MC-17-2048Miami Shores Village
,c,(31%-) "` Building Department
A-<-/ 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 ❑ REVISION
❑PLUMBING ❑■ MECHANICAL ❑ PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
JOB ADDRESS: 170 NW 97th Street
City: Miami Shores
FBCyt2t-
O
{�
Master Permit No. t 1
Sub Permit No.
❑ EXTENSION ❑ RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
County: Miami Dade
Folio/Parcel#:
Occupancy Type:
Load: Construction Type:
Zip:33150
Is the Building Historically Designated: Yes
Flood Zone:
OWNER: Name (Fee Simple Titleholder): Robert Rosenwald
•
Address: 170 NW 97th Street
City: Miami Shores State: FL
Tenant/Lessee Name: NA
Email: thomasrob170@gmail.com
Phone
'=re „ •!. .I
NO X
FFE:
Zip: 331
Phone#:
CONTRACTOR: Company Name: Blue Air Conditioning, INC
Address: 400 N Royal POINCIANA BLVD
City: Miami Shores State: FL
Qualifier Name: Nelson Castaya
State Certification or Registration #: CAC1817271
DESIGNER: Architect/Engineer: NA
Address:
Valueof Work for this Permit: $2,100
$
Type of Work: ❑ Addition ❑ Alteration
Description of Work: Installation of A/C mini split.
Phone#: 305.553.4504
Zip: 33166
Phone#: 305.553.4504
Certificate of Competency #:
Phone#:
City: State: Zip:
uare/Linear Footage of Work: 600
❑ Repair/Replace ❑ Demolition
Specify color of color thru tile:
Submittal Fee $ v - 03 Permit Fee $ I t CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
RECEIVED
AUG I410�
(Revised02/24/2014)
TOTAL FEE NOW DUE $
2-6)
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
ro' 'Robed' da/ fj -t%cJ`� ,20 /7 ,by
{/�Os wf' , who is personally known to
me or who has produced `V as
identification and who did take an oath.
NOTARY P BLIC:
Sign:
Pri
Se
***
4 lo ,1_,f.!// 7 .7",,...•
Sea
munimaionwr
a•• GUADALUPE C RAMOS
J ,tt Wiry Public - Stete of Florida
Commission 0 FF 992352
,_ My Comm. Eyi es Sep S•.2020
APPROVED BY
440
Signature
The foregoing instrument was acknowledged before me this
` day of -S1 , 20 (-1 , by
t.J i. ' N C li7 Fio is personally known to
me or who has produced r`-� as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
*************
l naminer
_arch 6, 2p� fo �.•
. #FF 954760 :Q�S
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/' "?STATE�
Z/C.\
.41
(Revised02/24/2014)
Structural Review Clerk
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7-28-17 3:16pm p. 4 of 5
To: 3057568972
From: Annie Obregon
Nelson Carta . a
Ph: 3O5-S53 Q4:
Blue Air iConditiouhgig, Iris.
Safes + Service . Installation
Air Conditioning:
Refrigeration Heating
CAC-1817271
Licensed & Insured
Date:;; ,:.'aitork.....
State of
Countyof:
Before me .this ;day personally appeared who, :being..:
duly sworn, deposes and "says:.:
That he will be the only person working on the project located at:..
Contractor Signature
am to (r affirmed) and subscribed before me this day of
.2017- Personally Known
ttlEM:MAAIA.CARRASCO: M
NtRttfli,Put '� Slats 01 Ftofld ::: 1
My Cotddi •00.0. iMar:20, 2 18
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Miami Shores Village
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.
Owner
State of Florida
County of Miami -Dade
Th regoing was acknowledge before me this b ' day of�jC� , 20 a.
BY p\°rf- -(11,0/n
G"`'1
who is personally known to me or has produced
as identification.
GUADALUPE C RAMOS
;.µ '�A� NOW Public - State of Florida
Commiswbn • FF 092352
My Comm. Es/Ma Sep 0. 2020
007585
Local Business Tax Receipt
Miami -Dade County, State of Florida
—THIS IS NOT A BILL — DO NOT PAY
7073752
BUSINESS NAME/LOCATION
BLUEAIR
400 N ROYAL POINCIANA BLVD G-6
MIAMI SPRINGS FL 33166
OWNER
BLUE AIR CONDITIONING INC
C/O NELSON CARTAYA
Worker(s) 1
RECEIPT NO.
RENEWAL
7351521
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 AYMENT RECEIVED
196 GENERAL MECHANICAL CONTRACTO.BY TAX COLLECTOR
CAC1817271 $75.00 08/31/2016
CREDITCARD-16-050351
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 holders 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 vehicles — Miami —Dade Code Sec 8a-276.
For more information, visit www.miamidade.gov/taxcollector
STATE OF.FLORIDA
DEPARTMFENT OFINANCIAL' SERVICES'
DIVISION OF WORKERS COMPENSATION
CONSTRUCTION INDUSTRY EXEMPTION
CERTIFICATEOFELECTION TO BE EXEMP•TFROM FLORIDA
WORKERS COMPENSATION LAW
EFFECTIVE DATE: 9/6/2016
PERSON: CARTAYA
FEIN: 46076E404
BUSINESS NAME AND ADDRESS:
BLUE AIR CONDITIONING INC
EXPIRATION DATE:
NELSON
400'NORTH,ROYAL POINCIANA;BLVD
MIAMI SPRINGS'. FL' 33166
I w
SCOPES OFBUSINESS OR TRA
BEATING; VENTILATION
AIR-COND
9/6/2018
.r-
° STATE OF FLORIDA
DEPA TMENT.OF RI SINESS,AND.:
,,,... P,ROFOIVAL.RE
C.1 817271 I:, I S ED o7f_1201,6�"-�
CERTIFIED'AIR CONDCOWTR— �l
cARTAy,Af Ek:goN <t
iR GONDI• fO NGINC
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{VI ED,un ,rthe-pr.ovisions*of!Cht489; S
te'1 t, , L 6607.11--00
To: 3057568972
From: Annie Obregon
7-28-17 3:16pm p. 3 of 5
• INSU
Blue Air Conditioning Inc
400 N:Royal Poinciana Blvd # GC
Miami Springs ..
• DATE (MMIDDryyyy)
' -' 07/28I2017
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'AME:ND,: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'THECERTIFICATE: HOLDER:.. -
IMPORTANT: If the certificate holder Is eh ADDITIONAL INSURED,.the pollcy((es) must .have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the *inns end condtlions'.of the policy, certain poiicles.rriay require an'endorsement.. A statement. on: this';certif late loss in ot Confer rlgtits.to the :certificate holder in lieu"of such .endorsemeni(sy.
PRODUCER. .... - ... .....-......
•CONTACT
Obregon Insurance Corp PHONE Ercilia Ferias
c,�tl::. xn:. 305-285-6226 ,.. It �,ay 305-265-8246
1740 SW 57 Avenue AIL. .
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Nliami,.FL.33155 • INSu a AFFORDINGCISWE,ILOE F.
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DESCRIPTION OF OPERATIOINS I LOCATIONS I VEHICLES':(ACORD 101,.A.dditlona! Remarks Schedule, maybe
.
Air Conditioning Equipment-'installationi•:servicing,
, or repair
License'seW# :CAC1:8.'17271).AG#01532704 .._'
.. .
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(ladled If riot* *Paco I, raqulr.d)
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Miami Shores Village :Suilding150pt;'
10050 NE 2nd Avenut.
Miami Shores, FL=33138
CANCELLATION
SHOULD'ANY OF'.YHE ABOVE DESCRIB!D POLICIES BE:CANCELLED BEFORE
:THE : EXPIRATION DATE: THEREOF, ".NOTICE WILL .0E.• DELIVERED.- IN
ACCORDANCE WITH THE: Po,(Icy PRbvIgIONs.. .
AUTIKORSERDREPRESENT
(fl 1988-2 5 ACORD CORPORATION.. All rights reserved.
ACORD:25 (2O16/03) The ACORD name and logo are registered marks Of CORO