Loading...
MC-14-914 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number:, INSP- 205875 Permit Number: MC- 1 -14 -91 Scheduled Inspection Date: January 27, 2014 Inspector: Perez, JanPierre Owner: LAMAZARES, MANUEL Job Address: 230 NE 101 Street Miami Shores, FL 33138 -2423 Project: <NONE> Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: A/C Replacement Contractor: FERGUSON MARINE SERVICES AIR CONDITIONING & REFF esunamg Department comments Phone Number (305)401 -3012 Parcel Number 1132060134640 Phone: (305)233 -5336 REPLACE STOLEN 4 TON UNIT Infractio Passed Comments INSPECTOR COMMENTS False January 24, 2014 For Inspections please call: (305)762 -4949 Page 11 of 20 Inspector Comments Passed Failed Correction Needed ❑ Re- Inspection ❑ Fee No Additional Inspections can be scheduled until re- inspection fee is paid. January 24, 2014 For Inspections please call: (305)762 -4949 Page 11 of 20 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 Permit Type: MECHANICAL JAN 21 2014 FBC 20 Permit No. Master Permit No. f �, JOB ADDRESS: ® 1d c lot 5,,�' City: Miami Shores County: Miami Dade Zip: 3 3 13 9 Folio/Parcel #: 6l - 32.0(P -- ®13.- 46gO Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): M eLn V erl i...arn cc.x o --re-s Phone #: Address:_ ® l') e 10 ! s4-, City: (Y1 [. v .5 h o reS State: F 1 Or MjjtA­ Zip: -3..S 139 Tenanvlzssee Name: Phone #: Email: Pet` aJ s o n fn Qn i nee_ CONTRACTOR: Company Name: 4; r Co rw&. -1-, or% 1 net f Rem, a r-& -e on, LLAone #: _ 3 05 -A33 ° 5 33 Address: A t � 16, 5 LJ q) +h C'as jr {" City: C U e-r 8.- State: d- L Zip: 3 31 ? 1 Qualifier Name: :mimes re4 q J s ®n Phone #: .10 5- 1715- 3 3 State Certification or Registration #: Certificate of Competency #: (2 A C. I 'f ( 5 D i Contact Phone #: Email Address: Xe_ra o.-a, r 1 i2 I b Je_ a Wrn DESIGNER: Architect/Engineer. Phone #: Value of Work for this Permit: $ V. t— Square/Linear Footage of Work: Type of Work: DAddress DAlteration ONew ORepair/Replace UDemolition In Description of Work: 4t4- A /,Q ° 00o&.-) 0OV, 7' .<2 V1,0,6_ rani s'e� L�o� 1_ 444e PV9cv r_ i% - par '!( 7vviv Submittal Fee $ SQ60 Permit Fee $ ' L ® CCF $ CO /CC $ Scanning Fee $ Notary Radon Fee $ DBPR $ Bond $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ r �� r :.'% Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip 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 IMYROVEMENTS 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 --inspection fee will be charged Signat�ire Owner or Agent The foregoing instrument was acknowledged before me this X-3 day of / , 20/,4�, by E. 3' 4-�.et -e who Ajersonall known o me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: t F. My Commission Expires: q/►bl ►s APPROVED BY E J. ABELL * MY COMMISSION # EE 080814 EXPIRES: April 10, 2015 8afded T* Suftr Signature tf 4-- ontractor The foregoing instrument was acknowledged before me this /-3 day of // . 20 6 by JF.17- C( who is ersona y rtp me or who has produced Mans Examiner Structural Review (Revised 3 /12/2012)(Revised 07/10/07 )(Revised 06 /10/2009)(Revised 3115/09) as identification and who did take an oath. NOTARY PUBLIC: Sign: Print: �' _ �. Ai --eL4 My Commission Expires: ta►r ore * MY COMMISSION# EE =14 3 t * _ EXPIRES: April 10, 2015 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): A 3 0 15AL- City: Miami Shores Village County: Miami Dade Zip Code: 3 3 / 3 8 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 A SUBMITALS ARI (AHRI) DATA SHEET REQUIRE _ Change Disconnecting means: YES NO ❑ ARHI Sheet Attached: Y NO ❑ Contract Attached: YES 1. Minimum Circuit Ampacity (Mire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: State Certificate or Registration N Signature (Qualifier's signature only) Certificate of Competency N. Phone: Date: UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL # COND. UNIT MODEL # KW HEAT NOM TONS 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 YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4 °CONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity (Mire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: State Certificate or Registration N Signature (Qualifier's signature only) Certificate of Competency N. Phone: Date: V12014 a PropartySearch I. I -415rne I Departivients I Government I Employees Calanjar MIAMI -DADE COUNW PROPERTY APPRAISER Carlos LonP' Cantera PRQPERIY AIQPRAI$Bt �� •t .F " Property Appraiser Exemptions & Real Estate Tangible Public Online Tax Roll About Us Contact Us Bane Other Benefits Personal Property Records Tools Administration The Properly Appraiser does not send tax bills and does not set or collect taxes. Please visit the Sax Collector's website direedyfor additional Informadon. Facebook I Twitter 8 Print Email Link ' + Folio: r -0,3 -4640 3eareh Folfo, Owner Name orAddress Property Arlo, e s _: 230, NF 1011 ST Enter egher folio, owner narna, or address. Selected Property Information Property Information Fill Legal Descrlptlon Assessment Information Benefits Information Sales Information Additional Information Featured Online Tools Report Homestead Fraud Tax Comparison Tax Estimator TRIM Notice View Taxes Additional Online Tooth Comparable Sales Owner: �MANZAr�PS Back to results Mailing ,kids f ss: 2: 1'0 NE-101 ST MhN }f S 10PES FL 33138 Property Information Prbn ery Zone: 1000 SGL FAWLY - 2101 -2300 SQ Land Use: 0101 RESVEICfIAL-SIMMEFAMILY:1 UW SedsMaths/Half: 21210 Floors: 1 Living Units: 1 Adjusted Sq. Footage: 1.451 Lot Ske: 9.626 SO FT Year Bu9t: 1942 Street tvlap I Aerial Map in OWNER'S NAME: Ferguson Marine Services, ,INVOICE A/C & Refrigeration, LLC 7609 MECHANICAL CONTRACTORS CAC 1815070 21515 S.W. 97 Ct. • Miami, Florida 33189 DATE OFFICE: 305 - 233 -5336 • FAX: 305- 235 -2246 BOB: 305 - 775 -7796 PERMANENT ADD 2-4 " 1, � �-: z 1� 3 f ADDRESS:_ -,-).� C) '5�4 CITY. 2'-_L ° _y _%S'. STATE: ZIP: 3`' 3 PHONE: ADDRESS: CITY: PHON STATE: ZIP: SALESPERSON UNIT MAKE MODEL NUMBER SERIAL NUMBER WARRANTY DATE PARTS & MATERIALS WORK PERFORMED UNIT PRICE LINE TOTAL c- le IT IS UNDERSTOOD THAT FERGUSON AIR CONDITIONING AND REFRIGERATION, LLC, IS IN NO WAY RESPONSIBLE FOR WARRANTY FOR TERMS: Payments due ANY EQUIPMENT OTHER THAN WHAT THEY MANUFACTURE AND CAN ONLY PERFORM SERVICES AS PRESCRIBED BY THE by 15th of following MANUFACTURER OF SUCH EQUIPMENT. FERGUSON AIR CONDITIONING AND REFRIGERATION LLC, WILL TRY TO OBTAIN SUCH WARRANTY month. A charge Of BUT CUSTOMER WILL HAVE TO PAY FOR TIME INVOLVED. IT IS THE CUSTOMER'S RESPONSIBILITY TO PAY FOR ALL WORK OR LABOR g PERFORMED BY FERGUSON AIR CONDITIONING AND REFRIGERATION, LLC, AND ALL EQUIPMENT LISTED WILL REMAIN THE PROPERTY OF 1.5% per month on all FERGUSON AIR CONDITIONING AND REFRIGERATION, LLC, UNTIL BILLS ARE PAID IN FULL. CUSTOMER IS RESPONSIBLE FOR SAID accounts 30 days past EQUIPMENT ONCE R IS INSTALLED. due (18% annually). In I HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE AND AGREE TO PAY AS DESCRIBED. HOURLY RATE IS the event Of non - PLUS TAX AND TRAVEL TIME. payment, collection THE CUSTOMER HEREBY AUTHORIZES THE WORK AS SHOWN ON THE FACE HEREOF TO BE DONE ALONG WITH THE NECESSARY fees and/or reason - MATERIALS AND HEREBY GRANTS UNTO FERGUSON AIR CONDITIONING AND REFRIGERATION LLC, ITS AGENTS OR EMPLOYEES able attorney's fees PERMISSION TO OPERATE THE EQUIPMENT CONCERNED, FOR THE PURPOSE OF TESTING, INSPECTION, AND OTHERWISE. AN EXPRESS• uultl he rharnoahla to TOTAL PART TOTAL LABOR SUB TOTAL TAX TOTAL CIO MEGHMIua Gen is HEWT AuMOWLeuueu AND GRANTED ON THE EQUIPMENT ON WHICH ANY SUCH WORK Amu MA1E.num.5 Am MH — a..«..... — FURNISHED a- - FURNISHED AND SAME IS IN ADDITION TO ANY COER, R IG T THE DEALER MAY HAVE TO RECOVER THE PROPER CHARGES the customer. THEREFORE. Signature: Date THANK YOU FOR YOUR BUSINESS! MAKE ALL CHECKS PAYABLE TO FERGUSON M E SERVICES AIR CONDITIONING & REFRIGERATION U.C. This combination qualifies for a Federal Energy Efficiency Tax Credit when placed in service between Feb 17, 2009 and Dec 31, 2013. Lill AHRI Certified Reference Number: 3858343 Date: 1/12/2014 Product: Spilt System: Air - Cooled Condensing Unit, Coll with Blower Outdoor Unit Model Number. UASL4MWEC Indoor Unit Model Number. RHPN- HM4824 +RCSN -H *4824 Manufacturer: RHEEM SALES COMPANY, INC. Trade/Brand name: RUUD Series name: Manufacturer responsible for the rating of this system combination Is RHEEM SALES COMPANY, INC. 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 AHRlsponsor*A independent, third ply testing: Rage Mowed by an aMrisk (q hWkx to a wkadaty merge of ply p dam, urdm acwm aided with a WAS, which hang an kwwhoary raabe. 02013 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 1303403 M 51974957 UUDI 3esignStar Load Resuhs are intended fbr use with Ruud heating and oDoling systems Ceiling height Window U -value moisture grains Duct gain % Heating infiltration: (ACH) Summer ventilation 0 Heatin , L, ds t ;! . . a Mm Windows Heating Loads 18,442 BTU/hr m Efficiency Loss Wall ation r Windows Cooling Loads 40,973 BTU/hr Sensible People Load Latent People Load Internal im:v— ' i- Wall "°" `- Ceiling Latent Infiltration System Sensible Winter Outdoor 50 °F girl r la oor 700F' Sensible Cooling 35,082 Btuh AED Graph 5&890 Btuh ........ 1.595 CFM 71 7.777 Sen�ble Westing 20000 _... ... - .... _ ............. -._ ..... ......-_- ........... ._ .................. ---- .................. - .... --- .......................... _ ..................... ...... ........__................. - - ----- ..................... _ ...... - ... __ ............ _.._ ... _ .............................. __ ... _ ............. _ ..... -- 240 CFM All cakulations are based upon approved hvac Industry standards and procedures, and comply with all local, state and federal cbde`requirements. All computed results are Estimates. Product provided by Energy Design 15000 -�_ _.._ ......... -- ---- .._..._.._.- _...._.._._..- .............._._.__........................... ..... ...._._—...__.........-------- ................... -.----... .......--- .......... _.......... - .._._........_.. ._...—.__.._._.._..-- a 10000 --- ........................................ ..._...............—..._................__............................_............................................._.................................................................................................._................................_._._............................._..........,............................ ............................... 5000 ___ ___ 0 Bam. gam loam ..., _ _.,.. _ _.. -,,.. _ ...._,..._ clam 12pm 1pm 2pm 3pm 4pm 5pm 5pm 7pm Bpm — Hourly Loads — Average Sy5tern equipment selection wlU be made using the following derived values. Glass (E) : 104 sq. ft. 7. - Glass (N) 60 sq. ft . Glass (�� 73 sq. . Summer Outdoor 96 *F urrik(ier ,'U1�et;8u(l 77 °F' Winter Outdoor 50 °F girl r la oor 700F' Sensible Cooling 35,082 Btuh Me It C l llrl 5&890 Btuh Required Cooling Airflow �. _. 1.595 CFM 71 7.777 Sen�ble Westing 18,442 Rtuh Required Heating Airflow" 240 CFM All cakulations are based upon approved hvac Industry standards and procedures, and comply with all local, state and federal cbde`requirements. All computed results are Estimates. Product provided by Energy Design Systx�ms and Idea Tree i This combination qualifies for a Federal E Efficiency Tax Credit when placed in s between Feb 17, 2009 and Dec 31, , rr�,Iqik �T'Rtl` "t"k, -.-p" AHRI Certified Reference Number: 3858343 Date: 1/3/2014 Product: Split System: Air - Cooled Condensing Unit, Coil with Blower Outdoor Unit Model Number: UASL- 048JEC Indoor Unit Model Number: RHPN- HM4824 +RCSN -H *4824 Manufacturer: RHEEM SALES COMPANY, INC. Trade/Brand name: RUUD Series name: Manufacturer responsible for the rating of this system combination is RHEEM SALES COMPANY, INC. 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): 48500 EER Rating (Cooling): 13.00 SEER !Rating (Cooling): 18.00 IEER Rating (Cooling): * Ratings followed by an asterisk (q Indicate a voluntary rerate of previously published data, unless accompanied with a WAS, which indicates an involuntary rerate. 02013 Air - Conditioning, Heating, and Refrigeration Institute CERTIFICATE NO.: 130332592753071416 01/03/,2014 15:07 FAX 3052352246 F 2001 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' ,REGISTRATION FORM ALL CONTRACTORS MUST PROVIDE COPIES OF LICENCES AND INSURANCES EACH TIME A PERMIT IS SUBMITTED OR THE VILLAGE MAY MAINTAIN A FILE WITH YOUR INFORMATION FOR A $30.00 FEE PER YEAR. IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LIC CARD B. �� COPY OF LOCAL BUSINESS TAX RECEIPT 40 /� v �o IIGC,.� - I-ram '411 /�U.o. i1 �I) S - C. COPY OF LIABILITY INSURANCE (CERTIFICATE HOLDER TO BE MIAMI SHORES DG DEPT) D. V COPY OF WORKERS COMPENSATION (EITHER CERTIFICATE OR EXEMPTION) IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMMENCY: A. — COPY OF CERTIFICE OF COMPETENCY OF QUALIFIER B. COPY OF MIAMI DADE COUNTY MUNICIPAL CONTRACTOR'S TAX RECEIPT C. COPY OF LIABILITY INSURACE (CERTIFICATE HOLDER MUST BE MIAMI SHORES VILLAGE BLDG DEPTI D. COPY OF WORKER COMP INSURANCE (EITHER CEEIFICATE OR EXEMPTW" YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE HOLDER AS FOLLOW: MIAMI SHORES VILLAGE BLDG DEPT 1 DDSD NE 2ND AVE MIAMI SHORES, FL 33138 COMPLETE CONTRACTOR' SINFORMATIpN�������� ■�r�uu����������.u�� BUSINESS NAME: a n !1'la.11i n g- Se-ru)c s zr zna, �'r�, s %�� �ra a rani Win, b BUSINESS ADDRESS: A l 4515 -.5W Q -)+h 4 CI'T'Y u r STATE � ZIP CODE .33 l gQ BUSINESS PHONE: 3( 5- A 3 - .'573 36 FAX NUMBER ( 3 0 1 4�k3 S —aa Yb CELL PHONE (.3 D,51 77 S7- 33 1 F QUALIFIER'S NAME: T•�Mes i'e�t:g uson QUALIFIER'S LIC NUMBER: _ C Ag G 1? 1 S 0 7 D E -MAIL ADDRESS (IF APPLICABLE): 6a ( �� 6' C_ii l • 41)q Cmattd on 3M9JD9 BY MM I RV 3/ZM w bV '& o4 a q IpajC,5 / 3 -- 1414 01/03/2014 15:08 FAX 3052352246 F STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUS'T'RY LICENSING BOARD 1940 NORTH MONROA STRZET TALLAHASSEE FL 32399 -0783 FERGUSON, JA1lii8S MICHAEL FERGUSON 97 MARINE SERVICES 215 CUTLER 7 COURT RXB FL 9 002 (850) 487 -1395 AIR CONDITIONING & REFRIGERATION LL 33189 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professlonal Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to Improve the way we do business in order to serve you bette For Inforrrration about our services, please log onto www.myflorldalicense eom. There you can find more information about our divisions and the regulations that lmpact you, subscribe to department newsletters and team more about the Depertment'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 customem- Thank you for doing business in Florida, and congratulations on your new Itcensel L AmSTATE of FLOMDA AC# 5 300081 D$PARTUMU OF SUSIX8139 AND qw PROFESSIONAL,. RMUL,ATION mci!3150701' ' y 8/ ✓;12 128052585 CBRTIFaISD - �i� : ol'0A` C N'.C>t FERGUSON-j`. FERGUSON CES AIR COt IS CBRT=LpxBb ww*r the yrovieiems or ch.489 js mWi=ti" Ores, JMG 31, 2014 L12082401558 THIS DOCUMENT WAS A CULOR�D BACKGROUND • NVCT40PRfNTING - LINETAARK" PATENTED PAPER "tee kC#6300081 STATE OF •' ' •DEPARTMENT• OF SII 1 290 AND PROpFESSIONAL REGULATION C. CONSTRUCT ON INl�pSTiZY LICENS TG BOARD $EWL12092401659 'ghti- CLASS' •8.•Air C01dDITTOb1TNG --- :- _ -_ - -- Nzlmed held IS CERTIFIED `Under the • provisinne of •Chep�'$: Expiration Gate: AUG 31 2014:: ` w �lJ •L } tlf/:Y 'h N•S. AIR .varwl ; R., REFRIGrRATION LL 33157' '•FSRGUSON.. JAMB. MICNAEL, FERGUSON MARINE: SERVICES 9233 SW 182ND ST MIAMI FL RICK '' SCOT'S • • 00"V NOR XW LANSON SECRETARY 01/03/2014 15:08 FAX 3052352246 F 1@003 001477 Local Business Tax Receipt Miami —Dade County, State of Florida 114IS IS NOT A BILL - DO NOT PAY 3217858 LB�T BLISS MS A"lw a TION RECEIPT No. EXPIRES FERGUSON MARINE SERVICES AIR CONDITIONING fed R--ON ISEPYEMBER 30, 2014 21515 SW 97 CT 3352515 Must be displayed at place of buslneaa CUTLER BAY FL 33184 Pursuant to county Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYpE OF Bi81NEW PAYMENT BECEW19D OW FERGUSON MARINE 5VC5 A/C B,R�FRIG 1913 SPEC MECHANICAL CONTRACTOR B. TAX Cp1.1.ECTOR CACIS15070 $45.00 09/05/2013 Worker(s) 1 TXKSI -13- 054755 ibis Lewd Busin*" Tax Receipt easy confirms psi of die Local Op2hum Tans The RoceiPt is 01A licanse, awfficaUan claw r b pmapy vtb any gonmermi or rnmmnmenml gulat lac e d� wMch WPMa hue TMMCOPT Ift ohm am be displayed oh all commercial "1114103 - MAisati -Dada We Soc 8*1" . for more inisraaation, vbdt wa 01/03/2014 15:08 FAX 3052352246 F 1@004 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 law. EFFECTIVE DATE: 5/15/2013 EXPIRATION DATE: 5/15/2015 PERSON: FERGUSON JAMES M FEIN: 113721738 BUSINESS NAME AND ADDRESS: FERGUSON MARINE SERVICES AIR CONDITIONING & REFRIGERATION LLC 21515 SW 97TH CT CUTLER BAY FL 331893711 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR -COND Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who effects exemption from this chapter by flung a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.B., CertiAeates of election to be exempt.,, apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant io Chapter 440.05(13), F.S.. Notices of election to be exempt and certificates of erection to be exempt shalt be subject to revocation If, at any time after the 1(kv 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 any time for failure of the Person narnsd on the c0a icsate to meet the requirements of this section. IFS- F2 -DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07 -12 QUESTIONS? (1350)413 -i609 01/03/2014 18:16 3052358606 ALL AMERICAN INSURAE PAGE 01/01 DATE (140 MOIYYYY) _. CERTIFICATE OF LIABILITY INSURANCE _ _ 01/03/14 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, EXTENT] 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 CIERTIFICATE HOLDER. IMPORTANT: if the nertmem holder is an ADDITIONAL INSURED, the pollWfes) must be endmwd. If $UWWGATION IS WAIVED, subJeet to the terms and acmdItlons of the pulley, certain polleles may mqure an endorsement. A statement on this certlReate does not confer rights to the PRODUCER All American Insurance 9036 SW 162nd St Miami, FL 33167 Phone (305) 233-M Rex (305)2364WO INWRSD Ferguson Marina Services, Air Conditioning & Refrigeration, LLC (ID 724$33) 21516 SW 97th Court Miami, Ft. 33189 QUOTES Klg�f NOINSURANCE.COM INSURERM) AFFORDING C E _ NAidi # gVQ NMM!M A; Westem World Insurance CompRny COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE 69EN 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 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 13Y PAID CLAIM, A GIRMAL LIAMUTY ® COMMERCIAL 09NERAL LIABILITY (] ❑ CLAIMS-MADS EM OCCUR © _ ❑ GeOL AGGREGATE LIMIT APPLIES PM micy 40C NPP1325727 02127/2013 02127!2014 EACH OCCURRENCR S ED PRE I ems MED FxP (mr — ten) $ � PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMPIOP AGO $ AV MOMLB LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS El S4HE�JLED AUTOS ❑ HIRED AUTO$ IL"JI NON -OWNED AUTOS _ _ COMBINED SINGLE LIMIT (Ea ac�Idrmt) � � BODILY INJURY (Par P...) $ BODILY INJURY (Pot awMerlt) $ PROPERTY DAMAGE (per ago" $ EACH OCCURRENCE $ $ B ❑ UNIBR0.LA LIAR ❑ OCCUR ❑ EXCESS UAB ❑ CLAIMS -MADE AGGREGATE $ 0 DMX=13LE RETIMIMN S _ 3 r"T C 37 T OTH. IJ_ $ WORKERS COMPENSATION AND BMPLOYERCSR'�pLIAAINLLITY ARCM BER &V 9 UP M ' Fn71 N I A F-L. EACH ACCIDENT G 01MOMPTION OF OPERATIONS I LOCATIONS I VEHiOLM (Attach ACORD 401, Addrtieaal Remarks Schedule. If more spaoo IR required) THE PARTY LISTED BELOW IS RECOGNIZED AS CERTIFICATE HOLDER. IERTIFICATE HOLDER MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ACORD 28 (2009109) QF CANCELLATION SHOULD ANY OF TM ADWS ORWRI13ED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOP, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLJQYPROVISIONS. AUTHOR9M REpm7d71V I • .�1 ; 0 19131 2M A100 CORPORATION. AI rights reserved. TtiO.ACORD dame Od logo are registered marks of ACORD