MC-13-368 Miami Shores Village -
Building Department ` 0`i {
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(30S)762.4949
BUILDING Permit No._ C
PERMIT APPLICATION Master Permit No.
FBC 20 1 0
Permit Type:MECHANICAL
OWNER:Name(Fee Simple Titleholder): l:1' t-C- e w t p yq Phone#:_ &(9_X 6®�q�
Address: IvE Lup
city: Utz xa i/ofl l �' rge S State: FL_- f zip:_ 3 0�;
TenantUssee Name: Phone#:
Email:
JOB ADDRESS: iy ®�
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#t
Is the Building Historically Designated:Yes NO Flood Zone: t
CONTRACTOR:Company Name&-Tye M6 ..Ow( yeYy l(f, Phone#: _;M-382
Address: I3FS9L0 -qi sr x`7(0
City: 1 '11 State• L Zip: 3 3/47S-
Qualifier Name: LAS t/Gt L4 Phone#. 30139 Z'4SZt
State Certification or Registration#: GIG Certificate of competency#:
Contact Phone#: 3C76"38 2-4 Zo Email Address: X' re(re Y)LVr_ Q_�jG hk U• co wq
DESIGNER:Architect/Engineer: Phone#:
Value of Work for this Permit:$ 0 0 Square/Linear Footage of Work: S 0
Type of Work: OAddresS OAlteration A&w ORepair eplace ODemolition
Description of Work: ��`� � I' V>C t `f�®� >
ITT
.. �. THT�kP+k�k�TkkkMT+ks�TRTTTTd�TT4WT�?skTTTk�rppp+HakMTHaRTTN�THT,*&TTMkTTkTTkT4.THTT�TTT�4TATkTTTT
Submittal Fee$50 'C Permit Fee$ L' ` CCF$ CO/CC$
Scanning Fee$ Radon Fee$ DBPR$ Bond$
Notary$ Training/Education Fee$ Technology Fee$
Double Fee$ Structural Review$
TOTAL FEE NOW DUE$ 101 U
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 nt. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first insp ic)t occ s seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection wi .not pproved a a reinspection ill be charged
Signature Signature
Owner or Agent �ntractor
The foregoing instrument was acknowledged before me this , The foregoing instrument was acknowledged before me this
day of VfA�X-S ,20—P—,by Cal S- hn 14NM day of 20 L3-,-by 11 S �fgPuWJ '
who is personally known tome or who has produced who is ersonally known or who has produced
As identification and w�(hdidWlw,in oath. as identification and who did take an oath.
NOTARY PUBLIC: ,�`;�d ...... NOTARY PUBLIC:
/' y @ d x=� S �.
Sign: Sign:
Print: �.s� � Print:
My Commission Expires: '1/, .......' lav �`� My Commissio •°c My COMMISSION#EEO
,�����r►t►►nntti���`�®°�`
EXPIRES Septenber28..ZQf`
M-0153 F7aiC3rk�n 8ervioe com=
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09)
CERTIFICATE OF LIABILITY IN URANCE DATe"AAmDl1fYM
02114/13
THIS CERTIFICATE is ISSUED AS A MATTER O>=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 INSUREA(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:if the MWICaft holderis an ADDITIONAL WSURED.this pogcy0w).roust be indorsed.#:St ATM IS'WAKgM sWged t0
the terms and conditions of ft PoNCy,cettahr.poitc(es may require an eudorserrWIL.A slatement on tids cerdlicate doss not°cater rights to the
cartiffteft holder In Iieu of such endorssem gs).
PRODUCER
JOSE M0kurcl6Srr
FrewmW Insurance Florida#52 (.954)558-2129 F NO.' (954)358-2130
6129 SdrlirTg Road JMAU RI&S> F FR t tAYI�ISUIi+ EFL,GOM
Davie,FL 33314 AFFORDRiGCOaF tAr3E "LC
Phone
(954)35&2929 Fax 954 358-2930 wsuRaRA MOUNT VERNON FIRE
INSURE17 - - SURER S.
X-TREME COOT.SERVICES CORP INSURERS
73876 SIN 56 St #276 INSURERO:
Miami,FL 33175= 305 382-4500 ROUPER a
INSURER F.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBERS
THIS IS TO CERTIFY THAT THE POLICIES OF IAiSSURAcNCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREARENT,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 IES.LI*. SHOWt4 MAYHAVE SEEN REDUCED B.Y ... CLANS. .
MISR AM=
LTR Tile£OF iRANC>s POLICYNUIffiot OWN& PgfLIC1f CtM
GiBI�RALLfABtia'[Y _.
EACH OCGU S 7>04t),IX -00
AA FTED
GOMERCIAL GEI+lERAL LWSRSTY S 1()0'0()0#00
CLAWS-MADE 0 OCCUR: CL2607795 NED EStP'Any cite $ 5,000,00
A F�1-y N N 10112/2012 10112f2013
IJ 3 PERSONAL$AI'Ni'MAW $ 1406,000.00
Q ? GEN3M AGGREGATE $ 2,000,000.00
GEWL AGGREGATE LWITAPPLIES PER �tODClCIS>Citli4iP161tAE3t3 $ 1,000,000.00
POLICY 0 PRO- 0 ±OC $
AUfOIIiOU"UABRJrY udED siNGC RLwr
Q ANY AUTO BODILY MURY'(Per OMM) s
ci AALL ❑ AUTC1 PULED IODILY 9QURY(Per 9odd6 $
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WED AUTOS CI AUTOS
C3 0 $
0 U{IeBRELLA—u". D OCCUR EACH OCOIRR84M S
' Q EXCESS LIAB Cl cLk S sE ! AGGREGATE $
OED ❑ RETENTIONS
WORKPA"COMPENSATION �fC$TATU�.'
0-efw
AND EMPLOYE1�LUORM YIN I estTs DER
ANY PROPRIETOMPARTNERIE KECUf NL
EXCLUDER? NIA ELEACHALCIDEbn $
(MMddwy in NHI El EL DISEASE-EA EMFLOY $
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OE8aR OMO OF OPERATIONS below { EL DISEASE-POLICY LIMIT $
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DESCRUrMNOFOPERAMONSILWATIONSIVEHICLES(A"achAOOM104,AddMonWRanurWSche&doltnwmspneisrequbeo
A/C SERVICES
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Miami Shores Village THE EXPIRATION DATETHEREOF,NOTICE W L BE DaIVERED IN
! ACCORDANCE VOTH THE POLICY PFICIVISIONS,
Building went
10050 NE 2nd Avenue
AurHa>eiEa REPREMENTATiVE
Mlami'Shor+es,FL 3313¢
JOSE MAURISSET
X11988=2010 ACORD CDRP0RATI0N. All rigtlts reserved.
ACORD 25(201=5)OF The ACORD name and logo are registered nfvks of ACORD
.• •V611.112,17; -. •.• i
AC# 61 5 3 7 7 9 STATE OF FLORIDA
DEPARTMENT BUSINESS AND SEW L12060600701
0 , - LICENSE NBR
06/06 2012 110415338 CAC1815536
The CLASS A AIR CONDITIONING CONTRACTOR
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2014
CARVAJAL, LUIS
13876MSWCO6LSSERVICE CORPORATION
MIAMI FL 33175
RICK SCOTT KEN LAWSON
GOVERNOR SECRETARY
DISPLAY AS REQUIRED BY LAW
r
AER:t:tlljNTY015 At fAX# 1` "r` 2015 FIRST-CLASS
TAX COLLECTOR V ;FTATE OF FLAT U.S.POSTAGE
40 -FLAtiMSf PAID
1i;d FLR E ;,, Yti#T !tJ10E O� MIAMI,FL
MAIAMf.PE.3'3i3f� ty�t p fEFI SA-ART 8 ak'1d� PERMIT NO,231
THIS IS NOT A BILL-DO NOT PAY
bfl7699-6 RENEWAL
BUSINESS NAME/LOCATION RECEIPT NO. 633933-7
XTREME COOL SERVICES CORPORATION STATE# CAC1815536
13780 SW 56 ST 214
33175 UNIN DADE COUNTY
OWNER
XTREME COOL SERVICES CORPORATION
See.Type of Business WORKER/S
THIS 1Y6A� C MECHANICAL CONTRACTOR 1
BUSINESS TAX RECEIPT.R
DOEs NOT PERMIT THE
HOLDER TO VIOLATE ANY
ZOON04 LAWS OFRYTHE DO NOT FORWARD
COUNTY OR CITIES. NOR
DOES IT EXEMPT THE
HOLDER FROM ANY OTHER
PERMIT OR LICEIM
NOO1 CR XTREME COOL SERVICES CORPORATION
THE HOLO—S OUALIMA• JUAN C PATTERSON PRES
ro"S' 13876 SW"56 ST 276
PAYMENT RECEIVED MIAMI FL 33175
MIAMFDADE COUNTY TAX
COLLECTOR:
07/13/2012 i iiji jj((## # gi i# t tt! {
60040000129 �itl�iiftl iiiilli1IfIIi tiIIIIIIIItIlffltlitf tlii1ifIItI
000075.00 kill
i
SEE OTHER SIDE _. .
PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE
STATE OF FLORIDA IMPORTANT
j DEPARTMENT OF FINANCIAL SERVICES
it DIVISION OF WORKERS COMPENSATION O Pursuant to Chapter 440.05(141, F.S., an officer of a corporation who
CONSTRUCTION INDUSTRY 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 D chapter.
EFFECTIVE: 07/27/2011 EXPIRATION DATE: 07/26/2013 Pursuant to Chapter 440.05(12), F.S., Certificates of election to be
PERSON: JUAN C PATTERSON H exempt... apply only within the scope of the business or trade listed on
+ FEIN: 680635399 R
the notice of election to be exempt
BUSINESS NAME AND ADDRESS: E Pursuant to Chapter 440.0503), F.S., Notices of election to be exempt
X TREME COOL SERVICES CORPORATION and certificates of election to be exempt shall be subject to revocation
a 13878 SW 56TH STREET 4276 if, at any time after the filing of the notice or the Issuance of the
MIAMI, FL 33175 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- MECHANICAL CONTRACT Section.
QUESTIONS? (850) 413-1609
CUT HERE
Carry bottom portion on the job, keep upper portion for your records.
OWC-252 CERTIFICATE.OF ELECTION TO BE EXEMPT REVISED 01-11