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MC-13-838Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 189819 Permit Number: MC -4-13 -838 Scheduled Inspection Date: May 01, 2013 Inspector: Perez, JanPierre Owner: SANTIAGO, MARIA Job Address: 8937 NE 4 Avenue Road Miami Shores, FL Project: <NONE> Contractor: BLUE PANTHER AIR CONDITIONG Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Phone Number Parcel Number 1132060460340 Phone: (786)299 -7578 Building Department Comments EXACT 2 TONS NC REPLACEMENT Infractio Passed Comments INSPECTOR COMMENTS False Inspector Comments Passed OAP Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. April 30, 2013 For Inspections please call: (305)762 -4949 Page 14 of 25 e 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 Type: MECHANICAL OWNER: Name (Fee Simple Titleholder Address:) Cj 3 /7 % G e✓ City: M (a ei 1 c f> State: - Pet, ,O' e ce Tenant/Lessee Name: Phone#: e ri OLZEWM d AFR232O13 Permit No. MC) 157 Master Permit No. -F, 4 Phone#: i O .t0) • 6'rl../ ] Zip: / y Email: JOB ADDRESS: VG a P County: /> )P Miami Dade City: Miami Shores Folio/Parcel#: Is the Building Historically Designated: Yes NO Zip: 3 3 CONTRACTOR: Company Name: 1---„„-.,, Address: Lf C 12 5-CCe / a! City: ice+ c , ems.-- , State: / � ` 4 or.ce GI Zip: °,7 Qualifier Name: —� �' ` ' 0 1/•-e_. ,' a 1,1 1 Phone#: State Certification or Re 'station #: r4 C lit,/ 3 4-4- Certificate of Competency #: Contact Phone #: 4. 4 `)- s- Y Email Address: DESIGNER: Architect/Engineer: Phone #: Flood Zone: r i cr,-d rt" Qo JPhone #: �'1% qqI 0 Value of Work for this Permit: $ �/- 5 Type of Work: OAddress DA1te*ation Description of Work: e c Square/Linear Footage of Work: ONew J epair/Replace 1DDerpolition 7e- ,r e ** *** * ******* + *Fees *Si **** * **** *111* * * * *s * * * *Ole w ** * * * * * * * * ** w* Submittal Fee $ Permit Fee $ )16 it 1.-4&? CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ �I� 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 RI.F,CTRICAL 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 properly is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted of 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 wine?! approved and a reinspection fee will be charged. o Signature f� > Signa Owner or Agent The foregoing instrument was acknowged before me this a� day of, i9 r ° (-, 20 by who is personally known to me or who has produced L As identification and who did take an oath. NOTARY PUBLIC: Contractor The foregoing instrument was acknowledg fore me this °a,� day of A. c ° 1 , 20 t7 by who is personally known to me or who has produced t° P as identification and who did take an oath. NOTARY PUBLIC: * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** **** a��LsL***+************************** a�* * * * * * * * * * * * * * * *a� * * * * * * * * * * * * ** APPROVED BY ( I j IIII,"`jjj Plans Examiner Zoning Structural Review Clerk (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Miami Shores Village Building Department 10050 N.F.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 AIR CONDITIONING REPLACEMENT DATA 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. J , .: ,cress ({ is being done: i 6"l 3 v ))° City: Miami Shores Village ) County: Miami Dade Zip Code: SING 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,g NO ❑ ARHI Sheet Attached: YES NO ❑ Contract Attached: YES UNIT EING REPLACED DATA NEW UNIT -He, C MANUFACTURER Ice n vvev ire 1 ci A.9 ').-°-t i 01_ AHU or PKG. UNIT MODEL # �,C? ?O �� \� l�-k L. M � % k�\�'C COND. UNIT MODEL # A 6 ?- c 5-1c t.l i KW HEAT L ° .,, -, > _ NOM TONS --0,,, s, 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 , -L/ 0 AHU CU PKG PKG UNIT / / V / PKG UNIT / / " /A- EERISEER YES REPLACING DUCTS YES NO ° NO REPLACING THERMOSTAT (YE • S • ; NEW 4 "CONCRETE SLAB YES ( YES -1 • NEW ROOF STAND YES YES N e)) NEW RETURN PLENUM BOX YES 0 1. Minimum Circuit Ampacity (Wire Size): '% 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: ©� arf v 5 f 1 S ° W^ ►'LQ ` �j 0 �— VO ' Contractor's Company Name: 4. # l0V i' ' ✓ (1 Phone: I`° } ��4 P Y t° �� State Certificate or Registration N. G lY 1'13''0 Certificate of Competency N. Signature �� • .1 Date: Qualiflet's s gnature only) Office Location: ORLANDO Proposal Date 04/15/2013 IJob Number 15312688 Sea,Ii:s Home Improvement Products Sears Home Improvement Products, Inc. Customer Name MARIA SANTIAGO P.O. Box 522290 1024 Florida Central Parkway Longwood, FL 32750 -7579 Phone (800) 469 -4663 Customer's Home Phone (305) 801 -6437 Customer's Work Phone Street Address 8937 NE 4TH AVENUE RD ESTIMATE AND PROPOSAL Heating & Cooling Contractor License/Registration Number FL (CGC012538, CMC1249510) City MIAMI SHORES !State FL Zip Code 33138 Is installation within city limits? (Yes /No): YES Installation Address County MIAMI -DADE Billing Address (if different from above) City State Zip Code Project Consultant Name & License No (if applicable) RAMON JIRON 22672 De sal + on SYSTEM INFORMATION: Equipment of the Pr +' =ct Brand: 23400.00 and Desen of the Si +nii"i KENMORE (Split nt Materials to be Used and E • e ment to be installed System/Package /Dual Fuel /Straight Cool/Heat Pump / Fumace): AIR HANDLER 0 R-410A 15.50 SEER: Cooling BTU:_.. KW: 5.00 AC EQUIPMENT SPECIFICATIONS: MODEL # OF NEW COMPONENT COIL FEA4X2405A FURNACE FUEL: (Gas /Oil /LP Gas /Electric): Existing New • ® FURNACE/FAN ❑ ® CONDENSER UNIT AFUE (up to): Heating BTU: ELECTRICAL: CONNECT NEW DISCONNECT GFI TO EXISTING ELECTRICAL NEW AMP MAIN PANEL ❑ CONDENSER LIGHT & RECEPTACLE TXA624GKA '2 ❑ INSTALL • ❑ EVAPORATOR COIL ❑ FURNACE OUTLET ❑ ATTIC • ❑ PACKAGE UNIT • ❑ NEW Other: • • THERMOSTAT • • HUMIDIFIER ❑ ❑ AIR CLEANER DUCT ® ❑ INSTALL ❑ ❑ WORK. RE -USE EXISTING DUCT NEW DUCT REBUILD PLENUM NEW TRUNK LINE(S) RETURN GRILL(S) RETURN REPLACE REGISTER(S)# CLEANING SYSTEM SYSTEM (Supply (Supply WITH # NEW RUNS • ❑ UV LIGHT • • EVAP COOLER MISCELLANEOUS: PAD CONDENSATE Other " x /Retum): • • LINE SET i • /Retum): ❑ PUMP X X ❑ • DRAIN LINE • NEW ❑ EXISTING ❑ ❑ DUCT Other: • • AUXILIARY DRAIN INSULATION: PAN • GRILL SIZE R -Value ❑ • (Batt/Blown): FLUE VENTING ANDIOR CHIMNEY: • Use existing vent or chimney Air • Install ❑ Vertical new chimney liner Size: Pipe ❑ PVC Vent Pipe for High - Efficiency Fumace ❑ 1 Pipe Installation ❑ 2 Pipe Installation • Horizontal • Type -B Vent Pipe • Stainless Steel Vent • Combustion • Existing • Modify SPECIAL INSTRUCTIONS: ASAP All of the above check boxes and "Special Instructions" section have been reviewed and Customer(s) initials explained to me. S . SH1 -FL (Dig.) Rev 02/10/12 Page 1 of 3 1111111111 111111 Job Number: 15312688 APPROXIMATE START DATE and APPROXIMATE COMPLETION DATE: The work will start approximately ASAP (Approximate Start Date) Completion Date) time by mutual prior to this date to It will be substantially completed by approximately ASAP (Approximate These dates are subject to change at the time the contract is accepted by Sears Home Improvement Products, Inc. ( "Sears ") or at any other written agreement. Customer understands that the Approximate Start Date is only an estimated date and the Customer will be contacted schedule the actual start date. ASBESTOS ABATEMENT: This Estimate and Proposal assumes that there are no asbestos containing materials ( performance of the installation work. If upon further inspection by the contractor or others it is teamed that ACMs have Customer must arrange and pay for abatement of asbestos by a qualified person prior to the start or continuation necessary asbestos abatement within thirty (30) days, Sears may cancel this contract upon written notice to Customer. Customer(s) initials "ACMs ") that would be disturbed in the to be disturbed to perform work, then of work. If Customer fails to arrange for %y - r„ PLEASE NOTE that Sears is not responsible for correcting any existing code violations or pre - existing conditions of or equipment not being replaced at this time. If additional work is required, it will be the Customer's responsibility. Any approved prior to the start of any additional work. Customer(s) initials any ductwork, piping, electrical supplies additional charges will be quoted and q THE CONTRACT PRICE INCLUDES: Price A copy of the terms and conditions of pair Protection Agreement (as applicable) Customer(s) initials the Master Protection Agreement or Re- have been provided to Customer. -Year Master Protection Agreement • $ -Year Repair Protection Agreement • $ S ,S The TOTAL PRICE including all labor, material, taxes and any applicable discount Customer Payment is due prior to Sears' placement of Special Order for products. is $ 5, 547.03 Contract Price State Sales Tax Local Sales Tax FPL REBATE $ 5, 547.03 ( 0.00 %) $ 0.00 ( o . oo %) $ 0. oo $265.00 Total Amount Duel $ 5,282.03 The form and method by which the Customer(s) will pay is described in a separate Cash /Credit Customer(s) initials Card Pa mentAddendum made a part of and incor. orated into this contract b reference. 5/( S . NOTICE TO BUYER: YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY (FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER) AFTER THE DATE OF THIS TRANSAC- TION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ADDITIONAL PROVISIONS Proposal and Approval. Sears offers to fumish the materials and arrange for their delivery and installation as specified on the first page and /or the attached sketches and specification sheets for the TOTAL PRICE shown. This offer must be approved by the Installation Department. If this is a credit sale or a payment on completion sale, it must be approved by the Credit Sales Department. If this proposal is not approved or the installation cannot be made in accordance with the law, this offer will be withdrawn and any payments you have made will be refunded to you. Any materials left over after the installation has been completed are Sears property and will be removed by Sears. Installation. I understand that Sears will not install the materials but will arrange for the installation. Sears is not responsible for materials or installation NOT furnished or arranged by Sears. Sears' installation contractor(s) will obtain all building permits required by local law. For homes located in historic or landmark zoning districts, Customer will be responsible for obtaining required approvals and related permits prior to the commencement of work on this contract. Authorization. I authorize Sears to: (1) arrange for a contractor (licensed where required by law) to make the installation of materials; (2) issue a work order for this installation to a contractor; (3) inspect the installation; and (4) pay the contractor when the installation is complete if I have signed a certificate that the installation has been completed to my satisfaction. Delays in Installation. I agree that Sears is not responsible for delays in delivery or installation due to weather, fire, strikes, war, govemment regulations or any causes beyond Sears' control. Oral Agreements and Changes in Contract. I understand that there are no oral agreements between Sears and me. Everything I expect Sears to do has been included in writing in this contract. Nothing can be changed in this contract unless it is in writing on a separate form accepted by me and Sears. Responsibility of Buyer. I agree that any information or measurements that I give to Sears are correct and complete. I am responsible for any special work described in this contract. Electrical & Plumbing Service. I will provide adequate electrical and /or plumbing service(s) to run any newly installed appliances or other fumishings. If the electrical and /or plumbing service(s) do not meet the standards of the utility company or electrical and /or plumbing codes, I will make the necessary changes at my expense unless Sears has agreed in this contract to make the changes. Payment. I will pay Sears the cash price that covers the price of material and installation as shown on the first page. Warranty Information. Appropriate product warranty documents will be given to me by Sears. Sears' Warranty on Installation is: SEARS' LIMITED WARRANTY ON INSTALLATION In addition to any manufacturer warranty extended to you on the product(s) used (which warranty becomes effective the date the merchandise is installed), if the workmanship (or application) of any Sears' arranged installation proves faulty within one year after the completion of installation, then upon notice from you Sears will cause such faults to be corrected by repair at no additional cost to you. If Sears determines that repair is not commercially practicable or cannot be timely made, then, at Sears' sole discretion, Sears may elect to provide replacement or refund. Service under this Limited Warranty is available by calling Sears Home Improvement Products at 1 -800- 222 -5030, Option 4. This warranty gives you specific legal rights, and you may also have other rights that vary from State to State. SH1 -FL (Dig.) Rev 02/10/12 Page 2 of 3 'Eu11111i111111 Job Number: 15312688 NOTICE TO BUYER 1. DO NOT SIGN THE AGREEMENT IF ANY OF THE SPACES INTENDED FOR THE AGREED TERMS TO THE EXTENT OF THE AVAILABLE INFORMATION ARE LEFT BLANK. 2. YOU ARE ENTITLED TO A COPY OF THIS AGREEMENT AT THE TIME YOU SIGN IT. KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 3. THIS HOME IMPROVEMENT CONTRACT MAY CONTAIN A MORTGAGE OR OTHERWISE CREATE A LIEN ON YOUR PROPERTY THAT COULD BE FORECLOSED ON IF YOU DO NOT PAY. BE SURE YOU UNDERSTAND ALL PROVISIONS OF THIS CONTRACT BEFORE YOU SIGN. 4. YOU MAY PAY OFF THE FULL UNPAID BALANCE DUE UNDER THE AGREEMENT AT ANY TIME, AND IN SO DOING YOU SHALL BE ENTITLED TO A FULL REBATE OF THE UNEARNED FINANCE AND INSURANCE CHARGES. 5. YOU MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY [FIFTH BUSINESS DAY IN ALASKA, FIFTEENTH BUSINESS DAY IN NORTH DAKOTA IF YOU ARE AGE 65 OR OLDER] AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. FAILURE TO EXERCISE THIS OPTION, HOWEVER, WILL NOT INTERFERE WITH ANY OTHER REMEDIES AGAINST THE RETAIL SELLER YOU MAY POSSESS. IF YOU WISH, YOU MAY USE THIS PAGE AS NOTIFICATION BY WRITING "I HEREBY RESCIND" AND ADDING YOUR NAME AND ADDRESS. A DUPLICATE OF THIS RECEIPT IS PROVIDED BY THE SELLER FOR YOUR RECORDS. 6. IT SHALL NOT BE LEGAL FOR THE SELLER TO ENTER YOUR PREMISES UNLAWFULLY OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS AGREEMENT. FLORIDA HOMEOWNERS' CONSTRUCTION RECOVERY FUND PAYMENT MAY BE AVAILABLE FROM THE FLORIDA HOMEOWNERS' CONSTRUCTION RECOVERY FUND IF YOU LOSE MONEY ON A PROJECT PERFORMED UNDER CONTRACT, WHERE THE LOSS RESULTS FROM SPECIFIED VIOLATIONS OF FLORIDA LAW BY A LICENSED CONTRACTOR. FOR INFORMATION ABOUT THE RECOVERY FUND AND FILING A CLAIM, CONTACT THE FLORIDA CONSTRUCTION INDUSTRY LICENSING BOARD AT THE FOLLOWING TELEPHONE NUMBER AND ADDRESS: CONSTRUCTION INDUSTRIES RECOVERY FUND, 1940 NORTH MONROE STREET, TALLAHASSEE, FL 32399; TELEPHONE: (850) 921 -6593. ACCORDING TO FLORIDA'S CONSTRUCTION LIEN LAW (SECTIONS 713.001- 713.37, FLORIDA STATUTES), THOSE WHO WORK ON YOUR PROPERTY OR PROVIDE MATERIALS AND SERVICES AND ARE NOT PAID IN FULL HAVE A RIGHT TO ENFORCE THEIR CLAIM FOR PAYMENT AGAINST YOUR PROPERTY. THIS CLAIM IS KNOWN AS A CONSTRUCTION LIEN. IF YOUR CONTRACTOR OR A SUBCONTRACTOR FAILS TO PAY SUBCONTRACTORS, SUB - SUBCONTRACTORS, OR MATERIAL SUPPLIERS, THOSE PEOPLE WHO ARE OWED MONEY MAY LOOK TO YOUR PROPERTY FOR PAYMENT, EVEN IF YOU HAVE ALREADY PAID YOUR CONTRACTOR IN FULL. IF YOU FAIL TO PAY YOUR CONTRACTOR, YOUR CONTRACTOR MAY ALSO HAVE A LIEN ON YOUR PROPERTY. THIS MEANS IF A LIEN IS FILED YOUR PROPERTY COULD BE SOLD AGAINST YOUR WILL TO PAY FOR LABOR, MATERIALS, OR OTHER SERVICES THAT YOUR CONTRACTOR OR A SUBCONTRACTOR MAY HAVE FAILED TO PAY. TO PROTECT YOURSELF, YOU SHOULD STIPULATE IN THIS CONTRACT THAT BEFORE ANY PAYMENT IS MADE, YOUR CONTRACTOR IS REQUIRED TO PROVIDE YOU WITH A WRITTEN RELEASE OF LIEN FROM ANY PERSON OR COMPANY THAT HAS PROVIDED TO YOU A "NOTICE TO OWNER." FLORIDA'S CONSTRUCTION LIEN LAW IS COMPLEX, AND IT IS RECOMMENDED THAT YOU CONSULT AN ATTORNEY. Mm" SANTNCA Customer's signature 04/15/2013 Date Accepted by Sears Home Improvement Products, Inc. ( "Sears ") on 04/15/2013 by: Date Management Representative 04/15/2013 Customer's signature Date SH1 -FL (Dig.) Rev 02/10/12 Page3of3 ACC)RLi �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 4/16/2013 PRODUCER ANDYS ASSURANCE AGENCIES 1441 W Flagler St Miami, FL 33135 (305) 642 -8407 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 BLUE PANTHER AIR CONDITIONING CORP . 4630 SW 13TH TERRACE MIAMI , FL 33134 (305) 316 -8557 INSURER A: SCOTTSDALE INS CO . A INSURER B: GENERAL INSURER C: CPS1653267 INSURER D: 10/03/13 INSURER E: $ 1,000,000 $ 50,000 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MDD/YYYY) POLICY EXPIRATION DATE LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CPS1653267 10/03/12 10/03/13 EACH OCCURRENCE $ 1,000,000 $ 50,000 X DAMAGE O(EaEoccurenoe) CLAIMS MADE X OCCUR MED EXP (Any one person) $ 1,000 PERSONAL&ADVINJURY $ 1,000,000 $ 2, 000,000 GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP /OP AGG $ 1,000,000 X POLICY JECT LOC AUTOMOBILE LIABILITY ANYAUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY ANYAUTO AUTO ONLY -EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS / UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ $ WORKERS AND EMPLOYERS' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER (Mandatory If yes, describe SPECIAL COMPENSATION LIABILITY Y/N WC STATU- OTH- TORY LIMITS ER EL EACH ACCIDENT $ EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ In NH) under PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS AIR CONDITIONING REPAIR & INSTALLATION CERTIFICATE HOLDER CANCELLATION VILLAGE OF MIAMI SHORES 10050 NE 2 AVE MIAMI SHORES,FL. 33138 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION ? = ILITY OF KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES., AUTHORIZED RE . NTATIVE ACORD 25 (2009/01) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD .. rium•ioe COUMIY 2011V,- , iitx.: FIRST-CLASS TAX cousaTOR COIXiTY; STATE GF - c-ifa A U.S. POSTAGE EXMRESSOnr. 30, 20T ;1-:- PAID LAVED AT P14cE OF BUSNESS MIAMI, FL P PERMIT NO. 231 ,r.::: ,1,,,:',7":`,!-, , ...,' , ..,1 C -3- ,x...,,,,,, :: ,,,, •,,,,,, ._.,,,,,I3,,-. ..5.; THISISNOTABILL-DONOTPAY 550691-1 RENEWAL BUSINESS NAME! LOCATION BLUE PANTHER AIR CONDITIONING CORP 4630 SW 13 TERR 33134 UNIN DADE COUNTY OWNER BLUE PANTHER AIR CONDIT CORP Sec. Type Of Business WORKER/S 196 SPEC MECHANICAL CONTRACTOR 1 nos ts ONLY A LOCAL !BUSINESS TAX RECePT. IT !COES NOT PERMIT THE HOLDER TO VIOLATE ANY • EXISTING REGULATORY OR ZONING LAWS OF THE COUNTY OR CITIES. Non GOES IT EXEMPT TX HOLDER FROM ANY OTHER PERMIT OR LICENSE mourn° BF LAW. THIS IS NOT A CERTIFICATION OF THE HOLDERS OUALIFICA. TIONS. RECEIPT NO. 574721-8 STATER CAC1814377 mmairmarmo kammuxammreux COLLECRft 07/12/2012 09010115001 000075.00 SEE OTHER SIDE DO NOT FORWARD BLUE PANTHER AIR CONDITIONING CORP JUAN C ORELLANA PRES 4630 SW 13 TERR MIAMI FL 33134 JEFF ATWATER CHIEF FINANCIAL OFFICER STATE OF FLORIDA 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 taw. EFFECTIVE DATE: 4/5/2013 EXPIRATION DATE: 4/512015 PERSON: ORELIANA JUAN FEIN: 202231602 BUSINESS NAME AND ADDRESS: BLUE PANTHER AIR CONDMONING CORP 4630 SW 13 TERRACE MIAMI FL 33134 SCOPES OF BUSINESS OR TRADE; I1EATING VENTILATION, AIRCOND Psirmart Choptc 440 0.,500, F&, an ahze•VJ Qvror.4t vitti, C172.0.4, 131 f.r14 t-Vri'LVM, deLvor: urat,. 11,5 ted*P grtav rtntwar S2tiVonoat,on untte P.,,ftwarstZc Cholitl 440 CE•4 12t, F& CttrlitkOsa CettlOn 0,41mr 72 ywi !ttu arapt fT, Nal,thell trado Wed On Ina MiC8 of cum" to Ca exe091 P8.46)Ert le CAI aptu 44.V. NO".244 of Ce<ittica 1st ariOseV,,*10& slara,an ta eldemOt CA+ keml ,evslreiln rf, al arty t.me SCf.T fl:AO the nrce tsie msuan.t.e kVirelesetlaw,th-fa pomom refr?.0 4ilthe noke calit4r.aim no ktnvar nlaris multoroattii tfts 4..tliOn for re c.31 f-zatp Tr* ceoemmIlt arC.rtveeN4 a tottikata oars t tm) Rat) nagit24 on Mt ftiMt2ZSO ta meet WN Tell; nt*.n 0FS•F2.INWC-252 CERTIFICATE OF LCTON TO BE EXEMPT REVISED 07-12 OUESTIONS? (0)41:1-1 - S T A T E OK F L O R I D A AC# 6 . 1 . 4 9 0 DEPART :OZ0 ;BU$INESs. AND PROP`ESSIONAL .REGULATION CAC1814377 0..6 /01/12 110409107 CERTIFIED AIR CORD CONTR ORELLANA, arm :C SUE PANTHER. AIR. CONDITIININC CO IS .CERTIFIED and *z :xAs ipzovialcOs di ,Oki :489 FS. cp xatxan apt :. AUG '31, 2014 420.15461:I0