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MC-19-2044Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit No.. MC-09-19-2044 i Dr , Permit Type: Mechanical - Residential ��} }Work Classification: Alteration Y Permit Status: Approved Issue Date: 09/09/2019 I Expiration: 03/09/2020 Location Address Parcel Number 9701 N MIAMI AVE, Miami Shores, FL 33150 1132060130970 Contacts STARFISH HOMES LLC Owner 3001 W HALLANDALE BEACH BLVD, PEMBROKE PARK, FL 33009 Business: 9549811154 AIR SYSTEM SERVICES, INC Contractor JOSE JACINTO VELASQUEZ 988 W 40 PL, HIALEAH , FL 33012 Business: 3058268855 Description: BATHROOM / KITCHEN REMODELING, INTERIOR Valuation: $ 3,500.00 Inspection Requests: RENOVATION, FLOORING 305-762-4949 Total Sq Feet: 447.00 Fees Amount Application Fee - Other $50.00 CCF $2.40 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.80 Permit Fee $72.50 Scanning Fee $3.00 Technology Fee $3.06 Total: $135.76 Payments Date Paid Amt Paid Total Fees $135.76 Credit Card 09/09/2019 $85.76 Credit Card 09/03/2019 $50.00 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 al the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating c ucti zoni ermore, I authorize the above named contractor to do the work stated. Authorized Si ur�r / Applicant / Contractor / Agent Date September 09, 2019 Page 2 of 2 : AIR SYSTEM SERVICE, INC ;988 W. 40 Place. �IIRSYSTEMSERME Hialeah, FL 33012 a , ` Phone: (305) 826-8855 Fax: (305) 362-8778 `J Email:airsystemservice@yahoo.com DATE: 03/22/2013 —1 State of t 1 fi " cam, County of I) oL LQ— Lic & Insured CAC 1813477 Before me this day personally appeared 7(z '' ?E�R-who, being duly sworn deposes and say: That he or shq be the only person working on the project located at: 05 e ';; Vdg>Q u C— 1- - q -10_( Al ell 1(�1'74 / A1/ - - gnature 20b Sworn to (or a d) anEFI�d subscribed before me this _day of y eeq� Personally know Or Produced Identification =-�> Type of identification Produced _1D2 ROSALIN ALZAMORA ,State of Florips•NOWY Public ' •= commission # GG 242544 �= My commiss nn Expires AUQUOI -t : VI 2 'R,c>sfNLi�J RL-Z-AinoTz Print, Type or Stamp Name of Notary 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 RECE1VED SEP 0 3 1019 FBC 20 R Master Permit No. Z(--o-7-Ig- \-120 Sub Permit No. at,- ®- -11q- All ❑ REVISION ❑ EXTENSION ❑RENEWAL PLUMBING MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 9301 M. Ave - City: Miami Shores County: Miami Dade Zip: :3311 ;o Folio/Parcel#: US3 •- 0170 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FIFE: OWNER: Name (Fee Simple Titleholder): Phone#: Address: 300i UN ",—Ii fJJf RhJ SwNe goo City: 6rok t 2�i State: Zip: Z17 0C41A Tenant/Lessee Name: n ` Phone#: Email: asc L-�Ct):`� to'Jr.ziwr! aro';a . net 1 CONTRACTOR: Company Name: � 3 � SA-�-N� S-G f J \' � -$ivy t- Phone#: So- �- S 7-6- F k S7S- Address: rT ��Q,S L%b PZ 4C-0 City: W/ State: .Z/_ Zip: S Qualifier Name: State Certification or Registratio DESIGNER: Architect/Engineer: Address: Value of Work for this Type of Work: ❑ Description of Work: U�. o-> on CJ Alteration Specify color of color thru tile: Submittal Fee $_ Scanning Fee $' " rj Permit Fee $ ne#: of Competency #: ne#: City: State: Zip: Footage of Work: Z%y-7- New ❑ Repair/Replace ❑ Demolition /e CCF $ Radon Fee '$ DBPR $ Technology Fee $ Training/Education Fee $ Structural Reviews $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) Ikm 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 reinspection fee will be charged. )(Signature 0 R or AGENT The foregoing instrument was acknowledged before me this aCr day of nt.+ti1UWi , 20 k6 by 00-ona h1 �a I , who is personally known to ,me or who has produced identification and who did take an oath. NOTARY PUBLIC: \` 00 NiIONNDIb/ iy i Sign: oitFXai ' C� r1 r�(� Print:a C OR ;z �s _ Seal: 0'0petie ,: A i �y'•,lT� �onded�gg,: rt'� �� J�• '.���e� tJota;'�.- CYO ♦� APPROVED B' as Signatu F CONTRACTOR The foregoing instrument was acknowledged before me this day of "OL4 20 LCI by WC� NoeL who is personally known to me or who has produced D/L as identification and who did take an oath. NOTARY PUBLIC: Sign: ('L CA_ L-1 Print: ��" A(JA'V\J/,)\ Seal: ,,.►.Y...�,,, ROSALIN ALZAMORA ;,p ;Stet° of Florida -Notary Public •= Commission N GG 242544 pmission Expires Plans Examiner Zoning Clerk (Revised02/24/2014) Structural Review RICK SCOTT, GOVERNOR JONATHAN 7ACHEM. SECRETARY •�eonait�. STATE OF FLORIDA DEPARTMENT OF BUSINESS -AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD THE CLASS B AIR CONDITIONING'CONTRACTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS-OF'CHAPTER 489, FI ORIDA STATUTES VELASQUEZ;: JOSEJACINTO AIR SYSTEMSERVICE INC. 988 WEST 40 PiACE HIAL'EAN FL,33012 UCENSE NUMBER: CAC1813477 ^� EXPIRATION DATE: -AUGUST 31, 2020 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. Lwai Busi ness Tax Faecei pt Miami -Dade County, State of Florida -THISISNOTABILL DONOTPAY 5002498 BUSINESS NAM E/LOCATION AIR SYSTEM SERVICE INC 988 W 40TH PL HIALEAH, FL 33012 OWNER AIR SYSTEM SERVICE INC Worker(s) II� RECEIPT NO EXPIRES RENEWAL SEPTEMBER 30, 2019 5223540 Must be displayed at place of business Pursuant to County Code Chapter BA Art. 9 & 10 SEC. TYPE OF BUSINESS pAYY ENT RECEIVED 196 SPEC MECHANICAL BY TAX COLLECTOR CONTRACTOR 45.00 09/1912018 CAC1813477 0204-18-001760 Thistacal Business Tax Fampt only con"rrrs payment d the Local BusinessTax. The Fisceipt is rota license, pernit, or a anti"cation d the holder'squad"catiom to do business. Holder mist comply with any gomrtw entel or norgooernnentat regulatory laws and recpLUementswhich apply to the business ( TheFEBPTNQabmemstbedsplayedonailcarrmercialveNdes-Miarri-OadeO3deSec8a-276. �►noo Fbr more irtomvbon, visit ACORa CERTIFICATE OF LIABILITY INSURANCE `� FDATE (MMIDD/YYYY) 08/15/2019 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 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 lieu of such endorsement(s). PRODUCER CONTACT NAME; CITINSURANCE AGENCY CORP. Citinsurance Agency Corp PHONE x . (305) 228-1533 NC No): (305) 228-1525 8390 West Flag ler St Suite 213 E-MAIL ADDRESS: Citins@citi-ins.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: HALLMARK SPECIALTY INSURANCE CO 26808 _Miami FL 33144 INSURED INsuRERB: PROGRESSIVE INSURER C : Air System Service Inc. INSURER D : 988 W 40th PI INSURER E : INSURER F : Hialeah FL 33012- 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 I TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE ❑ OCCUR PRDAMAGE TO RENTED EMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A j NPP8421239-1 10/23/2018 10/23/2019 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L f POLICY PRO- JECT L_J LOC PRODUCTS -COMP/OP AGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ 25,000 ANY AUTO B OWNED �/ SCHEDULED AUTOS ONLY /� AUTOS 04720349-7 05/26/2019 05/26/2020 BODILY INJURY (Per accident) $ 50,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per. accident $ 25,000 PIP $ 10,000 UMBRELLA LIAR HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ --- - — --- E.L. DISEASE - EA EMPLOYE (Mandatory in NH) $ If yes, describe under DESCRIPTION OF OPERATIONS below I I I E.L. DISEASE - POLICY LIMIT $ A DEDUCTIBLE NPP842123-1 10/23/2018 10/23/2019 $250 BI/PD DIED DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AIR CONDITIONING CONTRACTOR LICENSEM CAC1813477 L;ANL;tLLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES VILLAGE BUILDING DEPT ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2ND AVE AUTHORIZED REPRESENTATIVE MIAMI SHORES FL 33138 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD JIMMY PATRONIS 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: 10/8/2018 PERSON: JOSE J VELASOUEZ FEIN: 651099695 BUSINESS NAME AND ADDRESS: AIR SYSTEM SERVICE INC 988 WEST 40 PLACE HIALEAH, FL 33012 SCOPE OF BUSINESS OR TRADE: Heating, Ventilation, Air - Conditioning and Refrigeration Systems Installation, Service and Repair, Shop, Yard 3 Drivers EXPIRATION DATE: 10/7/2020 EMAIL: AIRSYSTEMSERVICE@YAHOO.COM IMPORTANT: Pursuant to Chapter 440.05(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 fling 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? (650)413-1609 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 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: Ow State of Florida County of Miami -Dade The foregoing was acknowledge before me this 2G day of k)gO34 , 20 lCt By ►�i\CA �A z��r� who is personally known to me or has produced Notary: SEAL: as identification. ROSALIN ALZAMORA 3a State of Florida -Notary Public • Commission it GG 242544 My Commission Expires Au ust 25, 2022