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MC-18-1825Miami Shores Village 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 Permit Permit NO. MC-7-18-1825 Permit Type: Mechanical - Residential Worts Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 7/10/2018 Expiration: 01/06/2019 Project Address Parcel Number Applicant 1240 NE 91 Terrace 1132050010540 Miami Shores, FL 33138- Block: Lot: DAINEL OCARIZ Owner Information Address Phone Cell DAINEL OCARIZ 1240 NE 91 Terrace (305)487-3535 MIAMI SHORES FL 33138- 1240 NE 91 Terrace MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone CSR AIR CONDITIONING INC (305)325-1211 Tons: lional Info: INTERIOR REMODELING, NEW MECHANICAL sification: Residential oved: In Review ments: Date Approved:: In Review Denied: Type of Work: ning: 1 Fees Due Amount CCF $6.00 DBPR Fee $5.12 DCA Fee $3.41 Education Surcharge $2.00 Permit Fee $341.25 Scanning Fee $3.00 Technology Fee $8.00 Total: $368.78 Valuation: $ 9,750.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # MC-7-18-68142 07/03/2018 Credit Card $ 50.00 $ 318.78 07/10/2018 Credit Card $ 318.78 $ 0.00 HvauaDie inspections: Inspection Type: Final Rough Duct Review Mechanical Underground 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. Futhermore, I authorize the above -named contractor to do the work stated. July 10, 2018 ,��Signature: owner / Applicant / Contractor / Agent Building Department Copy 1 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 PERMIT APPLICATION F-IBUILDING ❑ ELECTRIC ❑ ROOFING JU 09 2618 I FBC 201'1 S ITT_ Master Permit No. C- % % 7" 4� Sub Permit No. (� c� ❑ REVISION ❑ EXTENSION ❑ RENEWAL (PLUMBING _W MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP /} CONTRACTOR DRAWINGS JOB ADDRESS: I��C� Alt/� City: Miami Shores Count : Miami Dade Zi Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): � q 0 � clkt "To —tam .[. Address: /IE City: "It tl t- Tenant/Lessee Name: Email: State: ¢ C 3 3 l 3 Zip: Phone#: go0( CONTRACTOR: Company Name: `—� V rL�1 q4( jdj� Phone#: _ SOS' V� III Address/::OL) City: `A Qualifier Name: V 1 t'ua �'% C VL 33111� Zip: A Phone#: State Certification or Registration #: CfC �� �s �oi� Certificate of Competency #: _ DESIGNER: Architect/Engineer: _ Address: hone#: City: State: Value of Work for this Permit: $_ j Square/Linear Footage of Work: Type of Work: ❑ Ad/diti n ❑ Alteration _ ❑ New ❑ Reoair/Renlara Description of Work: ll.(wtor A Specify color of color thru tile: 3 q )rQ 2� Submittal Fee $ Permit Fee $ f CCF $ Scanning Fee $ Radon Fee $ Z Zip: ❑ Demolition CO/CC $ DBPR $ _ Notary $ Technology Fee $ Structural Reviews $ (Revised02/24/2014) Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ )� ' M�/ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State 2E 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved do reinspection fee will be charged. l Signature Signature R or AGENT The foregoing instrument was acknowledged before me this day of µ 20 1 g by DQfNGl oce, Id 7L who is personally known to rXe or who has produced as identification and who did take an oath. NOTARY PUBLIC: The foregoing instrument was acknowledged before me this 0 day of l-1 a &/ 20 18 by ( M Uyl E1` VQ6r4V2.-k, , who is personally known to me or who has produced d n' ✓er / Cc ¢ n Se as identification and who did take an oath. NOTARY PUBLIC: �• Sign: Sign: Print:' �-• dr���ez Print 1 mgmy rMum - W= Oi ► orWa Seal: ; :' %o BRENDAL. RODRIGUEZ Seal: , S Coi��M131on # GG 008421 .. ,_ MY COMMISSION# GG 134318 '• fq;; My Corn. Explr�a 8ct'23, 2020 Po ` EXPIRES: December 13, 2021 W-&d 1bM Notary P001 UndeiwrNers APPROVED BY Js Examiner Zoning Structural Review Clerk (Revised02/24/2014) STATE OF FLORIDA . DEPARTMENT OF BUSINESS AND � . PROFESSIONAL REGULATION CAC 1815686 ISSUED: 07/17/2016 CERTIFIED AlR COND OONTR,, VASQUEZ, OLMAN GEOVANY, C$R AIR CONDITIONING -(".C. IS CERTIFIED under the provisions of Ch 489 FS Expiration date AUG Z1, 2018 L1607170001073 Lxal Business Tax fecei pt —� 1 Miami Dade County, State of Florida 113T iM� t, NnTAeu [a-i40T Mr 61S1A27 tJ4'.f\S NaYl.4C\:�r �F�f aT Yr CSR AIR CONDITIONING INC EXPIRES RENEWAL 2016 NE a 81 SEPTEMBER 30, 2018 CA 15012 HOMESTEAD FL 33033 u.\,aa\pfgr rprc. ,, •.Y...,\ CSR AIR CONDITIONING INC 10 SPEC ME CNANCAL ir'Y ArT f[t[ •[ • Cr .•Y. CONTRACTOR 4 -0D 87tt/M17 MNlbr(t) 1 CAC1315f86 :RCOVI-11-099245 Tly\lpOr fi�'af3lcrM aiYaaf'mrOM•�rtr leoY aYrrAi� trgeYp r[a.•. aYr Vr+•to .anTa[ana e.ma..Mb-un:a. r aran•.luar nu[.mpY.:wiM![�Ywr a mp�fwaRr np/ruy.Ia\flrwy'r�t\a WADY bhbr+Y1\ nrRamrRYnrw•w n.e[a.lamr mr[wrw.�.. wnaraster ra Arnmfnw:ra\Jr ■�Ym[rt!a[aamf[n.tox » 70 Ac"�'Rv CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDOrfYYY) 4/26/2018 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 1NSURER(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 SOTILLO INSURANCE AGENCY, INC. 6605 S DIXIE HIGHWAY, SUITE# 100 WEST PALM BEACH FL 33405 CONTACT NAME: PHONE FAX C No. Ext): IAlt:, Not: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAICf! (561)547-5784 (561)547-5785 INSURER A: FEDERATED NATIONAL T 10790 INSURED CSR AIR CONDITIONING, INC. INSURER 8 : INSURER C INSURER D : 2520 CORAL WAY #2-123 CORAL GABLES, FL 33145 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 7ypE OF INSURANCE ADDL S SUBR POLICY NUMBER i POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS ED GENERAL LIABILITY ✓ COM•MERCIALGIFNER�ALLIABILITY CLAIMS -MADE I F OCCUR GL-0504011998-04 4/22/2018 4/22/2019 EACH OCCURRENCE S $1,000,000 PRFMI F Ea occurrence S $100,000 MED EXP (Any one persan) $ $5,000 PERSONAL& ADV INJURY $ $$1,000,000 GENERAL AGGREGATE $ $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: ✓ POLICY PRO- JECTLOC PRODUCTS - COMPIOP AGG S $2, 000, 000 S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS COMBINED SIN L LIMIT Ea accident I IS BODILY INJURY (Per person) S BODILY INJURY (Per accident) $ PROPERTY DAMAGE era c9denl $ S j UMBRELLA LAB EXCESS UAB RCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS �I 1 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N_To ANY PROPRIETORIPARTNEWEXECUTIVE ' OFFiCERIMEMBrR EXCLUDED? ❑ (Mandatory in NH) it yas, describe under DESCRIPTION OF OPERATIONS below t N I A 1 VJCSTATU- 07H- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE S E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Attach ACORD 101, Additional RamarNs Schedule, it more space is required) AIR CONDITIONING INSTALL AND REPAIR LtKI it-IUA I t HVLUCK LANLtLLA I IVN MIAMI SHORES BUILDING DEPARTMENT 10050 NE 2 AVE MIAMI SHORES VILLAGE 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. AUTHORIZED REPRESENTATIVE @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD J E FF ATWATIr R CH!E t q!;ArJICt OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION F' 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' Corrpensation law EFFECTIVE DATE: 2/21/2017 PERSON: VASQUEZ FEIN, 205115627 BUSINESS NAME AND ADDRESS: CSR AIR CONDITIONING INC 1820 NV18 TI BRACE MlAtrfh FL 33125 SCOPE OF BUSINESS OR TRADE: � � aaf�nq,YMt46a'4�irr� � Conatrup am Refrgeratim systems installation.Swv,ca , *ierwd Repair, Shop, fad, 6 Drivers EXPIRATION DATE: Z21/2019 OLMAN 44PORTANT Awrj�jal it to C riaptor •140 05;14,, F C- , a, cthCet of d corperatnon "C; e'eCts e>en ttlioi tnim tnis ^.hJu:Cr r, 1 .ry a eM'f .1r9 his sectlasi ,nay nct foc019r of r7Pfd5 Gf Cal:r:)ansat'or) VrWjr this ChBptar Pursuant 10 Q--.4plo, 44,j G5(' 2I. F 4 Z* trtfy wltNn the accipe of the bvs1no3s or traUe listed on trte nOUCe CI e!W#011 to Oe OXOMPt Aufst,am tD �;naptm 440 ^5t t 3t " 5 NGLCOe Of eN;V!on to tie exempt and cartrNcafes of e!ecwn to be exempt shall be suolect to revocation it, at any time attar ". 1-11riq Ol the notice or ire ssuance of the Certfca:a. 111E )Bison named on the notice or certificate no anger meets tho requirements of this section for issuance of a oer1.! :.tie Tha department shali,evotw s :e(Wlcate at any time for fa,ture of the person named on the certil"te to meet the fequirstt'lents of this section )FS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08.13 OUFSTIONS? (95^t413-1609 COMPANY LETTER HEAD Date: --TI3 f2,0 t v, State of: J 10 rid a County Of A4i19tm ( - •fa de Before me this day personally appeared ©�wcA� �• V*-970 2 who, being duly sworn, deposes and says: That he or she will be the only person working on the project located at I Lgo 1 T-e�,-w Sworn to (or affirmed) and subscribed before me this Zg day of `' WAC 20 f 8 by 01 &" a" G • VC, %q ae 2 Personally Know. OR Produced Identification Type of identification Produced L� 94 V ?2o - 6y7- 68 - o.23 - f �A44` Print, Type or Stamp Name of Notary No' , F ZI �t F : , '•�. '1 '')• I.+y Cr•--,. _ r es Dec 3^. L�1 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: l . 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 insury�ce coverage from the contractor's company for day labor, part-time employees or subcontractors. BY SIGNING BELOW YJJU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. //JJ _ Signature: ner State of Florida County of Miami -Dade The foregoing was acknowledge before me this q* day of 14�`f 20 IS By VQhte� �CaY� who is personally known to me or has produced as identification. Notary: 4{ "Aw� SEAL: BRENDAL. RODRIGUEZ MY COMMISSION # GG 134318 Bond:d Thru Notary Public Underwriters