MC-11-22061 1 - 1 0 3
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 167125
Permit Number: MC -11 -11 -2206
Scheduled Inspection Date: June 27, 2012
Inspector: Perez, JanPierre
Owner: , SHORES SQUARE INVESTMENTS
Job Address: 9025 BISCAYNE Boulevard
Miami Shores, FL 33138 -0000
Project: <NONE>
Contractor: RESULTS AIR CONDITIONING CO
Permit Type: Mechanical - Commercial
Inspection Type: Final
Work Classification: New
Phone Number
Parcel Number 1132060110051 -25
Phone: 305 -886 -2534
Building Department Comments
INSTALL CARRIER SPLIT A/C SYSTEMS ALL WITH 8KW
HEAT, DUCTWORK AND BATHROOMS EXHAUST FANS
q-Ig
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
p2 (51_‘„ ale
June 26, 2012
For Inspections please call: (305)762 -4949
Page 6 of 36
Balance Certification Rep
NATIONAL
BALANCING
COUNCIL-
6/25/2012
PROJECT
PROJECT NAME
Fit 4 Life
ADDRESS
9025 Biscayne Blvd.
Miami, FL 33138
CUSTOMER
Results A/C
Fit 4 Life
SYSTEM
All Systems
READINGS BY
Sergio Aguirre
JOB NUMBER
The data presented in this report is an exact record of
system performance and was obtained in accordance with
the NBC Standard Procedures. Any variances from
design quantities which exceed NBC tolerances are noted
throughout this report.
The air distribution systems and water distribution
systems if applicable, have been tested and balance and
final adjustments have been made in accordance with
NBC "Procedural Standards for Testing, Adjusting,
Balancing of Environmental Systems" and the project
specifications.
NBC TAB FIRM: Mechanical Systems & Controls Inc.
TAB SUPERVISOR: Luis Prats
REG NUMBER: 0177
CERTIFICATION EXPIRATION DATE: July -17 -2014
COMMENTS:
TB -12 -25
Luis U Prate
Mechanical Systems
& Controls Inc,
#1177 Expires 07/17/2014
NA;IONAL BALANCING COUNCIL
1 of 18
NATIONAL
BALANCING
COUNCIL'TM
NBC Air and Hydronic Balancing Certification
The National Balancing Council is committed to providing and maintaining a
comprehensive set of values, standards, practices, and procedures governing the field
of testing, balancing, and adjusting commercial environmental systems. Our
members pledge to faithfully uphold the highest standards of integrity and
professionalism in the industry as a requisite to certification. NBC stands fully
dedicated to the advancement of the testing and balancing field, and the support of its
membership through training, communication, and leading -edge methodology.
NBC Philosophy
The distinguishing characteristic of an NBC certified technician is the ability to
prescribe solutions to the endless field conditions that prohibit an HVAC system
from achieving balance and maximum field performance. Nearly all NBC
technicians have extensive field experience in HVAC system repair, installation or
service and possess skills required to troubleshoot the most difficult field conditions
that can be revealed by their testing. These technicians test, diagnose and maximize
the performance of over 200,000 HVAC systems per year.
Practical Standards
Each certified technician prescribes to National Balancing Council Practical
Standards and Procedures. These cover a full range of testing, balancing, adjusting,
and diagnostic practices backed up by NBC reporting forms.
CSERTM and HSERTM
In addition to traditional independent test reports, NBC Technicians can provide an
efficiency rating of the installed system. These ratings can be compared to the
manufacturer's equipment efficiency ratings to offer a new view of system
performance that is not offered anywhere else in the HVAC industry. CSERTM
represents Cooling System Efficiency Rating and HSERTM is Heating System
Efficiency Rating.
Technical Support and Backup
NBC provides its certified technicians with toll free technical support. New field
conditions affecting HVAC system performance are uncovered daily. Experienced
support is available as a benefit of certification. Architects, engineers, and building
maintenance staff are welcome to contact us with their questions and comments as
well at 800- 633 -7058.
2 of 14
CEI3'I'IFIE1D,
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
NATIONAL BALANCING COUNCIL)
Why MSC
Experienced
Staff
Over 5 years of
Service
Quick
dotes
NBC Certified
Easy to read
Reports
Serving 111 of
Sontli Florida
Responsive
Service
Advanced
Instruments
Large or Sn�lall
Projects
PII. 786- 228 -8925
FAX 786- 228 -8348
STAFF
Luis Prats
Vice - President
Luis brings to your projects over balancing experience. He
has been a controls Contractor for over 5 years and a
Mechanical Engineer for over 17 years. He holds an NBC air
and hydronic balancing certification with an emphasis in
engineered solutions through diagnostics for HVAC systems.
Luis is also a LEED AP and an expert in duct renovation,
reaching beyond the typical air balancing limits, delivering
complete system solutions and creating measured system
performance.
Victor Gomez
President
Victor has design & implemented controls strategies for
over 200 commercial and industrial HVAC systems over
the past 12 years. He specializes in performance controls,
and system evaluations. He holds an Mechanical &
Electrical Contractor's License and has been an Electrical
Engineer for the last 12 years with an emphasis in
engineered solutions through diagnostics for HVAC
systems. Victor is also a LEED AP and an expert in duct
renovation, reaching beyond the typical air balancing limits,
delivering complete system solutions and creating measured
system performance. Victor Holds an NBC air and hydronic
balancing certification.
3of14
CERTIFIEDD
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
NATIONAL BALANCING COUNCIL I
Schedule of Tools and rlest Instruments
NATIONAL
BALANCING
COUNCIL'
Instrument Manufacturer \1ndel
Air Capture Hood
Air Multimeter
Pitot Tubes
Electrical Meter
Tachometer
Thermocouples
Theatrical Fog
Hydronic Meter
TSI
Testo
Dwyer
AEMC
Testo
Testo
NCI
Alnor
8371
435-4
160
502
Model 460
Various
SP -2
HM680
Serial
70915122
1658950/903
None
25358JACT
38807427/104
Various
71002014
Calibrated
Jul -11
Jul -11
N/A
Jul -11
Jul -11
N/A
N/A
Jul -11
Description
Hood
Velocity /Pressure/Temperature /Humidity
18 ", and 24"
Amp/Volt/Temperature /Ohms
1- 10,000 RPM. Non - Contact
Multiple Ranges and applications
Smoke Stick
Hydronic Differential Gauge
4of14
CFM Cubic Feet per Minute
Diameter
Supply
Return
Exhaust
Direction of Airflow
T Thermostat/control
D Damper
Volume Damper
OBD Opposed Blade Damper
BD Backdraft Damper
Unit Location
CR Ceiling Retum
Retum Duct
Supply Duct
OSA Outside Air
Equipment Designation
SP Static Pressure
SWS Sidewall Supply
SWR Sidewall Retum
CS Ceiling Supply
HP Horsepower
V Volts
FLA Full Load Amps
SF Service Factor
BHP Brake Horsepower
CU Condensing Unit DNA Data Not Available
CC Cooling Coil
AH Air Handler
L Louver
DNL Data Not Listed
NA
NT
NATIONAL
BALANCING
COUNCIL"
DATE
6/25/2012
PROJECT
Fit 4 Life
SYSTEM
All Systems
READINGS BY
Sergio Aguirre
JOB NUMBER
TB -12 -25
ots
co
2
W V
Z
J
J 0
a�
(1)
Z z
Q 0
W
2
00
CO
N
N
to
00
ti
co
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10
N
0?
Oo
m
00
ti
0)
0
Not Accessible
Not Taken - no valid
location
ERTIFIE
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
ATIONAL BALANCING COUNC
5of14
UNIT DATA
DESIGN
ACTUAL
COMMENT
Unit Designation (TAG)
AHU -1
AHU -1
DATE
Unit Manufacturer
Carrier
Carrier
Unit Model Number
FY4ANF060T00
FB4CNF048
6/25/2012
Unit Serial Number
4711A83440
PROJECT
FAN /AIRFLOW DATA
DESIGN
ACTUAL
COMMENT
Fit 4 Life
Supply Air Flow (cfm)
1600
N/A
No Valid Traverse Could Be Taken
SYSTEM
Outside Air Flow (cfm)
402
390
Retum Air Flow (cfm)
1198
940
All Systems
Total Outlet Airflow (cfm)
1330
READINGS BY
External Static Pressure
0.4
0.49
Sergio Aguirre
Fan Speed
HIGH
JOB NUMBER
MOTOR DATA
DESIGN
ACTUAL
COMMENT
TB -12 -25
Motor HP (or Kw)
3/4
3/4
RPM
N/A
Motor Volts (V)
208
208
Motor Amps (A)
2.03
Phase (PH)
1
1
Operating Frequency (Hz)
60
60
Motor Service Factor
N/A
Heater Size (Kw)
10
N/A
Units Were Set To High Speed
Luis U Prats
Mechanical Systems
& Controls Inc.
e 0177 Expires 07/17/2014
N- TIONAL BALANCING COUNCII
6 of 14
SYSTEM TO BE BALANCED TO
SYSTEM DESIGNATION (TAG)
SYSTEM TOTAL DESIGN AIRFLOW
10 %
AHU -1
1600
Number
1
2
3
4
5
6
7
8
Area Served
Corridor
Nurse Station
Waiting Area
Waiting Area
Waiting Area
Waiting Area
Reception
Reception
Grille
Type
CS
CS
CS
CS
CS
CS
CS
CS
Size
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
Design
CFM
100
200
220
220
220
220
220
220
AK Factor
Test 1
186
171
151
160
151
150
143
218
Final CFM
84
163
182
180
179
184
183
181
% of
Design
DATE
6/25/2012
PROJECT
Fit 4 Life
SYSTEM
All Systems
READINGS BY
JOB NUMBER
TB -12 -25
ets
Cl)
G
W Iv
Z
c
co J
J 0
0 '-
Z
0
C)
s
c)
W
2
Grilles Were Proportionally Balanced
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
ATIONAL BALANCING COUN
7of14
sir w viii
UNIT DATA
DESIGN
ACTUAL
COMMENT
Unit Designation (TAG)
AHU -2
AHU -2
DATE
Unit Manufacturer
Carrier
Carrier
Unit Model Number
FY4ANF060T00
FB4CNF048
6/25/2012
Unit Serial Number
4911A82993
PROJECT
FAN /AIRFLOW DATA
DESIGN
ACTUAL
COMMENT
Fit 4 Life
Supply Air Flow (cfm)
1600
N/A
No Valid Traverse Could Be Taken
SYSTEM
Outside Air Flow (cfm)
394
415
Retum Air Flow (cfm)
1206
972
All Systems
Total Outlet Airflow (cfm)
1387
READINGS BY
External Static S.P (inwc)
0.4
0.4
Sergio Aguirre
Fan Speed
HIGH
JOB NUMBER
MOTOR DATA
DESIGN
ACTUAL
COMMENT
TB -12 -25
Motor HP (or Kw)
3/4
3/4
RPM
NA/
Motor Volts (V)
208
208
Motor Amps (A)
2.06
Phase (PH)
1
1
Operating Frequency (Hz)
60
60
Motor Service Factor
N/A
Heater Size (Kw)
10
N/A
Units Were Set To High Speed
*V T LoL° co
C M
2 t000
W •
V �� N
I— Z — LL CO
.1 0 u..in
are •g
Q I-- c °°
— o�
Z0 .cN
Q V CO 0) h
♦_
v N v
W rte•
2 o0
iV
Luis U Prats
Mechanical Systems
& Controls Inc.
#1177 Expires 07/17/2014
NAZIONAL BALANCING COUNCIL
8of 14
SYSTEM TO BE BALANCED TO
SYSTEM DESIGNATION (TAG)
SYSTEM TOTAL DESIGN AIRFLOW
10%
AHU -2
1600
Number
1
2
3
4
5
6
7
8
Area Served
Corridor
Waiting Area
Waiting Area
Waiting Area
Waiting Area
Corridor
Reception
Reception
Grille
Type
CS
CS
CS
CS
CS
CS
CS
CS
Size
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
Design
CFM
110
230
230
230
230
110
230
230
AK Factor
Test 1
161
194
184
183
156
157
127
195
Final CFM
98
206
209
210
191
91
189
193
% of
Design
91%
91%
DATE
6/25/2012
PROJECT
Fit 4 Life
SYSTEM
All Systems
READINGS BY
JOB NUMBER
TB -12 -25
otS
co
2
w (j
co
>-
_1 O
vH
— Z
ZO
Q
♦_
V
w
2
ERTIFIE
REMARKS Grilles Were Proportionally Balanced
Luis U Prats r'<
Mechanical Systems
& Controls Inc,
0177 Expires 07/17/2014
IONAL BALANCING COUNCI
9of14
UNIT DATA
DESIGN ACTUAL
COMMENT
Unit Designation (TAG)
AHU -3
AHU -3
DATE
Unit Manufacturer
Carrier Carrier
Unit Model Number FY4ANF060T00 FB4CNF060
6/25/2012
Unit Serial Number 4911A83608
PROJECT
FAN /AIRFLOW DATA
DESIGN ACTUAL COMMENT
Fit 4 Life
Supply Air Flow (cfm)
2000 N/A No Valid Traverse Could Be Taken
SYSTEM
Outside Air Flow (cfm)
295 284
Retum Air Flow (cfm)
1705 1066
All Systems
Total Outlet Airflow (cfm)
1350
READINGS BY
Extemal Static S.P (inwc)
0.4 0.41
Sergio Aguirre
Fan Speed HIGH
JOB NUMBER
MOTOR DATA
DESIGN
ACTUAL
COMMENT
TB-1
2 -25
Motor HP (or Kw)
3/4
3/4
RPM
N/A
Motor Volts (V)
208
208
Motor Amps (A)
2.31
Phase (PH)
1
1
Operating Frequency (Hz)
60
60
Motor Service Factor
N/A
Heater Size (Kw)
10
N/A
Units Were Set To High Speed
06
co
2
LV 0
cn
Z
cn
J
J0
a re
v
Z z
0
a�
s
w
d
M
00
co
N
N
t0
O
LL
N
00
o
N
o 0
t
w
v
0
E R T I F I E D
Luis U Prats
Mechanical Systems
& Controls Inc.
0177 Expires 07/17/2014
NATIONAL BALANCING COUNCL.
10of14
SYSTEM TO BE BALANCED TO
SYSTEM DESIGNATION (TAG)
SYSTEM TOTAL DESIGN AIRFLOW
10%
AHU -3
2000
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Area Served
Office #4
Exam Room #7
Exam Room #8
Exam Room #5
Exam Room #6
File Area
Lab Area
Corridor
X -Ray
Restroom
Pharmacy
Storage
Restroom
Exam Room #4
Exam Room #3
Exam Room #2
Exam Room #1
Grille
Type
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
Size
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
Design
CFM
140
130
130
130
130
120
170
50
170
40
140
90
40
130
130
130
130
AK Factor
Test 1
105
129
118
107
133
122
Final CFM
112
105
101
103
102
96
Does Not Exist
79
106
43
127
79
74
142
106
116
41
131
33
111
73
34
105
100
103
Does Not Exist
% of
Design
DATE
6/25/2012
PROJECT
Fit 4 Life
SYSTEM
All Systems
• READINGS BY
JOB NUMBER
TB -12 -25
co
2
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= Z
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0
W
2
to
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0
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(0
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N
REMARKS Grilles Were Proportionally Balanced
ERTgFIE
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
NATIONAL BALANCING COU
11 of 14
UNIT DATA
DESIGN
ACTUAL
COMMENT
Unit Designation (TAG)
AHU-4
AHU-4
DATE
Unit Manufacturer
Carrier
Carrier
Unit Model Number
FY4ANF060T00
FB4CNF060
6/25/2012
Unit Serial Number
4911A83659
PROJECT
FAN /AIRFLOW DATA
DESIGN
ACTUAL
COMMENT
Fit 4 Life
Supply Air Flow (cfm)
2000
N/A
No Valid Traverse Could Be Taken
SYSTEM
Outside Air Flow (cfm)
393
400
Retum Air Flow (cfm)
1607
1009
All Systems
Total Outlet Airflow (cfm)
1409
READINGS BY
External Discharge S.P (inwc)
0.4
0.5
External Static S.P (inwc)
0.009
Sergio Aguirre
HIGH
JOB NUMBER
MOTOR DATA
DESIGN
ACTUAL
COMMENT
TB -12 -25
Motor HP (or Kw)
3/4
3/4
RPM
N/A
Motor Volts (V)
208
208
Motor Amps (A)
2.21
Phase (PH)
1
1
Operating Frequency (Hz)
60
60
Motor Service Factor
N/A
Heater Size (Kw)
10
N/A
Units Were Set To High Speed
oes
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W V
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00
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N
N
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0
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00
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Luis U Prats
Mechanical Systems
& Controls Inc.
x0177 Expires 07/17/2014
N rIOMAL BALANCING COUNCIL
12 of 14
SYSTEM TO BE BALANCED TO
SYSTEM DESIGNATION (TAG)
SYSTEM TOTAL DESIGN AIRFLOW
10%
AHU-4
2000
Number
1
2
3
4
5
6
7
8
9
10
11
12
13
Area Served
Weight Rm #1
Weight Rm #2
Weight Rm #3
Weight Rm #4
Weight Rm #5
Weight Rm #6
Office #1
Private Restrm
Corridor
Office #2
I.T. Room
Office #3
Lounge
Grille
Type
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
CS
Size
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
24 x 24
Design
CFM
150
150
150
150
150
150
210
40
60
210
160
210
210
AK Factor
Test 1
154
135
103
129
130
Final CFM
115
116
114
117
115
Does Not Exist
150
130
80
146
81
152
121
157
33
49
156
124
159
154
% of
Design
DATE
6/25/2012
PROJECT
Fit 4 Life
SYSTEM
All Systems
READINGS BY
JOB NUMBER
TB -12 -25
2
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co Z
cn
V 1—
Z
Z 0
V
W
2
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d'
M
CO
0
N
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N
0)
00
co
N
CO
C
d
t)
O
ERTIFIE
REMARKS Grilles Were Proportionally Balanced
Luis LI Prats
Mechanical Systems
& Controls Inc.
0177 Expires 07/17/2014
IONAL BALANCING COUNCI
13of 14
UNIT DATA
FAN NUMBER
FAN NUMBER
FAN NUMBER
Unit Designation (TAG)
EF -1 A
EF -2 B
EF -3 C
DATE
Type Of Service
Bathroom
Bathroom
Bathroom
Manufacturer
Broan
Broan
Broan
6/25/2012
Model Number
S5OU 1 S5OU
S5OU
PROJECT
TEST DATA 1 DESIGN
AC N
I
ACTUAL DESIGN
Total Airflow (CFM) 50
60 50
ACTUAL 1 DESIGN
ACTUAL
Fit 4 Life
51 1 50
55
SYSTEM
All Systems
READINGS BY
JOB NUMBER
TB -12 -25
LiJ
CO Z LL ti
•
CO i ii ;
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I-- 0 0D
U
<0 �m
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ERT IFIE
Luis U Prats
Mechanical Systems
& Controls Inc.
#0177 Expires 07/17/2014
NATIONAL BALANCING COUNC
L�
14 of 14
t 1 Njj
BUILDING
PERMIT APPLICATION
FBC 20
Miami Shores Village
Building Department
10050 N.B.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fa= (305) 756.8972
INSPECTION'S PHONE NUMBER (305) 762.4949
Permit Type: MECHANICAL
1ii NOV 2 9 2A11
BY:
Permit No. WC> 1 aaat)
Master Permit No 11-1693
OWNER: Name (Fee Single Tittehotder):Shores Square Investments
Address9017 Riseaynp R117td
City: Mi amt ShnrA
Tenant/Lessee Name: Edmundo R. Tamayo . M.D.
Email :tama157 @bellsouth.net
Phoned: 3 05 - 7 7 9 - 8 04 8
State: FT.
Zip: 33138
P:305- 835 -6322
JOB ADDRESS: ,9 02 5 >3 i_seayn T31_vd _
City: Miami Shores
Folio/Parcel#: 1132060110051 -25
Is the Building Historically Designated: Yes
County: Miami Dade
Zip: 33138
NO Flood Zone:
CONTRACTOR. Company Name: e.5.(1/7:3- dfr oty-It P 1144
Address: 'Y % -61 /
City: i State: t g ;6')
Qualifier Name: (}
State Certification or Registration d:
Contact Phoned:
DESIGNER A rnhiteet/Engineer:
Phone#:
hp: 66
Phone#: 30. ?eff- ',
61C Certificate of Competency t:
Email Address: re V /�1'arrIA0 6,4eket,04 • "tef
Phoned:
Value of Work for this Permit: $ 3 CriNQ Sguare/Linear Footage of Work 5 , 000 SF
Type of Work: °Address °Alteration
Description of Work:
�i1s G.l� (c ) CLtrrter r »f- 4A fy e ,4// f.M7k f /0w ✓` x
ivel 4° 7 i/ t zxda.eau4 d' •► s
CINew tlltepairlRepiace Qllentolition
o,c. *+
Submits Fee $ Ponnit Fee $ \ D .`� "�CCF $ coicc $
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $ Tediumtlogy Fee $
Double Fee $ _ Structural Review $
DBPR $ Bond $
t \o�.cp
:WDUE$ it
Vb\\l2 qd)
Bonding Company's Name (if applicable) N/A
Bonding Company's Address N/A
City State �p
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address N/A
City State Zip
N/A
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
connnenced prior to the issuance of a permit and that all work will be performed to >neet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit mum be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, MINTERS, 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 consttemicat 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: Asa conditicm to the issuance of a building permit with an estimated value exceeding $25(7tt. the applicant muss
promise in good faith that a copy of the notice of rrmtmencement and construction lien lays= brochure will be delivered to the person
whose property is subject to anadtment. Also, a certified copy of the recorded Ralice of conunencentent must be posted at the jab site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of suit pasted notice. the
inspection wilt not be approved and e t einspectlon fee will be charged
Signature
Owner or Agent
The foregoing instrument was aciotowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print
My Commission Expires:
Contractor
The fling instrument was acknowledged before me this !"6.-
day of 40ovArr►.4 ev-, 20 _t, by
who is personally kmmo to me or who has produced
as identitieattn
NOTARY PUBLIC:
Structural Review
(Revised 07110107)Qtevi®ed 05110P�) Revised 3/15109)
Sign:
Print:
My Conomissio
did take:ati bdtlgODRIGUEZ
# DD804481
July 08, 2012
-GryService.com
MAO. #D'.`rEr:
-;;' IRES July 08, 2012
4b
m7)388-0153 FloridallotaryService.com
Zoning
Clerk
Miami Shores Village
Building Department
10050 ALE2nd 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):
City: Miami Shores Village County: Miami Dade Zip Code:
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
Aid (AHRI) DATA SHEET REQUIRED
Change Disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑
UNIT BEING REPLACED
DATA
NEW UNIT
MANUFACTURER
AHU or PKG. UNIT MODEL #
COND. UNIT MODEL #
KW HEAT
NOM TONS
AHU CU
PKG
1) M.CA
AHU CU
PKG
AHU CU
PKG
2) M.O.P
AHU CU
PKG
AHU CU
PKG
3) VOLTS
AHU CU
PKG
PKG UNIT
1
I
PKG UNIT
1 1
EER/SER
YES
NO
REPLACING DUCTS
YES
NO
YES
NO
REPLACING THERMOSTAT
YES
NO
YES
NO
NEW eCONCRETE SLAB
YES
NO
YES
NO
NEW ROOF STAND
YES
NO
YES
NO
NEW RETURN PLENUM BOX
YES
NO
1. Minimum Circuit Ampacity (tire Size):.
2. Maxhnum Overcurrent Protection (Fuse/Breaker Size):
3. Voltage of Circuit (208<24W480):
4. Size Disconnecting Means:
Contractor's Company Nam= Rao Can t< try? (0, phone: 30," tir -,) 63
State Certificate or Re bstion N. C Q- 0-6:? 60 Certikete of Cropetency N.
Signature
(a3us8Refs signature only)
Date: /! /,S /,�O//
11 -1693
P ID: ILGU
1 CERTIFICATE OF LIABILITY INSURANCE
DAT01111112
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), AUht1R12ED'
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, snbjert to
the terms and conditions of the policy, Certain policies may require an endorsement, A statement on this cortliic¢ite does not confer rights to the
certificate holder In lieu of Stich endorse= s
PRODUCER 305 462 -5244
All Safe Insurance
7171 Coral W 7884884244
Miami, FL 38158 #208
Jorge Pena, PIAM
�^
-imTAGT
+ } ire, No[:
A�AIt =
" R
USIOMENIOIe ESULI
INSURER(S)AFFORDS *COVERAGE
NAICB
INSURED Results AirCondlontloning
Company
7451 Nw 72 Ave
Miami, FL 33166
iNsuRERA :WESTERN WORLD
OCCUR
INsurom a : BRIDGEFIRLD
10701
awsuRta c :COMMERCE AND INDUSTRIES
10/R8112
nusURER a •
$ 1,000,000
INSURER 9 •
OAMABET d RiATED
S tE a ecnate ne[
INSURER F :
1]
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUOIES OF INSURANCE LISTED BELOW HAVE REEN,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 SE 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
waft LIR
TYPE OF INSURANCE
)N R
WW
POLICY NUMBER
iMaIO ppLYY1
10/28111
�p
Mme.
A
SALLUABPJ1Y
COMMERAA GENERALUAeiL1TY
—1 CLAIM$43ADE
BIIPDED DEO $260
OCCUR
NPP132277
10/R8112
EACH OCCURRENCE
$ 1,000,000
X
OAMABET d RiATED
S tE a ecnate ne[
S � �,000
1]
•
MED EXP {Ater orin Qermn)
$ 5,0011
X
PERSONAL a ADV INJURY
S 1,000,000
GENERAL AQC TE
$ 2,000,000
Gan.
AGERESATE LIMIT
I POLIOY 1 4.
APPLIES PER:
PRODIIGTS • COMP/OP A00
9 2,000,000
X
I I LOC
$
AUTOMOBILE
LIABILITY
ANY AU1t1�
HIRED AUTOS
NON•0M4EDAUTOS
COMBINED SINGLE UMrr
$
—
BODILYINJURY(Farecddent)
$
_
PROPERTY DAMAGE
$
—
$
O
X
uMBI1E11A 1,1313
EXCESS LIAB
X
Ott
CLAIMS -MADE
Ef3U015273340
11109111
10129112
EACH OCCURRENCE
9 1,000,000
AGGREGATE
$ 1,000,000
DE UOTBBLE
RETENTION $
$
$
B
AND EMPLOYERS' S LIA p.rffy
PROPRIETOWPART
pyaeene,tlatory N N
DEsc ON OF GPERATIaNS
NIA
0830.3567
01/26/11
01/28/12
YVC: b A .X p� MRS
UTn+9Y•
E.L EACH ACCIDENNT
5 600,000
E.L. DISEASE- EA EMPLOYEE
$ 500,000
below
EL DISEASE . POLICY LIMIT
$ 500,000
Maw= OF DPFRATJONS I LOCA710N9 J VEHICLES (Arendr ACbRD 101, Ammons Remeri%Sdrdauls, If mom egmao IS regffbed)
VILMIAM
VILLAGE OF MIAMI SHORES
10090 NE a AVE
MIAMI SHORES, FL 33138
I .
�...- -__...... -•• .
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCEU.Eb BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRE,
ACORD 25 (2008109)
�? 9988.2009 ACORD CORPORATION. All lights reserved.
The ACORD name and Togo are registered marks of ACORD