MC-15-2698 Inspection Worksheet ,
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-267823 PermitNumber: MC-10-15-2698
Scheduled Inspection Date: September 26, 2016 Permit Type: Mechanical - Residential
Inspector: Perez,JlanPierre Inspection Type: Final
Owner: URRUTIA, MONICA Work Classification: A/C,Replacement
Job Address:361 NE 101 Street
Miami Shores, FL 33138-2424 Phone Number (786)356-3445
Parcel Number 1132060135220
Project: <NONE>
Contractor: PHOENIX COOLING SYSTEMS CORP Phone: (305)744-2145
Building Department Comments
NEW AIR CONDITION INSTALLED. Infractio Passed Comments
INSPECTOR COMMENTS False
1C/
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-246350. missing lock caps
-----------Failed--------------- a -- -----
Correction ❑
Needed
Re-Inspection ❑
Fee
No Additional Inspections can be scheduled until
re-inspection fee is paid.
September 23, 2016 For Inspections please call: (305)762-4949 Page 25 of 36
i
Permit No. MC4 0-15-2698
ASN°RES�� Miami Shores Village Permit Type.' Mechanical-Residential
10050 N.E.2nd Avenue NE
=•���i ,,,,,�, er'� ' warkC/assitfeatian:A/C,Replacement
Miami Shores,FL 33138-0000 Pennit'Status:APPROVED
= oma Phone: (305)7955-M4
f�ORI�P
Issue Date: 10/27/2015 "FExpi ration: 04/24/2016
F
Project Address Parcel Number Applicant
361 NE 101 Street 1132060135220
Miami Shores, FL 33138-2424 Block: Lot: MONICA URRUTIA
Owner Information Address Phone Cell
MONICA URRUTIA 361 NE 101 Street (786)356-3445
MIAMI FL 33138-
361 NE 101 Street
t MIAMI FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 4,000.00
PHOENIX COOLING SYSTEMS CORP (305)744-2145
___._.... ... ............ ...__ .. Total Sq Feet: 0
Tons: Available Inspections:
Additional Info:NEW AIR CONDITION INSTALLED. Inspection Type:
Classification:Residential
Final
Approved:In Review Review Mechanical
Comments: Date Approved: : In Review
Date Denied: Type of Work:
Scanning: 1
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $2.40
DBPR Fee Invoice# MC-10-15-57524
$2.10 10/22/2015 Credit Card $50.00 $ 103.60
DCA Fee $2.10
Education Surcharge $0,80 10/27/2015 Check#:400 $ 103.60 $0.00
Permit Fee $140.00
Scanning Fee $3.00
Technology Fee $3.20
Total: $153.60
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Fu he uthorize the above-named contractor to do the work stated.
October 27, 2015
Authorized Si nature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
October 27,2015 1
I°
Miami Shores Village 417, E_ D]Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138BYTel: (305)795-2204 Fax: (305)756-8972 �f
INSPECTION'LINE PHONE NUMBER:(305)762-4949
FBC 20 N
BUILDING Master Permit NoT-01 1,15– 2PERMIT APPLICATION sub Permit No. M CI 5-2-99
I
❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION' ❑ EXTENSION ❑RENEWAL
❑PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
,-
JOB ADDRESS: 3 6► 10 J eet y c(ps .Tr
3
City: Miami Shores• County: Miami Dade. Zip: 331 -32
Folio/Parcel#: Is the Building Historically Designated:Yes NO
Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE:
OWNER: Name(Fee Simple Titleholder): M O'00A 041(A'
" •
Phone#:
Address: Weji (/ #k- Ur( 3 O3 )33�$City: MState: �
Tenant/Lessee Name: Phone#:
'�-Emaih'1
CONTRACTOR:Company Name: 1 I'IMI)IX C001 W& 1 1 sTP�(S CCQ'p Phone#: 1770) 74 3 S 7 Z&
222.1 ulcer _ &j 5r �lnif t
Address:)
City:I l l;q k6 h State: FL Zi(p.:,
Qualifier Name: EDY 002-CO , Phone#: tffq 44 3 S 77{o
Q f- —� 13,
ti t.. '
State Certification or Registration#: C6C 19 1713 5n Certificate of Competency#:
DESIGNER:Architect/Engineer: Phone#:
Address: ` City: State: Zip:
Value of Work for this Permit:$ �(000 - Square/Linear Footage of Work:
type of Work: ❑ Addition 54 Alteration [&New ❑ Repair/Replace ❑ Demolition
t;
'Description'of Work:
�
Jrs le d.
t k:i Ar r$•z=5 w klC t tilA`0l i> ym
.'0 ti0 #V. S!IX3 4y�t�6°" �P � ��� �''""'tit e�t1t r„ n kA o. F
Specify color of color thru.tile:
Submittal Fee$GO Permit Fee$ CCF$ CO/CC$' `.•`
Scanning Fee$ Radon Fee$ DBPR$` Notary$
Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$ iO3 . GO
(i evised02/24/2014)
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. 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 1 Signature
t
OWNER or AGENT [ CONTRACTOR s
The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this
day of ( b+�el 20 �� by I' 1 ,-+ day of — ,,20 by
VN\Wt(,G U /Y U11(A who is personally known to l ���' 4/LD 3 E 0 ,who is peroo/pally known to,
me or who has produced 7 �. as me or who has produced, XAQ-1�� _ as
identification and who did take an oath. identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
n
Print: '` ` Pnn 1 0 1
Notary Public State of Fiori a :� MY COMMISSION FF228453
Seal: ,'" "'ry, ,loanna M Feliciano Seal: EXPIRE8 Mey 02.2019
Of
APPROVED
Exprei011121201g082753 �
w..r
APPROVED BY I`aKs Examiner Zoning
Structural Review Clerk
(Revised02/24/2014)
COMPANY LETTER HEAD
Date:
State of -- (r7�1 +
Country of D'DP
Before me this day personally appeared !"�1�/� J IWR4 who, being duly sworn, deposes and
Says:
That he or she will be the only person working on the project located at: uE X01 r
e
Sworn to (or affirmed) and subscribed before me this 1,6 day of eef .20_L by
personally know
OR Produced Identification
Type of Identification Produced
DANIEL MARTINEZ
•� •: MY COMMISSION N FF228453
f _ _
Print,Type or Stamp Name of Notary.
ti.
♦S�ORFS
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l,,, ,,,,, Miami shores Village
Building Department
s
OR 10050 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
1 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.
t �
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this LZ day of OG ,20
who is personally known to me or has produced
r
as identification.
Nota pubtw state of Ft4t`�a
Notary: ►u Joannam s lon Fp 08259
SEAL: tixp res p111212018
F