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MC-13-558Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 189845 Scheduled Inspection Date: April 24, 2013 Inspector: Perez, JanPierre Owner: BARBLAN, CORSIN Job Address: 169 NW 110 Street Miami Shores, FL 33161- Permit Number: MC -3 -13 -558 Project: <NONE> Contractor: JORDEN MAINTENANCE INC Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1121360030510 Phone: (786)712 -1350 Building Department Comments REPLACE EXISTING A/C Infractio Passed Comments INSPECTOR COMMENTS False 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 - 187734. c/u ok need to check a/h inside April 23, 2013 For Inspections please call: (305)762 -4949 Page 43 of 43 4 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. MC) 15— PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: MECHANICAL OWNER: Name (Fee Simple Titleholder): CO c S i r B r b 1 / Phone #: 7 e6 P/ 3 Co O YO Address: I (� �J EV VI/ 11 C S 1 City: f l ► L, ®c 6 state: i— zip: .3 Tenant/Lessee Name: Phone# Email: JOB ADDRESS: ((6,=) IV 1 ( S l City: Miami Shores Folio/Parcel #: Is the Building Historically Designated: Yes NO County: Miami Dade Zip: i & Flood Zone: AI 0 Phone#: 30,C d l er-( 13 CONTRACTOR: Company Name: ay, cte vt 01/4-14, tn I evq v,, c Q l. ski. Address: 3 7 ,7 rTd\A VI Sov S#-- City: istollti U11 toc 1 State: FL Zip: Qualifier Name: !Tor .e \NQ nat. OA : 4 V ') Phone#: 0 -(7 -6 rO State Certification or Registrdfion #: CA -r 1f1-3— 19 2_. Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work; for this Permit: $ 2-1 &® O. 0e Square/Linear Footage of Work: Type of Works OAddress DAlteration ONew Description of Work: Q t (, l a c e e x, S t e r A / C AkRepair/Replace ODemolition ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** 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 $ 1.11' 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 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 The foregoi ins day of .lam • 1,1,, s NOTARY Owner or Agent ent was ac wled : ed befo 0 nally known y .Ili1 o me or who has produced 1i /L Signature Contractor The foregoing ins ment was acknowledged before me this t day of 20 by -10"r _ dg,"YIdG�rJPaa who i fication and who did take an oath. LIC: Sign: Print: My Commiss n Expires: * * * * * * * * * * * * * * * * * * * * * * * * * * *- * * * * * ** 0444 APPROVED BY personally known NOTARY Sign: Print: My Commission Expires: 4.r. ci 1 t f o me or who has produced dentification and who did take an oath. LIC: SEM Juan Hernandez - Notary Public Commission No. DD969347 Notary I.D. No. 1279421 March 9, 2014 i .41 qa e2 ** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** lans Examiner Structural Review (Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) * * * * * * * * * * * * * * * * * * * * * * * * * ** Zoning 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): b q tD ley l 10 Si" City: Miami Shores Village County: Miami Dade Zip Code: S .3 16, 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 El NO ❑ Contract Attached: YES UNIT BEING REPLACED DATA NEW UNIT RR,y 1-1,1 l MANUFACTURER Lee M I .LIT —CIA 00 AHU or PKG. UNIT MODEL # A 1-att 14 _ COND. UNIT MODEL # KW HEAT NOM TONS i d T 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 CU PKG PKG UNIT / / PKG UNIT / / EER/SEER YES NO REPLACING DUCTS YE NO YES NO REPLACING THERMOSTAT NO YES NO NEW 4 °CONCRETE SLAB S NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX'Eq NO 1. Minimum Circuit Ampacity (Wire Size): 3() PrV S 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (20 : 480): 4. Size Disconnecting Means: _ t Contractor's Company Name: Li o (/ et e I" State Certificate or Registr • ion N. Signature (Qualifier's signature only) dldtL�CC_ Certificate of Com . ; ten uan ernan ez - Nota Commission No. DD9 Notary I.D. No. 1279 March 9, 2014 Phone: 3Os 9 ER S4 Jorden Air Conditioning 3822 Johnson Sreet Hollywood Lic CAC 1817192 7867121350 Bill To Barblan 169NW110thSt Miami Shores, 33168 Invoice Invoice No: 29 Date: 19 Mar 2013 1 escrlption Install new 1.5 ton air conditioning system, Rheem, 13 Seer, air handler and condensing unit Install new digital thermostat Quantity Rate Amount 1.00 $1,900.00 $1,900.00 Replace return box Replace ducts (02) and plenum 1.00 $900.00 $900.00 * Indicates non - taxable item Subtotal $2,800.00 TAX (0.00 %) $0.00 Total $2,800.00 Paid $0.00 Balance Due $2,800.00 Page 1 of 1 Certificate of Product Ratings AHRI Certified Reference Number: 4525312 Date: 3/19/2013 Product: Split System: Air - Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: 13AJN18 Indoor Unit Model Number: RHSL- HM1817 +RCSL -H *2417 Manufacturer: RHEEM MANUFACTURING COMPANY Trade/Brand name: RHEEM 13AJN SERIES Manufacturer responsible for the rating of this system combination is RHEEM MANUFACTURING COMPANY Rated as follows in accordance with AHRI Standard 210/240 -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): 17700 EER Rating (Cooling): 11.00 SEER Rating (Cooling): ; 13.00 *Ratings followed by an asterisk ( *) indicate a voluntary rerate of previously published data, unless accompanied with a WAS, which indicates an involuntary rerate, DISCLAIMER AHRI does not endorse the product(s) listed on this Certificate and makes no representations, warranties or guarantees as to, and assumes no responsibility for, the product(s) listed on this Certificate. AHRI expressly disclaims ail liability for damages of any kind arising out of the use or performance of the product(s), or the unauthorized alteration of data listed on this Certificate. Certified ratings are valid only for models and configurations listed in the directory at www.ahridirectory.org. TERMS AND CONDITIONS This Certificate and its contents are proprietary products of AHRI. This Certificate shall only be used for Individual, personal and confidential reference purposes. The contents of this Certificate may not in whole or In part, be reproduced; copied; disseminated; entered into a computer database; or otherwise utilized, In any form or manner or by any means, except for the user's individual, personal and confidential reference. CERTIFICATE VERIFICATION LID Infonnatton for the model cited on this certificate can be verified at wwwahridirectory.org, click on "Verify Certificate" fink and enter the AHRI Certified Reference Number and the date on which the certificate was Issued, which is listed above, and the Certificate No., which is fisted below. ©2012 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 130081925385437964 Air - Conditioning, Heating, OM ® and Refrigeration Instttute 1166014.24,111,11(0,001tar4e4,4 STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD 1940 NORTH MONROE STREET TALLAHASSEE FL 32399-0783 DENACIMIENTO, JORGE L JORDEN MAINTHITANCE INC 3822 JOHNSON STREET HOLLYWOOD FL 33021 Congratulations/ With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regu(ation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. 3 -sscr (850) 487-1395 STATE OF FLORIDA AC# 246411'i DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION I CAC1817192 08/06/12 120050319 Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto www.myfloridanc:ense.com. C TIFIED AIR COND CONTR There you can find more information about our divisions and the regulations that , DENAcnamoo, down L impact you, subscribe to department newsletters and learn more about the , JORDEN ' MAINTENAZICS INC Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. IS CERTIFIED under the provisions of Ch. 489 FS Thank you for doing business In Florida, and congratulations on your new license! axpiration da t 0 : AUG 31, 2014 L12080600165 DETACH HERE FtE"' :3# 624849- DEPAR STATE OF FLORIDA OF mums AND PROFESSIONAL ONSTRUCTION INDUSTRY LICENSING B Z $ • " 0 TION SECI# L12080600165 DATE 1-3ATCli NliMF.IER LICENSE NBR 08/06/2012 120050319 CAC1817192 rhe CLASS B AIR CONDITIONING CONTRACTOR lamed below IS CERTIFIED Tnder the provisions of Chapter 489 FS. 3xpiration date: AUG 31, 2014 DENACIMIENTO JORGE L JORDEN MAINTENANCE INC 3822 JOHNSON STREET HOLLYWOOD FL 33021 RICK SCOTT GOVERNOR LAWSON SECRETARY p 08 -30 -2012 . JEFF ATWA T ER STATE OF FLORIDA CHEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION LAW CONSTRUCTION JNDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: PERSON: FEIN: 08130/2012 DENACIMIENTO 204861530 BUSINESS NAME AND ADDRESS: JORDEN MAINTENANCE INC ©8A JORDEN AIR CONDITIONING 3822 JOHNSON STREET HOLLYWOOD FL 33021 SCOPES OF BUSINESS OR TRADE: 1- HEATING, VENTILATION, AIR -COND EXPIRATION DATE: 08/30/2014 JORGE L SR IMPORTANT: Pursuant to Chapter 440 . 115(14 }, r.s., an officer of a corporation who elects exemption from this chapter by filing a certificate of election tinder 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 business or trade listed on the notice of election to be exempt. Furst not 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 Of the issuance of the certificate. the person named on the 'notice or certificate no longer meets the requirements of this section Inc issuance of a certificate. The department shalt 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 -1 OWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT P,EifISED 01 -11 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: 08/30/2012 EXPIRATION DATE: PERSON: JORGE L DENACIMIENTO SR FEIN: 204861530 BUSINESS NAME AND ADDRESS: !ORDEN MAINTENANCE INC DIG. JORDEN AIR CONDITIONING 3822 JOHNSON STREET HOLLYWOOD, FL 2.302 1 SCOPE OF BUSINESS OR TRADE 1- HEATING, VENTILATION, AIR -COND 08/30/2014 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(12), 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. R E Pursuant to Chapter 440.05(13), F.S, Notices of election to be exempt and certificates of election to be exempt shall he 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. QUESTIONS? (850) 413 -1603 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. 03/19/2013 13:50 9544759821 MOODY INSURANCE PAGE 01/01 CERTIFICATE OF 'LIABILITY INSURANCE DA'T'E (MMIDD/YYTY1 03/19/2013 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 POUCIES 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 ADO1T ONAL INSURED, the p0licy(ie$) must be endorsed. If SUBROGATION 1S WAIVED, Subject t0 the terms and condition's of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certtificato holder in lieu of such ehdorsament(s). PRODUCER Moody Insurance Group 1939 Tyler Street Hollywood, FL33020 GONTAGT PHONE 'A/C. Ne. Ext1: E-MAIL ADDRESS- Tom bent (054)266 -7700 TDenteMIGFL.com (i, NOT: (064)4764821 INSURER(31 AFFOIWING OOVERAGE HNC $ INSURED Jordan Maintenance Inc DBA Jorden Air Conditioning Inc 3822 Johnson Street Hollywood, FL 33021 COVERAGES INSURER A: Scpttjditie Inguraggq Company INSURER B : INSURER C INSURER D : INSURER E INSURER F: .,- . ,.,,..,I ,..,,.Los,.• •, THIS IS 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 RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN; THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU. THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR LYIt TYPE OF INSURANCE . o INBR N : u:,- Wvb N POLICY NUMBER CPSI631649 • FOLIC EFF iMM1ODiYYYY1 0813012012 POLICY Y' fMMIDD/YYYY1 08/30/2013 UMrrS A GENERAL LIABILITY - EACH OCCURRENCE $ 1.000.000 $ 100,000 $ 5,000 COMMER(ALGENERAILUmUTY 1 CLAIMS -MADE X OCCUR PREMISES artcncm $�X MED EXP (My dris Fin) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OPAGO $ 1.000.000 $ 2.000.000 0 1,000,000 $ GERI. AGGREGATE UMIT APPUES PER: POLICY n JE!ar n 100 AUTOMOBILE — — LIABILITY - COMBINED SINGLE UMIT S ANY AVM AAUP D HIRED AUTOS — SCHEDULED OS Amos - BODILY INJURY (Perpersorq $ BODILY iNJURY(PeraocidanU a PROPERTY DAMAGE (Pereaadent $ 4 $ — UMBRELLA A6 LA EXXE$SLIAB OCCUR C1AIM8 -MADE r EACH OCCURRENCE ♦ $ AGGREGATE 0 DED RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIET PARTNERIEXECUTNE Y/N OFFICER/MEMBER E(CLUDED? (Mtlndatory ht NH) Ir s deaal0a under R(PnON OF OPERATIONS bebw N / A • I WG "ATV- I I OTt t TORY LIMITS ER EL EACH ACCIDENT $ E• .L DISEASE - EA EMPLOYEE $ E.L DISEASE - POLICY OMIT $ i DESCRIPTION OF OPERATIONS (I.00ATIONB /VEHICLES (ANach ACORD 101, Adt&fienat Remark; Schedule, if more space is required) Certificate of General Liability, insurance. • • CERTIFICATP Wni r►ne _ -_ ---- - Miami Shores Village 10050 NE 2nd Ave Miami Shores, FL 33138.2382 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Bs CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE W(t,t. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AuyHDRUED REPRESENTATIVE ACORD 25 (2010105) ppm 519884010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD • Printed by TAD on Muth h 19, 2013 at 01:49 PM