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MC-11-904Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 L Inspection Number: INSP - 159919 Permit Number: MC -5 -11 -904 Scheduled Inspection Date: June 08, 2011 Inspector: Bruhn, Norman Owner: EUGENE, KERMITH & LOUIS Job Address: 524 NW 113 Street Miami Shores, FL 33168- Project: <NONE> Contractor: FREEZE AIR CORP Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 3021360210860 Phone: 786 -412 -3308 Building Department Comments CHANGE OUT 2 SYSTEM TONS EACH qig glo/i/ Inspector Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. June 07, 2011 For Inspections please call: (305)762 -4949 Page 14 of 24 (1P(j( _,zsts- ' Miami Shores Village Building Department'; 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 BUILDING Permit No. !AC ) i l PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: MECHANICAL Owner's Name (Fee Simple Titleholder) W& Phone # State Owner's Address City mil Tenant/Lessee Name Email 7P& (-9-M �C Zip 3 9 3g Job Address (where the work is being done) , 02 4 W Phone # City Miami Shores Village County Miami -Dade Zip �v? FOLIO / PARCEL # Is Building Historically Designated YES NO Flood Zone Contractor's Company Name 401:1,111 ( :4 /Id( C IC'P Phone # 7,‘ 7 f 1S- Contractor's Address 7 /c 6 A, ,Z 5 7- City ,OZ-i / i# .01 Qualifier Name�%� -�3 State Certificate or Registration No. K. At 0o1(7, State 6C4 6C4f Zip 3 3/ 3 Phone # 7,c -5 le' e? 8 / Certificate of Competency No. Contact Phone J. 1 7?, 5— E -mail Architect/Engineer's Name (if applicable) Phone # of Work For this Permit y CO Type of Work: ['Addition II EAlterat'.n ONew 1 X Repair/Replace O Demolition Square / Linear Footage Of Work: Describe Work: ***************************************F ** 7'' *** * * * * *** * * * * * * * * * * * * * * * ** * * * * * ** Submittal Fee $ Permit Fee $ \ V V CCF $ CO /CC $ Notary $ Training/Education Fee $ Scanning $ Radon $ DPBR $ Double Fee $ Violation date: Structural Review. $ Technology Fee $ Bond $ Total Fee Now Due $ 440 See Reverse side i t P2 C Bonding Company's Name (if applicable) / &(jF .4 . t2 e'(9/1P Bonding Company's Address City /r /l /we / State c%A Zip J3 %34) 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, SINS, 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 lll 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 5 5 11.-a 6 e- Alf Signature i/ / Owner or Agent Contractor The foregoing instrument was acknowledged before me this ,/%:- :' The foregoing instrument was acknowledged before me this/ ( day o , 20 / 1 , by , day of , 20/" , by who is persona ly known to me or who has produced who is personally known to me or who has produced .t = /p As identification and who did take an oath. NOTARY PUBLIC: Sign / as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: Print: My Commission MILTON ROMERO My Co l Sn , r i j Sj ROMERO DDR 0464 MY COMMISSION # DD 704640 EXPIRES: December 3, 201 „ EXPIRES: December 3, 201 Nf94 OF FLO�`OP Bonded Thru Budget Notary Services. a�9rFOa FIO�``OP Bonded Thru Budget Notary Services ** * * * * * * * * * * * * * * * ******'** ***** *fie * ** **:** ******k *******: FAY: F3C9c**: F ****: ti**** ************* **:F*:F ***3* *********** APPROVED BY / Plans Examiner Engineer (Revised 07 /10 /07)(Revised 06/10/2009) Zoning Clerk checked '3 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 unit change -out must be on its own data sheet. Multiple units on single sheets are not acceptable. Job Address (where the work is being done): d s '-y A N /fi s7 City: I maM i Shores Village County: Miami Dade Zip Code: .93 I 3 1 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 ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means?YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ a UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER - ` AHU or PKG. UNIT MODEL # ,4 wUP 4i It COND. UNIT MODEL # C3 5 X I.® I KW HEAT ,S (.4 uJ NOM TONS 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 [ 3 6C---'; YES NO REPLACING DUCTS YES NO /� YES NO REPLACING THERMOSTAT may' NO YES NO NEW 4 "CONCRETE SLAB ES ' NO YES NO NEW ROOF STAND YES NO )/ 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: Phone: State Certificate or Registrati , N. 4C a 3 -3 /2 Certificate of Competency N. Signature (Qualifier's signature only) Date: ACCORD' CERTIFICATE OF LIABILITY INSURANCE DATE(MNUDD/YYY1� 05/11/11 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 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 Accurate 8300 West Flagler Suite 114 Miami, FL 33144 Phone (305)226 -8727 Fax (305)226 -8767 CONTACT Lucia Estrella NAME: (a(c °Nlu). (305)226 -8727 FAX No): (305)226 -8767 E-MAIL SS. luciaestrella@bellsouth.net INSURERS) AFFORDING COVERAGE NAIC # INSURER A: FUBA GENERAL LIABILITY INSURED Freeze Air Corp 7001 W 35 Ave #192 Hialeah, FL 33018- (786) 346 -0881 INSURER B : 1305 551 1546 INSURER C : $ INSURER D : MED EXP (Any one person) INSURER E : PERSONAL & ADV INJURY 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY EFF JMMIDD/YYYY)JMM/DDIYYYYL POLICY EXP LIMITS EACH OCCURRENCE $ Miami Shores, FL 33138 GENERAL LIABILITY A jai 1305 551 1546 DAM TO PREMISES (Ea occurrence) $ El COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE ❑ OCCUR ❑ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ ❑ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PE ❑ LOC PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED ❑ SCHEDULED NON -OWNED ❑ HIRED AUTOS ❑ AUTOS (Ea aBI dentSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ . ❑ ❑ UMBRELLA L.IAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y / N PROPRIETOR/PARTNER/EXECUTIVE ANY PRIE R ECUT� N / A WC 0519327 09/11 /2010 09/11/2011 V WC STATU- OTH- TORY LIMITS ❑ ER E.L. EACH ACCIDENT $ 1,000,000.00 N (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000.00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CANCELLATION ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF, NOTIC , `LL BE ACCORDANCE WITH THE POLICY PR" ..1' =� D IVERED IN (, 10050 NE 2ND AVE Miami Shores, FL 33138 AUTHORIZED REPRESENTATIVE; A jai 1305 551 1546 Lucia Estrella ACORD 25 (2010/05) QF © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ` ' ` CERTIFICATE OF LIABILITY INSURANCE DATE 05/25DIYYYY) 05/25/11 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 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 Accurate 8300 West Flagler Suite 114 Miami, FL 33144 Phone (305)226 -8727 Fax (305)226 -8767 CONTACT Lucia Estrella NAME: PHONE 305 226 -8727 FAX (AIC No. Ext): (305)226-8727 (AIC. No): (305)226-8767 ADDRESS: luciaestrella @bellsouth.net INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A : FUBA INSURED Freeze Air Corp 7001 W 35 Ave #192 Hialeah, FL 33018- (786) 346 -0881 INSURER B : INSURER C : $ INSURER D : $ 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE INSR POLICY NUMBER SMMIDDY EIYYYY)J POLICY VMITS GENERAL LIABILITY ❑ COMMERCIAL GENERAL LIABILITY ❑ ❑ CLAIMS -MADE ❑ OCCUR ❑ EACH OCCURRENCE $ DAMAGE TO PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ ❑ GENERAL AGGREGATE $ GEM_ AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ $ ❑ POLICY • EC ❑ LOC AUTOMOBILE LIABILITY ❑ ANY AUTO ALL ❑ AUTOS OWNED ❑ SCHEDULED UTO NON -OWNED ❑ HIRED AUTOS ❑ AUTOS COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LIAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER /EXECUTIVE NIA WC 0519327 09/11/2010 09/11/2011 V TORYTLM ❑ ERH E.L. EACH ACCIDENT $ 1,000,000.00 (Mandl ENH) EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000.00 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule. If more space Is required) AIR CONDITIONING CONTRACTOR CERTIFICATE HOLDER Miami Shores Village 10050 NE 2ND AVE Miami Shores, FL 33138 305 756 8972 ACORD 25 (2010/05) QF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE , OTICE WILL BE DELIVERED IN ACCORDANCE WITH / (Y� �ROVJSIONS. AUTHORIZED REPRES ( T Lucia Estrella © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �`� °® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYY) 05/25/11 PRODUCER Pinnacle Insurance Group Inc. 2525 S.W. 27th Ave, Suite 100 Miami, FL 33133 Phone (305) 854 -9898 Fax (305) 854 -9899 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERT FICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Freeze Air, Corp 7001 W 35th Ave #192 Miami, FL 33018 (786) 346 -0881 INSURER A: Ascendant Underwriters, LLC INSURER B: INSURER C: 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 LTR ADM- INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DDIYY) POLICY EXPIRATION DATE (MMIDDIYY) OMITS A ❑ GENERAL V ❑ ❑ LIABILITY COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE n OCCUR GL- 33834 -1 09/23/10 09/23/11 EACH OCCURRENCE 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurence) 100,000 MED EXP (Any one person) 5,000 PERSONAL&ADVINJURY 1,000,000 GENERAL AGGREGATE 2,000,000 ❑ PRODUCTS - COMP /OP AGG 1,000,000 GEN L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PROJECT ❑ LOC ❑ AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ SCHEDULED AUTOS ❑ HIRED AUTOS ❑ NON OWNED AUTOS ❑ COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) ❑ ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT OTHER THAN EA ACC AUTO ONLY: AGG ❑ EXCESSIUMBRELLA LIABILITY ❑ OCCUR ❑ CLAIMS MADE ❑ DEDUCTIBLE ❑ RETENTION $ EACH OCCURRENCE AGGREGATE WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below ❑ WC STATU- ❑ OTH- TORY LIMITS ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Air Conditioning Contractor CERTIFICATE HOLDER CANCELLATION Miami Shores Village 10050 NE 2ND AVE Miami Shores, FL 33138 Fax:305 -756 -8972 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OALii PRE.. NTATIVES. AUTHORIZED REPRESEN Tiv ii i Marcia C. Alvarez ) '' �'',, ACORD 25 (2001/08) QF © ACORD CORPORATION 988 IMPORTANT 0 Pursuant to Chapter 440.05(14), F.S., an officer of a corp elects exemption from this chapter by filing a certificate 1- under this section may not recover benefits or compensat D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of electi H exempt.. apply only within the scope of the business or E the notice of election to be exempt. R E Pursuant to Chapter 440.05(13), F.S., Notices of election t and certificates of election to be exempt shall be subjec if, at any time after the filing of the notice or the issut certificate, the person named on the notice or certificate the requirements of this section for issuance of a certif department shall revoke a certificate at any time for fail person named on the certificate to meet the requirement section. Vs— air —tvia JEFF ATWATER 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: PERSON: FEIN: 02/15/2011 EXPIRATION DATE: 02/14/2013 ROSALES REINEIRO 650671877 BUSINESS NAME AND ADDRESS: FREEZE AIR CORP 7001 W 36TH AVE UNIT 192 HIALEAH FL 33018 SCOPES OF BUSINESS OR TRADE: 1- AIR CONDITIONING IMPORTANT: Pursuant to Chapter 440. 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election owlet section may not recover benefits or compensation ander this chapter. Pursuant to Chapter 440.06112), F.S., Certificates of election to be exempt... apply only wit scope of the business or trade Ilsted on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certif it 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 n 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 t named on the certificate to meet the requirements of this section. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 PLEASE CUT OUT THE CARD BELOW QUESTION: AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DMSION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 02/15/2011 EXPIRATION DATE: 02/14/2013 PERSON: REINEIRO ROSALES FEIN: 550871877 BUSINESS NAME AND ADDRESS: FREEZE AIR CORP 7001 W 35TH AVE UNIT 192 HIALEAH. FL 33018 SCOPE OF BUSINESS OR TRADE: 1- AIR CONDITIONING QUESTIONS? CUT HERE * Carry bottom portion on the job, keep upper portion for your records. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11