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MC-12-186Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 CA Inspection Number: INSP- 176006 Permit Number: MC -2 -12 -186 Scheduled Inspection Date: July 18, 2012 Inspector: Perez, JanPierre Owner: GOWDISH, LAWRENCE Job Address: 8727 NE 4 Avenue Road Miami Shores, FL Project: <NONE> Contractor: A ALL MAJOR BRANDS CORP Permit Type: Mechanical - Residential Inspection Type: - Work Classification: A/C Repl cement FtW9-) Phone Number Parcel Number 1132060460790 Phone: (305)688 -4406 Building Department Comments REPLACE A/C WITH 3 TON SPLIT SYSTEM T--C Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments CC, July 17, 2012 For Inspections please call: (305)762 -4949 Page 24 of 29 5/(2.— S�rw�a�k BIIILDING 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 Permit No. Permit No. PERMIT APPLICATION Permit Type: MECHANICAL �7 �j/ ^7 OWNER: Name (Fee Simple Titleholder): /ZL�6 / C Phone #: 1 Z 02 , (�/ -514 6.- Address: City: %%9'/7) / S #i p E S State: L Zip: 33'4,0 Tenant/Le see Name: / Phone #: Email: b,e 9 dJ .`� C9 0 yOhld . !1D ni JOB ADDRESS: g ? A e. «)1)J ..44enL/ � I C3Qc./ City: Miami Shores County: 12#9 /7Skiami Dade Zip: 3314 0 Folio/Parcel #: Is the Building Historically Designated: Yes NO L/' Flood Zone: CON'I ILACTOR: Company Name: 4 h L L /" 6TO Address: , l% , &n' Q ) 4 ,11_ City: Ai Qualifier Name: /r / G iC /t/vl- C' ./ /•%S/ ,. State Certification or Registration #: ern/1 3'3 , j 7 / Contact Phone #: 3 "5-4' -ies, /3e4iPS CD P#: State: DESIGNER: Architect/Engineer: Email Address: 3,0,5-66U4110 Zip: 332cF3- J -- Phone #: 76.5- '4 4 Certificate of Competency #: Phone #: Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: DAddress DAlteration UNew laRepair/Replace Demolition Description of Work: 4)//01-1 5 AY 19-c W / i& Sff/Ne. 3 -rvN) ,...„.,.....„..„„„„„„„,„ .. . Submittal Fee $ Permit Fee $ Scanning Fee $ Radon Fee $ t) * **************** CCF $ CO /CC $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ � l 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 nd 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 inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will n' e a roved and a reinsp. tion fee will be charged. Signature% t %�`. The day o who is p sonall own to me or who has produced VI ho is personally known to me or who has produced �� • tification and who did take an oath. I� ')-4 i' Jr4.0 as identification and who sd� l i4 #,oath. NOT Y,PUBLIC: NOTARY PUBLIC: �e` \��` `��� °� -_-_, '•° Commission # c :��.4.0165901 °•' Owner or " <ent ment was ackno 20 1 'Lby ledge The foregoing instrument was acknowledged before me this f 3 / ,201 .c-by PAC &C. ' 1 ie4 Sign: Print: My Commission Expires: APPROVED BY 00 da _!11 °i X' „„ 0* " <eg Sep 2°N- - n I <et`! i 1 S5 No m tixP # e °�aty P ruse; ,, "CIN g. a�N (Revised 07 /10 /07XRevised 06 /10 /2009)(Revised 3/15/09) Sign: Print: My Commission Expires: Plans Examiner Zoning Structural Review Clerk 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): 072-7 /2& 4 ,4-v 1 City: Miami Shores Village County: Miami Dade Zip Code: T3/ 6 ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.MA MINIMUM FLOOD ELEVATION A COPY OF THE CONTRACT IS REQUIRED WITH ALL SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO 1X ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ UNIT BEING REPLACED DATA NEW UNIT /cow MANUFACTURER fkyvk /9 ny/✓ 1574 -3 4 see & AHU or PKG. UNIT MODEL # de/f Pi P .tra” COND. UNIT MODEL # PA/ to/irk!) (® !0 KW HEAT 69"( 3 NOM TONS 3 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 PeCU )4'KG PKG UNIT / / PKG UNIT / / r EER/SEER f 4 YES ciSTP REPLACING DUCTS YES Imo' YES ,►, REPLACING THERMOSTAT YES 4V YES alre NEW 4 "CONCRETE SLAB YES .y YES ,,'r NEW ROOF STAND YES C0' YES IA NEW RETURN PLENUM BOX YES 1. Minimum Circuit Ampacity (Wire Size): et® 2. Maximum Overcurrent Protection (Fuse /Breaker Size): '1 0 3. Voltage of Circuit (208/240/480): ,. 4 d 4. Size Disconnecting Means: To Contractor's Company Name: G9 ALL AMOR J0,E j3 i4" Co" /" Phone: State Certificate or Regis oVy� ":'%�- 6-7 / Certificate of Competency N. Date: 3f --Zo /' Signature 2011 / 2012 MONROE COUNTY BUSINESS TAX RECEIPT EXPIRES SEPTEMBER 30, 2012 RECEIPT* 30140-76422 1441,.IN.. Mit,i*Adt A -4 : krv.tid Business Name: Owner Name: Mailing Address: KEY LARGO, FL 33037 Business Phone: 305-930-4247 • -BUSineSS Type: CON-TRACTORS (AIR CONDITIONING CONTRACTOR) Machines THIS BECOMES A TAX RECEIPT WHEN VALIDATED THIS IS ONLY A TAX. YOU MUST MEET ALL COUNTY AND/OR MUNICIPALITY PLANNING AND ZONING REQUIREMENTS. ..,...!evivrypirryi frrilli 'WW1 `-`,, A000AL1 OP ID: ED A °=RD CERTIFICATE CAF LIABILITY INSURANCE DATE (M 01125112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOL.DER. 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 certiflcate holder is an ADDITIONAL INSURED, the poilcy(ies) must be endorsed. if SUBROGATION 15 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 Neu of such endorsement(s). PRODUCER 954 -883 -2900 Tanenbaum Harbor of Florida 2900 SW 149th Avenue 954=5174400 Miramar, FL 33027 -6608 Tanenbaum Herber of Florida arr. A PHau�l a. t - Mx INC, Nok E- ; INSURERS) AFFORDING COVERAGE NAIC 0 INSURER A :Scottsdale insurance Company 4129T INSURED A All Major Brands Corp. Mr. Kulczynskl P O Box 832432 Miami, FL 33283 -2432 INSURER B: CP81359284 INSURER c: f 00123112 INSURER D : $ 1,000,000 INSURER E: $ 50,000 INSURER F : COVERAGES CERTIFICATE NUMBER: • THIS 1S 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 BB_Y PAID CLAIMS. INSR LTR TYPE OF INSURANCE AUTHORED) RE�PR,ESENTATIVE - �� (i' t e9LICY NUMBER tw fll r1 Jl p� LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY CP81359284 00123111 f 00123112 EACH OCCURRENCE $ 1,000,000 PRD sue° } $ 50,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 1,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES 7 POLICY Ti TA PER: LOC PRODUCTS - COMP/OP AGG $ 1,000,000 $ AUTOMOBILE _ UAMU1Y ANY AUTO AU AU. HIRED AUTOS — _ SCHEDULED AUTOS AUTOS COT0BINED }SINGLE L MIT BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (Pert)}AINAGE $ $ UMBRELLA LIAR EXCESS LIAB _ OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I RETTNT ON IS $ COMPENSATION WORKERS AND EMPLOYERS LIABIUTY ANY PROPRIETORJPARTNERIEXECUTIVE Y / N OFFICERIMEMBER EXCWDED? n (Mandatory NH) under DESCRIPTION OF Of ERATIONB below N / A TORYTLI :. I I FR EL EACH ACCIDENT $ ELL_ DISEASE -EA EMPLOYEE $ EL DISEASE - POLICY LIMIT $ , DESCRIPTION OF OPERATION / LOCATIONS / VEHICLES (Attach ACORD 101, AddIUonal Remarks Schedule, Dime 81100010104014 CERTIFICATE HOLD MIAMI SHORES VILLAGE 10050 NE 2 AVENUE Miami Shores, FL 33138 MIAM138 J SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORED) RE�PR,ESENTATIVE - �� (i' t 1988.2010 ACORD CORPORATION. All rights reserved. Name WC Horne Exemption Detail Page This database was last updated Thursday, January 26, 2012 11:30 PM. Title Effective Date Return to Previous Page WC Databases CFO Home Exemption Details 'Termination Date Exemption Type ' "Business Acttvides Employer Name RICK KULCZYNSKI PR Mar 29 2010 Mar282012 Construction Click Here to view Ac ivkies Listed on F_ M112,ion A ALL MAJOR BRANDS CORP RICK KULCZYNSKI DI Mar 14 2008 Mar Construction ds Hereto Ca Vlea A&fies Lsted on gaMlaft A ALL MAJOR BRANDS CORP RICK KULCZYNSKI DI Feb 20 2006 Feb 202008 Construction Click Hera to View AtxMIes Usted on i A ALL MAJOR SRANDS CORP RICK KULCZYNSKI DI Jan 23 2004 Feb 20 2006 ConstnictIon Click Here to V[ew Ac tivides List on 0220 A ALL MAJOR BRANDS CORP RICK KULCZYNSKI OT Jan 5 2002 Dec 312003 Construction auction Click Here to View Aciv8es Listed on A ALL MAJOR BRANDS CORP Critic Here to View RICK KULCZYNSKI. DI Jan 8 2000 Jan 5 2002 Consiniction Activities Dated on ftillOggn *Termination may be through the revocation of the exemption, or expiration of the exemption. The exemption only applies to the business activities listed on the exemption. AALL MAJOR 13RANDS CORP Return to Search Page WC Home WC Databases Business Activities Detail Page This database was last updated Thursday, January 26, 201211:30 PM. Return to Exemption Detail Page Business Activities on Exemption for RICK KULCZYNSKI - ( CERTIFIED AC CONTRACTOR HEATING & AIR CONDRIONING Return to Search Page ! CFO Home WC Home WC Databases Employer Detail Page This database was last updated Thursday, January 26, 2012 11:30 PM. Carrier Location information Return to Search Page 1 Employer Information Employer Name Employer Type NAICS Code A ALL MAJOR BRANDS CORP CORPORATION I N/A I INo Coverage History Coverage History Exemption Listings Exemption Holder Name !RICK KULCZYNSKI Owner Election Listings INo Owner Election of Coverage Listings Employer Name History Employer Name Name Type Change Date LA ALL MAJOR BRANDS CORP 1 Legal 1 Current ' Return to Search Page 1 CFO Home A ALL MAJOR BRANDS CORP. P.O. BOX 832432 MIAMI, FL 33283 306 -688 -4628 FAX 305 -596 -5590 E -MAIL AAMBCORP@AQL.COM BUDDY & ELIABETH MECHANIC 8727 NE 4 AVE. ROAD Miami Shores, FL 33160 A ALL MAJOR BRANDS CORP. shall replace air conditioning system according to the following specifications, terms and conditions on the premises described above. 1— REPLACE 3 TON SPLIT SYSTEM SEER 16.0 HOOK UP TO EXISTING DUCTS AND FT.ECTRICAL Warranty one year labor and ten years parts thru A ALL MAJOR BRANDS CORP. Excluded: permits, PRICING GOOD FOR 30 DAYS WE PROPOSE hereby to furnish material and labor - complete in accordance with above specifications, for the sum of $ $3,456.00 Payment to be made as follows: 50% at acceptance and balance upon completion. All material is guaranteed to to standard practices. executed only with Owner to carry Compensatio ed. All work to be completed in a w e manner according deviation from above ons involving extra costs will be will become : , charge over and delays beyond our control. other nece . msurance. Our workers are fully covered by Workmen's ACCEPTANCE OF PROPOSAL -The above, specifications and conditions are satisfactory and are hereby accepted You are authorized to do work as specified. Payment will be made as outline above. Acceptance By; - Date of Acceptance: ©F UJ/ CERTIFIED: www.ahridirectory , ory Certificate of Product Ratings AHRI Certified Reference Number: 3659442 Date: 1/31/2012 Product: Spilt System: Air - Cooled Condensing Unit, Coll with Blower Outdoor Unit Model Number PA16NA030****A Indoor Unit Model Number FFIENP031 Manufacturer: PAYNE HEATING AND COOUNG Trade/Brand name: PAYNE PAI6 Manufacturer responsible for the rating of this system combination is PAYNE HEATING AND COOLING Rated as follows in accordance with AHRI Standard 2101240 -2008 for Unitary Air -Conditioning and Air- Source Heat Pump Equipment and subject to verification of rating accuracy by AHRI- sponsored, Independent, third party testing: Cooling Capacity (Btuh): 28200 EER Rating (Coaling): 12.50 SEER Rating (Cooling): 15.00 • Ratings foilowed by an asterisk {') indicate a voluntary remte of previously published data, unless accompanied with a WAS, which indicates an involuntary rerate. DISCLAIMER AHRI does not endorse to product(s) listed on this Certificate and makes no remesentations, warranntes orguarantees alto, and assumes no res ley for, the product(s) listed on this Certificate. AHRi expressly disclaims all IlairMty for damages of any kind arising out of the use or performance of the product(s), attire unau homtzed alteration of data listed on this Certificate. Certified ratings are valid only for motels and configurations listed in the directory at www.ahridirectory.org. mil r9.. TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRL This Certificate shall only be used for kulivklual, personal and confidential reference proposes. The contents of this Certificate may not, In whole or in part, be reproduced; copied; ; entered into a computer database; or otherwise utilized, In any form or manner or by any means, except forte user's individual, personal and confidential reference. CERTIFICATE VERIFICATION The information for the model cited on this certificate can be verified at www.ahridirectory.org, Air- Conditioning, Heating, click on "verify Certificate" fink and ender to AHRI Certified Relevance Number and the date on ®® and Refrigeration Institute which the e�tlflcate was Issued, whkh is above, and the Certificate No., which Is below. g ®2012 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 129725199977058117