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RC-18-1702:s
BUILDING
PERMIT APPLICATION
❑BUILDING ❑ ELECTRIC
PLUMBING 'MECHANICAL
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
6,ZOjg
FBC 20• OA\
Master Permit No.ir G' G - t$' l7Oa
Sub Permit No.
❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL
❑ PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: I4a IiE 103 5t
City: Miami Shores
Folio/Parcel#: t 13R 06O 131750
Occupancy Type: Load:
County:
Construction Type: Flood Zone:
OWNER: Name (Fee Simple Titleholder): fe.12Wto.roo /p
Address:
City: MZhit7 SnoVLtz_5 State: Ft- Zip: 33 i35
142- NE 103Ivo 57
Miami Dade Zip: 331 3rp
Is the Building Historically Designated: Yes NO
BFE: FFE:
Phone#: 305.6t0 - 33%
Tenant/Lessee Name: Phone#:
felts piJasf PU & me. tam
Email:
CONTRACTOR: Company ,Name: L tfy f(.1(,15?.iiA � .(142'3 LA--C.. Phone#: 5 ? g 8O
Address: .4 9 F g
City: y1Ftt}V\ I State:. Zip: 33U/
L
Qualifier Name: A GalVY1g5 Phone#: 365 Ul 6O ¥0$ 4
State Certification or Registration #: VA( (c 1'0 Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this PIrp Termit: $ '� o(9, �%:> Square/Linear Footage of Work:
+
Type of Work:. ❑ Addition ❑ Alteration ❑
Description of Work: R t(1\ ' A-t o U,u t� OF
RA
:Wilt
� :OL'O • /(.041 v✓.S
New // -- Repair/Replace ❑ Demolition
'eCQSS Or• te-OcivvN
Specify color of color thru tile:
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $
Technology Fee $ Training/Education Fee $
Structural Reviews $
(Revised02/24/2014)
CCF $ CO/CC $
DBPR $ Notary $
Double Fee $
Bond $....)......R
r^
TOTAL FEE NOW DUE $ I S. S2
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.
., r
"WARNINGTO 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."', :E. w .•, Notice to Applicant: As a condition to the issuance of a building permit with an estimated value'ekceeding i$2500, the applicant must
promise in good faith that a copy of the notice of co mencement and construction lien law broch will be delivered to the person
whose property is subject to attachment. Al a cert ied copy of the recorded notice of commence y' t must b`e posted at the job site
for the first inspection which occurs seve ') days after the building permit is issued. In th • . nce of such posted notice, the
1.. li
inspection 1ad�J-� ed . . a r. : ction will be charged. ,� , r r AMA, , r�f
.. I '
Signature �f�!�;� Signature Ii''
..
OWNER or A NT t /liA/RACTOR
r
The fforeg ing instrume t wasacknowledged before me this The foregoing instrument was acknowledged before me this
13 day of v , 20 1' , by L 5 day of N1.0 , 20 __ , by
1 ikO VI-51° CI N'e w2io is personally known to W kS LJr L rfL , who is personally known to
me or who has produced
as me or who has produced r'Ape-Cv I y as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
-1 .
o = °O
•�
,���„ "
i'iii'
A S LrnA HAHH soN
Notary Public, State of Florida
Commission# FF 987414
My comm. expires May 20.2020
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
************************************* ********************************************************************
APPROVED BY
Plans Examiner Zoning
Structural Review Clerk
•
-(Revised02/24/2014)
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 is being done): / l Zi (f1Z w-5 / 0 $�
City Miami Shores Village \ County: Miami Dade
Zip Code: 2
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
AHRI DATA SHEET REQUIRED
Change disconnecting means: YES ❑ NO K.'. ARHI Sheet Attached: YES ❑ NO ❑ (Ccintract Attached: YES/0
UNIT BEING REPLACED
DATA
NEWUNIT
4E,tits.l1C1'rc.-
}1�j/%&'fO4if2Dl(5fb l
1`(4ffe-tol-ta00-
MANUFACTURER
(M
AHU or PKG. UNIT MODEL#
COND. UNIT MODEL#
49
KW HEAT
/QL4-/
NOM TONS .314 --IVA),
AHU
CU
PKG
1) M.C.A ,5
AHU CU PKG
AHU
CU
PKG
2) M.O.P
AHU CU PKG
AHU
CU
PKG
.4�
3) VOLTS c c a :✓'
AHU CU PKG
PKG UNIT
/
/
d
PKG UNIT / /
EER/SEER /4-f. $
YES
NO
REPLACING DUCTS
YECil
YES
NO
REPLACING THERMOSTAT
YE NO
YES
NO
NEW 4"CONCRETE SLAB
YES
YES
NO
NEW ROOF STAND
YES A'
YES
NO
NEW RETURN PLENUM BOX
YES Q
1. Minimum Circuit Ampacity (Wire Size):
2. Maximum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (20 %24 480): ,p24"-f0 (/
4. Size Disconnecting Means: CObf
Contractor's Company Name• 4
• o. �u i;, � � Certificate
ers signature)
State Certificate or Registr
Signature
CO
(Revised02/24/2014)
1d35'(oZz
Certificate of Product Ratings
AHRI Certified Reference Number : 10346022 Date : 11-15-2018
AHRI Type : RCU-A-CB
Outdoor Unit Brand Name : AMERISTAR
Outdoor Unit Model Number (Condenser or Single Package) : M4AC4042D1
Indoor Unit Model Number (Evaporator and/or Air Handler) : M4AH4044A1000AA
Region : All
Region Note : 1803
The manufacturer of this AMERISTAR product is responsible for the rating of this system combination.
Model Status : Active
Rated as follows in accordance with the latest edition of ANSI/AHRI 210/240 with Addenda 1 and 2, Performance Rating of Unitary
Air -Conditioning & Air -Source Heat Pump Equipment and subject to rating accuracy by AHRI-sponsored, independent, third party testing:
Cooling Capacity (A2),7 Single or. High Stage (95F), btuh : 42000.
SEER 14.f50 h � �
xV ?
EER (A2) 7'Single or,,High Stage (95F,
"Active" Model Status are those that an AHRI Certification Program Participant is currently producing AND selling or offering for sale; OR new models that are being
marketed but are not yet being produced."Production Stopped" Model Status are those that an AHRI Certification Program Participant is no longer producing BUT is still
selling or offering for sale.
Ratings that are accompanied by WAS indicate an involuntary re -rate. The new published rating is shown along with the previous (i.e. WAS) rating.
DISCLAIMER
AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for,
the product(s) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the 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.ahridlrectory.org.
TERMS AND CONDITIONS
This Certificate and its contents are proprietary 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 otherwise utilized, in any form 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.ahridirectory.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 the Certificate No., which is listed at bottom right.
AIR-coNDmONING, HEATING,
& REFRIGERATION INSTITh E
we make life better
131867893674397708
©2018Air-Conditioning, Heating, and Refrigeration Institute
-1CATE NO
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
CONTRACTORS' REGISTRATION
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A / COPY OF QUALIFIER'S STATE LICENCES
B V—� COPY OF LOCAL BUSINESS TAX RECEIPT
C.'✓' COPY OF LIABILITY INSURANCE*
D. C D COPY OF WORKERS COMPENSATION INSURANCE* - -- -
(Workers Compensation -EXEMPTION. must have NOTICE'TO:OWNER for and,Contractor Affid I
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL
CONTRACTOR'S TAX RECEIPT.
D. COPY OF LIABILITY INSURACE*
E. COPY OF WORKERS COMPENSATION INSURANCE*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit)
*YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW:
Certificate Holder:
MIAMI7SHORES-VIL-LAGE.BLDG,DEPT
,10050_NE'2ND:AVE g:3
MIAMI'SHORES,-FL-33138_
Certificate,must.specify thedescription of-operations,or contractor license.number.1
Lw
BUSINESS NAME: I_ In f ^,� 1dvlel Ccb (\ -4
BUSINESS ADDRESS: 49cI L t<�) CITY ft� F/A STATE ZIP 330 /3_
BUSINESS PHONE: (3() ) `lZ 8(� FAX NUMBER ( 6) 00//O
CELL PHONE ( ) ,6S CZ )— QUALIFIER'S NAME: . Y 6 d/ 1�' -
QUALIFIER'S LIC NUMBER: C a 5 16 c c� 2'752 —5 33
LLB
P
Proposal
Sales
Agreement
and
%
Refrigeration
Control
L.
LICENSED g INSURED
LIC. CAC 1816470
1640 SW 16 ST. Miami FL. 33145
L. C Ph: 305.968.8087
luis31@live.com
PRO R1EDTO
if+PQ di-6 r Vt04`PHONEL
�A0I�'��STREETE
t,t6-yct„ V�
JOB NAME V b _"- I g
CRY, STATE 8 P DE
JOB LOCATION ,
MASTER PERMIT No.
Xi
FOLIO No.
AIRHORIZED BY:
DATE
Equipment Schedule
QUANTITY
BRAND
BEER
CONDENSING UNIT MODEL
AIR HANDLER MODEL
PACKAGE MODEL
STRIP HEAT Sig
TONS
4.
AN€SMfL
t4Cq) /a d low-
't1g-1 S (it
iwd A
to
,-,
Qn„,
.
(to J
4.
etiageatb .,e'
z. 67-2.e,s. „04:26,_ict___
/.2.-e? eryiacy-a-45. cal._
orica5ide„ rayen-,--
Service Warranty: Wilt be Provided free by us for a period of one year from date of certMcate of occupancy or start up date whatever happens first, providing is not
more than six months from Installation date, and during regular working days at regural working hours. Weekends, Holidays and maintenance are excluded.
RESPONSIBIUTY
LG. REFRIG.
OTHER
N/A
RESPONSIBILITY
LG. REFRIG.
OTHER
N/A
MANUFACTURER WARRANTY
YEARS ON COMPRESSOR
DRAIN PIPING
DELIVERY
YEARS ON EVAPORATOR COIL
AIR HANDLER
SUPPORTS
INSTALLATION Of
EQUIPMENT
YEARS ON CONDENSER COIL
PITCH PANS /
ROOF WORK
DUCTWORK'
YEARS ON PARTS
CUTTING OF
HOLES FOR PIPES,
DUCTS, ETC.
GRILLS
DOCTWORK NOTES: f tisk ci.
DAINTING AND
DECORATING
PERMITS FEE
,, s
+ea¢S Oti �• - '
BATHROOM
EXHAUST
CONDENSER UNIT
PLATFORM
CONTROLS NOTES:. t UQ
ELECTRICAL
WIRING FROM
PANEL TO UNIT
FREE RETURN -
DUCTED RETURN
/� p �..�
.t ; 41.
FRESH AIR
INTAKE
REFRIGERATION
PIPING
REMARKS:. it 63 U141-"
0M� ��-"t4.1T dS
v - 1
> 44 a tori2!h?V4 A 0.) do to ai i 3%2 " a,
�i4
often L�uJ�lae t /14 i a„t" R.A4/14,4 ./12.aca ,442.--
/Mee ropose y to furnish mate Ian r - compie In accord c ce wtih ve specifications, for the sum oft aa
�
Uft-e_ Dollars $ -130 a , cyo
6n d o C7 -ci c29 ✓ — ,- 30`0 4r
I. 't /
gryijzi ,„.,-4,-,,cci....037,,,..&.,_ of' 4 brtlek _.,./.), . s
cd_
_26,..ye
AB material Is guaranteed to be as specified. All work to be completed In a workmanlike LG Refrigeration Control LLC. /!
Authoriz ignature J
manner according to standard practices. Any alteration or deviation from above speclfica-
Moms Involving extra cost wifi be executed only upon written orders, and will become an extra
charge over and above the estimate. AB agreemenh contigen upon strikes, accidents or delays Note: this p I may be
beyond our control. Owner to carry fire, tornado and other necessary Insurance. tf dOys•
by
withdrawn us not within
Acceptance of Proposal - The above prices, specifications r2z.ii9 L t.1l 3 i I $
and conditions are satisfactory and are hereby accepted. You are authorized _..it !RC,. ei7
to do the work specified. t will made outlined above. Signature
Date of Acceptance: Signature
,1 Aca l 1�13d r�
LGREF-1
OP ID: MP
A R� CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
11/15/2018
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).
PRODUCER
Avante Insurance Agency, Inc.
7490 West Flagler Street
Miami, FL 33144
Gabriela F. Dominguez
CONTACT
NAME:Avante Insurance Agency
PHONE FAX
(A/C. No. ExtU 305-648-7070 ( No): 305-648-7090
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : United States Liability
25895
INSURED L G Refrigeration Control, LLC
4299 E 8th Lane
Hialeah, FL 33013
INSURER B :
INSURER C :
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
LTR
TYPE OF INSURANCE
ADDL
INSR_Nvn
SUBR
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
CL1730741 B
12/12/2017
12/12/2018
EACH OCCURRENCE
$ 1 ,000,000
PRS RENTED
PREMISES ( (Ea occurrence)
$ 100,000
CLAIMS -MADE
X
OCCUR
MED EXP {Any one person)
$ 5,000
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GEN'L AGGREGATE
7 POLICY
LIMIT APPLIES
PRO
JFCT
PER:
LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
$
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED
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 $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y /N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
N/A
VC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space Is required)
Air Conditioning/Refrigeration Installation, Service and Repair.
CERTIFICATE HOLDER
CANCELLATION
1
Miami Shores Village
g
Bldg Dept.
10050 NE 2nd Ave
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.
AUTHORQEDREPRESENTATIVE
ACORD 25 (2010/05)
©1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
RICK SCOTT, GOVERNOR
JONATHAN ZACHEM, SECRETARY
STATE OF FLORIDA
DEPARTMENT OF BUSINESS D R t FESSIONAL REGULATION
CONSTRUCT ING BOARD
THE CLASS B AIR CONDITI 01 tNG CANT TOR H REIN IStCERTIFIED UNDER THE
PROVISIONS�OF W iT i 489, F I ' STATUTES
Always verify licenses online at MyFloridaLicense.com
Do not alter this document in any form.
This is your license. It is unlawful for anyone other than the Licensee to use this document.
Florida
006267
LOCa
rrnra,
7�;
66379471 - -,
RTy '/ ,4 Y 1 f T' k,, 4�
BUSINESS NAMEILOCATION4`h d y
L G REF�R6ERAT7oNV CONTROL Le
4299 E ilTh; LN / * ` tr trig,
I11AEEAHJFI33O13� _;' z 1'"
r -°l ip �r r 44' [ I tr
,p r,•
y Mr.r
'n3fi l°
dui ss rax:= ce p#
'-Dade CoL nttate of ,Florida-
vTHsISNOT`ABill' DbP10TPAYr-b
owNE<i s'
1 G REFRIGERATIO.:CONTRO LLC�;;
CAT LLI'SIM GAIIMES
•
a RECEIPT NO.
+0464.
4.RENEWAL
'6908652' k,.
rt , EXPIRES
S'EPTEMB2019°
196 SPbC MECRANICAL CONTRACTOR] PAYMENT, RECEIVED
CAC1816470 �v-£ ". , TAX COLLECTOR,
�. = 3 r n r$45.00 0 /26/2Q,i$ -
,Worker(s} • 1 .0--3 [, 1CHECK21—�18-0750'
of 1
This Local Business Tax Receipt only caMirms payment of theLocal al Business Tax. The Receipts not a lice
r pee or certification"of the holdersqualifications,todobusiness. Holder,mustcomply-wah snygoveMeman
g rnmental regulatory laves au�equirements which apply to the business."'
t 1° •R , t, St!t r t 4 t
:1 ,Thtre RECEIPI.NS: above mist be 'splayed ott all coin erc'ai vehicles 1 Bair-DadeGode Sec 6a-776.
y* ,, For more information, visj�-www.miamidade.aovkaxeollector.
Must be 'splayed 'at, place of business.
-qa,..ePu suant'�to,4County Code l<<^r
ChaterBAr=Ark 9 &• 10 r�&,;
ytrt ��.s
y
SEC. TYRE OF BUSINESS: w I
A
JEFF ATWATER
CHIEF FINANICAL 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.
EFFECTIVE DATE: 4/6/2017 EXPIRATION DATE: 4/6/2019
PERSON: GALMES LUIS M
FEIN: 263812818
BUSINESS NAME AND ADDRESS:
LG REFRIGERATION CONTROL LLC
4299 EAST 8 LN
HIALEAH FL 33013
SCOPE OF BUSINESS OR TRADE:
--Heating;Ventilation. Air -
Conditioning and Refrigeration
Systems Installation, Service
and Repair. Shop, Yard &
Drivers
IMPORTANT: Pursuant to Chapter440.05(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.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
Proposal and Sales Agreement
LICENSED & INSURED
LIC. CAC 1816470
<c>Refrigeration 1640 SW 16 ST. Miami FL. 33145
Control L.L.0 Ph: 305.968.8087
luis31@live.com
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ithkyLe
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.
Signature:
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this 13 day of U , 20/
By Y s1ct nd Ci 1. )16
e z' who is personally known to me or has produced
L
as identification.
CASSANDRA HARRISON
Notary Public. State of Florida
Commission# FF 987414
My comm. expires May 20.2020