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MC-01-20-206Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Permit NO.: MC-01-20-206 Permit Type: Mechanical - Residential Work Classification: A/C Replacement Permit Status: Approved Issue Date:02/19/2020 Expiration: 08/17/2020 Parcel Number 353 NE 91ST ST, Miami Shores, FL 33138 1132060136520 Contacts MEHRDAD FARID Owner MAGIC AIR AC CORP Contractor 726 92 11L MIGUEL VAQUERO 55 W 33 ST, HIALEAH, FL 33012 Business: 7863128705 Description: LEGALIZE AIR CONDITIONER THAT HAS ALREADY Valuation: $ 2 400.00 Inse ction Requests: BEEN INSTALLED 2 TONS Total Sq Feet: 0.00 SI Fees Amount Application Fee - Other $50.00 CCF $1.80 DBPR Fee $2.00 DCA Fee $2.00 Education Surcharge $0.60 Permit Fee $50.00 Scanning Fee $9.00 Technology Fee $2.50 Total: $117.90 Payments Date Paid Arm Paid Total Fees $117.90 Cash 01/29/2020 $50.00 Credit Card 02/19/2020 $67.90 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 forego' g information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I Prize the above named contractor t9,.do4he- rVork stated. Authorized Signature: Owner / Applicant / Contractor 1/ I Agent Date February 19, Z020 Page 2 of 2 2'-2-02 U Miami Shores Village 06i 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 .--17 7 77TM11ED .2 9 2020 BY: FBC 201-4 1pA\-' Master Permit No.MC- 0 1 - 20 - 2(Ao Sub Permit No. ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING [MECHANICAL ❑PUBLICWORKS [—]CHANGE OF ❑CANCELLATION ❑SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade zip: 3 31 3 y Folio/Parcel#: /I-;5>0('-0 Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER: Name (Fee n�, Simple Titleholder): "e AADA'10 414"C 4 &,(6 Phone#: Address: �7 k) C> Q/ S 7 city: NI , RAI Tenant/Lessee Name: State: 33/3e Email: CONTRACTOR: Company Name: �lq'j /L Phone#: M Address: S�S (t % -'t;- City: Gt'-e R Qualifier Name: ( State Certification or Registra . DESIGNER: Value of Work for th Type of Work: ❑ Description of Work: of Competency #: IV v Square/Linear Footage of Work: Alteration ❑New ❑ Repair/Replace Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $ Structural Reviews $ Permit Fee $ CCF $_ Radon Fee $ DBPR $ Training/Education Fee $ Kip: 3 [7 /�- 73'(u Zip:_ ❑ Demolition cO/cc $ Notary Double Fee $ Bond $ (Revised02/24/2014) TOTAL FEE NOW DUE Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lenders 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 fpo®regoing instrument was acknowledged before me this /O L day of JWAJU2¢/L/ .20 eLo 'by F&t V i? %1 # C who is personally known to me or.who has i2 oduced Fl— w •Lie/fF63J15 1-3 e A.2/gs 0 identificaton and who did take an oath. NOTARY=PU&LICv Print: /Yl Eiti� • . Seal: r,: MY COMMISSION N GG 074786 it i EXPIRES: April 14, 2021 t'F„oie °+ Bonded Thnr Notary Public lMdnrli m Signatur CONTRACTOR The foregoing instrument was acknowledged before me this N dayof c Ada 20 � by q'G i.es A'Uu-�I� of personallyknow me or who has produced as identification and who did take an oath. NOTARY Je, COmmIS51 tl s Aug3 2023 My Comm. E op l Nar Bonded through Na tonal Notary Assn. APPROVED BY " Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) e Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unjrghang4tI; must ...... be on its own data sheet. Multiple units on single sheets are not acceptable. : Job Address (where the work is being done): 3 3 F ot 1 S :: • 5t City: Miami Shores Village t- County: Zip Code-. •'3 'i C g1 • . - Coun Miami Dade P ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CQPkRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATIO19 A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITAI; AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES Q NO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL # q COND. UNIT MODEL# 6i;X lgPl- f KW HEAT NOM TONS Z 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 A YES NO YES NO NEW RETURN PLENUM BOX I YES NO 1. Minimum Circuit Ampacity (Wire Size): 6 2. Maximum Overcurrent Protection (Fuse/Breaker Size): �i r7 /� te-e- 9kc f` 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: El Contractor's Company Name: _ r r� f—ice— C C-n1\ F,0 )Phone: 1- 810 S State Certificate or Registr lion No. Certificate of Competency No. Signature Date: 1, 2- ZJ Iq� flers signature) (Revised02/24/2014) 0000 0 0 000000 00.0 0 0 0 0 • • 0 0 0 0 00 0 000000 000000 0 :e0000 0 0 0 0 00ooeo 000000 0 o e ee eeos 0 0 0 0 0 00000 •• .- 0 .0000 0 0 00000 000 0 o :e000 0 00000 0 0 os 0004 00 00 0 0 • 0.000�e O O O e 000000 O 00 • 0 O 0 0 O 0 00 O O • 000000 O 0 • 0 O 0000 0 0o O 0 0000 Certificate of Product Ratings AHRI Certified Reference Number: 10425125 Date: 01-29-2020 Model Status: Active AHRI Type: RCU-A-CB . Outdoor Unit Brand Name: GOETTL ...... Outdoor Unit Model Number (Condenser or Single Package) : GSX140241 L' , , , : „ ;' • • • • Indoor Unit Model Number (Evaporator and/or Air Handler) : ARUF29B14A' Region: Southeast and North (AL. AR, DC, DE, FL, GA, HI, KY, LA, MD, MS, NC, OK, SC. TN, T)Z, V.%Ak, CO, gT,1Q ft, IA, IN, KS, MA, ME, MI, MN, MO, MT, ND, NE, NH, NJ, NY, OH, OR, PA, RI, SD, UT, Vi•, ". 110W, WI, WY, U.S. .. .. .... Territories) Region Note : Central air Conditioners manufactured prior to January 1, 2015 are eligible to be installed in all regions until June 30, 2016. Beginning July 1, 2016 central air conditioners can only be installed Trtir roioj(s) for which they meet the regional efficiency requirement. ...... The manufacturer of this GOETTL product is responsible for the rating of this system combination. Rated asfollows in accordancewith the latest edition:of AHRI 2101240 with Addendum'., Performance Rating of Unitary Air -Conditioning & Air -Source Heat Pump Equipment and subject to rating accuracy by AHRI-sponsored, independent, third party testing: Cooling Capacity (A2) - Single or High Stage (95F), btuh' 23600 SEER: 14.00 EER (A2) - Single or High Stage (95F) : 11.50 t"Active" Model Status are those that an AHRI Certification Program Participant is currently producing AND selling or offering for sale; OR new models that are being marketed but are not yet being producedl'Production Stopped" Model Status are those that an AHRI Certification Program Participant Is no longer producing BUT is still sagm or offenng for sale. Rang, s that are ccomoari d by WAS I dirate an voluntaire-rate The new published radne Is shown alone with the orevious If.e. WA reline. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representi warranties or guarantees as to, and assumes no responsibility for, the products) listed on this Certificate. AHRI expressly disclaims all liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid onlyfor models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS son This Certificate and Its contents are proprietary products of AHRI. This Certificate shall only be used For individual, personal and confidential reference purposes. The contents of this Certificate may not, In whole or In part. be reproducer; copied; disseminated; Armw entered into a computer database; or otherwise utilized, in any forth or manner or by any means, except for the user's Individual. personal and confidential reference. AIR-CONDITIONING, HEATING. CERTIFICATE VERIFICATION & REFRIGERATION INSTOUTE The Information for the model cited on this certificate can be verified at www.aliridlrectory.org, click on Verify Certificate' link .„� make life beuur^ and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which Is listed above, and the Certificate No., which Is listed at bottom right L: - 02020Air-Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 3�47t781?-' 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. Star. § 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 arc 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: Owner State of Florida County of Miami -Dade The foregoing -was acknowledge before me this � � day of �' 20020 . By ^ T� �C r r/ am"! who is personally known to me or has produced FL P7I V-1- r:y/ Lr as identification. JESUS MANUEL MEDINA SEAL: =°,�P•� Notary Punk— Slate dFbutla •' Ganmissinn#GG M735 ,. p2 My Comm. Expires Jun 30,2021 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE* D. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT. D. COPY OF LIABILITY INSURACE* E. COPY OF WORKERS COMPENSATION INSURANCE* (Workers Compensation EXEMPTION must have NOTICE TO OWNER form and Contractor Affidavit) *YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW: Certificate Holder: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 Certificate must specify the description of operations or contractor license number. ........................................................................................... BUSINESS NAME: BUSINESS ADDRESS: BUSINESS PHONE: (4i6) 2 S-�qS_ 3 `( FAX NUMBER ( ) / CELL PHONE (—LE-�) Z S 3 W-s `I QUALIFIER'S NAME: rcN QUALIFIER'S LIC NUMBER: 2 ZIP_7_� 1 2— COMPANY LETTER HEAD Date: State of County of oL(( to AA V- S Before me this day personally appeared —J n " A26L who, being duly sworn, deposes and says: That he or she will be only S 2-N EA)` t -S working on the project located at: 33/3k Sworn (to affirmed) and subscribed before me, this day of a 0 Z By A.J� /¢ Personally Or produced identification Type or r e ewsc KAREN G. PANTOJA MY COMMISSION B GG 168900 EXPIRES: December 19.2021 , Type or Stamp Name of Notary •' • s' f �j:l� r{J; 1:'�fli1:•.11�l•j .��i�.?��lt�.:i '.I6ffTx�$b,tj':i+?;r .'r.: � rn� ACU'IRI. v CERTIFICATE OF LIABILITY INSURANCE DATE(27=YYYlf) �� 01/27/2020 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 pollcy(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 lieu of such endorsement(s). PRODUCER All Insurance Services CONTACT All Insurance Services PHONE (305) 822- 472 No ; (305) 556-4354 1548 W. 37 St -MAIL jfemandez@aisrv.com INSURERS AFFORDING COVERAGE NAIC # Hialeah, FL 33012 INSURER A: UNITED STATES LIABILITY INSURANCE CO Phone 305 822-4472 Fax (305) 556-4354 INSURED INSURER B : INFINITY INSURER C : MAGIC AIR AC CORPORATION INSURER D : 55 W 33RD ST HLAELAf j FL 33012 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. LIMIT'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTTRR TYPE OF INSURANCE ADDL WvD UBR POUCY NUMBER POLICY EFF MP�p EXP LIMITS A Q COMMERCIAL GENERAL LIABILITY ❑ CLAIMS -MADE Q OCCUR Y Y MGL019S02A4 09/15/2019 09/15/2020 EACH OCCURRENCE $ 1,000,000.00 AMARENTED PREMISESEa occurrence)$ 100,000.00 MED EXP (Any one person) $ 5,000.00 ❑ GEN'L AGGREGATE LIMIT APPLIES PER: ❑� POLICY ❑ PRE ❑ LOC ❑ OTHER PERSONAL & ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 PRODUCTS - COMP/OP AGG $ 1,000,000.00 $ B AUTOMOBILE LUOUTY ❑ ANY AUTO ❑ AUTOS D OWNED d ❑ AUTOS ONLY ❑HIRED " ❑ NON -OWNED AUTOS ONLY ❑ AUTOS ONLY 509 OWO-7145-001 09/30/2019 09/30/2020 C(E0a N en SINGLE LIMB $ 50,000.00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P�ROrPER Y DAMAGE $ $ ❑ UMBRELLA UAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ El DED ❑ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTfV� OFFICER/MEMBER EXCLUDED? �J (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑PER Aum ❑ OER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMI'T $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) LIC#1817746 cr-12T11=tr ATF Hnr nFR CANCELLATION MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ACORD 25 (2016103) OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOROM REPRESENTATIVE U 1StSU 1U15 At:OKu c:uKruKAI tutu. Aur ngnis reservea. The ACORD name and logo are registered marks of ACORD