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MC-11-1780
Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 G � nspection Number: I NS P- 164897 Inspection Date: January 25, 2012 Inspector: Perez, JanPierre Owner: MARIA GONZALEZ, ISABELLA DCTDI r7ci r r Job Address: 9546 NW 1 Avenue Miami Shores, FL Project: <NONE> Permit Number: MC -9 -11 -1780 J Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: Addition /Alteration Contractor: 4 SEASONS AIR CONDITIONING & REFRIGERATION INC Phone Number Parcel Number 1131010240240 Phone: (786)255 -0486 Building Department Comments A/C INTALLATION 3 TON SPLIT SYSTEM --q .1,5 2---- Passed Inspector Comments ri Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until January 25, 2012 For Inspections please call: (305)762 -4949 Page 1 of 1 Sep 29 2011 1:47PM 9542728011 p.1 Per - - rnC—q --1 --PS CD This combination qualifies for a Pedarai Energy Efficiency rex Credit when placed In fi<f>:rdce between Feb 1Y, 2000 and Dec 31, 2011. Cerflflcateof Prod uct Rai n Msaa�.w..�wr wr - AHRi Certified Refer+anoe Number 1291792 Date: 9/28/2011 Product: Year -Round Air- Corditloner, Remota Air - oolid Condonsin0 Unit Outdoor Unit Mcdel Number: SILIC11i0361A* Indoor Unit Modal Number: ASPF42S 1 A * +TXV Marwfacturatt GOODMAN MANUFACTURING CO., LP. TradeNtrand runnel GOODMAN, .JAN AMANA DISE1MCTiONS, EVERREST, ONE HOUR AIR CONDITIONING AND HEATING, ENERGI A R Manufacturer responsible for the rating of Vile *Warn combination Is AOODMA.N MANUFACTURING CO., LP. Rated as follow' in accordance with AHRI Standard 2101240 -2008 for Unitary Alr•CondJlaning and Adr-Souro Heat Pump Equipment and subject to vertIlcadon of rating accuracy by AHRI-sponsored, Indepaetdartt, third ply testing: Cooling Capacity (Btul1): 34600 EER Rating (Cooling): '1340 SEER Rating (Cooling) 16.00 • Ream faovwwd by an imad I.mbite • vc1rduy mete 40 area:aney ptaankked dew. manes aoosmeenId um* wets. wad lo+tleetaa an invalatary ands. wenwenowsawnwel 01IM A *ER AIM doles not endorse MP prAducus) Ladd on Oda Certified, and makas no mpreasstdone„ woman, or guarani' allele,end aseutem ale noponalini r for, the pan Eskaa3nti&bo tasa.A1410eep iodyrdisdainale fordamapeaofanykinbsitilha; MAoltne Val &efafarmsnoaoforsPrangona!,Oleg ar uabodged Graf dais Wad oft die Csrtmado. Csttned nanny N wad * for 'Hade' and connounalarn Maud In Ow dk ary Advn w.eliddimclatama TERIae AND common This Cereiiealo tlrd it* cadent' use proprietary prsaduotr WAlitr. Toga Ceralkal. dun only ko used far irativ: lual, Mmaontlandeenralardal ashram' pupae& Tim ae4LMS WinnCJeatllbaie may not in whitlow Won. b raped wad; copied; elineernindasn entered soda eaanpabr database; or othentiei abed, ti Pay faun wnunnarasby any mum elourtfor!heaasar'a Indnackun. pe►ewan end {Derdldsr tray; utden6e. CERTIFICATE VE A: CATION The irdonrrsdOSfnr Ova madslafiadantntaona fkieidaoanbo verified slwr+a wh Irotonro+E, Aif -COii rdng,HogNng, dish on 'Many Wingat:" One *tad enter denting Certified usfusrrea Nimbi, sad tos data on i� and (1YItbaFrCMm1 InatilUto Wean theaeeassu was bend. ethical* Met stove, and *a Canillona No.. rddoh M balled beiow. 432011 Alr- Conditions rtg, Heating, and Refrigeration Institute CERTIFICATE NO.: 12961Th 424i1e8 • t c1 ■i aiallemaaawa .,_ -.. .... _ Xtdd 13C2t3Skl'I wdH • -14;4-41.. d 4est -I TO. .8—a- Project Address Miami Shores Village 10050 N.E. 2nd Avenue NW Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Parcel Number Applicant 9546 NW 1 Avenue Miami Shores, FL 1131010240240 Block: Lot: ISABELLA PETRUZELLI MARIA 1 Owner Information Address Phone CeII ISABELLA PETRUZELLI MARIA GONZAL 9546 NW 1 Avenue MIAMI SHORES FL 33150 -1702 Contractor(s) Phone CeII Phone 4 SEASONS AIR CONDITIONING & RE (786)255 -0486 Tons: 3 Additional Info: A/H & COND UNIT INSTALLATION Classification: Residential Approved: In Review Comments: Date Denied: Scanning: 1 Date Approved: : In Review Type of Work: MECHANICAL Fees Due CCF DBPR Fee DCA Fee Education Surcharge Permit Fee Scanning Fee Technology Fee Total: Amount $1.80 $2.00 $2.00 $0.60 $100.00 $3.00 $2.40 $111.80 Pay Date Pay Type Amt Paid Amt Due Invoice # MC-9-11-42139 10/11/2011 Check #: 1310 $ 61.80 $ 50.00 09/28/2011 Check #: 1308 $ 50.00 $ 0.00 Available Inspections: Inspection Type: Ventilation Final Hood Rough Duct Underground 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. October 11, 2011 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Date October 11, 2011 1 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 Permit No. Master Permit No. Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): 'S�l\q �e off.`l i Phone #: 30S -q-SIA - �'+°1G1 Address: R 511 is (LILO \ A c__. City: iOmA ■ S�cz� State: Zip: 3315 Tenant/Lessee Name: ` Phone#: Email: I Saheilq�Je VA1clk(Q (cmCG.S-t ne\' JOB ADDRESS: CI SLI (., k) � )51- �� e City: Miami Shores County: Miami Dade Zip: 3 )3 0 Folio/Parcel #: I d _-31 O -0521 -� LI® Is the Building Historically Designated: Yes NO V Flood Zone: CONTRACTOR: Company Name: s2�SD�7s 4'7 delis 7/d'/�f I Phone #: Arb. Ps''d5<r40 Address: / /0 • 1/ e2 City: "ill Ac. Qualifier Name: f ehlaV e/Se-O State Certification or Registration #: State: L0.4i.1944 �2ve;e CAd / ',6 2-cose' Contact Phone #: 73 *' PFC. a '/f5° Email Address: Zip: 3304a- Phone#: 7f°i ?'4747' ojle° Certificate of Competency #: AVaa/1 Seasons a��d�oo� Qom DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ Type of Work: DAddress ❑Alteration Description of Work: �, .I ( ) Y1 ∎4c 1 i J b.. CL, ita-kcot, /2 eoci 1 © Square/Linear Footage of Work: °l f Jt °)i ) ,a0 0 "(New URepair/Replace ❑Demolition • ******** * * *** * * ** * * * * * * * * * * * * * * * * * * * * ** ***** * * * * * * * * * * * * * ** * * * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ �' V� ' �CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ C TOTAL FEE NOW DUE $ PI ' (110 Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) ) Mortgage Lender's Address City I 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 poste 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 The foregoing instrument was ac day , 2011 , who is I Ogks- sonally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print My Commission Expires: Contractor The foregoing ' strument was acknowledged before. dayo ,2011 , whois pers nally known to me or who has produced am. as identification and w o did take an oath. NOTARY PUBLIC: Sign: Print: My Commission Ex APPROVED BY APlans Examiner (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Structural Review Zoning Clerk Miami Snores 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): §-5/' iGt% / Roe .. re-)iti,-.a 5 df l 3- ISO City: Miami Shores Village County: Miami Dade Zip Code: 3/.0 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 MANUFACTURER 6,e:900k9Iii-01A/ M,br✓* AHU or PKG. UNIT MODEL # A. SpP 9a&®/k COND. UNIT MODEL # SS$ /6 o / KW HEAT X ,k 1A/ NOM TONS .3 AHU CU PKG 1) M.C.A AHU CO, PKG AHU CU PKG 2) M.O.P AHU CU PKG AHU CU PKG 3) VOLTS AHU CU PKG PKG UNIT / / PKG UNIT / / EERISEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4 "CONCRETE SLAB 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: I) ,r‘.5 Ki r C Q 12 �3+CJ&:4 i, Phone try State Certificate or Register tion N. ; ' /f7' r' '' Certificate o ?Competency N. Date: 9/ -2/// Signet (Qualifier's sig re only) Sep 28 11 06:40e furniture boutique 305 623 8660 p.1 4 Seasons Air Conditioning & Refrigeration, Inc. Florida State Licensed & Insured CAC1111626S t to w SO' street :1liclvah. FL 33012 Voice 7:K735.046 Pax: 305.$:1 905 t PROPOSAL Proposal Submitted to: Isabella Pettuzzelli September, 27`s. 20 i 1 JOB LOCATION: 9546 NW I"Avenue, Miami Shores, FL 33150 We hereby propose to parts. material and skilled labor necessary to perform the installation of a three (3) ton split system air conditioning unit , Manufacturer •-Goodrnan.Amana. nodele ASPF426016 /SSX 1 60361 for the sum of S 2.300.00 ELECTRICAL INSTALLATION AND WIRING MUST BE PERFORMED BY OTHER. CUSTOMER IS RESPONSIBLE IN THE HIRE OF AN ELECTRICAL CONTRACTOR. TERMS: All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practice. Any alteration or deviation from above specifications involving extra cost will be execuud only upon written orders, and will become an extra charge over and above the estimate. MI agreements are contingent on strikes. accidents or delays beyond our control. NOTE: This proposal may be withdrawn by us if not accepted within 30 days. ACCEPTANCE OF PROPOSAL The above price, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do *tile work as specified above. Customer signature: —5-WI G Date: ,q Customer name: (Prin* -1 1 i 3 / Comptny Authorized Representative: Viet Rubio-Bayer J (. Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Ronda 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES VILLAGE BLDG DEPTI D. COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXCEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY: A. COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPT). D. COPY OF WORKER COMP INSURANCE (EITHER CERTIFICATE OR EXEMPTIONI YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR'S INFORMATION BUSINESS NAME: r• o Cam ►�, °F� `s too, hC BUSINESS ADDRESS: ) ■o CITY k STATE ¶` ZIP CODE 3 5 0 i a BUSINESS PHONE: (c-)"SL) `-I `6L, FAX NUMBER E600) 3-31 —CO I') CELL PHONE RN., )35( QUALIFIER'S NAME: 1S rC. CO 5 Ubls7 QUALIFIER'S LIC NUMBER: C f\C- t E -MAIL ADDRESS (IF APPLICABLE): \-\OJ 5C-4.53+1.5 Coi Created on3119109BYMILDV1RV3126109MLDV STATE OF FLORIDA A DEPARTMENT OP BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD .,,.., 1940 NORTH MONROE STREET TALLAHASSEE FL 323990783 RUBIO, FRANCISCO 4 SEASONS AIR CONDITIONING & REFRIGERATION INC 110 W 50 STREET HIALEAH FL 33012 -3720 Congratutetaefls! W'itl' this iicenss yam:, bey a ors th, Hearty one ntilt:c Floridians licensed by the Oopenment Of Eiusir ;'ss and Pre essionai RegalatiOn Oar professionals and businesses range tarn arl:rt to yActtt brokers from baoxers to barbeque restaurants. anon May xee,. g.lortca's eranOrny strong. Every day we wok to improve the way we do bossiness i cider to serve you better.; Fur it arruat Qn about our services, ptoa e i onto wwy.myfloridalicense.com There y s-.d can rind more information ebout our dwwisiil-s and the reoubatinrEs thai istpact you sutrscrit to depaitmentnewsietters :re earn more about titer Depart'' tent`s in+ttcttnses_ fur rtiss:or at the Department is: License Efficiently, Regulate Fairly. We constantly s!r v; It) serve you better sc+ that you can serve your customers. Thank you for doing :busmen c sans in Florida end oongrattilations on your row license° DEP - — •9 DETACH HERE t850) 487 -1395 STATE Of- FLORA EPARTZ1T OF BUSINESS AND PROPESSION AL `REGULATION CAC1016268 i °29/10 0901S340 CERTIFIED AIR CONS CONTS i t 2IO f FRANCISCO 4 SEASONS AIR CONDITIONING . IS REF ua. AUG 31, IRS proilzaz n a: - 4S5.;13. 2012 L3!;' STATE OF FLORIDA TMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY ICE ING BOA BE 11100529004 27 Ep1AiE ; ATCH 'Nt,t3P. ICENSE NBR X29/2010 ¢098183404 ICAC18162 The CLAES .A AIR CONDITIONING CONTRACTOR Named bra os IS CERTIFIED Under the provisions cf Chapter 489 FS. Expire :ion date: AUG i1, 2012 Ri3BIO, FRANCISCO 4 SEASONS AIR CONDITIONING /0 W SU STREET :IALEAH FL 33012 -" CHARLIE CRIST GOVERNOR FRI(SEi 720 • DISPLAY t S FEE ,! RE C BYLAW CHARLIE 'LI t =TERM SECRETARY MIAMI- DADE!COUNTY TAX COLLECTOR 444 W; FLAGLER ST. ist FLOOR MIANI(; FL 33130 2010 LOCAL BUSINESS TAX RECEIPT 2011 MIAMI -DADE COUNTY - STATE OF FLORIDA EXPIRESSEPT. 30, 2011 MUST BE DISPLAYED AT PLACE OF BUSINESS PURSUANT TO COUNTY CODE CHAPTER 8A - ART. 9 & 10 FIRST -CLASS U.S. POSTAGE PAID MIAMI, FL PERMIT NO. 231 646666-8 THIS 18 NOT A BILL — DO NOT PAY RENEWAL BUSINESS NAM/ LOCATION RECEIPT NO. 673561 -8 4 SEASONS AIR CONDITIONING & STATE# CAC1816268 REFRIGERATION INC 110 W SO ST 33012 HIALEAH OWNER 4 SEASONS AIR COND & REFRIG INC Sec. Type et Business WORKER /S 196 AS MECHANICAL CONTRACTOR 1 LOCAL THIS IS ONLY BUSINESS MEWL IT DOES ANY HOLDER TO EXISTING REGULATORY Y CO "LINTY CITIES. ,rro DO NOT FORWARD DOES 11' EXEMPT THE HOLDER FROM ANY OTHER PERMIT ULCIENSE REQUIRED EY LAW BUS 18 NOT A CERTIFICATION OF THE ROLDERBHOLDERS QUALIFICA- PAYMENT REDER+ED IIIIAW-DADEWIWITY COLLECTOft 07/06/2010 09010394001 000045.00 SEE OTHER SIDE 4 SEASONS AIR CONDITIONING & REFRIGERATION INC FRANCISCO RUBIO PRES 110 W 50 ST HIALEAH FL 33012 ACC)RO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 09/27/2011 PRODUCER TWFG INSURANCE SERVICES INC 3323 NW 55TH STREET FT LAUDERDALE FL 33309 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED 4 SEASONS AIR CONDITIONING & REFRIGERATIO 110 W 50TH STREET HIALEAH FL 33012 INSURER A LLOYDS OF LONDON INSURER B: N/A INSURER c: N/A INSURER 0: N/A INSURER E COVERAGES 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 S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTA AUU L WIRD TYPE OF INSURANCE POLICY NUMBER ATE (. , k4 a4441. fir' 1 '4 : t(. PI r` LIMITS $ 1000,000.00 GENERAL U BILm Z COMMERCIAL GENERAL LIABILITY AMTE003821 07/08/2011 07/08/2012 EACH OCCURRENCE PREMISES (Ea ) $ 50,000.00 CLAIMS MADE V OCCUR MED EXP (My one person) $ 5,000.00 Dj PERSONAL & ADV INJURY $ 1000,000.00 GENERAL AGGREGATE s 2000,000.00 GENJL AGGREGATE LIMIT APPLIES PER: 7 I POLICY n PROJECT I I LOC PRODUCTS - COMP /OP AGG $ 1000,000.00 DEDUCTIBLE 500 O BIS LIABILITY ANY AO ] ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS EaaMB dent) LIMIT $ BODILY INJURY (Per Parson) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ —'�I I 1L GARAGE LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ Li 1J EXCESS 1 UMBRELLA LI�ITY ] OCCUR CLAIMS MADE DEDUCTIBLE 7 RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ WORKERS EMPLOYERS' ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER ((1Mandaes�ry SPECIAL N� ON AND UABIL EXCLUDED'? rif -I OY �& n OE R E.L. EACH ACCIDENT $ L____ In NH) PROVISIONS below EL DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY UNIT $ OTHER DES8MIPflON OF OPtRATIONS I LOCA IONS 1 Vt tC_ES 1 EXCLUSIONS ADDED BY tNDORSEM NT 1 SPEUAL PROVISIONS 91111- AIRCONDITIONING SYSTEMS OR EQUIPMENT SERVICNG, INSTALLATION & REPAIRING 95648 - HEATING OR COMBINED HEATING & AIRCONDITIONING SERVICNG, INSTALLATION & REPAIRING 98636 - REFRIGERATION SYSTEMS OR EQUIPMENT INSTATLLATION, SERVICING OR REPAIRING 1 ) ERTIFICATE HOLDER CANCELLATION MIAMI SHORE VILLAGE BUILDING DEPT. 10050 NE 2ND AVENUE MIAMI SHORE FL 33138 ACORD 25 (2009101) SHOULD ANY OF THE ABOVE DESCRIBED PO DATE THEREOF, THE ISSUING INSURER WILL ENDEA NOTICE TO THE CERTIFICATE HOLDER ' TO IMPOSE NO OBLIGATION OR REPRESENTATIVES. NCELLED BEFORE THE EXPIRATION TO MAIL 30 DAYS WRITTEN . BUT FAILURE TO DO SO SHALL THE INSURER, rrs AGENTS OR Page 1 of 2 ID 1988 -200 _. CORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks of ACORD 09 -30 -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: PERSON: 09/30/2009 EXPIRATION DATE: 09/30/2011 RUBIO FRANCISCO FEIN: 261090174 BUSINESS NAME AND ADDRESS: 4 SEASONS AIR CONDITIONING & REFRIGERATION INC 110 W 50TH STREET HIALEAH FL 33012 SCOPES OF BUSINESS OR TRADE 1— CERTIFIED AC CONTRACTOR * 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 440.05112), 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 440.05(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. QUESTIONS? (850) 413-1609 WC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 10 -03 -2011 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: 10/03/2011 EXPIRATION DATE 10/02/2013 RUBIO FRANCISCO FEIN: 261090194 BUSINESS NAME AND ADDRESS: 4 SEASONS AIR CONDITIONING & REFRIGERATION INC 110 W 60TH ST HIALEAH FL 33012 -3720 SCOPES OF BUSINESS OR TRADE 1- HVAC CONTRACTOR 2- CERTIFIED AC CONTRACTOR IMPORTANT: Pursuant to Chapter 440 . 06114), F.S., an officor of a corporation who elects exemption from tilts chapter by filing a certificate of election ander this section may net recover benefits or compensation ander this chapter. Pursuant to Chapter 440.06112), F.S., Certif(cotes 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 440.06113), F.S., Notices of election to be exempt and certiflcates 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 certiftcate to meet the requirements of this section. DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01 -11 QUESTIONS? (850) 413 -1609 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE 10/03/2011 EXPIRATION DATE: 10/02/2013 PERSON: FRANCISCO RUBIO FEIN: 281090194 BUSINESS NAME AND ADDRESS: 4 SEASONS AIR CONDITIONING & REFRIGERATION INC 110 W 50TH ST HIALEAH, FL 33012 -3720 SCOPE OF BUSINESS OR TRADE 1- HVAC CONTRACTOR 2- CERTIFIED AC CONTRACTOR IMPORTANT F 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. Pursuant to Chapter 440.05(121, F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed on E the 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 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. 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