MC-11-1556Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
A
Inspection Number: INSP- 164372 Permit Number: MC -8 -11 -1556
Scheduled Inspection Date: September 14, 2011
Inspector: Perez, JanPierre
Owner: HOLLOMAN, WILLIAM & CECILIA
Job Address: 90 NE 101 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: AVENTURA AIR CONDITIONING INC
Permit Type: Mechanical - Residential
Inspection Type: Final
Work Classification: A/C Replacement
Phone Number 305- 762 -7941
Parcel Number 1132060131320
Phone: (305)938 -1418
Building Department Comments
REMOVE AND REPLACE 3 TON AMERICAN STANDARD
R 410 SYSTEM
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP- 163682. need spec on slab jpp
September 13, 2011
For Inspections please call: (305)762 -4949
Page 26 of 30
**\niot■ ,(Pc-2
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 APPLICATION
FBC 20
IV
C_ No. ►. J i J
Master Permit No.
Permit Type: MECHANICAL , /
OWNER: Name (Fee Simple Titleholder): /014E1 23c-425i-1 Phone#: 12:4-205--/.35-y
Address: 90 M /00 =T ST
City: z// /4M/ ,51/®irES
Tenant/Lessee Name:
State: �L
Email: ', -'� L: ;�; ,._ 6
Zip: -!/'
Phone#: A4`%
JOB ADDRESS: % Ak-- /0 /'r $7—
City: Miami Shores County: Miami Dade Zip: __F�'� -fg'
Folio/Parcel #: ii °3Z(7(, — 0/2 — /3Z0
Is the Building Historically Designated: Yes NO Flood Zone: X
CONTRACTOR: Company Name: U ✓Ca AI 04
CJa 4i4l ,r f Pon# .306--.93i-/W8
Address: .2) 3) / £ � sr 7
City: /4') i av-Pv, , State: Zip: 33S 79
Qualifier Name: He o `j 759 I.' Phone#: a 0.47-670 3330
State Certification or Registration #:
Contact Phone#: .342c- -9 3i(— / ® W g Email Address: Ave pi 171/4, 0 r i 40 • �, moi
e
DESIGNER: Architect/Engineer: Phone#:
a
Value of Work for this Permit: . �! Square/Linear Footage of Work:
�
Type of Work: °Address °Alteration °New
f
Certificate of Competency #:
epair/Replace °Demolition
Description of Work: Re I'11®Vet. r BeAt' �
31Vmer , ..art c6!✓- f
• a •�o
�hNr�k�k�N�k�k�k +1� *�kK��k�k�k+k****�kN� N�k�k�k�kY��k*** �k ak ees �kk�kK�kkRN�NkNkNknkkk k+kkk�kN�ksN kk�AkFyA+kNk�kN
Submittal Fee
$ Permit Fee $ CF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE
001'
Post -it® Fax Note 7671 •
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 FT.F,CTRICAL 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
Owner or Agent
The foregoing instrument was acknowledged before me this 2Z" The fore
day of 4i91- ,20 AL by /1111CI#AEL lnt Ci+ , day of
who is personally known to me or who has produced who is
As identification and who did take an oath. 170
•
NOTARY PUBLIC:
Contractor
ment w acki
,2011 , by
kle&eu oer re s -
Sign:
Print:
My Commission Expires: 0 3' a gI I 1
wr4o me or who has p;Fs duced
ntification and who did take an oath.
PUBLIC: - °
Sign:
Print: , �. 107:1 i
� 3
y Commission , a '
\MI 3 • ,lY
1 1'1= •Yi1-
�k*** *****************L******************************
***
Structural Review Clerk
(Revised 07!10 /07)(Revised 06/10/2009)(Revised 3/15/09)
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 I HI T-5,.e
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): ?o ii / s
City: Miami Shores Village County: Miami Dade Zip Code: 33/S
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 ❑
UNIT BEING REPLACED
DATA
NEW UNIT
A c ee, "
MANUFACTURER 4M ey, .e04,,, $Z0 G
r
AHU or PKG. UNIT MODEL #
g7Kf,G 00 /oc•► 4
74 5 3 y%,4 QUA
COND. UNIT MODEL #
KW HEAT
NOM TONS
AHU VCU to, PKG
1) M.C.A
AHU v CU eaPPKG
AHU CU PKG
2) M.O.P
AHU CU PKG
AHU CU PKG
3) VOLTS g esA s) a
AHU CU PKG
PKG UNIT / /
PKG UNIT / /
EERISEER //A
YES NO
REPLACING DUCTS
YES NO
YES NO
REPLACING THERMOSTAT
YES e " NO
YES NO
NEW 4 "CONCRETE SLAB
YES ✓ NO
YES NO
NEW ROOF STAND
YES NO
YES NO
NEW RETURN PLENUM BOX
YES ' NO
1. Minimum Circuit Ampacity (Wire Size):
2. Maximum Overcurrent Protection (Fuse /Breaker Size):
3. Voltage of Circuit (208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name: Phone:
State Certificate or Registration N. Certificate of Competency N.
Signature Date:
(Qualifier's signature only)
_, _ FL:t3RiDA
rIS` ...•••:•,•., '
08/31/2010 107005:519 CAp)578-
4 =
The CLASS A AIR CONDIT t� t C T r.CTi R
Named ' below. IS CERTIFI
Expiration date: AVG 31 _ -�
9, FS:
Et3HT$SSADI, .HLDAYAI
AVENTURA AIR CONDIT3ON
' 2131 147L 205. STREET :- •
NORTH MIAMI FL :33179
CHARLIE CRISP
GOVERNOR
SEE OTHER SIDE
DO NOT FORWARD
AVEN1WRA AIR CONDITIONING INC
2131 NE 205 ST
N MIAMI BEACH FL 33179
111} }1,1} } Ili ,1 } } },1J} }1 }11 117, }11 }1 }if }i7IIS1 }1,1,11 ,ii'tf} i
3
IMPORTANT
OF Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who
elects exemption from this chapter by filing a certificate of election
L under this section may not recover benefits or compensation under this
D chapter.
H Pursuant to Chapter 440.05(12), F.S., Certificates of election to be
exempt.. apply only within the scope of the business or trade listed on
Rthe notice of election to be exempt
E Pursuant to Chapter 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 meet;
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.
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:
06/03/2011 EXPIRATION DATE: 06/02/2013
EGHTESSADI
FEIN: 270041185
BUSINESS NAME AND ADDRESS:
AVENTURA AIR CONDITIONING INC
2131 NE 205 STREET
MIAMI FL 33179
SCOPES OF BUSINESS OR TRADE:
1- AIR CONDITIONING CONTRACTOR
HEDAVAT
e
IMPORTANT: Pursuant to Chapter 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 Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the
scope of the badness or trade listed on the notice of election to be exempt. Pursuant to Chapter 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.
DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11
PLEASE CUT OUT THE CARD BELOW
QUESTIONS? (850) 413 -1
AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
CONSTRUCTION INDUSTRY
CERTIFICATE OF ELECTION TO RE EXEMPT FROM FLORIDA
WORKERS' COMPENSATION LAW
EFFECTIVE 06/03/2011 EXPIRATION DATE: 08/02/2013
PERSON: HEDAYAT EGHTESSADI
FEIN 270041185
BUSINESS NAME AND ADDRESS:
AVENTURA AIR CONDITIONING INC
2131 NE 205 STREET
MIAMI, FL 33179
SCOPE OF BUSINESS OR TRADE
1- AIR CONDITIONING CONTRACTOR
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 01 -11
Page No.
V ENrV � AIR
2131 N.E. iMI, FLORIDA 31 jg G' INC.
I4I8
of
..........
e hereby submit
specifications estimates f
(jam ... or.•
................ /rte
............
......� ,.......Pitt s
.........
............
..............
. . .. . .. . .. . . . . . .. .. .
........................................................................... ...............................
............. .
•
.............. ........................ .............................
..................... .
. ..............................
Propose
.......... .
Yment to be made as follows:
hereby .. .. . . . . . . . . . .. ... . . . . . .
. . . .. . . . . . . . .. . . . . . . . .
to furbish __.:..... , ..._.........._..
material and labor -_ .................
..........
complete in ...........t
aerial
r according guaranteed to be
'9 extra as specified. dollars i
over andtrn standard tobea d•All
s beyond above the executed only alteration r d to be eviation completed e our control. cars and as ve the
owner t. agreements co orders, and n above is become an
N �� covered by Workman's Compensation ado and other lnecessary strikes, insurance. d a
��P n� n Insu ant;
insurance.
'itions are satisfactory /
work Proposal -_ T and are work e. specified. ayment will be accepted. s out prices, above. lions
3„ de as outlined above authorized
Auth
Sig
withdrawn by us This pp,
of:
A°RO CERTIFICATE
Luis Pettis CPCU CLU, Agent
11400 N. Kendall Dr Suite 103
Miami, FL 33176
OF LIABILITY INSURANCE
X11
TINS CERT1FICAnoti is i581ED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO morns UPON TIE ATE
HOWER. TABS CERTIFICATE DOES NOT Alm, MEM OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURES AFFORDING COVERAGE
NAiC
INSURES
AVEN1URA AiR COMMUNING INC
2131 NE 205TH ST
MIAMI FL 33179 -2224
BRUER A: Stab, Foto Raids humane Company 107W
ROMER Et
WSURBt a
INSURER a
INSURER E
COVERAGES
THE POUCHES OF INSURANCE USTED FELON HAVE BEEN ISSUED TO THE INSURED NANED ABOVE FOR THE POLICY PERIOD INDICATED. NO1IMTHSTANDHAG
ANY RECIUMEMENT. MIMI OR CONDITION OF ANY CON1RACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTWJCATE MAY BEfSSU®OR
MAY PERTAIN, THE 94SURANCEAFFORDED BY THE POUCIES DESCRIBED HEREIN IS S CTTOALL THE TERMS EXCLUSIONS AND =anon OF SUCH
POLICES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
U▪ R TYPE OFINS AICE RIMY WARM CYt1E F! W11E Y11 IBfiB
A
X
( GLLLR®JiY
X CORNIERCIAL IRWERAL UAaIUTY
Ian OCCUR
X
GEbi AGGREGATE UNIT APPLIES Pat
n `= n
AUTO
ANY AUTO
ALL cmeas3 AUTOS
X SCHEOIA.EDAUTOS
H/REGAURRS
AUTOS
0171212011
0511212012
✓ iooaaaRENcE x IM0.000
PROEMS (Ea wawa* s
803) L7O (Airy iepeson) $ 5,000
PERSONALS ADM10LHURY $ 800.000
GENERAL AGGREGATE S 1,000.010
PRODUCTS - COMP/OP A G $ 1,000,000
012714648268990.
1999 CHEVROLET 03500 VAN
VAN IGCHG35R9911192297
011
0192 83011
X0,1
( N °SHALE LOOT
(Ea widen)
BODILY INJURY
(Pm'PeNm)
1,000,000
SOW OwRJRY
widen*
1,000,000
PROPERTY DAMAGE
>
1,000.000
GARAGE UMW/
ANY AUTO
AUTOCMLY-EAACCEENT
OTHER THAN
MAO CND':
EA/CC
AGG
EXCESS/ Ina JA LIABILITY
OCCUR n wets WOE
REIENTIONDEMUTURE
EACH OCCURRENCE
ANTE
s
$
$
$
S
WCIRKERSCONIPENSAMINIAND
Y/N
ANYPTOiRPAR
OFFICERMEMBER t�LUaEnr
l• a Met
mum
�yyy� 7T�ayy.
TWiYSLTIBT4I I
EL EACH ACCIDENT $
EL DISEASE - EA EINPIOYEF $
EEO - POLICY MOT $
E GICRIPTION OF °PEWWOWLOCATIONSrV6RC.ES/13CU AVOIRIBY woonsEtworrsPEcw. PROVIS
CERTIFICATE HOLDER
CANCELLATitNI
IYMAMI SHORES VILLAGE
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
SHOW.DANYOF THE ABOVE DESCRIBED WANES OE WRICE1.110 BEFORETHEEZPRIATIIN
DATE THERETO, WE =IWO B al1/J, TONNLL 10 011YB TTNTi -i
BDTICETD THE MI RK=NOLDERNImmTOTaHELE RUT EMMETT, 000OSHALL
IMPOSE NITOBUGATION OR LIAIRISIT OP ANY ICIND IIPON "WORM ITSAGENIS OR
REPRESENTATNES.
AURIORRED REPRESENTATIVE
Luis D Peters Agent
Acs 20 (2009/01)
019 5 ACORD CORPORATION. AN rigs reserved.
The ACORD name and logo we registered marks a1ACONI) 1001486 1328493 01-06 -2009