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MC-11-23-2767Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address 61 NE 104TH ST, Miami Shores, FL 33138 Contacts Permit NO.! MG-11-23-2767 ' PermitType: Mechanical - Residential Work Clossification: A/C Replacement Permit Status: Approved issue Date: 11/08/2023 Expiration: 05/08/2024 Parcel Number 1121360120030 David Gerhardt Owner I I BIMINI BREEZE HVAC INC Contractor 61 NE 104 ST, Miami Shores, FL 33138 JUSTIN ROMER 7010 NW 169 ST, HIALEAH, FL 33015 Business: 3059684205 Bimini_breeze@outlook.com Description: ac change out Fees Amount Application Fee - Other $50.00 CCF $4.80 DBPR Fee $3.87 DCA Fee $2.58 Education Surcharge $2.40 Permit Fee $208.30 Scanning Fee $9.00 Technology Fee $25.83 Total: $306.78 Building Department Copy Valuation: $ 7,380.00 Insection Requests: Total Sq Feet: 0.00 l�i�l#p M Payments Date Paid Amt Paid Total Fees $306.78 Check# 1297 11/08/2023 $306.78 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 regulating I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws and zoning. Futhermore, I authonz he above named contractor to do the work stated. Owner / Applicant / Contractor / Agent Date 2023 Page 2 of 2 Miami Shores Village t f (, (23 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 Master PermitNo.F►y' IC1II 1— Z1�T PERMIT APPLICATION Sub Permit No. ®BUILDING ® ELECTRIC ® ROOFING ® REVISION ® EXTENSION ®RENEWAL PLUMBING IECHANICAL CHANGE OF ® CANCELLATION ® SHOP CONTRACTOR DRAWINGS Folio/Parcel#: //—, -1 3 (6 —0LV!! Is the Building Historically Designated: Yes NO 40'� Occupancy Type: Load: Construction Type: Zone: BFE: FFE: r OWNER: Name_(Fee Simple Titleholder): m9f!'Phone#: City: //l 141W Tenant/Lessee Name: Email: 0-- r CONTRACTOR: Company Name: Address: / 0 /0 r r Email: Qualifier Name: State:/5-L Zip: hone#:r71 4094Y�'�— ne#: 30T—V W y12w5 State Certification or Registration #: Cl4C /876 3 /- Q Certificate of Competency #: DESIGNER: Architect/Engineer: _Zip: Value of Work for this Permit: $ m / 0 If U ' " I'X Square/Linear Footage of Work: Type of Work: 173 Additions El Alteration 0 Neew g2ltepair//Reepllaace' ® Demolition /4/C Description of Work: e6-7c— Ou./ Specify color of color thru tile: Submittal Fee $ �q Permit Fee $ A-'b ' C)V CCF $ • '60 CO/CC $ Scanning Fee $ l ' (7� DCA Fee $ Z • 5 DBPR $ -3�2' 1 Notary $ Technology Fee $ Z-5 7 Training/Education Fee $ .7 - C(t Double Fee $ Structural Reviews $ P&Z Review $ Bond $ TOTAL FEE NOW DUE$ (Revised04/05/2022) 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. 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! ' d OWN ER or AG ENT The foregoing instrument was acknowledged before me this day of AM r7On A he 20 2 by D4�1 Pi Ge-;�OlKlr ho is personally know o me or who has produced as Signature CONTRACTOR The foregoing instrument was acknowledged before me this 3 day of n0k-6W9.C� 20 23 by dUS-1�1\1 (ZoAj�-" 6Eiersonally kno to me or who has produced as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: r 'V^}^�'7, p',�t Wit,.., Sign: , Lt"i*;7w Print: /DiAl� {iv/vCa2- Print: rcyt7/Wkl BV%7aZ Seal: ��,,,� ry?or n� •st*saris C APPROVED BY Notary Publk Stale of FlOdtla Seal: lys" . r�,L Notary Public Slate o! Floritla Regina Butler iJ?� 'h Regina Butler My Commission HH 083108 �f 7 _ • My Commission HH 083108 Expires 0mi=25 ?,,, .,oR Expires 01/31/2025 p 1 iaaaaa*iRaaaataaaaaaa a aiaaaaaaaa 112 1 nansExaminerZoning Structural Review Clerk (Revised04/05/2022) me-ll-23 CITY AIR CONDIA14MOLACEAENT DATA Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax:(305) 756.8972 PERMIT NUMBER: MC This form must accompany ALL air conditioning replacement permit applications. Each unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. S� Job Address (where the work is being done): la/ Ao/— Aq City: Miami Shores Village County: Miami Dade Zip Code: ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO 2 ARHI Sheet Attached: YES U�rvO ❑ Contract Attached: YES EE UNIT BEING REPLACED DATA 44EW UNIT i MANUFACTURER AHU or PKG. UNIT MODEL H Z ZGO S/ 00 COND. UNIT MODEL H Q KW HEAT Q NOM TONS AHU QCU KG 1)M.C.A AHU CCU PKG AHU QCU 50 PKG 2) M.O.P AHU U &0 PKG AHU CU PKG 3) VOLTS AHU CU PKG PKG UNIT / / PKG UNIT EER/SEER - 2 YES N3 REPLACING DUCTS YES YES NO REPLACING THERMOSTAT YES fop YES NO NEW 4"CONCRETE SLAB fES NO YES NO NEW ROOF STAND YES TO YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: _ State Certificate or Registration Signature 3 Certificate of Competency No. Date: (A� (Revised02/24/2014) Ilk IE.LIVI J/"'ILLJ y„AV IV II 3 I• I� II�V• WIND LOAD CERTIFICATION OF MECHANICAL UNIT CABINETRY AND STEEL/ALUMINUM TIE -DOWN CLIPS: AT GRADE MOUNTED 3000 Psi MIN, CONCRETE BY t:ati S, m ( PIN IACI tlCUEBY \ MEM, TYP. « 1 MECHANICAL UNIT 2 ME( 1 N.T.S. mowlSOMEIRIC 1 N.T.S. IORAMMAnCAL PLIRPOSK ONLY: ALmNMATE MEEM UFXTS MAY VARY IN APPEARANCE (A)-r IU NiEpppL pp5 sMS PER��'�/`-y�/1AD]ACEM TO BRAOfEf, �1^ IOON'MD wx 33 ��1444hhhFFF---111 TYP. IA.1 ® B C ARE SIM AND RON 0". FACES 1 / N.T.s. NCHOR SCHEDULE: RDIRpATE I DIBDRDI3ON CONDMIT: PI— GneaNs®.sIKS ,• MIOe MIK LCNOElE3'MIN. Te206TNMCL 3000PSIMIN.) 11}WY�Fa.NuC¢QM }T� SIM.I0'A DUI ON OPP. WE BACK ISOMETRIC TIE -DOWN BRACKET MIAMI TECIe Q P: 14GA (0.01•) ASIM M53 W-W MI STEEL (CU 13 0) 0R 0.080' 5052-M32 ALUMINUM (CUTDAIO), MIAMI TECH Kn d RRCUTOLK OR MCUTOALK E/SE �O PAN 80.5E PAN ,cum � A DIM.1 II I� O MPOIMMffDIMIRNSIONSNALI�_f�,_._�WXIXOL BE TAKEN FROM TX19 BIDE ONLY DAWN fAQ KETS 4 TIE -DOWN BRACKET LAYOUT LEVATIOX 1 X.T.S. PUN TIE -DOWN BRACKET OFFSETS: OIM. 3 A.50' MAIL pfFSET FROM DATUM FAQ 30.00•MIN OiFSEf FROM DANM FAQ T1t%'MRIBwmm .rouXADvmlr AxoroA DIM.2 .DIM.3 3LOp NIX OFFSET FROM DATUM FACE M eMIeO. DIM. • 13.00 FIA%OFf5Ef fROM OANM FAQ PRODUCT REVISED eo�nply�rq . Usa F de NO.. . Cade 20.1102.09 EMplmtloa Dete OZ2512026 By 20-2880OGD uLerm�uaz+orm�u LAI L Certificate of Product Rati AHRI Certified Reference Number: 209429863 Date: 10-30-2023 Model Status: Active AHRI Type: RCU-A-CB (Split System: Air -Cooled Condensing Unit, Coil with Blower) Series: ACHIEVER SERIES Outdoor Unit Brand Name: RUUD Outdoor Unit Model Number (Condenser or Single Package) : RA14AZ60AJIN Indoor Unit Model Number (Evaporator and/or Air Handier): RH2TZ6024STANN Region : All (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, Hl, ID, IL, IA, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA. VT, WA, WV, WI, WY, U.S. Tenttories) Region Note: On January 1, 2023, efficiency standards increased for central air conditioners. Beginning January 1, 2023, central air conditioners can only be installed in regions) for which they meet the new regional efficiency requirements. The manufacturer of this RUUD product is responsible for the rating of this system combination. Rated as follows in accordance with the latest edition of AHRI 2101240 —2023, Performance Rating of Unitary Air -Conditioning & Air -Source Heat Pump Equipment and subject to rating accuracy by AHRI-sponsored, independent, third parry testing: Cooling Capacity (AFull) — Single or High Stage (95F), WIT : 56500 SEER2 : 15.20 EER2 (AFull) — Single or High Stage (95F) : 12.00 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 produced -"Production Stopped' Model Status are those that an AHRI Certification Program Participant is no longer producing BUT Is still selling or offering for sale. Ratings that are accompanied by WAS Indicate an involuntary re -rate. The new published rating is shown along with the previous (i.e. WAS) rating. The Department of Energy has published updated energy efficiency metrics for central air conditioners and heat pumps. This publication reflects both the 1987 metric (SEER) and the 2023 metric (SEER2). Efficiency requirements are published at 10 C.F.R. 430.32(c). Please refer to www.AHRinet.org for more irdonnation about updated energy efficiency metrics. DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, the product(s) 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 mild only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS �� 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 reproduced; copied; disseminated; .■ `' entered into a computer database; or otherwise utilized, in any form or manner or by any means, except for the user's individual, personal and confidential reference. AIR-CONDITIONING, HEATING, CERTIFICATE VERIFICATION & REFRIGERATION INSTITUTE The Information for the model cited on this cemflcate can be verified atwww.ahridirectory.org, click on "Verify Certiflcate' link we make life keuer" and enter the AHRI Certified Reference Number and the date an which the certificate was Issued, which is listed above, and the Certificate No., which Is listed at bottom right. ©2023Air-Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 133431509133186731 Local Business Tax Receipt Miami —Dade County, State of Florida THIS IS NOT A BILL - DO NOT PAY 6484729 BUSINESS NAME/LOCATION BIMINI BREEZE HVAC INC 7010 NW 169TH ST HIALEAH, FL 33015-4213 OWNER BIMINI BREEZE HVAC INC Worker(s) RECEIPT NO. RENEWAL 6754528 L E) Ir EXPIRES SEPTEMBER 30, 2024 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 SEC. TYPE OF BUSINESS 196 SPEC MECHANICAL CONTRACTOR CAC1816329 PAYMENT RECEIVED BY TAX COLLECTOR 82.59 10/02/2023 INT 24-001182 This Local Business Tax Receipt only confirms paymeat of the local BuslaessTax. The Receipt is not a license, permit or a certification of the holder's qualifications, to do business. Holiday must comply with any govern meatal or nangovemrnental regulatory laws and requirements which apply to the business. saffillL The RECEIPT NO. above must be displayed an all commercial vehicles - Miami -Dade Code Sec 89-M. mmm Formore iMomr dlMvisitwww.miamidade.novhaxcoilector BIMIBRE-01 NANETTEPEREZ ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �aw� 11 /712023 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 lieu of such endorsements . PRODUCER NAMCONTACT . E: - - - - - -- — NFP Property S Casualty Services, Inc. PHONE 704 523-4222 FAX 704 523-0024 1901 Roxborough Road -(A/C, No, Ext): ( ) (A/C, No):( ) Suite 300 ADDRE6;>;;- - - --- - - Charlotte, NC 28211 [NSURER(S) AFFORDING COVERAGE - NAIC 0 _ __- - __ - _ ___ __ INSURER A : Hiscox Insurance Company Inc. _ 10200 INSURED INSURER B_: Bimini Breeze HVAC Inc. INSURER -C 7010 NW 169 St I INSURER D : Miami, FL 33015 - - F1NSURERE---_-- INSURER F : 1%nvcQAn=Q PPRTICH ATIP NIIIUIRIPR- IRFVICInN NlIMRFR- 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. [NSR I TYPE OF INSURANCE ADD L SUBR POLICY NUMBER I POLICY EFF ' POLTR (MMLICY EXP I LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX7 OCCUR P100.531.255.5 EACH OCCURRENCE $ 9112/2023 9/12/2024 ! DAMAGE �(EaEo�an.,E nce)_- $ 1,000,000 _ 100,000 - -- MED EXP (A� one personZ_ $ - 5,000 - - j PERSONAL & ADV INJURY , $ 1,000,000 _ L_ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY i I j CT ' LOC _PRODUCTS - COMP/OP AGG I $ _ - 2,000,000 OTHER: Is AUTOMOBILE LIABILITY A COMBINED SINGLE LIMIT -(EaL-acddeat)_ --- -- $ ANY AUTO BODILY INJURY (Per parson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BOBBODILY AUTOS ONLY AUTOS ONNLY INJURY (Per accident):$ Peroade t�AMAGE I $ - - $ UMBRELLA LIAR I OCCUR EXCESS LIAB CLAIMS -MADE EACH OCCURRENCE AGGREGATE $ -- DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS LWBtLl Y ANY PROPRIETOR/PARTNER/EXECUTIVE Y�—j �NIA� 4FICER/MMBER EXCLUDED? _ f andata y n NH) �I STATUS-1_FTH- - - E.L. EACH ACCIDENT _ $ E.L. DISEASE_ -_ EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Air conditioning contractor license# Cac1816329 Miami Shores Village 10050 NE 2nd Ave Miami Shores, 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 REPRESE NTATIVE �qqax"cx— ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CAC #1816329 CHECK LIST PRICE BIMINI BREEZE HVAC INC 'A,E -I L;Op:PRBSSER ❑v un.I. xma.IE ❑ m" G „a^I� ❑ "•�^• AN•.em•^' ❑ H•e... ❑ T., lt� 0 $U01"ION _ PsI IT HEAD— PSI ❑vary —Ps g E(.1_CYRICAL CONNECTIONS PI CONTACT$ TIGHT & CLEAN CIOIL I cvu & CONOITRA, CO► DENSER COIL _. Commercial ° Residential Air Conditioning Services Inc, isle h F t 3 St Hialeah FL -4205 Ph 305-968-4205 f?- LAST YAM FIR N E O 1✓ rM'CLF,41 COIa4L,$ CHECK FIN. COND. LI ENT -F LVG _7 REFRIGERANT QLEAK ': C)CHARGE 7 FAN AND MOTOR. q VOLTB______.—.AMPS ti ELECTRICAL CONNECTIONS u..la ❑c ❑ h N...... v ❑ R.,..oe.,,.^. STHEFT yI. , 7 �i Q p CITY su*E L 1AAKE +IODIC $E P'II •:o'.ID_a IT CONTACTS TIGHT .& CLEAN Q FAg PULu:.YS (ADJUST OELT - 0 CVRKX. LU0 SEANINGS A MO D EVAPORATOR COIL r CLEAN COIL & CHECK Fi I) ENT IF LYO SO r i ❑ ❑ �=w.nn. PHONE • � I IN _ U ENTYNBm'f LYG 1Yb , •P (� GONOEttFtSATE AfiEAB .^ _ 5 ! J� CI WSPECTaCI,E•.AN ORAMl Pk4! ❑ INSPECT &aX.AN URAIN / /� �_I�J _ . D AIR FILTERS CI GLT.ANED :.: O REPLI+OED .TITTER Him, C3 HEAnNGASSK.'_. - -4 .] BURNER H HV V "CHASIG+ER T] FJEL SUPPLY & PRESSURE' 'n At� --{ - n PR�jYASBEBIBL.Y .'I=LAME AWUSTMENP TtiIAL PARTS 4AO40 5 �jt/ �� •� �/ ems% -4w4�/ _ __—,O (7 PRIMARY RElAYA6 FLUE/"ii/L1S/✓ n FAN a 1-Wi7 SWITCH OPER. Fly VALlB USTRIPHEAT..q DEFROST CYCLE - UFN, WAfRNPA 4 MOTOR U R�AY4 TJKCI A' - �. WARRANTY . < -."..re .. .<,I .,,e ,...... .. LABOR GUARANTY I"^ n II 11 e I V - sv,r AV^toTECHNICIAN omo Eelec .• va me/ "" Ix `J'°"ueC T.nourtlySIGNATURE DLN'PARTS /�.�9✓ .. �•fa �it D00o E:E /1 IANDR CERI a L AN �''� , OCR. UNW4E 93'*LOCA1L ENVIRONMENT CHECK THIc TYPE SYSTEM R c°^a REF0.1G -_ _ OW_ E O1 RECOVERED'' YES NOGlY --- LIST _ CHARGED OUT 13 REPL(ACED)? OR YE❑S NO "S.® Q MANTLED? YES NO © -- I HAVE THE AUTHORITY TO ORDER THE ABOVE WORK AND Be EO ORDER AS OUTLINED ABOVE IT IS AGREED THAT THE SELLER WILL RETAIN TITLE TO ANY EQUIPMENT OR MATERIAL FURNISHED UNTIL FINAL S COMPLETE PAYMENT IS MADE. AND IF SETTLEMENT ISNOT MADE AS AGREED. THE SELLER SHALL HAVE THE RIGHT TO REMOVE SAME AND THE SELLER WILL RE HELD HARMLESS FOR ANY DAMAGES RESULTING FROM THE REMOVALTHEREOF. su TAb.'. TOTAL. ITEM k REPAIR ESTIMATE E Q U I M IN T - TRIP CHARGE F R RECYCLED' ® 0 CITY — YES NO I Q RELCAIMED? a in Q7Y — vEs NO G TAX OUR PERSONNEL RECOMMEND: RETURNED TO e ® CITY E THIS SYSTEM? YES NO I♦ } ® DISPOSAI. TIME ARRIVED TIME DEPARTED A OWNER'S INITIALS N NON USABLE O ® OTY — IUA a xT ACCEPTED DECLINED - • ) (5) iuy sal Ron DeSantis, Governor STATE OF FLORIDA Melanie S. Griffin, Secretary DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION 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. 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: 8/17/2023 PERSON: JUSTIN P ROMER FEIN: 371574398 BUSINESS NAME AND ADDRESS: BIMINI BREEZE HVAC INC 7010 NW 169 ST HIALEAH, FL 33015 EXPIRATION DATE: 8/16/2025 EMAIL: BIMINI_BREEZE@OUTLOOK.COM This certificate of election to be exempt is NOT a license issued by the Department of Business and Professional Regulation. To determine if the certificate holder is required to have a license to perform work or to verify the license of the certificate holder, go to www.myfloridalicense.com. IMPORTANT: Pursuant to subsection 440.05(13), 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(11), F.S., certificates of election to be exempt issued under subsection (3) apply only to the corporate officer named on the notice of election to be exempt. Pursuant to subsection 440.05(12), 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 E01759297 QUESTIONS? (850) 413-1609 RULE 69L-6.012, F.A.C. REVISED 01/2023 Miami Shores Village - BUILDING DEPARTMENT 10050 NE 2 Ave Miami Shores, FL 33138 305-795-2204 www.msvfl.gov 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: 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: 1J1�z 84(—M /7'l mc%c 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: 0=f Address: / Owner State of Florida County of Miami -Dade ��// The foregoing was acknowledge before me this 3 day of ffir�a►1%a,t4c- 20 23. By DA\ 1- r0ek%FAgT who is Eonally know o me or has produced as identification. Notary: Notary Public Slate of Flontla SEAL: Regina Butler My Gomm18Ei0a NH OBat Oa L rn� EKpire�071�1120Y5 Rev 12 to Owner Pace 1 of 1 BIMINI BREEZE HVAC, INC. CAC1816329 Date: November 3, 2023 County of Miami -Dade Before me this day personally appeared J use-( &K who, being duly sworn, deposes and says: That he will be the only person working on the project located at: 61 North East 104 Street, Miami Shores, Florida 33138 Sworn to (or affirmed) and subscribed before me this 3 day of*A(a*J6d .20 / , byL- Personally Know, Or Produced Identification Type of Identification Produced V 0 iNotary Public State7FlodddaRegina Butler My Commission HH Expires0 Print, Type or Stamp Name of Notary