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MC-13-1157 j r, ,x M Village Shores Villa e MAY �o» Building Department artment 10050 NE-2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795.2204 Fag:(305)756.8972 INSPECTION'S PHONE NUMBER:(305)762.4949 BUILDING Permit N PERMIT APPLICATION Master Permit No. — S ° 2�r FBC 20 Permit TC pe:MMCHA.NJCAL OWNER:Name(Fee Simple Titleholder): Phone#• Address• aq �4 't AO O City ki State: C gip. " 313 TenantJteisee Name• ' ; Email• Phone#: • JOB ADDRESS: 9 0 L)'E- !I- :fib- City: Miami Shores County: Miami Dade Zip: t Folio/Parcel#: Is the Building Historically Designated:Yes NO Flood Zone: ' g- e4D--?CONTRACTOR:Company Name: Phone# ° Address: t-J-0 L O. city: l ' State: gi Qualifier Name Phone# p; State Certification or kegisttation CC�A - S ®2-1� Certificate of'Compete�nycy#: Contact Phone#:2S ° JAS" 1 c" 2 Email Address: ^,S detL.e [� / DESIGNERS ArchitectlEngineer. )?hone#: Value of Work for this Permits$° Sq tage of Work: f Type of Work: DAddress DAlteration DNew DRepair/Replace ODemolition Description of Work: ` N c� S a S -�- CIA Pv2 s' Submittal Fee$ Permit Fee$ 0!5 OD CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Bond$ Notary$ Training/Education Fee$„Technology Fee$ Double Fee$ Structural Review$ TOTAL FEE NOW DUE$ y�� 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 instaftt on 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 ELECTP CAT.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 an 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 COM ENCEMENT." 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 Signature Own or Agent Contractor The foregoing instrument was ac J owledg before me this? The foregoing instrument was ac ]edged before e s day of ,20 6)by �ti day of 20 I�,by r t� who is personally kno to me or who has produced who is person ly known to me or who has produced As identification and who did take an oath. as id cation and who did take an oath. • ptMY AL ,qgB.DARIp R11B NOTARY PUB C: r..v �0�� NOTARY PUBLI �.•_., "��` �p 932�FA * * MY COMMISSION i DD 993 769 v rues, � EXPIRES:October 13,2013 Sign: ern �edThlu Sign: Print: Print: ° My Commission Expire : My Commission Exp es: APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised 07/10/07)(Revised 06/1=009)(Revised 3/15/09) From: 05/24/2013 11 :53 #604 P.001/001 A"' & CERTIFICATE OF LIABILITY INSURANCE M~DATE(MM/DD/YYW) 05/24/13 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(ies)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 CONTACT Lucia Estrella Accurate PHONE (305)226-8727 a/c No). (305)226-8767 8300 West Flagler Suite 114 E-MAIL ludaestrella®bellsouth_net ADDRESS.Miami,FL 33144 INSURE s AFFORDING COVERAGE NAIC# Phone (305)226-8727 Fax (305)226-8767 INSURER A.. Accident Insurance Co. INSURED INSURER 8: Denis Air Conditloing Contractor Inc. M URER C: 6726 NW 193 Lane INSURER D: Hialeah,FL 33015- INSURER E: INSURER F: 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 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 SUGH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTRR TYPE OF INSURANCE UD UB POLICY EFF POLICY EXP POLICY NUMBER MMtDD1YYYY M LIMrr3 GENERAL LIABILITY EACH OCC RRENCE $ 1:000,000.00 ® COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ❑ ❑ CLAIMS-MADE © OCCUR ISE5 a S 900,000.00 A Y CPPO001011-09 MED ExP An rson s 5,000.00 ❑ 02/0712093 02/07/2094 PERSONAL&ADV INJURY $ 1,000,000.00 _GENERALAGGREGATE 2 $ 000 000.00 GEML AGGREGATE"LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000.00 © POLICY ❑ PRO ❑ LOC $ AUTOMOBILE LIABILITY COMBIN D SINGLE LIMIT ❑ ALL OW O BODILY INJURY(Per person) s ❑ UTO$OWNED ❑ AUTOS BODILY D BODILY INJURY(Per accident $ ❑❑ HIRED AUTOS ❑ AUTOS AROPER Y DAMAGE $ ❑ UMBRELLA LIAR OCCUR -- $ EACH OCCURRENCE $ EXCESS LIAR ❑CLAIMS-MADE AGGREGATE $ ❑ DED El RETENTION$ WORKERS COMPENSATION ^— $ AND EMPLOYERS'LIABILITY YIN ❑WC STATU- ❑ OTH- CERIMEMBER EEXRCIT.UDED7 ECUTNE NIA E.L.EACH ACCIDENT TORY LIMITS - ER (Mandatory in NH) E.L.DISEASE-EA EMPLO $ D yyeass describe undsr DESG�RIP71pN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT s DESCRIPTION OF OPERATIONS I LOCATIONS J VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more specs Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Miami Shores Village THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 10050 NE 2nd Ave ACCORDANCE WITH THE POLICY PROVISIONS. Miami Shores, FL 33138 AUTHORIZED TA 305-756-8972 Lucia Estrella ACORD 28(2010105)QF GT9)ft-^2R0 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r �"`--� VV^ ,,(y a yl `�c'ttSi 6', f _ '..gA ,S'z e .L ;� 1'� y�F ;✓r-"n�``h�!N � ?i T�i4dAPa W�a4�.POSTAGE k 'g {SAID - z h 041*n,FL ij TI N , MRMIO.01 THIS 1S`NOT A SILL—DO NOT PAY RENEWAL 693612-5 RECEIFt NO. 721194-9 BUSINESS NAME I LOCATION DENIS AIR CONDITIONINC,CONTRACTOR .STAT # t C1250219 INC 6726 NW 193:1A 33015 UNIN DATE COUNTY OWNER DENIS AIR CONDITIONING CONTRACTO WORKER/S Sec.Type of B 6 eQfRAL MECHANICAL CONTRACTOR HE T - Is Y A Dees�T o Pgmw-THE - HOLDER TO VIOLATE ANY . E»Pte REWLATORY OR Do 140T IFORlI�ARC) ZWW LAWS OF TOE DES rr WMAWT THE HOLDER FROM ANY OTHER PEN" OR LWEM REQUIRED 4Y LAW.THM 0 DENIS AIR CONDITIONING CONTRACTOR HOT A CE nVMTION OF OUALIFWA- INC DENIS BELLO PRES pA R11 TAX 6726 NW 193 LN co,� MIAMI FL 33015 07/16/2012 09010.163001 000075.00 Is pill)111f1111tall((f 8 11111 Ill$11111 111 Itllfff;f i6f�li fY lt1 1 SEE OTHER SIDE R 03-12-2012 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER DEPARTMENT OF FINANCIAL VICES DIVISION OF WORKERS' COMPENSATION CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS COMPENSATION CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE PATE: 02117/2012 EXPIRATION DATE: 02/1612014 PERSON: REL LO DENIS FEIN: 454155472 BUSINESS NAME AND ADDRESS: DENIS AIR CONDITIONING CONTRACTOR INC 5725 NW 193 LANE HIALEAH FL 33015 SCOPES OF BUSINESS OR DE- 1- CERTIFIED MECHANICAL CDNTRACTO IMPORTANT: Pursuant to Chapter 440 . 0504), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05412), F.S., certificates of election to be exempt... apply only within the scope of the business or trade listed an the notice of election to be exempt. Pursuant 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 or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at arty time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1609 OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA IMPORTANT DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION F Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who CONSTRUCTION INDUSTRY O elects exemption from this chapter by filing a certificate of election CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA L under this section may not recover benefits or compensation under this WORKERS`COMPENSATION LAW a D chapter. EFFECTIVE: 02/17/2012 EXPIRATI DATE: 02/15/2014 Pursuant to Chapter 440.05 1121, F.S., Certificates of election to be PERSON DENIS SELLO exempt... apply only within the seape of the business or trade listed on FEIN 454155472 E the notice of election to be exempt. BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt DENIS AIR CONDITIONING CONTRACTOR INC and certificates of election to be exempt shall be subject to revocation 6726 NW 193 LANE if, at any time after the filing of the notice or the issuance of the HIALEAH, FL 33015 certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the SCOPE OF BUSiNESS OR TRADE: person named on the certificate to meet the requirements of this I- CERTIFIED MECHANICAL CONTRACTO section. QUESTIONS? (850) 413-1609 CUT MERE Carry bottom portion on tha.doh, keep tipper portion for your records. DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 �® ® �• � m •� °�•° !III 10�11 STATE FLORIDA.,. Ds rsz4zN N ss t; I STRY C AR RT p 4�E sro AL RBGV TZON I,I�N5��1G BQARU SE( L12053101754 : TaICEI�'SE" $ tD5 3I; 2:01.2 118 .9525 C C12'�0219 s x Tae. ; C. 1 CAL C �� Namad I7eI :.I CEId7 IF'YEIB nd r tea . a is isioxxs o£ .Chapt4 13 RS Expiration bates AUG 31., 2014 : i f BELLO., DMil. I)EI�IS'AIR 'C4 I3ITI4i1iI C4NT tAC 4R, t 6726 NW 193 .NE. _ HIALI:AH FL 330 5 R ICK SCOTT: KEN LAN1541�T G4uS1TOR SECRETARY DISPLAY AS REQUIRED BY"LAW DEPAR off";BUSI SS PROF SSo ,T�_.I� GttI,XTI:t7N C C1,28-fl 12: i '.195286 C -RTIFg N I Z A1, Y:QNTRt�CTOR; $EYaTo r DENZ'i.�x', ' D S AIR 0.O1DZT. I.*— CQ CTb I3- RTIFI under tale OFo is..ions of M.489 m ssp rat ou data': AUG.`:31', ;201$ I,�2ti533Q�7"5�