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MC-15-2368Miami Shores Village `yuoRFs 10050 N.E. 2nd Avenue NE Miami Shores, FL 33138-0000 Phone: (305)795-2204 FLOFtl Permit NO. MC-9-15-236s8 ■ Permit Type. Mechanical - Residential ' Work Classification: Addition/Alteration Permit Status: APPROVED Issue Date: 9 22120151 Expiration: 03/20/2016 Project Address Parcel Number Applicant 9730 NE 5 Avenue Road 1132060171470 Miami Shores, FL Block: Lot: JOHN & MARIE PERIKLES Owner Information Address Phone Cell JOHN & MARIE PERIKLES 9730 NE 5 Avenue Road (786)236-0254 MIAMI SHORES FL 33138- Contractor(s) Phone Cell Phone R & R APPLIANCES & AIR CONDITIOD (786)258-3862 Tons: Additional Info: INSTALL 2 HIGH EFFICIENCY A.0 UNITS Classification: Residential Approved: In Review Comments: Date Approved:: In Review Date Denied: Type of Work: Scanning: 1 Fees Due Amount CCF $10.80 DBPR Fee $9.35 DCA Fee $9.35 Education Surcharge $3.60 Permit Fee $623.00 Scanning Fee $3.00 Technology Fee $14.40 Total: $673.50 Valuation: $ 17,800.00 Total Sq Feet: 0 Pay Date Pay Type Amt Paid Amt Due Invoice # MC-9-15-57119 09/22/2015 Credit Card $ 623.50 $ 50.00 09/17/2015 Credit Card $ 50.00 $ 0.00 Available Inspection Type: Final Rouqh Duct 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. T: I certify thaat all th egoing information is accurate and that all work will be done in compliance with all applicable laws regulating ing. Futhermore, I apthorize the above -named contractor to do the work stated. September 22, 2015 Aut!�P"zed Signature: Owner /' Applicant / Contractor / Agent Date Building Department Copy September 22, 2015 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 ,,PSTED S E P 1 2015 L Y — — FBC 20(b BUILDING Master Permit No. 0— �') 13A 3 PERMIT APPLICATION Sub Permit No. l"tl ,(—(:�" 23�g ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING OMECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR JOB ADDRESS: iAl DRAWINGS City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 1-(-1 147 v Is the Building Historically Designated: Yes NO Occupancy Type: k Load: Construction Type: _Flood Zone: BFE: FFE: OW Add City: Tenant/Lessee Name: ►f —e Zip: Phone#: N Email: 1 CONTRACTOR: Company Name: 00 nL , ..Zj Address: l� Phone#: City Qualifier Name: �`' �'� (2 one#: p: -�l(I)' State Certification or Registration #: C hol 0 3 9 Certificate of Competency #: DESIGNER: Architect/Engineer: ( Phone4 �� :l0 Address: City: State: Zip: Value of Work for this Permit:: F ' © Square/Linear Footage of Work: � /l 3 Type of Work: ❑ Addition Alteration ❑ New ❑ Repair/Re lace p El Demolition Description of Work: �� �1 (� tL4Ci(AAC"/ L , FA Specify color of color thru the Submittal Fee $ _Permit Fee $�v`C. N 3 CCF $ '073CO/CC $ Scanning Fee $ �, �`) Radon Fee $ DBPR $ Notary $ Technology Fee $ y L o Training/Education Fee $ . Q0 Double Fee $ Structural Reviews $ (Revised02/24/2014) Bond $ TOTAL FEE NOW DUE $ b 2 • EDO ` 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 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 reins 'on fee will be charged. Sig OWNER or AGENT CONTRACTOR The foregoing instrum nt was acknowledged before me this day of iP�dt� - by h n who i personally know p me or who has produced as identificay'on anal who did take an oath. NOTARY P Pri The foregoing instrument wasacknowledgedbefore me this _ day of 20 l� by ri �b who i ersonally kno me or who has produced as identificn and who did take an oath. NOT. Seal: .. LORETTA COMES MY COMMISSION #tEE181658 Seal: EXPIRES: MAR 21, 2016 LORETTA COMES Bonded through let State Insurance = ' MY COMMISSION #EEE181658 EXPIRES: MAR 21, 2016 APPROVED BY V Plans Examiner Zoning Structural Review (Revised02/24/2014) Clerk Local Business Tax Receipt Miami —Dade County, State of Florida —THIS IS NOT BILL — DO NOT PAY 1878132 BUSINESS NAME/LOCATION RECEIPT NO. EXPIRES R & R APPLIANCES & AIR CONDITIONING INC RENEWAL SEPTEMBER 30, 2015 8078 W 21 CT 1878132 Must be displayed at place of business HIALEAH FL 33016 Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS R & R APPLIANCES & AIR COND INC 196 SPEC MECHANICAL CONTRACTOR PAYMENT RECEIVED CAC039628 BY TAX COLLECTOR Worker(s) 3 f 45.00 08/08/2014 CHECK21-14-046642 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 holder s gaal�cations, to do business. Holder must comply with any governmental or nea lavemmernal regulatory laws sad requirements which apply to the business. The RECEIPT NO. above must be displayed on sD commercial vehicles — Mismi—Dade Co Sec EI -ViL For more information, viskwww.miamidede.gowhagcoller tyr City of Hialeah Business Tax Receipt 2014-15 ��°aii�ii►��� Mayor Carlos Hernandez No: 238220-164 Amount: $ 150.00 The person, firm or corp. listed here has paid the business tax required to engage in or operate the business specified subject to the regulations and restrictions of the City of Hialeah, Florida Owner: RUBELIO H. JORGE Type of Business: Plumbing, Heating, and Air -Conditioning Contractors R & R APPLIANCES AND A/C 8078 W 21 CT HIAT AH, FL 33016 Validating No.: 0000 THIS IS NOT A BILL RICK SCOTT, GOVERNORv Business Location: 8078 W 21 CT Expires September 30, 2015 KEN LAWSON, SECRETARY STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The CLASS AAIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 PALACIO, IGNACIO A - R & R APPLIANCES & AIR CONDITIONING INC 10453 SW 21 TERRACE MIAMI FL 33165 . 09/14/2015 11:51 FAX 90001/0001 ACdRa - �..- CERTIFICATE OF LIABILITY INSURANCE DAY4(rrMtrMYYY) 09/14115 I 111It: (;LIl-tIFlcATC IG IGGUED AS A MATTER 6P"INF0AMA'noN ONLT ANU UUN11:115 NO BIGHTS UPON THE CERTIFICATE HOL.DER.'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 PQNTMQT DEMO THE MUM? MURPRtSj- 41IT4t1R17Fn f-1114hSENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED, the pok-y(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and ssrtdltlans a/ tits µsll, r, eo, taio pulh.lva may rayube an undursement. A statement on this ceniticate does not confer rights to the Certificate holder In lieu of such endorsement(s). !PRODUCER CONTACT NAME Maria ! Blanco Insurance Associated Inc. i PHONE 305. 888 0524 FAX 780 2y2 0044 1462E 4 Ave A0MS$:......_...• maria@biancoinsurance.com__._.... _ j Hialeah, FL 33010 . ... INSURER(S)AFFORL1lNGCOVERAGE A_ ! NAIC Phone (305) 888-0524 Fax (786) 272 0044 INSURER A: GRANADA INSURANCE COMPANY !INSURED INSURER B. „ R & R Appllaces and Air Conditioning Inc INSURER C I 8078 West 21 Th Court Ir+4, R. R D __. !Hialeah, FL 33016 INSURERE (305) 822-6833 -- -- _ ..._... _._.._._.. ._....... _; INSURER.F:... ... ............. ......._ ..._ _... �........ _._ ..__... COVERAGES CERTIFICATE NUMBER: REVfSION 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. 'SA[ (ADD aR _.....__._.___ _.____..!.., ._ , ILTft� - LIABILITYGENERAL INSURANCE--_--IN3&WIYD� POLICVNUMaER I POLICYEFF POLICYEXP LIMITS _. _ _ .-_- - . _..._ {Rwg1pfYYYY) (At pp1TY_YY) _ -- - l t l , EACH occuRRENCt l3_ 1 000.000 00 1� i © COMMERCIAL GENERAL LIABILITY ( l ! DMNAGE 70 RENTEb _ $ 100,000.00 ...... _ 1 I PREMISEs.(Fe.4ir4I149)_-_ _____.. { A ❑ ElCLAR�iS MADE OCCUR 10185FL00027813 i MED EXP (AnY onepersonJ 5,000.00 i Eli 07/14/2015 107/1412016 I ... - - _. __... _._............... i ; PERSONAL 8 ADV INJURY S 1 000,000.00 rr�� i-1 .___... ...._----...._.. _...-_-------- j i I ! GENERAL AGGREGATE I_S 2.000.000.00 f` GEN'L AGGREGATE LIMIT APPLIES PER: # i i PRODUCTS - COMPMP AGG l S 2,000,000,00 I PRLrJ POLICY. ❑� ❑. LOC._.. - - -- I - .._ AUTOMOBILE -- LIABILITYCOMBINED �(t�GLE LIMIT _ _SE_e_ett)....._. ... 5- ._..... ! ❑ ANY AUTO i f BODILY INJURY (per person) �' S r I ALL OWNED SCHEDULED ° i......__----.--.--- ii AUTOS ❑ AUTOS ( I I I BODILY INJURY (Per accident] $ i ❑ HIRED AUTOS ❑ AUTOHOM MED l OPER p� I El S i uMBRELLALIAR []OCCUR I � EACH OCCURRENCE ABS a -EXCESS LI--- - ❑ f _. __.._ .. --- ---_..._- ---- -- I ! -' 1 E t AGGREGATE ! $ RE TENTIONS. - - — -- t WORKERS COMPENSATION y_..—_-..__ ...._ _......-----....... . __... __ ... _. _.. __ ..—.. ._..-. AND EMPLOYERS' LIABILITY Y / N ? i I ❑ TORY LIMY S❑ ER f I rn_ in E.L. ------- DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, I more apace Is required) AC SERVICES AND INSTALLATION _.. _ HOLDER —.... - Miami Shores Village 10050 NE 2 Ave Miami Shores Village, FL 33138 ACORD 25 (2010105) OF CANCELLATION $ EA EMPLOYE4 S POLICY L Mrr $ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ! ACCORDANCE WITH THE POLICY PROVISIONS. ! I ' _. __...---...._._. - --... ....... -_ - - AUTHORIZED REPRESENTATIVE I VACORDcCORP'ORATION. All rights reserved. name and logo are registered marks of ACORD PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE ------------ STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY EXEMPTION ICEWMATE OF ELSMM TO BE EXM" MON R.OMA woNCEW COMPOMTM LAW EFFECTIVE CUTE. 1242015 EXPIRATION DATE IPERSON: PALACIO IGU400 FEIN; 6SW8713 BUSINESS NAME AND ADDRESS: f R & R APPLIANCES 3 AIR CONDITIONING INC 110W SW V TERRACE I MIAMI FL 33165 SCOPES OF BUSINESS OR TRA TING, VENTILATION, COND - - - - - - - - - IMPORTANT — — I Pursuant to Chapter 440.0504), F.S., an officer of a corporation who elects exemption from this chapter by thing a certificate of F election under this section may not recover benefits or compensation under W* chapter. 10 L Pursuant to Chapter 440.05(12), F.S., Certificates of election to D be exempt... apply only wdhin the scope of the business or trade 1MM17 I meted on the notice of election to be exempt. A I H Pursuant to Chapter 440.05(13), F.S., Notices of election to be (E exempt and certificates of election to be exempt shall be R subject to revocation if, at any lime after the fif.1g of the notice 1 E or the issuance of the oertificate, the person named on the notice or certificate no Ionger meets the requirements of this section for issuance of a certificate. The department shad revoke a certificate at any time for failure of the person named on the I 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 R&R Appliances and Air Conditioning, Inc. 10453 S.W. 21 Street Miami, FL 33165 State of Florida County of Miami -Dade Before me this day appearedin w who, being duly sworn, deposes and says that he will be a only person working on the project located at: Sworn to, or affilmed, and sujas,cl�ibed before me this 16th day of September, 2015 by Personally known Produced Identification or identification produced M,r LORETTA COMES ' I , GD MY COMMISSION 20 E�IRES: MAR 21212016 a Bonded through 1st State Insurance The By- Noti Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 \I -L= -- 1- 11VL1%..0 Lv vv1111G1 — YYVURWfb %.,umpensatlon insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. 3 440.05 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: 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; The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 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. Sign Owner State of Florida County of Miami -Dade �l was acknowledge before me this day of d l P 20 SEAL: 'J p,.ry, LORETTA COMES _(~., �+ W COMMISSION #EE161M � EXPIRES: MAR 21, 2016 who is personally known to me or has produced as identification. COWK .Tan . 13. 2016 IZC 06:25 PM R & R Air Conditioning 3058226833 VW, Iti µC_ - l 5 '23 6k Local Business Tax Receipt Miami —Dade County, State of Florida -THIS IS NOT BILL - DO NOT PAY 1878132 BUBINBS8 NAME/LOCATION RE691PT NO. R & R APPLIANCES & AIR CONDITIONING INC RENEWAL 8078 W 21 CT 1878132 HIALEAH FL 33016 PAGE. EXPIRES SEPTEM13ER 30, 2016 Must be displayed at place of business Pursuant to County Code Chapter BA —'Art. 9 & 10 OWNER SGC. TYPE OF aU81NN88 R & R APPLIANCES & AIR COND INC 196 SPEC MECHANICAL CONTRACTOR BY TAX C LLGCTOR BY TAX COLLECTOR Worker(s) 3 CAC039628 $45.00 09/28/2015 CHECK21-15-140215 This Deal Business Tex Receipt only copdirrns payment of the 14tol Business Tax. The Race!$pt is not a license, Permit ore certification of the holder's qualiffc■tlom, to do business, Holder meat comply whh any govammeataf or aongovernmomal rayulatory Iowa end requirements which apply to the business, The RECtiPr N0, above most be displayed on all commercial vehicles - Mlaml-Gads Code Sea 04-276. For more Information, visit W oy mlemidede.goyAoxcolleewr City of Hialeah 2015-16 Bu�siness Tax R.eceYPt Mayor Carlos IIernandez No: 238220-164 Amount: $ 150.00 The person, firm or corp. listed here has paid the business tax required to engage in or operate the business specified subject to the regulations and restrictions of the City of Hialeah, Florida Owner: RIJBCLIO H. JORGE Type0fBustrresys: Plumbing, Heating, and Air -Conditioning Cont:ractorn R & R APPLIANCES AND A/C 8078 W 21 CT Business Location: HIALEAH, rL 33016 8078 W 21 CT Validating No.: 0000 Expires September 30, 2016 THIS IS NOT A BILL 1/ 1