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MC-16-2020Project Address Miami Shores Village 10050 N.E. 2nd Avenue NE ' Miami Shores, FL 33138-0000 4 Phone: (305)795-2204 Permit Permit NO. MC -7-16-2020 Permit Type: Mechanical - Residential Work: Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 7/21/2016 Expiration: 01/17/2017 Parcel Number Applicant 5 NE 105 Street Miami Shores, FL 33138-2030 1121360060090 Block: Lot: GROUP 10 CAPITAL MANAGEMI Owner Information GROUP'10 CAPITAL MANAGEMENT, Address 1680 MICHIGAN AVE Avenue MIAMI BEACH FL 33139- Phone Cell Contractor(s) Phone DUAL TEMP AIR CONDITIONING COR (305)325-4502 Cell Phone Valuation: Total Sq Feet: $ 6,000.00 0 Tons: Additional Info: INSTALLATION OF DUCTS REFRIGIRATION Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved: : In Review Type of Work: Fees Due CCF DBPR Fee DCA Fee Education Surcharge Notary Fee Permit Fee Scanning Fee Technology Fee Total: Amount $3.60 $3.15 $3.15 $1.20 $5.00 $210.00 $3.00 $4.80 $233.90 Pay Date Pay Type Invoice # MC -7-16-60655 07/21/2016 Credit Card 07/19/2016 Credit Card P' a Amt Paid Amt Due $ 183.90 $ 50.00 $ 50.00 $ 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, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above-named contractor to do the work stated. July 21, 2016 Authorized Signa / Applicant / Contractor / Agent Building Depa%ment Copy Date July 21, 2016 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑PLUMBING n MECHANICAL JOB ADDRESS: 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 ❑ ROOFING ❑ PUBLIC WORKS City: Miami Shores County: RE77,D MAR 1 7 2017 FBC 2014 Master Permit No. ga G I L" 12S L ❑ REVISION -Sub Permit No.l'"_I 6 -2o20 HANGE OF �NTRACTO ❑ EXTENSION, ❑ RENEWAL ❑ CANCELLATION ❑ SHOP DRAWINGS Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: s F Load: Construction Type: r g5 Flood Zone: BFE: NO FFE: OWNER: Name (Fee Simple Titleholder): w'Y Op /0 P 1 i L. Phone#: V80 M ici4 IqA,/ AVE. Address:` City: M I A M I B 6PGPI State: ��- Zip: D 2.3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR: Company Name: TR� C EN ERA4L. SEJV frES Address: 2(‘'a `fC> 3 W 1 36 ft VEM CI 0 Phone#: 3c:5 -4(B` 2-33L4 City: b MES Es-re/1-6 State: Pi-- Qualifier LQualifier Name: ' e)//4- t`1 P etc E Z Phone#: State Certification or Registration #: DESIGNER: Architect/Engineer: Address: City: GAG (e lS7t4 Zip: 3 30 3 2- -7 a —78/v — 290 —o`%� Certificate of Competency #: Phone#: State: Zip: Value of Work for this Permit: $ 16 Square/Linear Footage of Work: Type of Work: ❑ Addition 71 Alteration CHan(CE Description of Work: ❑ New ❑ Repair/Replace GP NI rAmc-roe, r t J .. ❑ Demolition .r t F e (t: 2,A>1AV 0 A.1414,1" , L S�4LL^dir-i __ y ._ On 01 Specify color�of color `rule. roltsm Submittal Fee $ _.-------- ermit Fee $ W SPA.I'Sa� ,'AOIZZI:v;MOOYM :r; ergs .t43 rtairski 3:1;311x3 CCF $ CO/CC $ Scanning Fee $ . : Radon Fee $ DBPR $ nis Technology Fee $ \ 4 Training/Education Fee $ Structural Reviews $ (Revised02/24/2014) Notary $ Double Fee $ 9:g Bond $ TOTAL FEE NOW DUE $ J - • Q 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 OWNER or AGENT The foregoing instrument was acknowledged before me this (Z. day of ^ (���— )-1 L4 1. 1 e...n ,,, Q e who is personally known to Signature % v CONTRACTOR The foregoing instrument was acknowledged before me this , 20 f- , by L. day of r-'. , 20 t1 , by me or who has produced 1'i1D+C1n «Rr�'t , who is personally known to as me or who has produced as identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY UBLIC: Sign: Print: Seal: THA D VARGAS MY COMMISSION # FF 221452 EXPIRES March 24, 2019 ****************** APPROVED BY (Revised02/24/2014) ***i** * -****** A Sign: Print: Seal: Rr d •-.4"-t* THEA VARGAS MY COMMISSION # FF 221452 EXPIRES March 24.2019 ******************************************* lans Examiner *********** (0 3( Zoning Structural Review Clerk M iami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores,, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT Permit N. I CO Owner's Name (Fee Simple Title Holder): 6 roup 11 t C p 1 +� 1 Phone #: Owner's Address: ( gO M ich 1 /fir y'en (,( City: M I am 1 hac i State : 305-Lf7 rq 051 FL - Zip Code: 3302.3 Job Address (Of where work is being done): 5 me- 1 05 silted - City: Miami Shores State: Florida Zip Code: 33130 Contractor's Company Name: D Rai Temp I r Address: ('SS 3 5 S' (Al 1147 City: PA 1 a I State: FL - Qualifier's Name: R mon Mu -n Architect/ Engineer of Record Name: Address: City: Phone #: 505' 52-5'-''w502. Zip Code: '3/61 Lic. Number: CAG 1 g I toe) -7 Phone #: State: Zip Code: Describe Work: H VAc AIebk) 0;14-h clact work I hereby certify that the work has been abandoned and/or the contractor/architect is unable or unwilling to complete the contract. 1 hold the Building Official and the . i mi Shores harmless of all legal invohr ment. Signature 7i -t&-1?/ A ent Signature Owner g The foregoing instrument was aknowledged before me this ti day of (')`'r-'1 ,201 ,by Si' SOr%fo Who is personally known to me or who has produced as indentification. Notary Publ c: Sign: Seal: THEA D VARGAS MY COMMISSION # FF 221452 EXPIRES March 24, 2019 1, Contractor or Architect The foregoing instrument was aknowledged before me this `i day of PI , 2011 by 120t1.40^ ML.n 71 who is personallyLn_own to me or who has produced as indentification. Nota Sign: Seal: HEA D VARGAS i MY COMMISSION # FF 221452 EXPIRES March 24, 2019 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 2601 BLAIR STONE ROAD TALLAHASSEE FL 32399-0783 PEREZ, FABIAN J.R.H. GENERAL SERVICES, CORP. 26240 SW 130 AVE HOMESTEAD FL 33032 Congratulations! With this license you became one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! RICK SCOTT, GOVERNOR. LICENSE NUMBER' STATE OF FLORIDA DEPARTMENT;OF BUSINESS AND PROFESSIONAL REGULATION CAC 1817574ISStU.ED: 08/24/2016 CERTIFIED AIR= { PEREZ, FABIAN,. J.R.H.° GENERALSERVICES IS CERTIFIED under the provisions of Ch:489"FS. Expiration data : AUG.31'2018 - L1608240002004 r DETACH HERE KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION. INDUSTRY LICENSINGBOARD The CLASS B AIR CONDITIONING CONTRACTOR i Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2018 PEREZ FABIAN - • J R.H: GENERAL SERVICES+; CORP. 26240SW-130AVE, HOMESTEAD• ISSUED. X08/2 2018 DISPLAY AS REQUIRED'EINPt X SEQ'#''L1608240002004 JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF P FCTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * * CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual fisted below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 811212015 EXPIRATION DATE: 8/1112017 PERSON: PEREZ FABIAN FEIN: 650559518 BUSINESS NAME' AND ADDRESS: JRH GENERAL SERVICES CORP 26240 SW 130 AVENUE HOMESTEAD FL 33032 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR -GOND Pursuant to Cha pfer440.05(14), J FS., an otficerof a corporation who elects exemption from tivsdmpierby firing a cetb#"i oto of election under tits section may not recover beneitts or compensation underthis chapter. Pursuant to Chapter 940.05(12).,F.S„ Cm -Moat= oretex oton to be exempt_ apply only within the scope cite [wan= or trade Med on the tome °reaction to be sterno;. Pursuant to Chapter44t05(13). ES.. Mites DT wench t0 be exempt and certiffcates of election to be exempt shalt be subject to revocation N. at any time aft rthe litho afthe notice or the issuance cPtheeerb7rcate. the person named an the notice or tie no longerme eteYhe requirements of this ctlo t farissuence ora rer iiigte. The depattment shall revoke e DFS-F2-DWC-252 CERTIFICATE OF ELECTION! TO 8E EXEMPT REVISED 08-13 QUESflONS7 (850)413-1 1369 ACCoRD r ' DATE IMM/DD/TYYY) L.---- CERTIFICATE OF LIABILITY INSURANCE I 03/09/2017 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 1NSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 Continental III 5200 SW 8st Ste 250 CONTACT mraria Reyes PHONE FAX(305) 207-0555 r49:mrece30sVon416-ine0n7l8a16pac.co- m Coral Gables, FL 33134 INSURERIS) AFFORDING COVERAGE Phone (305) 207-7886 Fax (305) 207-0565 INSURER A : Scottsdale Insurance Company INSURED J R H General Services Inc 26240 SW 130 Ave Homestead COVERAGES FL 33032 INSURER B: INSURER C : INSURER 0 INSURER E INSURER F: NAIC # CERTIFICATE NUMBER: REVISION NUMBER: THIS INDICATED. CERTIFICATE EXCLUSIONS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD - NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE __INSR ADDLSueR _yymPOLICY NUMBERiMM/L3C=11MM/DO CPS2563771 Miley EFF 11/19/2016 POUCY EX ) 11/19/2017 LIMITS EACH OCCURRENCE DAMAGE TO RENTED PREMISES JEa occurrence) MED EXP (Any_ one parson) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG ...... $ 1,000,000.00 $ 100,000.00 $ 5,000.00 * $ 1,000,00-0-. ***** $ 2,000,000.00 $ 2,000,000.00 $ A In COMMERCIAL GENERAL LIABILITY 1 CLAIMS -MADE 9] OCCUR 11 0 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY 11] PR°.. LOCJEcT 0 OTHER$ AUTOMOBILE LIABIUTY D ANY AUTO r -ii ALL OWNED 1--1 SCHEDULED 1---I AUTOS 1......1 AUTOS COMBIREUSINGLE Lifer _ED arAISIen.IL_____ BODILY INJURY iPer person) BODILY INJURY (Per accident PROPERTY DAMAGE (er accident) $ $ $ $ r---1 NON -OWNED III HIRED AUTOS IJ AUTOS D ri D UMBRELLA MB MI OCCUR NIA EACH OCCURRENCE AGGREGATE _. .. ..,. El Ervir_r_ 1 24" - - E.L. EACH ACCIDENT E.L. DISEASE - EA EmPLOYE _ .... ._ $ $ $ - i --- $ $ El EXCESS UAB 0 CLAIMS -MADE • DED 0 RETENTIONS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE-7 OFFICER/MEMBER EXCLUDED? , , (Mandatory In NH) L --4 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT g .... _ .... ... ......._ DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace le required) _ Air Conditioning sales & Installations. Policy subject to policy terms and conditions. CERTIFICATE HOLDER CANCELLATION 1 Miami Shores Village Bldg Department 10050 NE 2ND AVE Miami Shores, FI 33138 1 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 REPRESENTATIVE ACORD 25 (2014101) QF 1 LI • / • 1 CORD CORPORATION. All rights reserved. T e ACORD name and logo are registered marks of ACORD 000281 Local Business Tax Receipt Miami -Dade County, State of Florida -THIS IS NOT A BILL -DO NOT PAY 3520146 BUSINESS NAME/LOCATION JRH GENERAL SERVICES CORP 26240 SW 130 AVE MIAMI FL 33032 OWNER JRH GENERAL SERVICES CORP C/OPEEREWorker(sZ FABIA2N RECEIPT NO. RENEWAL 3677789 LBT EXPIRES SEPTEMBER 30, 2017. Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SPEC MECHANICAL CONTRACTOR CAC1817574 PAYMENT RECEIVED BY TAX COLLECTOR $8250 10/04/2016 CREDITCARD-17-000322 This Local Business Tax Receipt only coofirmspayment of the Local Business Tax The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Halder 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-Dada Code Sec 8a-276.. for more information. visit www.miemidade.gov/taxi Lector )3Q, 106 6151 1e516/ Miami ShoresViIIage Building Department 10050 N.E.2nd Avenue Miami Shores, 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: Owner State of Florida County of Miami -Dade The foregoing was acknowledge before me this ro day of c iii, , 20 ,1 . By SGrn _SOr-i 0.-ro who is personally known to me or has produced. Notary: Ik; SEAL: or (407)388.0153 ac it ELEGRIN PI' ' S November 23, 2018 F .rldallotaryService.com entification. JRH GENERAL SERVICES CORP. April 5, 2017: State of: Florida County of: Broward Before me this day personally appeared tai-, ewho being duly sworn, deposes and says: That he will be the only person working on the project located at: 5 NE /06 57'. M c a r►., ; 6iA o re 5 1=L. 3313s 030 Sworn to (or affirmed) and subscribed before me this ' day of 20 17 , by --r6, c- v./ -5a • Notary Signat Personally, known Or produced Identification Type of Identification produced Print, Type or Stamp Name of Notary THEA D VARGAS •'E MY COMMISSION* FF 221452 4:47. EXPIRES March 24, 2019 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 BUILDING PERMIT APPLICATION El BUILDING ❑ ELECTRIC ❑ ROOFING ❑PLUMBING .154 MECHANICAL ❑PUBLIC WORKS JOB ADDRESS: City: RECETV .D .�u t 9;2016 BY: 5411 FBC 20N Master Permit No. (C- 14, — ZZs Sub Permit No. MCA ❑ REVISION ❑ EXTENSION ❑ RENEWAL ❑ CHANGE OF ❑ CANCELLATION 0 SHOP CONTRACTOR DRAWINGS SIvc 105 S - Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: S $ Load: Construction Type: GfS Flood Zone: ti • OWNER: Name (Fee Simple Titleholder): Address: l Ce s60 141 • City: Ai Tenant/Lessee Name: L Email: ai "CONTRACTOR: Company Name: 7U/%'-- 2 S --9;)e) BFE: FFE: (NI 'PI f -0 Y -°Z State: Zip: 359'39 • Phone#: Address: 758 ,5—S& / `I _Z. A...) . t, City: /ii/ Zip: State: /O/V• ` '" .t .400- Qualifier Name: 4) J4 j; hof/�-2; State Certification or Registration #: /C -4,e/ & / 4D 7/ Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ &'9 _av Square/LinearFootage of Work: Type of Work: IDAddition El Alteration EDE New re-pair/Replace ❑ Demolition Description of Work:;-- 57----)4z."4-y-/ 1 -, t r)/ r' -7 /.v ( (/J71-. •[1' 4,44 Ire-"-A)7iT/ chi, Phone#:, .5—a4) - 96-o Z. - Specify color of color thru tile: Submittal Fee $ 50 . W Permit Fee $ " ` CCF $ -3- GO Scanning Fee $ 3 GO Radon Radon Fee $ . ` ( DBPR $ 3 . (S rn Technology Fee $ �f' • t�O�N Training/Education Fee $ (. 2_0 Double Fee $ `f/�� Structural Reviews $ Bond $ SCJ CO/CC$ I� Notary $ 5 • W (Revised02/24/2014) TOTAL FEE NOW DUE $ 93 • ( Q 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: 1 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 is = • In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature 574g OWNER or AGENT The foregoing instrument was acknowledged before me this I Cr Sti•� day of Sa �i *moo 3K1� ,20 I(- ,by , who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBUC: Sign: Print: Seal: • u1 MY COMMISSION 4iFF171414 EXPIRES November 23, 2018 (407) 398-0153 FlorldallotaryServlce.com APPROVED BY (Revised02/24/2014) *******+1* Signature CONTRACTOR The foregoing instrument was acknowledged before Ine this 1, .day of� ,' 1,, 1 r y� Ilh1i ,w,"ho. perso'nallyk own me or who has produced JLJas identification and who did take an oath. NOTARY PUBUC: Sign: Print: Seal: *********************************************************** Plans Examiner Structural Review Zoning Clerk Miami=Dade:county;-S;ate.offloricip.: 'THIS IS NOT &BILL DO NOT PAY - • • , . ••' .•6422208 , • „ . • ' • _ • , • _:•fpu411NE47-V..04+1P/1;Pc*T1430-4:tirZ•.:::••;••RECIPT NO DUAL4- NDITIONIN CORP. 71'RENEWAI-2. ;.• • L 6690383 MIA611",FL33 ';'*-19-61: ° ;Art:9 &AO , • r " R EPTEMBERz30 2016- ' Must be disiifayed at business -Puruant to Codnty Code Chapter8A OWNER SEC. TYPE OF SUSINESS - DUAL -TEMP AIR CONDITIONING 196 SPEC MECHANICAL PAYMENT.RECEIVED • pORP . BY TAX COLLECTOR CONTRACTOR 75.00 08/06/2015 CAC1816071 0237-15-090077 Worker(s) 1 r • . - • •• • . This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, • • . _ • • • permit. ora certification of the holder's qiHifickitiori,lodO business. Holder must comply with any,governmeutal or nongoseriimintal regulatory laws and regUirsii!entsWhich apply to the ?usiness. The RECEIPT NO. above must be displayed on all 'LlShimercial vehicles 1:Miami-Dade Code Sec 8a-276. • rilAr42 • ;For more information, visit www.miamidade,gov/taxcollector • IMRE RICK SCOTT, GOVERNOR KEN LAWSON, SECRETARY ACORO® � CERTIFICATE OF "LIABILITY INSURANCE DATE (MM/DD/YYYY) 07/18/2016 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 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). Prestige Insurance Group, Inc. 15441 SW 137 Ave. Miami FL 33177 CONTPRODUCER NAMEACT Ralph Ceballos PHONE Ext): (305) 969-8776 FAX No): (305) 969-8744 ADDRESS: info@prestigeinsurancegrp.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : GRANADA INS CO 16870 INSURED Dual Temp Air Conditioning Corp. 15835 SW 147 Lane Miami FL 33196 INSURERB: ASSOCIATED INDUSTRIES INS CO INC 23140 INSURER C : 04/10/2017 INSURER D : $ 1000000 INSURER E : $ 100000 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF /Y (MM/DDYYY) POLICY EXP (MMIDD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 0185FL00018473 r 04/10/2016 04/10/2017 EACH OCCURRENCE $ 1000000 DAMAGE TO PREMISES (Ea occurrence) $ 100000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5000 PERSONAL & ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GE IL AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC PRODUCTS - COMP/OP AGG $ 2000000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS - SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ ' PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA AWC1028306 i , 12/20/2015 12/20/2016 PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1000000 E.L. DISEASE - EA EMPLOYEE $ 1000000 E.L. DISEASE - POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ' License Number Class A- CAC1816071 CERTIFICATE HOLDER CANCELLATION Miami Shore Village Bldg. Department 10050 Northeast 2nd Avenue Miami Shores FL 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 REPRESENTATIVE R EP R E S E N TA T I V E ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD STATE OF FLORIDA DEPARTMENT OF BUSINESS AND'PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 MUNOZ, RAMON YSIDRO DUAL TEMP AIR CONDITIONING CORP 13741 SW 139TH CT STE 102 MIAMI FL 33186 4 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! _ RICK SCC!TT,.G.OVERNOR . _ C ' ;54 - -',17;.7.;---- Jr: r.^ , . -arm_c-,r r:r�t ss'47,..-"7-2...47=‘,,,, t -e.. a�.x..?. r.3....+�ro..rT tr. " STATE OF_ELORIDA DEPARTMIOQ BUSINESS AND �/ PROFEma- ins'. GULATION CAC1816071 v ,,,,1'06/12/2016 — �-- CERTIFIED AIaOm` c= _MUNOZ,-RAM?, , Ig� IS' ..,:4,-.: _DU ALTEMPAIR vb., E'" ,r,-'' I CORP IS GERTIElED.•u'nder the proais.ions`of Ch 48;9- FS. 44111, aw;;sr rr s.r�sr bs,c• .�..aee:.v<...s:;aaf•F�:a]6 x DETACH HERE KEN LAWSON SECRETARY- STATE ECRETARY STATE OF FLORIDA DEPARTMENT OF, BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION:. INDUSTRY. LICENSING BOARD _ LICENSE NUMBER . ':-CACt816071 . The -GLASS AA1R-CONDITIONING CONT-RACTO "Nanedbelow IS.0ERT1FIEf} Under tf a provisions of•Chapter:489 FS._. =Expiration:date: AUG 31,.2018 0 ISSIIFn. n6/12/2016 DISPLAY'AS REQUIRED BY LAW SEQ # L1606120000478 Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING PERMIT APPLICATION FBC20tO Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder):olG1 L NY 1 ��+` Phone# / - �'e j 7 Address: G l0 o City: t..""( 1 1t State: Permit No. v,`� . c3 Master Permit No. Zip: 3.3 S 33138 Tenant/Lessee Name: Phone#: Email JOB ADDRESS: tAg 105 er. City: Miami Shores County: Folio/Parce]#: (.)• .213!0 ©2(o Is the Building Historically Designated: Yes Zip ajlOgi 7 3138 NO Flood Zone: CONTRACTOR: Company Name: A ni €-€AV 'i d/� -""T 'Phone#: _q°56I211-1 1 Address: / 4 /���/V e o �[ . City: , € 4 '/) State: P7 Zip: ••' /S Qualifier Name: .eA.5/! ie-cv //4 • I Phone#:.O.e0% Q State Certification or Registration #: Certificate of Competency #: Contact Phone#: Email Address: DESIGNER: Architect/Engineer: ' Phone#: falue of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: OAddress OAlterationONe1w O epair/Replace 03 ^ ,, \\ nJDemolition Descr]ption of Work: V y� W b,111/4 -J15 -T0 N-3 *************************r*************Fees***************************************** Submittal Fee $ CI° Permit Fee $ , 2 -it UCCF $ CO/CC $ CPWO Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ 4 Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 41: aO i 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS aid 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 TG 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 penuit 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 comitiencenient must be posted at the job site for the first inspection which occurs seven (7) days after the building pennit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. " •;f • /41°144 RYPtial‘t.‘ "Mini in& • Sign: Signature tialttilutt�t,/r, egointip)trumeat 2 IC: Print: Contractor d before me this. The fore:; n : instrument was ackslowledged before ' , day o Ca , 20 a by ' ek'Vle't i who is personally known to me or who has produced i s entification and who did take an oath. k 4.✓ LA... as identific • _ d ho did t NOTARY PUB o has produced ct My Commission Expires: \o,cA, + - *********+**************r**aye************:******+it*********************e**********************s************** Sign: Print: My Commission Expires:0i APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet- Multiple units on single sheets are not acceptable. Job Address (where the work id kaing done): NE { 0 5 "1"-• City: Miami Shores Village County: Miami Dade Zip Code: 0 31 ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means) YES 0 NO ❑ ARHI Sheet Attached: YES 0 NO 0 ,Contractached: YES ❑ UNIT BEING REPLACED , DATA NEW UNIT • MANUFACTURER kdti AHU or PKG. UNIT MODEL # Atatl F-.3foC I48A COND. UNIT MODEL# 6)<; Ij 03(01 A KW HEAT `J - p NOM TONS 'lj(,QrO p 3 AHU CU PKG 1) M.C.A AHU CU PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3) VOLTS AHU CU PKG PKG UNIT / / PKG UNIT / / EER/SEER .-• I g- YES .NO REPLACING DUCTS (Y N* . YES NO REPLACING THERMOSTAT �� YES NO NEW 4"CONCRETE SLAB YES ,(a YES NO NEW ROOF STAND � YES E e YES NO i NEW RETURN PLENUM BOX YES NO 1 Minimum Circuit Ampacity (IMre Size)* 2. Maximum Overcurrent Protection (FuselBreaker Size): C Voltage of Circuit (208/240/480): 23e. / -- GO 3. 4. Size Disconnecting Means* Contractor's Company Name: State Certificate or - - s 1 ation N.C*C /0,34& Certificate of Competency N. 4M E / ( }-kt Gone: S 72 - 7Z Signature only) Date: l ./ZO-t 3 006626 Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOT A BILL - DO NOT PAY 6495998 BUSINESS NAME/LOCATION AMERICAN AC CORP 19742 NW 60 CT MIAMI FL 33015 OWNER AMERICAN AC CORP Worker(s) 1 RECEIPT NO. RENEWAL 6765979 LBT EXPIRES SEPTEMBER 30, 2014 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SPEC MECHANICAL CONTRACTOR CAC1816346 PAYMENT RECEIVED BY TAX COLLECTOR $75.00 07/11/2013 FPPU06-13-002546 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 NO. above must be displayed on all commercial vehic`es - Miami -Dade Code Sec 8a-276. 'For more information, visit www.miamidggr, . ollector MIAMI-DADE COUNTY TAX COLLECTOR 140 W. FLAGLER ST. 1st FLOOR MIAMI, FL 33130 2012 LOCAL BUSINESS TAX RECEIPT 2013 MIAMI-DADE COUNTY - STATE OF FLORIDA EXPIRES SEPT. 30, 2013 MUST BE DISPLAYED AT PLACE OF BUSINESS PURS4..T TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 649599-8 "WMEksfefileffb 19742 NW 60 CT 33015 UNIN DADE COUNTY THIS IS NOT A BILL - DO NOT PAY RENEWAL STATE E9i ng16346 OWAmtRICAN AC CORP SecjWegffusC,jne1EsCHANICAL CONTRACTOR THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. NOR DOES IT EXEMPT THE HOLDER FROM ANY OTHER PERMIT OR LICENSE REQUIRED BY LAW. THIS IS NOT A CERTIFICATION OF THE HOLDER'S QUALIFICA- TIONS. PAYMENT RECEIVED MIAMI-DADE COUNTY TAX COLLECTOR: 07/27/2012 60010000298 000075.00 SEE OTHER SIDE WORKER/S 1 DO NOT FORWARD AMERICAN AC CORP CASIMIRO DIAZ PRES 19742 NW 60 CT MIAMI FL 33015 1111111111iiiFFliiii 1111111111111113 n 1 111111111111111114 X1 FIRST-CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 676597-9 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 DIAZ, CASIMIRO AMERICAN A/C CORP 19742 NW 60TH CT HIALEAH FL 33015 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! AC#6166722 DETACH HERE (850) 487-1395 STATE OF FLORIDA AC#?� DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC1816346 06/19/12 110436454 CERTIFIED AIR COND CONTR DIAZ, CASIMIRO AMERICAN A/C CORP IS CERTIFIED under the provisions of Ch.489 FS Expiration date: AUG 31, 2014 L12061900779 THIS DOCUMENT HAS A COLORED BACKGROUND • MICROPRINTING • LINEMARKT" PATENTED PAPER STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SEQ# L1206190077 DATE BATCH NUMBER LICENSE NBR 06/19/2012 110436454 CAC1816346 The CLASS B AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 DIAZ, CASIMIRO AMERICAN A/C CORP 19742 NW 60TH CT HIALEAH RICK SCOTT GOVERNOR DISPLAY AS REQUIRED BY LAW KEN LAWSON SECRETARY 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. 07-29-2011 EFFECTIVE DATE: PERSON: FEIN: 09/21/2011 EXPIRATION DATE:- 09/20/2013 DIAZ CASIMIRO 270721831 BUSINESS NAME AND ADDRESS: AMERICAN A/C CORP 19742 NW 60TH°CT HIALEAH FL 33015 SCOPES OF BUSINESS OR TRADE: 1- CERTIFIED AC CONTRACTOR 2- INSTALLATION SERVICES IMPORTANT: Pursuant to Chapter 440. 05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate 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 certificate at any time for failure of the person. named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 09/21/2011 EXPIRATION DATE: 09/20/2013 PERSON: CASIMIRO DIAZ FEIN: 270721831 BUSINESS NAME AND ADDRESS: AMERICAN A/C CORP 19742 NW 60TH CT HIALEAH, FL 33015 SCOPE OF BUSINESS OR TRADE: 1- CERTIFIED AC CONTRACTOR 2- INSTALLATION SERVICES IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election L under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt... apply only within the scope of the business or trade listed on E the notice of election to be exempt. R E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shalt 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 certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 ' 6 DATE (MMrooIYVYY) a CERTIFICATE OF LIABILITY INSURANCE06/19/13 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 la an ADDITIONAL INSURED, the poilcy(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 Ileu of ouch endorsements . PRODUCER Insurance Solutions Group 9920 SW 40t11 St, Miami , FL 33165 Phone (305) 661-4140 Fax (305) 661-4143 INSURED AMERICAN A,C, CORPORATION 19742 NW 60th Ct HIALEH, FL' 33015 CONNiTACT MARILOLA GUERRA PHONE t) (305) 661-4140 -------1 �Nod: (305) 661-4143 MAIL _ADDRESS: MLOLA ISG-INSURANCE.COM -- .---- pkciOUdtR 4752 _I U9TOMER IP INSURER(S) AFFORDING COVERAGE INSURER A: • GRANADA INSURANCE COMPANY INSURER 8 : INSURER D : NAIC INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 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 I TYPE OF INSURANCE INS- .. - - •--.-.. POLICY NUMBER---. —.. (MM/pDIYYYY) (MMIG?DIYYYY) ..—..--_,__- LfM1T9 GENERAL LIABILITY EACH OCCURRENCE A LTA COMMERCIAL GENERAL LIABILITY U U CLANS -MADE © OCCUR ❑ DED 500 ❑ GEN'L AGGREGATE LIMIT APPLIES PER ❑ POLICY ❑ 1,3e, ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON•OWNED AUTOS - — ❑ -----....0UMBRELLA OCCUR._... L1A8 ❑ EXCESS UAB ❑ CI.AIMS•MADE n._..DEDUCTBLE — — .EI -,_RETE-NTION $_- WORKERS COMPENSATION AND EMPLOYERS' UABILITY Y/ N ANY PROPRIETOR/PARTNERIEXECUTIVEI OFFICER/MEMBER EXCLUDED? (MRndr,tory In NH) If run, dnacrIbn under DESRIPTION OF OPERATIONS below NIA 0185FL00021523 09/18/2012 09/18/2013 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD fd1, Addltlonel RmmarkR $choduln, 11 morn Rpnoe IA required) A/C INSTALLATION, SERVICE AND REPAIR CERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPT, 10050 N.E. 2ND AVENUE MIAMI SHORES, FL 33138 ACORD 26 (2009/09) QF CANCELLATION DAMAGE 1'O RERTEO _PREMISES.(Ee occuEroLico]— MFD EXPiAny one Qereon) PERSONAL B,ADV INJURY GENERAL AGGREGATE 1,000,000 100,000 5,000 :a 1,000,000 s 2,000,000 PRODUCTS - COMP/OP AGO 2,000,000 a- - • . COMBINED SINGLE LIMIT (Ea occident) BODILY INJURY (Per person) S BODILY INJURY (Per accident( S PROPERTY DAMAGE (Por eeeldent) EACH OCCURRENCE AGGREGATE WC STATU• 0TH. "H: 'WC S S S E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT s SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN AC9O DANCE WITH THE POLICY • l SIONS. AUTHOf(� D yPRESE 1988-2009 AC sI - D CORPORATION. All rights reserved. Tho ACORD name '< nd logo are registered marks of ACORD 50003 AMERICAN A/C CORP. 19742 NW 60 Court Hialeah FI 33015 305 512 4729 UC # CACI 816346 PROPOSAL SUBMITTED TO: Page No ARCHITECT mismemin.im PROPOSAL megesnsmz Pag. DESCR1PT1ON OF JOB (Ai $0410"0.01151.0 4.4 42VIA -' HPRE:fir'SLIENITSFECIFKA71:0. AJD1X'A7 FOR.: *st 140 (.1:4 • tr-14.4.15 Loc,4 f- €:QtEo L'A !‘ • .1" We hereby propose to furnish r7at6rial and labor, complete in accordance with ab specifications. for the SUM of dollar's 5' 00- .69. with payment to be made as foflows: c,1". z::: Ail ,...vork. 1"t0 t3.e OrlfrIFIC..tCd in fr i weariimanAke mariner according to standard practices. My alteration. or deviation 'from specifications A.util,orized inVolving extra costs will e executed upc,n ,,vrituln orders.. .and win become ai'c. rqxtri SignAtut2 :-.heirgy over and above the extiirrati... Ali .areerrterits, contingent upon Itrikes, accidents cr deqays beyond our coritr6l. Ower to. carry ffry., tornado and other neiiiisary orNote:Pritishroposal may by withdrawn byaccepted insurance. Our ,....:orkers are fully e:ovEred by 'Wkers Corrientation Insurn ace. •vvithi Acceptarke of ProPos'af- The above prices.. speCifications .anci condi- tions are satdar.tory and are hereby acccpted.. You am authorized to do &lade,a outOrisii sbove. Signature Certificate of Product Ratings AHRI Certified Reference Number: 5526730 Date: 9/5/2013 Product: Split System: Air -Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: VSX130421A` Indoor Unit Model Number: ARUF42C14A* Manufacturer: GOODMAN MANUFACTURING CO., LP. Trade/Brand name: GOODMAN, JANITROL, AMANA DISTINCTIONS, EVERREST, ONE HOUR AIR CONDITIONIN Manufacturer responsible for the rating of this system combination is GOODMAN MANUFACTURING CO., LP. Rated as follows in accordance with AHRI Standard 210!240-2008 for Unitary Air -Conditioning and Air -Source Heat Pump Equipment and subject to verification of rating accuracy by AHRI-sponsored, independent, third party testing: Ratings €c•itnwo,d Cooling Capacity (Btuh): 39500 EER Rating (Cooling): 11.00 SEER Rating (Cooling): F 13.00 inr€ira'a retote at tareWcv Iy Publi:`,o cicri:z v'Y:t_SS aG: *' a WAS, indicates an ir:vcian:arf rara:r, sinummininswirrains DISCLAIMER AHRI dors not endorse the product(a) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, tate products) listed on this Certificate. AHRI expressly disclaims ail liability for damages of any kind arising out of tine use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www a hrldirectarf.crg. TERMS AND CONDITIONS This Certificate and Ka contarnta ars proprtatery products of AHRI. This Certificate shall only be used for individual, personal and confidential reference purposes. The contents of this Certificate may not, in whole or in part, be reproduced; copied; disseminated; entered Into a computer database; or othcrwis: titliized.. in any term or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The Information for the model cited on this certificate can be verified at www,ahridlrcctory.org, click on "Verify Certificate" link and enter the AHRI Certified Reference Number and the date on which the certificate was issued, which is listed above, and tide Certnteate No , which is listed below, ©2013 Air -Conditioning, Heating. and Refrigeration institute rt-a®� �� Ali• Conditioning. Heating, rand Refrigeration Institute CERTIFICATE NO.: 130228786218-362670