MC-18-2389Location Address
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Permit NO.: MC -9-18-2389
Permit Type: Mechanical - Residential
V?rn Work Classification: Addition/Alteration -r";5
Permit Status: Approved
Parcel Number
1421 NE 104 ST, Miami Shores, FL 33138-2663 1122320320060
Contacts
Expiration: 03/11/2019
HENRY DOW Owner HENRY DOW Applicant
1421 NE 104 ST, MIAMI SHORES, FL 33138 1421 NE 104 ST, MIAMI SHORES, FL 33138
Other: 3056612533 Other: 3056612533
PRIME AIR SERVICES CORP Contractor
BERNARDO DE JESUS PLA
30120 SW 156 AVE, HOMESTEAD, FL 33033
Business: 7863081422
Description: WORK AS PER BUILDING PERMIT PLANS AIR Valuation: $ 9,500.00
Inspection Requests:
305-762-4949CONDITIONINGREPLACEMENT
Total Sq Feet: 0.00
Fees Amount
CCF 6.00
DBPR Fee 4.99
DCA Fee 3.33
Education Surcharge 2.00
Permit Fee 332.50
Scanning Fee 3.00
Technology Fee 8.00
Total: 359.82
Payments Date Paid Amt Paid
Total Fees 359.82
Credit Card 09/07/2018 50.00
Credit Card 10/29/2018 309.82
Amount Due: 0.00
Building Department Copy
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.
OWNS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulat construction and zoning. Futhermore, I authorize the above named contractor to do the work stated.
re: Owner / Applicant / Contractor / Agent Date
October 29, 2018 Page 2 of 2
BUILDING
PERMIT APPLICATION
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 ELECTRIC ROOFING
RECEIVED
SEP 0*W10
C114dr,
Q
FBC 201-1
Master Permit No.A G -) $-19 Z _?
Sub Permit No. M G 16-2-399
REVISION EXTENSION [:]RENEWAL
PLUMBING(MECHANICAL [-]PUBLICWORKS F-]CHANGEOF F -] CANCELLATION [__j SHOP
CONTRACTOR DRAWINGS
JOB ADDRESS: JL4 Z I mg /69 S• t
City: Miami Shores County: Miami Dade zip: 3 3 )3
Folio/Parcel#:
Occupancy Type: Load: Construction Type:
the Building Historically Designated: Yes NO
Flood Zone: BFE: FIFE:
OWNER: Name (Fee Simple Titleholder): i-Ienrr i r Phone#5Z'-I `Z Y
Address: )Li Z) niC 10 L4_T'
City: X AM-' ,,Sh+YVs State: Zip: 33 3B
Tenant/Lessee Name:
Email
CONTRACTOR: Company Name: ;'?IjW P1 GG Phone#: 21: ' L L 2231
Address: * C)016(J Std
City:
Qualifier Name:
State Certification or Registration #: e Cl
DESIGNER: Architect/Engineer:
Zip: -5
Phone#:
of Competency #:
n e#:
Address: e3 City: State:
D
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work:" Addition Alteration New Repair/Replace
Description of Work: (4219,(L Ci S ix,(
Specify color of color thru tile:,
Submittal Fee $ Permit Fee $
Scanning Fee $ Radon Fee $ G
Technology Fee $ Training/Education Fee $
Structural Reviews $
Revised02/24/2014)
Zip:
El Demolition
n S. >),!
CCF $
C Gj
CO/CC $
DBPR $ r ` Notary $
Double Fee $
Bond $
G
TOTAL FEE NOW DUE $ - 1
Bonding'Company's Name (if applicable)
Bonding Company's Address
City State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State
Zip
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 of 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 `>
OWNER or AGENT
The foregoing instrument was acknowledged before me this
day of SC.P e,^bw' 20 1 g by
A -e nnt(.-/ . who is perso nplly known to
me or who has produc as
identification and
whoRgi
llcStetedFbrida
NOTARY PU LIC: sslon GG 117123Expires
Sign:
n
Print: Atbcj Iio/n
Seal:
CONTRACTOR
The foregoing instrument was acknowledged before me this
Q3
day of s 20 . by
1dr r' (+)) 1a who is nPr ii, -kaawn to
me or who has produced as
identification and who did take o.*P,, Notary Public State of Florida
NOTARY PUB C:
Abby Leon
N,[s MY CommissIon GG 117123
a, ct Expires 10/16/2021
Sign:
Print: AbhU (,vw)
Seal:
1
ssr**s*sr**ss*s**r****sss**r***ss**s*s***ss*rsssss*ss*****s******r***********s*:s*rrrr**srrrs::sss*•sssss
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: (30S) 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):
City: Miami Shores Village County: Miami Dade Zip Code:
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 ARHI Sheet Attached: YES NO Contract Attached: YES
1. Minimum Circuit Ampacity (Wire Size):
2. Maximum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name:
1 r—
Phone: _
State Certificate or gistration Certificate of Competency No.
Signature Date:
Qualifier's signature)
Revised02/24/2014)
UNIT BEING REPLACED DATA NEW UNIT
MANUFACTURER
AHU or PKG. UNIT MODEL #
COND. UNIT MODEL #
KW HEAT
NOM TONS
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
YES NO REPLACING DUCTS YES NO
YES NO REPLACING THERMOSTAT YES NO
YES NO NEW 4"CONCRETE SLAB YES NO
YES NO NEW ROOF STAND YES NO
YES NO NEW RETURN PLENUM BOX YES NO
1. Minimum Circuit Ampacity (Wire Size):
2. Maximum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name:
1 r—
Phone: _
State Certificate or gistration Certificate of Competency No.
Signature Date:
Qualifier's signature)
Revised02/24/2014)
Notice to Owner — Workers' Com
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
nsation 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: (_-7_1 4/
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before 'me this day of ()C V 6,e- ' 20-b .
BY 4enN bb W A ispersonally e or has produced
as identification.
Notary: Q( Gv& C C_Vk /1
SEAL:
ov k,., Marta Marin
ram ISSION # FF182845
EXPIRES: December 1 -,IM
WWW.AAR0NN0TARY.G0M
September 10, 2018
State of Florida
County of Miami Dade
Before me this day personally appeared Bernardo J Pla who, being duly sworn deposes and says:
That he or she will be the only person working the project located at:
1421 NE 104 St, Miami FL 33138
Sworn to (affirmed) and subscribed before me this 14th day of September, 2018, by Cj
Personally know I/
OR produced identification
Type of identification produced
M&ta Mari n
COMMISSION # FF182845
MaYL"
L EXPIRES: December 11, 2018
Print, Type or Stamp Name of M 'i„www.AARONNOTARY.COM
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