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MC-03-21-708, 970 NE 100th StMiami 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 P,1-4:�C jFRVF113 MAR 19 2021 FBC 2020 Master Permit No. 1z e / Z — 2 0 ZA9 °I Sub Permit No. W-C8-2- --O ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING MECHANICAL ❑PUBLIC WORKS Z CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 62 7CO /`* /CC-1h S t City: Miami Shores County: Miami Dade Zip: 3 139 Folio/Parcel#: 11 _-32-0(, - 0 3 -1 - ©/90 Is the Building Historically Designated: Yes NO ✓ Occupancy Type: Load: Construction Type: /% Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): C / �S��il �-6'�+a to 4- p i�5 �rR! Ci Phone#: ��S' �� S� Y7,4 Address: -70 City: State: ri- Zip: 3 313 9 Tenant/Lessee Name: Phone#: 30; - 219- q7 �c{ Email: U CONTRACTOR: Address: City: S7 Qualifier Name: I SJ/%�// ��>l�r S/ / Phonetq,:: L%— 2/� State Certification or Registration #: l��J J s �/ Certificate of Competency #: y DESIGNER: Architect/Engineer: Phone#: Address: p� City: State: Zip: Value of Work for this Permit: Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration New ❑ Repair/Replace ❑ Demolition Description of Work: Specify color of color thru tile: Submittal Fee $ Scanning Fee $ Technology Fee $_ Structural Reviews $ l/?ll / WC Wr 7 r Permit Fee $ Radon Fee $ Training/Education Fee $ CCF $ DBPR $ CO/CC $ Notary $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ j 9c 1 -9 i/ (Revised02/24/2014) Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: MC-03-21-708 Permit Type: Mechanical - Residential Work Classification: A/C Replacement Permit Status: Approved Issue Date: 04/15/2021 Expiration: 10/13/2021 Location Address Parcel Number 970 NE 100TH ST, Miami Shores, FL 33138 1132060340190 Contacts BORIS ARANGO Owner w air conditioning & maintenance Contractor 970 NE 100TH ST, Miami Shores, FL 33138 repair inc Home: 3052184729 Louis frisnel 6041 kimberly D, North Lauderdale, FL 33068 Mobile: 9542148557 berthodonestin@yahoo.com ---------------- Description: REPLACE CURRENT AC WITH 5 TON AC AND NEW: Valuation: Ins ection Requests: p $ 15,215.40 305-762-4949 DUCTS & VENTS Total Scl Feet: 305.00 .j Fees Amount Application Fee - Other $50.00 CCF $9.60 DBPR Fee $7.99 DCA Fee $5.33 Education Surcharge $3.20 Permit Fee $482.54 Scanning Fee $18.00 Technology Fee $13.31 Total: $589.97 Building Department Copy Payments Date Paid Amt Paid Total Fees $589.97 Credit Card 04/15/2021 $589.97 Amount Due: $0.00 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. Authorized Signature: Owner / Applicant / Contractor / Agent ate . C,q April 15, 2021 Page 2 of 2 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 Application is hereby made to obtain a permit to do the work and installations as indicated. 1 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 on 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 Inott approved and einspection fee will be charged. 5��5� Signatur Signature ,-- l I'%�/i/ lklw 4-1-11 The foregoing instrument was acknowledged before me this __Z '�;-_ day of ` Ei! 20 2 by .4(?4-A/, C who is perso y known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: „ cJ^ U .C%� _ 14 /1 J '► 1P, Notary Seal: ry Public State of Florida Zion Hay Cohen My Commission HH 075383 q n6� Expires 12/29/2024 *************************** APPROVED BY CONTRACTOR The foregoing instrument was acknowledged before me this day of ✓l/l f�l 20 f by �ho is personally known to as me or who has produced identification and who did take an oath. NOTARY PUBLIC: Sign: Print: IBC, 474 7X as Seal: �Vsr °4q,`Notary Public State of Florida � Zion Hay Cohen ****************ora a*,Selz** ************* Plans Examiner Zoning ' U Structural Review Clerk (Revised02/24/2014) 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 B. COPY OF LOCAL BUSINESS TAX RECEIPT C. jz� 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 B. 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: G BUSINESS ADDRESS: / � CITY � � � --ZIP BUSINESS PHONE: ( ) FAX NUMBER n( ) CELL PHONE (q� — QUALIFIER'S NAME: //^ �/� 1'JG /O, il QUALIFIER'S LIC NUMBER: � d Ci 411'p �I STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 2601 BLAIR STONE ROAD TALLA,HASSEE FL 32399-0783 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, piease log onto www.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives, Our mission at the Department is; License Efficiently, Regulate Fairly. We constantly strive to .serve you better so that you can serve your customers, Thank you for doing business in Florida, and congratulations on your new license! " STATE & FLORIDA E CAc18205a is CERII FIE@ AIR COND CONTR LOUI5,FR15NEL5R _ w. AIR CON€ FIFIGNINGAND MAINTENANC (8.50) 487-1395 12JcNW Ron DeSantis, Governor _ Halsey Beshears, Secretary .STATE OF FLORMA DEIPARTMENT"OF BU..SIMESS"AND,"PROFMIONAL,"REGULATION 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2020 THROUGH SEPTEMBER 30, 2021 Dme: W AIR CONDITIONING AND MAINTENANCE Receipt e:HEAPI G/AIRCONDITION Business Name: REPAIR INC Business Type: Owner Name: LOUIS FRISNEL SR Business Opened: 12/07/2020 Business Location: 6041 KIMBERLY BLVD State/County/Cert/Reg:CAC 18 2 0 5 5 4 NORTH LAUDERDALE Exemption Code: Business Phone: Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Tvoe: Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is j non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that j it is in compliance with State or local laws and regulations. Mailing Address: W AIR CONDITIONING AND MAINTENANCE 6041 KIMBERLY BLVD j NORTH LAUDERDALE, FL 33068 .. _ - - - - . .. .-..__ __ - _ - (U- 0 z Receipt #02A-20-00001766 Paid 12/07/2020 27.00 ACOROa `C CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 03/11/2021 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 CONTACTNAME: Angelica Munguia H.G. Holdam Insurance PHONN EX : (561) 434 4451 ac No : (561) 434-3505 E-MAIL h holdaminsurance ADDRESS: g @gmail.com 3830 Jo Rd g INSURERS AFFORDING COVERAGE NAIC # INSURER A: EVANSTON INSURANCE COMPANY 35378 Lake Worth FL 33467 INSURED INSURER B INSURER C : W Air Conditioning and Maintenance Repair Inc INSURER D : 3796 NW 78th Lane INSURER E : INSURER F : Coral Springs FL 33065 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 SUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DDIVYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 500,000 CLAIMS-MADEIS] OCCUR PREM SESRENOEa ocourrDence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 500,000 A N N 3AA419356 08/19/2020 08/19/2021 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X PRO PRO ❑ LOC POLICYFI PRODUCTS - COMP/OP AGG $ 1,000,000 S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AC SERVICE AND REPAIR CFRTIFICATF HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Miami Shores Village Bldg Department 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 _ 4n JIMMY PATRONIS CHIEF FINANCIAL 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: 3/4/2021 EXPIRATION DATE: 3/4/2023 PERSON: FRISNEL LOUIS EMAIL: BERTHODONESTIN@YAHOO.COM FEIN: 822582060 BUSINESS NAME AND ADDRESS: W. AIR CONDITIONING AND MAINTENANCE REPAIR INC 9545 NW 2ND PLACE CORAL SPRINGS, FL 33071 SCOPE OF BUSINESS OR TRADE: Heating, Ventilation, Air - Conditioning and Refrigeration Systems Installation, Service and Repair, Shop, Yard & Drivers IMPORTANT: Pursuant to subsection 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 subsection 440.05(12), F.S., Certificates of election to be exempt issued under subsection (3) shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to subsection 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 filing 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 E01309929 QUESTIONS? (850) 413-1609 37% NW 78TH LANE • CORAL SPRINGS, FL 33065 (954) 214m8557 vmm.waircondi#ioning.com CAC 1820554 Date State of---/�W��- �1--------- County----I��- Z�=--- ---- Before me this day personally appeared----'�----e-=---------- ---who, being duly sworn, Deposes and says: That he or she be the only person working on the project located at : y'7O l z5_ /q/� 16 � nlvlajwi Res ZV -_S 3V contractor signature Sworn to ( affirmed ) and subscribed before me this ---- [I----- day of ---- -- " - ---. 20 �--- Buy----------------------------------------- Personally know ---J ---------------------------------------- Or produced Identification Type of%defitificatiofi/produced Prir�, type or stamp name of notary MARC H GUERRIER �¢� = Notary Public -State of Florida �M Commission N HH 54111 My Commission Expires November 30, 2024 Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to UWner - 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: 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 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. 61-7 Signature: _ Owne State of Florida County of Miami -Dade The foregoing was acknowledge before me this Iq day of By .60elS AIZAN60 M-AQ,(-+A , )o z l . who is personally known to me or has produced n� as identification. Notary: i otir „ u,� DEYSI J. SANCHEZ SEAL: _0_4�7 Commission # GG 312634 Expires July 12, 2023 p Bonded Thru Budget Notary Services