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MC-16-1480
Project Address 103 NE 99 Street Miami Shores, FL 33138 - Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permi' Permit NO. MC -5-1,6-1480 Permit Type: Mechanical - Residential Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 12/27/2016 Expiration: 06/25/2017. Parcel Number 1132060132180 Block: Lot: Applicant GEORGE FISHMAN Owner Information GEORGE FISHMAN Address 103 NE 99 Street 'MIAMI SHORES FL 33138-2340 Phone Cell Contractor(s) Phone JOSE C YANE AIR CONDITIONING & / CeII Phone Valuation: Total Sq Feet: $ 2,150.00 00 Tons: Additional Info: Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 3 Date Approved: : In Review Type of Work: MINI SPLIT UNIT REPLACE OLD UN Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Amount $1.80 $2.00 $2.00 $0.60 $122.50 $9.00 $2.40 Total: $140.30 Pay Date Invoice # 05/27/2016 12/27/2016 Pay Type MC -5-16-59965 Credit Card Credit Card Amt Paid Amt Due $ 50.00 $ 90.30 $ 90.30 , $ 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 EL CTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWN constr SA ction D IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating g. Futhermore, I authorize the above - med c• • ractor to do the work stated. ri ed Signature: Owner / Applicant / Contractor) / Agent Buildin• Department Copy December 27, 2016 December 27, 2016 Date 1 Miami 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 FBC 20/9 - BUILDING Master Permit No Rao - ii -is PERMIT APPLICATION Sub Permit No./ {C, J13— y2P ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ PLUMBING 17:ME,CHANI�� ❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 1©3 1J. c ' `( //�� i"I cr City: Miami Shores County: Miami Dade Zip:'3 3 / 3 Folio/Parcel#: Isuilding Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): (y OSS f-vv1-,CD pho( �e#"3iOr" 713- Address: lc Ji / , gq r S� City: 1a/ / f 1 C)--rtej State:.. • Tenant/Lessee Name: P/,Q' Phone#: -3 01-- 7r3. ' .' t?)3 Email: -� b L.. �� CONTRACTOR: Company Name: Tal �7¢ 0 41 & NO t T2©.0 t J�4 --, ht o e#: � 8%- `� % ' 13 - q2�J,/ Address:ICU li S . 13)- Sl i' ' " Pwi9- _cl G---- City. I *s'' .. ` / State: Zip: 3 31 kb i Qualifier Name: /#cL, irS Phone#: SL Certification or Registration C, S7 / / 7 ((Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 3 Too a2/..rt • /`Square/Linear Footage of Work: zip: 3 Type of Work: ❑ Addition ❑ Alteration ❑ New Repair/Replace ❑ Demolition At � Description of Work: ( SP(,! i C. u49cr k -011 - Specify -011 - Specify color of color thru tile: �y Submittal Fee $ Permit Fee $ 12 4 5 V CCF $ Co/CC $ Scanning Fee $ - Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ IRovdcprin7 /,a/)m a1 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_ 1 certify that no vomit or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of alt laws regulating construction in this jurisdiction. I understand that a separate permit must besecured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, AIR CONDITIONERS, ETC..... OWNEWS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable taws 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 buliding 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 • e approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this '.0 day of C.s*�o4 Qe t� ---PIrkt444.3 n to me or who has produced as by identification an NOTARY PUBLI Sign: Print: Seal: ho did takeano o is personally kn sssssssssssssssssssssssss sl �•.� (e� ,' tsss APPROVED BY lai as cortin NA 11i11 Al Signatu The foregoing CONTRACTOR tent was acknowledged before me this 20 day of Pt 441 me or who has produced as identification and who did take an oath. NOTARY PO Sign: Print: Seal:F�oco osNik‹4409(1* F * * ************N*** 5fsss Examiner *ffffsfffsfffsf Zoning Structural Review Clerk RICK SCOIT, IIMERROR -4 FICER bWSOW, takerafti STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL RESPIRATION CONSTRUCTION INDUSTRY UCENSING BOARD CAC1515974 The CLASSBMR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provhdons C.haptsc 489 FS. Expiration date: AUG 31..2018 VANES, JOSE CLEMENTE JOSE C VANES AIR CONDITIONING & APPLIANCES SERVICES INC 1021 NE 132ND ST NORTH MIAMI FL. 33161 ISSUED: 06114i2014 DISPLAY AS REQUIRED BY LAW SEQ # L1401140001384 ovnalliv WO.* A/c &APPLHNC - , • • lailletial Swink • • 0 • ,• ea= Tref OP UM SPEC W0014141'; CAC1815974 PAvaisett ama) fly TAX C.OLLICTOO! - 05,00 07P1/2015 TCREDITCARD-1 5-Q37460 anin21%t. Thssaaa *sew • - , say gorelamental ft ta-VIL ' �'Rti CERTIFICATE OF LIABILITY INSURANCE Dais � 0 5 T1118 CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT'S UPON THE CERTIFICATE HOLDER. THIS CERT1FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMBO ECTEND OR ALTER THE COVERAGE AFFONDED BY THE POLICIES HELOW. MS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORED REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate hoidsr is an ADDITIONAL INSURED. the the terms and conditions of the policy, aarlaki policies may require an andorsamard. holler In Hsu must ba E SUBROGATION WANED. subject to cantor dgtlts to the pelicy(sts) amdoesad. IS A statement on this certificate dons not certificate of such andarsamengs). Torres Insurance Agency Inc. 6135 NW 167 STREET 6 125 . Masi Lakes FL 33015 Torres Lae Agency . iiip.„,_ (305)512-5880 we ,,,,,k (305)522-W01 INSUIMINSI APPplm13 QOYRRR*E NAIC A Renn ncAMapfra Insurance Company 11/13/201311/12/24)14 MIRED Jose C Tares Air Conditioning & Appliances $ervicos, Inc. 1021 NE 132 Street scums 16apfre Insurance COa ramnv $ 1,000,000 town • t 400, 000 0ISURERD • 1'osaassme say.L Lweanr cuumsasce ® OCCUR gpU'RERE. $ 5, 000 ,North. Miami FL 33161 . MUM( F - ....- COVERAGES CERTIFICATE N 11192721 THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOMtTHSTANDING MY RE1XRREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO VWIGH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED EY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL TIE TERMS. OCCLUSIONS AND CONDITIONS OF SUCH POLICIES UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS lig TYPE OP INSURANCE sr�t rum POLICYNLR0IQL POUCY IPP POLICY ESP LIMITS A 4aeL4ul.u*aALnM DE0323160 11/13/201311/12/24)14 EACH OCCURRENCE $ 1,000,000 DAMAGE i0 RE7NFED t 400, 000 X —, 1'osaassme say.L Lweanr cuumsasce ® OCCUR S IEy oov L hiED Ex. vim ars imor4 $ 5, 000 aelsONN.iAwswRr $ 1,000,000 ....- mot&AGGREGATE $ 2,000,000 Fin OM AGGREGATEUNIT LES � X 1 POLCY ► ) n LOC PRODUCTS -COMPAPAGG $ 1,000,000 1 B 4150120006143 - _ 7/17/2015 7/17/2016 MT s 100.000 AUTOSIODL1 w UASMJNY PAY AUTO AIL WANED AUTOS HIRED AUTOS X ASCNEDULED ur AUTOS O BODILY INJURY (Par penan) $ BODIYINJURY $ CM" aoa4uNt PROPERTY DAMAGE ere i PIP.0ASIC $ 10.000 � EACH OCCt1R�10E $ — atJa LJAa EL MS LIM �1[[ occte - 1 d.**s.MIIDE 1 AGGREGATE $ DEO I ) RETENTION$ - $ YMDRNERSCOMPDISATION IN LIABIftYMY PROFRIETORPARTNEFUEXECUIWE OFRCO1A1B6n ER EXCLUDED" y�Rn�sleM�apbs100 MCy DEScRPi!DN OF OPERATIONS bob" NIA !Ayala -al T1914,1.MDEMPLOYER, EL EACH ACCIDENT $ EI. DISEASE. FAE$APLOYE $ E L 0I$FASE - POUCY LMR $ Wenn eW /Instil s era » span 5 YEW PUMP ACORD101.Ae w r Conditioning oniaq ion slsnfket Additional Insured apply to General Liability policy 1 CP -000323760-5 as required by contract- CG 2033. * Inland Marine: aasaLl Toole *5,000/ (1500 Ded per itsa►/$5,000 per ooaarrsnne.. 1005 Coin*. 5)Ceaseroial Auto: Vets 1: 2002 Ford/ Eoonoline 1250 Van# 1198, V. 2: 2005 Chevrolet Silverado Vin#6819, , vsb 3: 2006 QL4wrolet Express Viol 22433 1500 Colllssion Cosiprehenaive nod 'on 2005 Chevrolet 8ilmscado Vin 1 6819 and . applicable only CERTIFICATE HOLDER CANCELLATION (305)756-8972 Miami Shores Village Bldg Dept 10050 NS ' 2nd Ave Miami Shores, FL 33138 SHOULD ANY OF THE ABOVE DESK:RMED POLICIES BE CANCELLED BEFORE INE EXPIRATION DATE TIS. NOTICE WILL BE DELIVERED 04 ACCORDANCE WRIH THE P0UCY PROWNON3. ACORD Z6 (2010106) INS025mac mot 01988-2010 ACORD CORPORATION. Ap rights twelved. The ACORD name and legs are registered narks of ACORD JEFF ATWATER Cyd 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 In vides listed below has elected tcs be exempt from Ronda Workers' Compensation law. EFFECTIVE DATE: 10123/2044 EXPIRATION DATE: 10/2212016 PERSON: YAKS - JOSE C FEIN: 205350884 BUSINESS NAME AND ADDRESS: JOSE C YANES AIR CONDITIONING & APPLIANCES SERVICES INC A 1021 NE 132ND ST NORTH MIAMI '. . FL 33161 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR-COND Pursuant to Chapter 440.05(14). FS., an officer of a corporation who elects exemption from this chapter by filing a cerffscate of election under this section may not recover benetfis or compensation under this chapter. Pursuant to (xrapta'440-0502), FS.. Ceram of election Lo be exempt- apply ordy within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), FS., Notices of election to be exempt and certificate's of election to be exempt shalt be subject to revocation U at any time after the Ifing of the rxffice or the issuance of the oet6flcata, the person named on the notice or certificate no (anger meets the requirements of this section for Issuance *fa certificate. The department shall revoke a DFS-F2-DWC-252 CERTIFICATE OF FLECTION TO BE EXEMPT REVISED 0? -11 • QUESTIONS? (850)413-1609 Miami Shores Vinage Building Department 10050 N.E.2nd Avenue Miami Shotes, 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 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 befo me this B w . is personally known to as identificati e or has produced Notary: SEAL: Atilt on PANES Alit 'CONDITIONING & APPLIANCES SERVICES,, INC. 1021 NE 132nd STfi1ET, NORTH MIAMI, FL 33161 t,cENslw) a ammo CELL: 700.603.9345 FA : 305,595.3595 Date: 5/25/2016 State of: 4--01-4 faA County of: Before me this day personally appeared Sas'6 \/&iU 1E5 who, herein duly sworn, deposes and says: That he or she will be the only person working on the project at: /n l�• t . q 1ST • Sworn to ( or affirmed) and subscribed before me this 44 day of /4&9. ersonally known 0 e dentification_ Type of Id ification Produced 20,10 ,by Print .Type or Stamp ame of Notary. {