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MC-09-1332 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspecti Number: INSP- 136604 Permit Number: MC -8 -09 -1332 Scheduled Inspection Date: March 02, 2010 Permit Type: Mechanical - Residential Inspector: Perez, JanPierre Inspection Type: Final Owner: WOLSTENHOLME, BRIAN Work Classification: A/C Replacement Job Address: 380 NE 91 Street Miami Shores, FL Phone Number (305)758 -3477 Parcel Number 113206019020 Project: <NONE> Contractor: FROSTY FROG A/C & REF INC Phone: (305)607 -7289 Building Department Comments a/c replacement Inspector Comments Passed Failed Correction ❑ Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. March 01, 2010 For Inspections please call: (305)762 -4949 Page 24 of 27 R Miami Shores Village 1e � i�dentral <� 10050 N.E. 2nd Avenue Allow t Qt11"ertii€3n s Miami Shores, FL 33138 -0000 , �rpv Phone: (305)795- 2204f�Cl PRVQ Expiration: 03/031201 LM Project Address Parcel Number Applicant 380 91 Street 1132060190200 BRIAN WOLSTENHOLME Miami Shores, FL Block: Lot: Owner Information A ddress Phone Cell BRIAN WOLSTENHOLME 380 NE 91 ST (305)758 -3477 i MIAMI SHORES FL 33138 -3130 Contractor(s) Phone Cell Phone Valuation: $ 1,000.00 CPS ELECTRIC, INC. 305 - 607 -8221 Total Sq Feet: 0 Type of Work: ELECTRICAL For Inspections please call: Additional Info: A/C HOOKUP (305)762 -4949 Classification: Residential Available Inspections: Inspection Type: Final Meter Box Alteration Relocation Fire Alarm Service Change Underground W. W. Fees Due Amount Invoice # Total Amt Paid Amt Due CCF $0.60 EL -8 -09 -35607 $ 167.80 $ 117.80 Education Surcharge $0.20 Permit Fee - Additions /Alterations $160.00 EL - 8 - 09 - 35607 $ 167.80 $ 167.80 $ 0.00 Permit Technology Fee $4.00 Check #: 2260 Scanning Fee $3.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Total: $167.80 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. January 20, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Copy January 20, 2010 1 i i t t wy 16 N. da ,p R4> S f ' L- ..i.�t d_ c aim y) a`kYf�:: ,.. :.a:t- ::dx�._sv�__..... 3: r.r to :�. <i :CS� a �.• �:� =2_: i ,' .:.. :.._ .M6 W!-afr W^ �j ffi �_ g . - "ta i : . is p " _ ��,yy���jjaa "• _ ' Sr.. / �w' �F`l J �s yi p tr a� VIA i� . VOA '',,„q,, ay : M .:. ".'�"'f i i t t c aim .M6 W!-afr W^ i i t t Miami Shores Village MR II �� t g A UG Building Department . 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 By Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. A - _ 5 ?5 PERMIT APPLICATION Master Permit No. U 1✓ FBC 20 Permit Type; ELECTRICAL r Owner's Name (Fee Simple Titleholder) ct, Weln PA Phone # Owner's Address D rif City State �— L Zip Tenant/Lessee Name Phone # Email Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # Is Building Historically Designated YES NO Flood Zone Contractor's Company Name �• Phone # Contracto Address City State Zip Qualifier Name Phone # State Certificate or Regis tion No -Eys MOW Certificate of Competency No. 2 . Contact Phone E -mail Architect/Engineer's Name (if applicable) Phone # Value of Work For this Permit $ Square / Linear Footage Of Work: Type of Work: ❑Addition ❑Alteration ❑New ❑ Repair/Replace El Demolition Describe Work: Submittal Fee $ 7 5 0. c Permit Fee $ hr CCF $ 0 4,0 CO /CC $ Notary $ Training/Education Fee $ D'J Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ l l� See Reverse side -4 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 Signature Owner or Agent Contractor The foregoing inArument was a owledged b e is The foregoing instrument was acknowledged before me this day of , 20f, by ay of , 20 _, by who is perso ally known to me or who has produced who is personally known to me or who has produced As identification and who did take an 0 as identification and who did take an oath. NOTARY P LIC: �ti'y > �"t �ti mac. NOTARY PUBLIC: Sign: �.�;" G" `� o Sign: Print: S _ Print: My Commission Expires: ®�er >•A s,jb `� My Commission Expires: w APPROVED BY _ 1� lans Examiner Zoning Engineer Clerk checked (Revised 07 /10 /07)(Revised 06 /10/2009) Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 BUILDING Permit No. PERMIT APPLICATION Master Permit No. FBC 2004 Permit Type: PAINT PERMIT Owner's Name (Fee Simple Titleholder) r ` . f - j L�; Wtln ��� Phone # Owner's Address _�> 9 d VE City M, S k o 61.E - -5 State [ Zip Tenant/Lessee Name Phone # E -MAIL: a a Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # Is Building Historically Designated YES NO Contractor's Company Name C /rS � j/j„�� Phone # 3v� 3 5 Contractor's Address �b f5 6 City Qualifier State Certificate or Registration No. 10 te I 02— 1 0 Certificate of Competency No. 0 Q 0 (72'-) 2) OWNER BUILDER: YES /NO ff 0 G C Value of Work Fo tthis Permit $ 3 Z S Type of Work: ❑ Addition / ❑ Alteration / New / � Repair /Replace Describe Work: -e- letc e— czmcA' G,l 5c.:0_11 noa 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. 1 understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC..... "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 ofsuch posted notice, the inspection will not be approved and a reinspection fee will be charged. Permit Fee $ CCF $ Technology Fee: Training /Education Fee $ Notary $ Code Enforcement $ Double Fee $ Zoning $ Total Fee Now Due $ See Reverse side -a PAINT COLOR APPROVAL AND AGREEMENT All elements on the site must be listed and indicate the color to be painted Directions: Please circle corresponding number to appropriate color sample Walls: 1 2 3 4 Attach color samples with name Fascia: 1 2 3 4 and number. Drip Cap/Drip Edge: _ 2 3 4 _ Soffit 1 2 3 4 1 Roof: 1 2 3 4 Flower Bins: — 1 2 3 4 Shutters: 1 2 3 4 Awnings: 1 2 3 4 2 Chimney 1 2 3 4 Doors and Door Jams 1 2 3 4 Garage Doors 1 2 3 4 Railings: - 2 3 4 3 Fences: 1 2 3 4 All brick (simulated or regular): 1 2 3 4_ Stucco Banding: 1 2 3 4 Any other Stucco Features: _ 2 3 4 4 Accessory Buildings Other: 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. Signature Signature Owner or Agent Contractor The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this ! O day of , 20 , by day of CLU- 20 0p , by who is personally known to me or who has produced who is personally known to me or who has produced As identification and who did take an oath. a$, identification and who did take an oath. °` PO B� NOTARY PUBLIC: NOTARY P MILTON ROMERO c* MyIuIMISS�IO # DD 704640 Sign: Sign: e 2011 Print: Print: T FF F O l °A onded ThN BodgetJflotary Services My Commission Expires: My Commission Expires: l APPLICATION APPROVED BY: Plans Examiner Preservation Board Code Enforcement (Revised 04/24/07) t 0 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FIL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 121751 Permit Number: EL -8 -09 -1333 Scheduled Inspection Date: February 24, 2010 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: WOLSTENHOLME, BRIAN Work Classification: Addition /Alteration Job Address: 380 NE 91 Street Miami Shores, FL Phone Number (305)758 -3477 Parcel Number 113206019020 Project: <NONE> Contractor: CPS ELECTRIC, INC. Phone: 305 -607 -8221 Building Department Comments HOOK UP FOR A/C REPLACEMENT Inspector Comments Passed Z Failed Correction Needed Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. February 23, 2010 For Inspections please call: (305)762 -4949 Page 6 of 34 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FIL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP 136380 Permit Number: EL -8 -09 -1333 Scheduled Inspection Date: March 03, 2010 Permit Type: Electrical - Residential Inspector: Devaney, Michael Inspection Type: Final Owner: WOLSTENHOLME, BRIAN Work Classification: Addition /Alteration Job Address: 380 NE 91 Street Miami Shores, FIL Phone Number (305)758 -3477 Parcel Number 113206019020 Project: <NONE> Contractor: CPS ELECTRIC, INC. Phone: 305 - 607 -8221 Building Department Comments HOOK UP FOR A/C REPLACEMENT Inspector Comments Passed CREATED AS REINSPECTION FOR INSP- 121751. No clearance to disconects on A. H. U. or A. C. C. U., Failed Correction ❑ Needed Re-Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. March 02, 2010 For Inspections please call: (305)762 -4949 Page 19 of 31 wm y t}s, i Miami Shores Village Z 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 `f Phone: (305)795 -2204 Expiration: 03/031201 Project Address Parcel Number Applicant 380 91 Street 1132060190200 Miami Shores, FL Block: Lot: BRIAN WOLSTENHOLME Owner Information Address Phone Cell BRIAN WOLSTENHOLME 380 NE 91 ST (305)758 -3477 MIAMI SHORES FL 33138 -3130 Contractor(s) Phone Cell Pho ne Valuation: $ 5,000.00 FROSTY FROG A/C & REF INC (305)607 -7289 (305)607 -7289 Total Sq Feet: 0 Tons: For Inspections please call: Additional Info: MECHANICAL (305)762 -4949 Classification: Residential Available Inspe ctions: Approved: In Review Inspection Type: Comments: Date Approved:: In Review Final Date Denied: Type of Work: A/C REPLACEMENT Fees Due Amount Invoice # Total Amt Paid Amt Due CCF $3.00 MC -8 -09 -35608 $ 229.42 $ 179.42 Education Surcharge $1.00 in' Permit Fee - Additions /Alterations $217.00 MC -8 -09- 35608 $ 229.42 $ 229.42 $ 0.00 Permit Technology Fee $5.42 Check #: 2260 Scanning Fee $3.00 Submittal Fee $50.00 Submittal Reversal Fee ($50.00) Total: $229.42 In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Futhermore, I authorize the above -named contractor to do the work stated. January 20, 2010 Authorized Signature: Owner / Applicant / Contractor / Agent Date Building Department Cop January 20, 2010 r 1 Miami Shores Village I AUG 11 2009 � Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: _.__.... ....... Tel: (305) 795.2204 Fax: (305)756.8972 BUILDING Permit N AC) 1 63o'l PERMIT APPLICATION Master Permit No. FBC 2004 Permit Type Mechanical Owner's Name (Fee Simple Titleholder) j �� ),S4h ��, (+� Phone Owner's AddressO U ®V s City r� Pn S _ State Zip 3 Tenant/Lessee Naive Phone # E -MAIL: Job Address (where the work is being done) d City Miami Shores Village County Miami -Dade Zip FOLIO / PARCEL # Is Building Historically Designated YES NO ` Contractor's Company Name i2 !� Phone # 3�5 tp ®T ' 2- Contractor's Address _ City t Y t /� I TT>� I � � — State zip - _33 t,�� Qualifier Nam �L . c-A J � >J /, Phone # State Certificate or Registration No. _ C,,, 1 ertificate of Competency No. E- MAIL: A-L€ HAJA -Ml Q A aL r �� Arch itect/Engineer's Name (if applicable) Phone # St y,A(ue of Work + Phr tW Permit$ Square /Linear Footage Of Work: Type of Work: ❑Addition ❑Alteration [ Repair /Replace ❑ Demolition Describe Work: A/C) daWo Submittal Fee $ Permit Fee $ �/ L i CCF $ �• CO /CC Notary $ Training /Education Fee $ Technology Fee $ S . Scanning $ Radon $ DPBR $ Zoning $ Bond $ Code Enforcement $ Double Fee $ ii 1 Structural Review. $ Total Fee Now Due $ 1 •4p` See Reverse side –� �r 6 A' . Bonding Company's Name (if applicable) Bonding Company's Address City State Zip 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In th e o uch posted notice, the inspection will not be approved and a reinspection fee will be charged. Signature Signature Owner or Agent ctor The fore oing i strument was ac nowledged bef re e. his The fore inginstrument was / acknowledged before me this da of 20 \ , b ay of 20 D "h by /� 1 Q7( F1 Y Y who is personally known to me or who has produced o is personally known to me r who has produced As identification and who did take an oath. as identification and who did take an oath. ywoftwom NOTAR UBLIC NOTARY PUBLIC: C M.# oorr • Da Sign: �.� , , ..,;t Sign: n /� Print: �i U Z Print:� My Commission Expires: p y ,' My Commission Expires Z1 2 %:[%%%% 1C%% % % % % % % %J: % % % % % % % % %X % % % % % % % %$('. � % *'A']tX % *'IC 1F'YY�iY iYX IY%% %1: % % %X%X %�. %XXiCXX % % %% % % % %iC ):%X%%%%<:%%%%)t%%%%- APPLICATION APPROVED BY: Plans Examiner Engineer Zoning (Revised .02/08/06) Aug 31 09 07:43p FROSTY FROG 3052641969 p.1 A/C & REF.R.IGERAY�� ���Q State Certified & Insured, CAC 18156?8 6551 SW 18 Terr., Miami, FL. 33155 p ph Phone: (305) 607 -7289 Fax: (305) 264 -1969 Date: 08109109 Submitted to: Mr.& Mrs. Brian Wolstenholme We hereby submit specifications and contract for: Wolstenholme Residence 380 NE 91 Street Miami Shores, Florida 33138 The job va a wil be $4,268 -00 For the in Ilation of a 5 tan R-410 15.2 Seer American Standard Alliance split system. The installation i1! be done according t lorida Building Codes and Miami -Dade Coun from the above pecification invo ng additional materials and/or labor costs, will be executed o n ly devi approval of Ge ral Contract rwith ahons r Owner with written orders, and if there is any charge for such alteration or deviation addition will be added to the price of this proposal. Alex R Figueroa Brian Wolstenholme President Owner 09 -133 7- AC# ; s1r�E CF FLOMDA I3PTitT CAFE , PROF kSS10 cAG1815618 09/d3/t3 087012t�' CS IED AIR COO C� 'EX 90 VR OA At �E3TY , FRt3G A/C S RR under the vsafte.cf „ ;8gg 3titla dace: AVG 31, 2 010 LifBt},4�$F►�2 �� t STATE OF FLQRoA AG# 4 4 :1.11 U I DEPARTMENT OF BUSINESS AND PROFESSIONAI REGULATION QB5739 06/08/09 °0'8051505'9 QUALIFIED BUSINESS ORGANIZATION FROSTY 'FROG A/C AND REFRIGERATIO (NOT :A L:ICENSS TO P ERFORM WORK. :.'ALLOWS COMPANY TO DO BUSINESS IF IT HAS A LICENSED `QUALIFIER.) I3 QUALIFIE'D under the provisions of Ch.489 Fs 8xgiratioa -Ca6e: AUC::31, 2011 LG9060800926 A4 _ 4 1 1 STATE OF FLORIDA -D ART [EN- , OF BUSINESS AND PROFESS=X7ON'1 -L- REGU�ATION CWTRUCTPN INDUSTRY = LICEI SIN ,BC7 iRD SEC,Z#r,09t 60 t 0926 DATE BATCH NUMBER - LICENSES =NBR 1 06/08/20091080515059 1 Q 87399: _ The BUSINESS "ORGANIZATIO - _ Named below IS QUALIF Tnder the provisions of _Ct apt-er 489 FS'. - Expiration date: AUG 31; '' (THIS IS NOT A LICENSE TO PERFORM WORK, THIS ALLOWS COMPANY TO DO BUSINESS ONLY IF!=IT HAS A'QUALIFIER - FROSTY FROG A/C AND �tEFRIGERATZON INC - - - 6551 SW 18TH-TERRACE MIAMI 'FL 33;;155 CHARLIE CRIST t CHARLES W DRAGO GOVERNOR - SECRETARY QJSPLAY AS REQUIRED BY MIAMI -DADE COUNTY 2009 LOCAL BUSINESS TAX RECEIPT 2010 FIRST -CLASS TAX COLLECTOR MIAMI -DADE COUNTY - STATE OF FLORIDA U.S. POSTAGE 140 W. FLAGLER ST. EXPIRES SEPT. 30, 2010 PAID 1st FLOOR MUST BE DISPLAYED AT PLACE OF BUSINESS MIAMI, FL MIAMI, FL 33130 PURSUANT TO COUNTY CODE CHAPTER $A - ART. 9 & 10 PERMIT NO. 231 612325-1 �' v RENEWAL BU FROSTY M FROG A A /C & REFRIGERATION STATE# CACI8 638611 -4 15618 INC 6551 SW 18 TERR 33155 WEST MIAMI OWNER FROSTY FROG A/C & REFRIGETON INC Sec . T pe of Business WORKER /S 146 SPEC MECHANICAL CONTRACTOR 1 THIS IS ONLY A LOCAL BUSINESS TAX RECEIPT. IT DOES NOT PERMIT THE HOLDER TO VIOLATE ANY EXISTING REGULATORY OR ZONING LAWS OF THE DO NOT FORWARD COUNTY OR CITIES. NOR DOES R EXEMPT THE HOLDER FROM ANY OTHER FROSTY FROG A/C & REFRIGERATION PERMIT OR LICENSE REQUIRED BY LAW. THIS IS INC NO THE HOLDS S OUALIFICAF ALEX R FIGUEROA PRES TINS. 6551 SW 18 TERR PAYMENT RECEIVED WEST MIAMI FL 33155 - MIAMI -DADE COUNTY TAX - COLLECTOR: 09/18/2009 09010043001 000045.00 � pp aj FF jj {{ jj qq {{ i{ yy j ii 7l! FFifi ?F?t�F ? ?F�f'r�ifF ?TILE kii��t ? ?1F ?!k�?ir(f'9�k �! ?Fill ii }Ft7 i SEE OTHER SIDE 11-17-2009 ALEX SINK STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 11/17/2009 EXPIRATION DATE: 11/17/2011 PERSON: FIGUEROA ALEX R FEIN: 260780541 BUSINESS NAME AND ADDRESS: FROSTY FROG A/C & REFRIGERATION INC 6551 SW 18TH TERRACE MIAMI FL 33155 SCOPES OF BUSINESS OR TRADE: 1- REPAIR SERVICE 2- CERTIFIED AC CONTRACTOR 3- INSTALLATION SERVICES IMPORTANT. Pursuant to Chapter 440 . 051141, 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 440.05112), 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 440.0503), 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 an 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. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 QUESTIONS? (850) 413 -1 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION F Pursuant to Chapter 440.0504), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA q L under this section may not recover benefits or compensation under this WORKERS' COMPENSATION LAW `��'°'� D chapter. EFFECTIVE: 11/17/2009 EXPIRATION DATE: 11/17/2011 H Pursuant to Chapter 440.05112), F.S., Certificates of election to be PERSON: ALEX R FIGUEROA exempt... apply only within the scope of the business or trade listed on FEIN: 260780541 R the notice of election to be exempt BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05!131, F.S., Notices of election to be exempt FROSTY FROG A/C & REFRIGERATION INC and certificates of election to be exempt shall be subject to revocation 6551 SW 18TH TERRACE if, at any time after the filing of the notice or the issuance of the MIAMI, FL 33155 certificate, the person named on the notice or certificate no longer mee the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF BUSINESS OR TRADE: person named on the certificate to meet the requirements of this 1- REPAIR SERVICE 2- CERTIFIED AC CONTRACTOR section. 3- INSTALLATION SERVICES QUESTIONS? (850) 413 -1609 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 01/20/2010 11:43 305 - 273 -4409 Jessica Perez Page 1/1 TE CERTIFICATE OF LIABILITY INSURANCE DA 01 20 /10 PRODUCER Insurance Professional Consult THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 10481 SW 88 St Ste. D -204 ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33176 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone (305) 273 -4530 Fax (305) 273 -4409 INSURERS AFFORDING COVERAGE NAIC # INSURED Frosty Frog A/c & Refrigeration INSURER A: NOVA 6551 SW 18 Terrace INSURER B: INSURER c: Miami, FL 33155- INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADUL TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD DATE (MWOD/YY) DATE (MWDD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 1,000, d❑ COMMERCIAL GENERAL LIABILITY 09AL067997 -1 10126109 10/26/10 PREMISES Ea occurence 100,000 ❑❑ CLAIMS MADE 0 OCCUR MED EXP (Any one person) 5 , 000 A ❑ ❑ PERSONAL & ADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG 2,000 000 ❑ POLICY ❑ PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ALL OWNED AUTOS BODILY INJURY ❑ ❑ SCHEDULED AUTOS (Per person) ❑ HIRED AUTOS ❑ BODILY INJURY NON OWNED AUTOS (Per accident) ❑ PROPERTY DAMAGE Lj (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESS /UMBRELLA LIABILITY EACH OCCURRENCE ❑ ❑ OCCUR ❑ CLAIMS MADE AGGREGATE ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND E] WC STATU- F] OTH EMPLOYERS LIABILITY TORY LIMITS ER ANY PROPRIETOR/ PARTNER/ EXECUTIVE E.L. EACH ACCIDENT OFFICER /MEMBER EXCLUDED? Ifyes, describe under E.L. DISEASE - EA EMPLOYEE SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS PERMIT# MC- 8091332 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL VILLAGE OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2ND AVENUE THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI SHORES, FL 33138 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE FAX: 305-756-8972 �. ACORD 25 (2001/08) QF © ACORD CORPORATION 1988