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MC-19-4Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address lr'v�NUuUl� Issue Date: 01/07 Parcel Number 295 GRAND CONC, Miami Shores, FL 33138 1132060133600 Contacts Permit NO.: MC-0149-4 Permit Type: Mechanical - Residential work Classification Alteration Permit Status: Approved FExpi rati on : 07/08/2019 NEIL HART Owner 295 GRAND CONCOURSE, MIAMI SHORES, FL 331382852 Other: 3059624547 AIR SOURCE INTL CORP Contractor JORGE ALFONSO 9044 NW 172 TER, MIAMI, FL 33018 Business: 7862551257 jorgealfonso63@gmail.com Description: RELOCATE 2 SUPPLY AIR DROPS, INSTALL 2 NEW Valuation: $ 850.00 Inspection Requests: BATHROOM EXHAUST FANS AND EXHAUST DUCT WORK . 305-762-4949 Total Sq Feet: 0.00 Fees Amount Application Fee - Other $50.00 CCF $0.60 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.20 Permit Fee $50.00 Scanning Fee $3.00 Technology Fee $2.50 Total: $110.30 Payments Date Paid Amt Paid Total Fees $110.30 Cash 01/02/2019 $50.00 Cash 01/07/2019 $60.30 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. 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. Fu rmore, I authorize the above named contractor to do the work stated. Authorized Signature: Owner /// Applicant / Contractor January 07, 2019 Date Page 2 of 2 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 ❑BUILDING ❑ ELECTRIC ❑ ROOFING TJAV2'olry Master Permit No. RC-11-18-33447 Sub Permit No. M Ci '" 1 ` I I ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING Q MECHANICAL [:]PUBLICWORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 295 GRAND CONCOURSE City: Miami Shores County: Miami Dade Zia: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: OWNER: Name (Fee Simple Titleholder): NEIL HART P Address: 295 GRAND CONCOURSE BFE: FFE: 1-3059629547 City: MIAMI SHORES State: FL Zip: 33138 Tenant/Lessee Name: N/A Phone#: N/A Email: N/A CONTRACTOR: Company Name: Ar % Q Sar ia'e , � t 1 Phone#: 7:5 Co c 5 -1-2,5 7 Address: `'l(��t'� ICI I-U City:lj(.^ State: Zip: Qualifier Name: Phone#: State Certification or Registration #: CM C, 17- 4 a Z- Certificate of Competency #: / DESIGNER: Architect/Engineer. _(`����}� S�) Phone#: EI Address: 413&�__. City: �I:t4 A, —State: Zip: Value of Work for this Permit: $ 850.00 Square/Linear Footage of Work: Type of Work: ❑ Addition M Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: RELOCATE 2 SUPPLY AIR DROPS, INSTALL 2 NEW BATHROOM EXHAUST FANS AND EXHAUST DUCT WORK Specify color of color thru tile: ` ,1 Submittal Fee $ �i� G� Permit Fee $ 1,y CCF $ CO/CC $ Scanning Fee $ Radon Fee $ Technology Fee $ Training/Education Fee $ Structural Reviews $ DBPR $ Notary $ Double Fee $ Bond $ I TOTAL FEE NOW DUE $ (Revised02/24/2014) \ Bonding Company's Name (if applicable) Bonding Company's Address N/A City State _ Mortgage Lender's Name (if applicable) N/A 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit, is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature OWNER or AGENT The foregoing instrument was acknowledged before me this 4-0 day of.eCe_ µ r 20 1$ ,by Nej g (Xr+ , who is personally known to me or who has produced as The foregoing instrument was acknowledged before me this j day of ' i �� 20J by thz(f-0 AlkfAois personally known to me or who has produced b as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: _ Q �i l Sign: �Y� Sign: Print. NEIL HART Print: Seal: LZOZ 'r I jegwelde$ Selldx � !, ,:!;SiwwO� �(w +�����,, Seal: ; �p�"'O ,°; y" Notary Public State of Florida 801evi Do # uolssltuwo0 ; iignd AieloN-anuolA ;o aielg % �; ;p y ,_ , Miguel Cubas My Commission GG 216oa1 11F! O H S 11301 �'�� ° A1r� �` kill++of �lo� Expires 05/09/2022 APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) °a CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDIYYYY) 12/28/2018 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 SUBROGATIONIS 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 CONTACT PAYCHEX INSURANCE AGENCY INC 76210705 NAME: PHONE (877)287-1312 (A/C, No, Ext): FAX (888)443-6112 150 SAWGRASS DRIVE E-MAIL ROCHESTER NY14620 ADDRESS: INSURERS) AFFORDING COVERAGE NAIC# INSURERA: The Hartford Underwriters Insurance Company 30104 INSURED INSURER B : AIR SOURCE INTERNATIONAL CORP INSURERC: 9044 NW 172ND TER INSURERD: HIALEAH FL 33018-6665 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NIIMRER- 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 SUB WVD POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE ❑ OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence MED EXP (Any one person) PERSONAL & ADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- ❑ LOC JECT GENERAL AGGREGATE PRODUCTS - COMP/OP AGG OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea acddent) ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) AUTOS AUTOS BODILY INJURY Per accident ( ) HIREDAUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS -MADE AGGREGATE — DED RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? N/A 76 WEG EQ9375 09/30/2018 09/30/2019 PER STATUTE X OTH- ER E.L. EACH ACCIDENT $1,000,00 E.L. DISEASE -EA EMPLOYEE $1 , 000,000 (Mandatory In NH) If yes, describe under D DESCRIPTIONFPERATI N below E.L. DISEASE - POLICY LIMIT $1,000,00 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. MIAMI SHORES VILLAGE 10050 NE 2ND AVE MIAMI FL 33138-2304 VMI\VCLLM I IVIY 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 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD (N RICK SCOTF', GOVERNOR jONATHAN ZACHEM, sEa:zE7Aizy d-bp--.r 'STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUST. RYUCENSING.-BOARD THE MECHANICAL CONTRACT -OF -HEREIN -IS CERTIFIED -UNDER THE PROVISIONS. OF CH -489.1, F APT -ER LORI DA STATUTES ALFONSQrJORGE A t P AIR-:756V Mrx. -OR 9044. NW 1:72146 TERIMAC.-E MIAMI'. FL $3018. LKENSE NUMBER; CM1C1249277 E)WIRATION DATE.- AUGUST 31,202D AlwaYs verify licenses ongne-at MyFloridaUcensexo- m Do not. alter this document" anyfor in m. This is -your-license. It Is. -unlawful for anyone -other that, the lkensee to use this document. Jan.02.2019 11:45 PM HART 3527501236 PAGE. 2/ 2 001771. :. XJ . �Illa . �•':•'p�ide�� •siri�y'��at��fi: .� . „rids-lsr�a'�:A;elut<-;8�•N.pfi.pj�Y •�' .. '`•`a, 0�"014: 9a4' �ri NV1I'9:2'�ii):.'T... A$..'`• :;i.Gedi'i�PlaYadt::A��c4}:,i�ualrxri . AIIIPM[ FL 30$ dur�itA.tft.roovitfyoild i. A '' : C1Yai,BA:; Art,.:�8iltiQ r : geC, TY>� OF p"IMBIBs • ' .. PAVMSNy eaORlVJ56- AiR:$OtykCEINTI.'CORP �','' .188 GEIVtRAI.•Mi:C{1ANIcALON7HAGTOR.nr rnx.C..oLtEcraR, * CMC1249277 05.0a 08/03/20.14' Workar(s) FOU 14-:18-021948 111IrJ:oopl Bwlnesf;TatAoovlpt on1Y cbilli►me pPrinn?�ahhq t,e�i+I Bueln.yp lax. The iteeq{pfla not a Ilaelieb;: ' IMOlt.or, a oerondptle,hof tho ttoldon'igqaaultaotlplid, to do buuaes.;. HoWRF tlw�t;ooniply: �irlgl �rtY gave nigl �er•;rtangoNerneaentM;segylatary IaiN� phdFenulrrmenlq whlokl;pppl�r to.d►o hll�i>lf.N: • , Thu ;RECEIPTNO: abora inuet;he dlrplgYed ort a►I comlrlarolet vehlnlat - M)eiid-�igde Coda Soo 8o�t7e. For'ipor*;Inlor uatlan, v.lA , .. I • ACOR-1 0 CERTIFICATE OF LIABILITY INSURANCE DATE (IdhVDDNYYY) 12/18/2018 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(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 Ileu of such endorsement(s). PRODUCER Torres Insurance Agency Inc 6135 NW 167 STREET # E25 Miami Lakes FL 33015 CONTACT NAME: Josset Jordan HO No Ext : (305) 512-5880 FAX No : (305) 512-5881 E-MAIL s: Bordan@torresinsuranoeagency.com ADDRE INSURERS AFFORDING COVERAGE NAIC I 114SURERA; Western World Ins. Company INSURED Air -Source International Corp 9044 Nw 172 Terr Miami FL 33018 INSURER B : Starstone National insurance Company INSURERC: INSURER D : INSURER E : INSURERF: rnVFRAr.Ps CERTIFICATE NUMRFR: CLIS11739613 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 CONTRACTOR 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 REOUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSO WVO POLICY NUMBER MMIDDIYYYY 6114IDDIY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 CLNhfS-btADE � OCCUR GE TO RLNTLEr PREt.tIS,$ Eso=rre $ 100,000 X IMED EXP (Anyone pemon) $ 5,000 $500 DED BUPD PERSONAL SADVINJURY $ 1,000,000 A NPP8504102 11/07/2018 11/07/2019 GENLAGGREGATELIMITAPPDESPER: GENERAL AGGREGATE $ 2,000,000 PRO - POLICY LOG POLICY ❑ PRODUCTS $ 2,000,000 S OTHER: AUTOMOBILE LIABILITY ..i I SINGLE LIMIT Ea aaideni $ BWLYINJURY (Per persw) $ ANYAUTO O'NNED SCHEDULED AUTOS ONLY AUTOS HIRED NON-OANED AUTOS ONLY AUTOS ONLY BODILY INJURY (PeraWdenl) $ PROPERTY DAMAGE Peracddent $ S UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 6,000,000 X AGGREGATE $ 6,000,000 e EXCESS LIAR [d CLAIMS -MADE 704780183ALI 11/07/2018 11/07/2019 DEC) I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ER OTPI STATUTE I I ER ANY PROPRIETORIPARTNERIEXECUFTWE E.L.EACHACCIDENT $ OFFICERIMEMBER EXCLUDED' ❑ NIA (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT S It yes, describe under DESCRIPTION OF OPERATIONS beknv DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD At, Additional Remarks Schedule, may be attached if more space Is required) Air Conditioning Contractor Location: 9044 NW 172 Terrace Miami, FL 33018 Additional Insured -Owners, Lessees or Contractors Automatic Status when required in a written contract or a construction agreement with you. Primary and Noncontributory included under form WW433. Waiver of Subrogation Included under form WW433. Designated Construction Project under form CG2503. Contractual Liability coverage under form WW191. Professional Liability Endorsement under form 1MN184 Included, Miami Shores Village Building Department 100%N.E, 2nd Avenue Miami 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 (c) 19RR.2015 ACORD CORPORATION. All rinhis reserved ACORD 26 (2016103) The ACORD name and logo are registered marks of ACORD