 King Air Conditioning & Refrigeration LLC State Certified Contractor CACI 818495 20470 SW 344 Street • Homestead, FL 33034 Tel (786) 283-2711 • Fax (305) 247-0712 CONTRACTOR AFFIDAVIT Date: State of � C"`° County of M r c c r -- La dc Before me this day personally appeared Matt Thomas Klefeker Owner / Operator of King Air Conditioning & Refrigeration, Ilc Who, being duly sworn, deposes and says: That he will be the only person working on the project located at: 726 NE 92 St. Apt 4L Miami Shores, FL 33138 Shores Plaz, ast Condomirum. Sworn to (or Affirmed) and subscribed before me this 143 day of _Tv .20 /Y , by 4441-T(T%1Orn43 _ Personally known OR Produced Identification �C—i�2vf�2—✓ Type of Identification Produced • Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 \‘ N QIrL c 0 v40 01•41\kr -Am3 d249,va eern oN0 Notice to Owner — Workers' Compensation Insurance Exemption ",./ W4/ 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 and has acknowledge that he or she will not use day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signature: State of Florida County of Miami -Dade The foregoing was acknowledge before me this \ day of 1 ,20‘‘ . By ��pe— \ . -O-r who is personally known to me or has produced r as identification. Notary: .••4�; °•. ;s' SEAL: I •� �� STELLA HORAN 1� Notary PubIIC - State of Florida Commission # FF 197803 % oak, My Comm. Expires Feb 9, 2019 - 4 L.)= i/ -%L. fl ri arc RICK SCOTT, GOVERNOR STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL RIGU CONSTRUCTION INDUSTRY LICENSING BOARD KEN LAWSON, SECRETARY TION The CLASS B AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 KLEFEKER, MATT THOMAS KING AIR CONDITIONING AND REFRIGERATION, LLC 20470 SW 344 STREET HOMESTEAD FL 33034 ISSUED: 06/12/2016 DISPLAY AS REQUIRED BY LAW Local Business Tax Receipt Miami—Dade County, State of Florida —THIS IS NOTA BILL—DO NOT PAY 6256432 BUSINESS NAME/LOCATION KING AIR CONDITIONING AND REFRIGERATION OPERATING IN DADE COUNTY RECEIPT NO. RENEWAL 6521000 SEQ # L1606120000842 LBT EXPIRES SEPTEMBER 30, 2017 Must be displayed at place of business Pursuant to County Code Chapter 8A — Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS KING AIR CONDITI & REFRIGET LLC 196 GENERAL MECHANICAL MATT KLEFEKER PRES CONTRACTOR Worker(s) 1 CAC1818495 PAYMENT RECEIVED BY TAX COLLECTOR 82.50 10/12/2016 0230-17-000115 This Local Business Tax Receipt only confirms 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 must comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT PND. above must be displayed on all commercial vehicles — Miami—Dade Code Sec 6a-216. MIAM For more information, visit www.miamidade.aovhaxcoilector ` fie c-12 51 LA MI5