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MC-17-1042 Permit NO. NSC-4-17-1042 Miami Shores Village Permit Type:Mechanical-Residential 't 10050 N.E.2nd ANW F ,.. venue ' WofkClassification:Addition/Alteration Miami Shores,FL 3313&0000 Per ,III- Phone: (305)795-2204 Permit-Status:APPROVED to.1 Issue Date-.4/21/2017 j Expiration: 10/18/2017 Project Address Parcel Number Applicant 93 NW 97 Street 1131010330250 Miami Shores, FL 33150- Block: Lot: BARBARA DELGADO Owner Information Address Phone Cell BARBARA DELGADO 93 NW.97 Street (786)499-7389 MIAMI SHORES FL 33150- 93 NW 97 Street MIAMI SHORES FL 33150- Contractor(s) Phone Cell Phone Valuation: $'4,000.00 ARTICA LLC (486)566-2454 _,.... :_ _..._. �,....._.. _ w.m _._ ........ Total Sq Feet: 0 Tons: Available Inspections: Additional Info:MINI SPLIT INSTALLATION Inspection Type: Classification:Residential Final Approved: In Review Rough Duct Comments: Date Approved: : In Review Review Mechanical Date Denied: Type of Work:MINI SPLIT INSTALLATION Underground Scanning: 1 1 Fees Due Amount Pay Date Pay Type Amt Paid Amt Due CCF $2.40 DBPR Fee Invoice# MC-4-17-63700 $2.10 04/13/2017 Credit Card $50.00 $ 103.60 DCA Fee $2.10 Education Surcharge $0.80 04/21/2017 Credit Card $ 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 zonin Futhermore, I a horize the above-named contractor to do the work stated. �— April 21, 2017 Authorized Signature:Owner / Applicant / Contractor / Agent Date Building Department Copy , April 21, 2017 1 a 1� Miami Shores Village RECEIVED Building Department APR 13 2017� 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 BUILDING Master Permit No.RC1 7-336 PERMIT APPLICATION Sub Permit No. M C I ­�_ I ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ,F-]PLUMBING 0 MECHANICAL PUBLIC WORKS CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 93 NW 97 ST City: Miami Shores County: Miami Dade Zip: Folio/Parcel#:11-3101-033-0250 Is the Building Historically Designated:Yes NO X Occupancy Type: SFR Load: Construction Type: Flood Zone: BFE: FFE: ,OWNER:Name(Fee Simple Titleholder):BARBARA DELGADO Phone#:305-815-1922 Address:93 NW 97 ST (--}�Cckll +V-)"s 11Ur��e► . City: MIAMI SHORES State: FL Zip: 33150 Tenant/Lessee Name: Phone#: Email: BARBARA.DELGADO@M IAM I-POLICE.ORG CONTRACTOR:Company Name: ARCTICA LLC Phone#: 786-288-1908 Address: 7051 SW 4 ST City: MIAMI State: FL Zip: 33144 Qualifier Name: JULIO MARTINEZPhone#: State Certification or Registration M 1CN C I I O Certificate of Competency M (', DESIGNER:Arch itect/Engineer:�[V II b ((/1�10�e� Phone#: ,OlU �O w T Address: 3 C, C+ Citf][21C00L State: Zip: Value of Work for this Permit:$ A. o oo Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration �UnNe 1w�; L EJ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee$ 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$ 10-5. (Revised02/24/2014) r ' •w Bonding Company's Name(if applicable) Bonding Company's Address I 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. "firWARNING 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 -Y- Signature duiiot OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this 221�� day of Opr i I 20 ' by iaS'" day of ( .1�� 1 20 by frJo.�b."-n laj qgC 2 .�,who is personally known to I ho is personally known to k'Jme or who has produced as me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sig . o----� Print: in Print k5t , (I(::� Seal: YAISLIN CASTILLO Seal: ')St.1N CASTILLO MY COMMISSION#GG029496 AMISSION#GG029496 a do EXPIRES September 13,2020 ES September 13,2020 Y�NlAPPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) ACORO® DATE(MM/DD/YYYY) ` OO CERTIFICATE OF LIABILITY INSURANCE 04/13/2017 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 INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or 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 N ME: r ALEJANDRO HERNANDEZ Popular Insurance PHONEFAX 2123 Southwest 27th Avenue E-MAILc._l^ Fo)•305-456-2841 lac No);305-200-8910 o Miami FL 33145 ADDRESS:P Pularins @9mail.com ' INSURERS AFFORDING COVERAGE NAIC# _ INSURER A:GRANADA INSURANCE INSURED ARCTICA LLC INSURER 8: 7051 SW 4TH ST INSURER C: MIAMI FL 33144 INSURER D: INSURER E: 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 I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MMIDD 11 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S1,000,000 CLAIMS-MADE OCCUR 01$5FL00057817 03/21/2017 03/21/2018 PAMAGE TO RENTED REMISES Es occurrence $100,000 A MED EXP(Any oneperson) S5,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 52,000,000 POLICY jE O- LOC PRODUCTS-COMP/OP AGG S 2,0001000 OTHER: $ AUTOMOBILE LIABILfTYLi COMBINED SINGLE LIMIT $ Ea ac i ent ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident I S UMBRELLA LWB OCCURLJ" EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS ( $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY Y/N STATLITE ERS ANYPROPRIETORFPARTNERIEXECUTIVE ❑ N/A E.L.EACH ACCIDENT S OFFICER/MEMBEREXCLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S EI F— 3 MFJ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Ac Equipment Installation,Repair,Maintenance,and Refrigeration. CERTIFICATE HOLDER CANCELLATION Miami shores village bldg.dept SHOULD ANY OF THE ABOVE DESCRIBED POLICIE BE CANCELLED BEFORE 10050 NE 2nd ave THE EXPIRATION DATE THEREOF, NOTICE LL BE DELIVERED IN Miami Shores FL 33138 ACCORDANCE WITH THE POLICY PROVISI NS. AUTHORIZED REPRESENTATIVE J ALEJANDRO HERNANDEZ 1 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Produced using Forms Boss Web Software.www.FormsBoiss.com(c)Impressive Publishing 800-208-1977 Arctica LLC April 19, 2017 State of Florida County of Miami-dade Before me this day personally appeared Julio Martinez who being duly sworn,deposes and says: That he or she will be the only person working on the project at CL-5 AW L lel i a" i Sn0 M6 T 3315D Sworn to (or affirmed) and subscribed before me this 19th day of April 2017 by Julio Martinez. Personally Known OR Produced Identification Type of Identification Produced L— A"'%-; YAISLIN CASTILLO MY COMMISSION*GG029496 'l+w; EXPIRES September 13,2020 Stamp of Notary Sigi iature of Notary SORES D,t Rol ,,,,,t" h(liami shores 'RVillage Building Department F�OR1Dp' 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: I. 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 t Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of i 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-17 — Owner State of Florida County of Miami-Dade The foregoing was acknowledge before me this i 3�day ofy-1 I 20 ' �. By,i V Gf� /�`N \� who is personally known to me or has produced D(_ as identification. Notary: YAISLIN CASTILLO SEAL: MY COMMISSION#GG029496 %,�„� EXPIRES September 13,2020