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MC-11-2179Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INS P- 166985 Permit Number: MC -11 -11 -2179 Scheduled Inspection Date: March 05, 2012 Inspector: Perez, JanPierre Owner: Rengstl, Jack Job Address: 1496 NE 104 Street Miami Shores, FL Project: <NONE> Contractor: EMPIRE AIR INC Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1122320320340 Phone: (786)236 -9043 Building Department Comments RE- INSTALL TWO EXHAUST FANS ,0t 1611 6,13et -1� Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments March 02, 2012 For Inspections please call: (305)762 -4949 Page 8 of 30 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. M/ II—' a/119 PERMIT APPLICATION Master Permit No. 1/�- 20oc.3 FBC20 Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): j_..t. .r., �< ��r. Phone#: •77 27lo " Z276- ')�" Address: /I% HE /otf se City: f'it 2.yy1 t (Li c 5; State: ,FL Tap: 3 3 / . X Tenant/Lessee Name: Phone#: Email: P JOB ADDRESS: /11% / ()I 56 City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: %/ — 2 Z 0 32.— 0 3 4jp Is the Building Historically : Yes NO Flood Zone: CONTRACTOR: Company Name: Address: _ &'� A(J ih 1 & ®,� City: , iarn .' Qualifier Name: 05r,✓t scat State Certification or Registrationll Contact Phone#: DESIGNER: Architect/Engineer: Pe /1 Phone#: State: YL Zip: 33 c� /, ' Phone#: S 43 ,r�Joeil, CAC 2 q Certificate of Competency #: • A6-5-24, 7 a2%1 ��i� 23 ® Email Adder: frVe'/ y o .ce Phone#: Value of Work for this Permit: $ CUD, SquarelUnear Footage of Work: Type of Work: OA. ddress ()Alteration Description of Work: ONew ORepair/Replace ODemolition *** **** ins s Submittal Fee $ Permit Fee $ ®` CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ 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 insp tion which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will ii be approved and a reinspection fee will be charged. Signature Owner or Agent The foregoing instrument was ackn wledged l re me this day of 1" bar' 20 tk , by Ji ' '7 who is personally known to me or who has produced As identification and who did take an oath. NOTARY PUBLIC: 4ti��N� +p ia' ti0, 2pre' 4 /11,.„ Sim s It Print: ,91'4.‘,,t-' ' _ w• • �•� <: My Commission Expires: p,,,% e #. S � • asaoua_, -, a*,x ,x�a+� *,xm�lsxNi�ssi*a�s� L/ 9-',' Contractor The foregoing instrument was acknowledged before me this I \� day of V , 20 (t , by �� a t d who is Pers onally known to me or who has produ as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: My Co ;,jreFRAN ISCO VALDES MY COMMISSION # E005558 EXPIRES June 30, 2014 APPROVED BY Plans Examiner Structural Review (Revised 07 /10/07)(Revised 06/10 /2009)(Revised 3/15/09) Zoning Clerk Accwor CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 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 Premium Insurance Group P 1622 West 68th Street Hialeah, FL 33014 Phone (305)821 -8777 Fax (305)821 -0339 CONTACT NAME: PHONE L 821 -8777 FAX 821 -0339 (A(C. No Ext • ( FAX No): ADDRESS: premiumins@gmail.com INSURER(S) AFFORDING COVERAGE NAICS INSURER A: GANADA INSURANCE CO UNDERWRITERS INSURED EMPIRE AIR INC 8640 NW 188 TERR # 3405 HIALEAH, FL 33015 INSURER B 07/30/2011 INSURER C: EACH OCCURRENCE INSURER D : n COMMERCIAL GENERAL LABILITY • • CLAIMS -MADE n OCCUR INSURER E: $ INSURER F: $ 5,000.00 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 PER OD 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 POUCY NUMBER POLICY EFF (MM(DD/YYYY) POLICY EXP (MMIDDIYYYY) UNITS A GENERAL LIABILITY 0185FL00020540 07/30/2011 07/30/2012 EACH OCCURRENCE $ 1,000,000.00 n COMMERCIAL GENERAL LABILITY • • CLAIMS -MADE n OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 al GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMITAPPLIES PER: • POLICY • JECTT • LOC PRODUCTS - COMP /OPAGO $ $ AUTOMOBILE LIABILITY • ANYAUTO • ALLYOWNED • SCHEDULED • HIRED AUTOS • AUTO NED ■ ■ (Ea COMBINED d SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ R ROaPEI J AMAGE F rltl $ $ • UMBRELLA LAB • OCCUR • EXCESS UAB • CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ • DED . RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A ■YSILIT S • FOR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ If yes describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT 10050 NE 2 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 REPRESENT ACORD 25 (2010/05) QF ©1988 -2010 AQORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 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 DEPT) 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 EXEMPTION) 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: ?Jam) ;LE , BUSINESS ADDRESS: Y& AAGe) fps I(em jz J CITY Aea STATE FL ZIP CODE 3 3 bfr BUSINESS PHONE: (%A4) Z3 X413 FAX NUMBER (3O. ) 3253 24 ?3 - CELL PHONE ( P14,) 2-36 ` 0'V3 QUALIFIER'S NAME: a",10ti-il QUALIFIER'S LIC NUMBER: c. Ac. / U i 6p67- ' 2G% E -MAIL ADDRESS (IF APPLICABLE): ki.ved127-6-evvelat e ahoo , Created on 3119109 BY MLDV 1 RV 3/ 09 MLDV