MC-14-868Miami 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
JOB ADDRESS: i oc , t g
City:
BY:
O
APR 302014
FBC 20
Permit No.
Master Permit No. HC /1/ " '6 8
Miami Shores County: Miami Dade Zip: aa►ea
Folio/Parcel #: V • z 2-11- - co Z6 - oG a .
Is the Building Historically Designated: Yes NO Flood Zone:
OWNER: Name (Fee Simple Titleholder): Z4 Gt.:01 , Phone #: YO 'DSO - ®S34_
Address: 106 t e, ►U . i Art-4-
City: -w' Swu.1Ss State: Zip: 3 5 $
Tenant/Lessee Name: Phone #:
Email:
LC.4 S'
CONTRACTOR: Company Name: dot it-tzsc:.at3 4 t e.0 "3 Phone #: 77410-446dre
Address: 3ito 5 •w X30 1.1t.a •
City: wlz+t• State: L- • Zip: 33
Qualifier Name: Fa -tA.m.c c�LAsa�&ty'i Phone #: C3es) azc• -w(,r
State Certification or Registration #: C-A c.o 3 Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ 5.3S'C) . 3.3 Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New C(epair/Replace ❑Demolition
Description of Work: G-x,ge r e 4,4-...tce° .. 0.. r 0s= 2 7:;:.) 6er- .rya rte,.•^,
* *** ** * * **** * ** ** * * * * ** * * **+ �r F* *******-k****************************
Submittal Fee $ --M (DC/ Permit Fee V{ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $ LL I �7
TOTAL FEE NOW DUE $, (7 ! • 1 T
<1/,
-,1
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 FLECTRICAL 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
reinspectiori fee'will be charged:
Signature
Own
The foregoing instrument was acknowledged before me this
day of -1000 i l , 20 I Li, by ejhvi.3CrritTh .) • e 5,
who is personally known to me or who has produced t ■ . I •
Z ZC.Z- - 070 -71.3)7 As identification and who did take an oath.
NOTAR _ PUBLIC:
or
� _ Sign:`_
Print: r m._� L. ^� u0 ww,d a .I:
(
Contractor
The foregoing instrument was acknowledged before me this]
day of A: , 20 % Lk , by C-rG1-,,k, C ypi(
who is personally known to me or who has produced
as identification and who did take an oath.
My Commission Expires: 1C4 u9`'n MY COPJ " ',32 03 My Commission Ex it ,, ����Q� 3
• `: ., � Y P �IYICOMP� . ;,Old ;�EE033803
E:i1'i,, e i EXp 1GT 10, 2014
Bonder, ' [_c� 0, 4
w „.gym' 9onlh ft l = )ate insurance
********* * * **r ** ** * * *** * *** ** * ** * ******* ********** *t** *************** * * * * * **** ** ** * * ** * * ** * ** * * *** ** *ter **
APPROVED BY 7i V Plan. .xami er Zoning
Structural Review Clerk
Revised 3 /12/2012)(Revise¢ 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
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): 1 n G + 2. . L . i I k V d . t n ^°"z - ►•41.t�S , iz •
City: Miami Shores Village County: Miami Dade Zip Code:
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 [rNO ❑ Contract Attached: YES a".
UNIT BEING REPLACED
DATA
NEW UNIT
r ez„tb,�,�..3
MANUFACTURER
WRItal.� --1
tac.3c. tot
AHU or PKG. UNIT MODEL#
9-4 4.1.14 et- ,6WzCS
`�sel ® ape',
COND. UNIT MODEL#
v- 4"%ra -r z,c.0 pq,e.
l0r-�
KW HEAT
ao W... 4-0
3 TcA›,,IS,
NOM TONS
z 1.6.,.z%
AHU ro CU so PKG
1) M.C.A
AHUD CU 3c, PKG
AHU [,o CU 3.1- PKG
2) M.O.P
AHU G,o CU 3j- PKG
AHU no CU WO PKG
3) VOLTS
AHU zso CU an) PKG
PKG UNIT / /
PKG UNIT / /
I o . o
EER/SEER
l ‘ .
YES NO
REPLACING DUCTS
YES (NO)
YES NO
REPLACING THERMOSTAT
NO
YES NO
NEW 4 °CONCRETE SLAB
YES NO
YES NO
NEW ROOF STAND
YES afi5)
YES NO
NEW RETURN PLENUM BOX
YES (MD
)
1. Minimum Circuit Ampacity (Wire Size): Al - 6
2. Maximum Overcurrent Protection (Fuse /Breaker Size):
3. Voltage of Circuit (208/240/480): Zor(a.ao V
4. Size Disconnecting Means: f®o P - ? .
cp.,- 3s
Contractor's Company Name: Co .. . 1\14_
State Certificate or Registration N. eeTco
Signature
Phone: C of y 2.u. - 2444
Certificate of Competency N.
(Qualifier's sIgnatu nly)
Date:
1-21
fa 41. "II D " Atzrp
sovvimi
• Air Conditioning Corp®
uiz ?Item. Heivrm
13120 S.W. 130 Terrace • Miami, FL 33186
Dade: 305 -226 -2665 • Broward: 954 -797 -0067 • Fax 305 -253 -4420
wwwcool- breezeac.com
C4CO 24325 (Licensed and Insured)
Proposal and Acceptance
PROPOSAL SUBMITTED TO
a,e,•l 'OGa..R.S
PHONE C)$#(.6
3`o - f3 8IS
JOB PHONE
DATE
Uri - 2.S- - t4-1
STREET
1OColt3 1.l.(. . it %w c-.
JOB NAME
CITY, STATE and ZIP CODE
Y yt7S e t X 3 3 13 E3
JOB LOCATION - S Ar•'•0t3' -
-
eL n/1 /
fir•» ?.z C : .p ,- a/ .Z.,-e.,aC.c • CO 0-A-",
MAIN CONTACT:
Scope of worlc (attach additional description and /or drawings if necessary)
t- . . 5..t IC1. -4% , L.=1. -r, - A '3 lI.-..l 1C.w`wv ■+ � ?L.t7- ` ms.-r .--.. Kati.-(+ -k
, II
t'"ivKArTc,1Z ''..4""4", )F1 %Le- !H4,,m.ripSTra'7. KSt�Y. -% v5,.cs5. N.2.4.0 cZ -4lari
,._?t.CC.a.Aerr.-
9- cam= kte, 01.Iq T■1 T Ps.4 't .S it-AIL. t G . 0 ~Sc.-.0 ? ,
1- I.7 °••T 'L L"`Ttt) -J T. ■-bc..c. -wN C� L-0 -r(.4%1_ ovol.. C.L7w •rA.FC�li SW-C ; CA
Avxtc tCC:4 NZ to PA ^) Na'rt•• vca"J• --r" .o.o 'ASS ol.3� (I\ A'a,A -c .� >•L )4
i t
A1•1 Gila t.s+�sc t. -me- \'pW". tc'c4�s.. C- :Co,J.. (4C.-r -rc celccs„-rwG G- GC3c >Zce.9c
,,_
4 Gle.7tvQ.e r.1..e•9r.43 er. .9.0d ■2cni ?rc( e. 7 ee,.26,4- - f-3cec.r r.)C.t --d Ls s c.'¢'3to.9
m.aTrA4S ,
Proposed Start Date:
Expected Completion Date:
RESPONSIBILITY SHALL BE ASSUMED AS INDICATED BELOW:
. Cool Breeze Sub- Others Not Cool Breeze Sub - Others Not
Atr Contr. Applicable Air Contr. Applicable
Remove and haul away existing system 0 ❑ ❑ Service Change from Amps to Amps ❑ ❑ i
�,/
Installation of iprpent ❑ ❑ ❑ Wiring from existing disco ect to equipment �.7 ❑ ❑ ❑
Drain piping.. 0- CQ^0^16rc� [ ❑ 0 ❑ Thermostat installation.. 04le4 n'9S f 'Ulu ❑ ❑
Refrigerant piping. /? cc� ,wctr ❑ ❑ ❑ Install condensate pump ❑ ❑ ❑'"
Water piping heat recovery ' ❑ ❑ ❑ lar Connect to existing duct system l ❑ ❑ ❑
Install ducts and grilles ❑ ❑ ❑ 13' Cutting ❑ ❑ ❑ la-
Duct repair U. Cl ❑ l Patching ❑ ❑ Cl
Bath exhaust fans/ ducts ❑ Cl ❑ I Access & clearance for ducts, grills & equip ❑ ❑ ❑ ❑"
Structural supports for equipment. ❑ ❑ ❑ Zi. Masonry ❑ ❑ ❑ ❑-
Pitch pans and or roof supports.. ❑ ❑ ❑ Er Carpentry Cl ❑ Cl 13"
Thermostat wiring 1 t 6 C7 Zr ❑ ❑ ❑ Painting ❑ ❑ ❑ izr-
Install new emergency drain pan ❑ ❑ ❑ Start up and balancing equipment ❑K ❑ ❑ ❑
Warranty:
/ Year manufacturer ontthermostat
/0 Year manufacturer on parts. / Year Cool Breeze Labor.
0+1'Ttuian4._
AO Year manufacturer on compressor. Extended labor warranty. ( *1 S . ° °)
at. o
Warranty effective during regular working hours, excluding general maintenance (filters, breakers, drain lines, accessories, fuses.)
Overtime warranty calls to be at prevailing rates.
I was offered an extended warranty and Accepted Rejected
I have been informed that the deposit given on this special order system(s) will not be refunded after three (3) days right to cancel period.
I acknowledge that I will forfeit my deposit if I cancel after the third day.
Sign here acknowledging statement above:
Comments: 0 L«., „..
Total Investment + $ s' 3 50. ' .
9o.
FPL Rebate - $ — .J 8S *."
\ Thoo.,TIr, -E-51 z '"",N'. t^G
Dealer Credit Rebate - $
" `A 4-2 ot-.C.I -t W s -A ,ZC, o .
I- Customer Balance $ 5/16 .1- oe
Down Payment - $ P397-. s-to
'ilea,. 1-4)
Remaining Balance $
Prices quoted will be VALID for a period or 60 days from the proposal date of this contract
Mail in Rebate -
NOTICE TO OWNER DO NOT SIGN THIS CONTRACT IP B LANT
'
Other Crag it -
YOU ARE' ENTITLED TO A1�QPY OF THIS°CONTRACT AT THE TIME YOIJ SIGN.
Net Cost to ustortier $
Payment'tobe made upon job completion and final inspection as required as follows:�'fr"i"y �' '�"�
4-0v /�9k1S C Y /9044 6-OZ tof ) ) .Z s r#' rec..") 1�� it t N G
.•yree.ut Term❑ s:
Personal Check orMoney Order 1Visa ❑ Mastercard ❑ Discover ❑ American Express
Acceptan `ustomer) Acceptance (Contracting Firm)
By ar.s.. L.., Date 1' 2-1" l 1 By . ssr{ ./e zcre- Date 04' • 2J -/V
Cool Breeze NC Corp. Representative
ir 'or
' This combination qualifies for a Federal Energy
Efficiency Tax Credit when placed in service
between Feb 17, 2009 and Dec 31, 2013.
rod
AHRI Certified Reference Number: 3805983
Date: 4/28/2014
Product: Split System: Air - Cooled Condensing Unit, Coil with Blower
Outdoor Unit Model Number: 14AJM36
Indoor Unit Model Number: RHLL- HM3821 +RCSL -H *3821
Manufacturer: RHEEM SALES COMPANY, INC.
Trade /Brand name: RHEEM, RUUD, WEATHERKING
Series name:
Manufacturer responsible for the rating of this system combination is RHEEM SALES COMPANY, INC.
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:
Coaling Ca acity_(Btuh): 36
E R'Rating (Cooling): % 13
SE 114,. at g:(Co ice.. 16
iEER Frig { r)•
* 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 all liability for damages of any Idnd 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.ahrldirectory.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
The information for the model cited on this certificate can be verified at www.ahridirectory.org, click on 'Verify Certificate" link
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 listed at bottom right
02014 Air - Conditioning, Heating, and Refrigeration Institute
AIR- CONOMOIONO, HEATING,
& REFRIGERATION INSTITUTE
we make life better°
bTENO.:
COOL BREEZE MATERIALS AND INSTALLERS LIST
SALES PERSON
MECHANIC
JOB NAME
JOB ADDRESS
CITY
UNIT LOCATION
PERMIT
oCo xlia> . tt lives
`L`n •K•,� g..�� -�. ?et.- 3. \_ e
l�l - k-r-rr e-
YES
MAJOR EQUIPMENT
SCHEDULE DATE 'MOIL Mr og v, 1‘t - bz- og .74
WORK ORDER
JOB PHONE c —(L-t yG) 812,3S
JOB ACCESS
NO HOME DEPOT
YES
REFRIGERATION SUPPLIES
ManuFacturer
? w.G. -,
Copper pipe
Cond. Model
t
ty,a. -xv,, 3co(4.o t
Copper pipe
Tstat
y\ r.,t.,,,
Copper Couplings
g
■
,Pr�cs��
Unistrut
4
NH Model
..v.k. .---.
Armaflex
N2`
' Is"
1
2vkl..1. m343'z1 .
Safety pan
C.
I `ly'`
Liq. Tight
•
Time Delay
Package Unit
Hard Start kit
Model
■
tlz."
Line driers
%
ac.. ,c 's4
i
3 IN"
Wood 2 x 4
Heater
GT ---. -,
Condensate pump
•
low voltage
iZac sim41 12't e.lo -
Water hoses red
-gUAF
braided
4
0 „3"oaL4.4v- CLAPS
DRAIN SUPPLIES
.,Thr..,
Sight Glass
.
PVC pipe
Drop cloth
Coupling
alti"
Z.
ELECTRICAL PARTS
BUILDING SUPPLIES
Disconnect
Bolt, nuts washers
Saw blades
Tstat
y\ r.,t.,,,
ISO pads
g
■
,Pr�cs��
Unistrut
4
Digital
All thread
4
Safety pan
■
sc • p jca-
Liq. Tight
Line chase
whip •
■
tlz."
Slab
%
ac.. ,c 's4
i
3 IN"
Wood 2 x 4
NH stand
low voltage
Condenser Stand
Condenser Tie dwn
4
0 „3"oaL4.4v- CLAPS
DRAIN SUPPLIES
.
PVC pipe
Drop cloth
Coupling
alti"
Z.
Tee
t
Sheet Rock
P -trap
1
Tape and paste
Cap
1
Angles 90
'Z
45
Flow Switch
I
MPT
'FPT
'Glue
Cleaner
'ttvq -c Swvre..x
t
'coit- .J
DUCKWORK SUPPLIES
DUCKWORK SUPPLIES
Aluminum Tape
Balance to collect I
C,..)
Duct Wrap
Roofing paper
R 22
Credit Card type Q isa
Grey/Black
Amex
Pitch pans
Sheet Metal
R 410
i/•
Roof jack
CRANE RENTAL
Stra Metal
Expiration Date
Bricks
Duct Board
V--c.
∎'l sHacs
Wire ties
Nitrogen I
U channel
Supply Registers
Plaster Ground
Supply Registers
Supply Registers
Flex duct
Supply Registers
Flex duct
Supply Registers
Flex duct
Supply Registers
Flex duct
Flex duct
Cans
Flex duct
Cans
Flex duct
Cans
Return air grilles
Collar
Return air grilles
Collar
Return air grilles
Collar
Collar
Filter back R/A
Mastic
Brushes
%as, -o •
- %'8S '~
Y? L i$AZcy
ROOFING SUPPLIES
PAYMENT INFORMATION
Roof Cement
Balance to collect I
C,..)
* Z a 8z . r-`O
Roofing paper
R 22
Credit Card type Q isa
C
Amex
Pitch pans
R 410
i/•
Roof jack
CRANE RENTAL
Expiration Date
Bricks
Refrigerant Recover
Amount collected +0 z 3 82 . /z•-c'
START UP SUPPLIES
TOOLS NEEDED
Refrigerant
LADDERS
C,..)
6 `
LtQA(
R 22
1
AN'Ct- Vtti Jott•.,.., r�c91Ai A .1t4. NRn4G�(, r.+4-7ce..•2 ^LS , `
LIFTING
R 410
i/•
LZti7Gi
CRANE RENTAL
Refrigerant Recover
CHIPP HAMMER
Nitrogen I
DESCRIPTION OF WORK
(r) L s A a c 3 k,
"yy'L.Z2 - SYST�,tr� E 'cGat. l IOtcW 4. T- S 14-r . (a .o6G?c
1 ■ 1 f
C,..)
%.a% T Ae_c. AI...
LtQA(
:a:twz.y ?it.* LC.rq"'t St.bL.Y L.. C� - S4."71 T %V 11ow.J (L•L#S
1
AN'Ct- Vtti Jott•.,.., r�c91Ai A .1t4. NRn4G�(, r.+4-7ce..•2 ^LS , `
at)
D.�C d1 O 1L1gLN
LZti7Gi
Z .+1 tt!' T(tC. if Z •.1S v -r -tc . (AK t 4 14.-Ci i. C.\
Property Search Application - Miami -Dade County
Summary Report
Property Information
Folio:
11- 2232 - 028 -0630
Property Address:
10618 NE 11 AVE
Owner
BENJAMIN JOHN ROGERS
KRISTINA ROGERS
Mailing Address
10618 NE 11 AVE
MIAMI , FL 33138
Primary Zone
1000 SGL FAMILY - 2101 -2300 SQ
Primary Land Use
0101 RESIDENTIAL - SINGLE
FAMILY : 1 UNIT
Beds /Baths /Half
3/2/0
Floors
1
Living Units
1
Actual Area
Sq.Ft
Living Area
Sq.Ft
Adjusted Area
3,011 Sq.Ft
Lot Size
9,750 Sq.Ft
Year Built
1951
Assessment information
Year
2013
2012
2011
Land Value
$136,620
$78,177
$97,911
Building Value
$197,900
$219,970
$220,291
XF Value
$22,142
$26,893
$27,055
Market Value
$356,662
$325,040
$345,257
Assessed Value
$330,565
$325,040
$258,342
Benefits Information
Benefit
Type
2013
2012
2011
Save Our Homes
Cap
Assessment
Reduction
$26,097
$50,000
$86,915
Homestead
Exemption
$25,000
$25,000
$25,000
Second Homestead
Exemption
$25,000
$25,000
$25,000
Note: Not all benefits are applicable to all Taxable Values (i.e. County,
School Board, City, Regional).
Short Legal Description
MIAMI SHORES ESTATES PB 47 -58
LOT 13 BLK 4
LOT SIZE 75.000 X 130
OR 20185-0785 01 20021
A!
Page 1 of 1
Generated On : 4/29/2014
Taxable Value Information
Previous
Sale
2013
2012
2011
County
Exemption Value
$50,000
$50,000
$50,000
Taxable Value
$280,565
$275,040
$208,342
School Board
Exemption Value
$25,000
$25,000
$25,000
Taxable Value
$305,565
$300,040
$233,342
City
Exemption Value
$50,000
$50,000
$50,000
Taxable Value
$280,565
$275,040
$208,342
Regional
Exemption Value
$50,000
$50,000
$50,000
Taxable Value
$280,565
$275,040
$208,342
Sales Information
Previous
Sale
Price
Price
OR Book-
Page
Description
12/16/2011
$450,000
27946 -3867
Qual by exam of deed
03/16/2011
$255,000
27664-3326
Financial inst or "In Lieu of
Fordosure" stated
01/20/2011
$415,144
27605 -4632
Financial inst or "In Lieu of
Forclosure" stated
01/01/2002
$226,000
20185-0785
2008 and prior year sales; Qual by
exam of deed
The Office of the Property Appraiser is continually editing and updating the tax roll. This website may not reflect the most current information on record. The Property
Appraiser and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at htto://www.miamidade.aoWinfo/disolaimer.aso
fhtto://www.miamidade.00v/Info/disciaimer.aso)
http://www.miamidade.gov/propertysearch/
4/29/2014
14 CO Cr •
1/4.- Y INSURANCE
-
� DATE EiwoorrYyn
04103/2014
THIS CERTIFICATE IS ISSUED AS-A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE HOLDER. THIS
, ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW. 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 CenifiCate holder. lean ADDITIONAL INSURED, the
the terms and conditions of the policy, certain policies may require an endorsement,
certificate holder in lieu of such end*rsement(s).
policypes) must be: endorsed. if SUBROGATION IS WAIVED, subject to
A statement on this certificate does not confer rights to the
ar
PRODUCER Phone:,: 305.221 -2400
8700' Weistt Fla Herr" to y2 Inc,. Fait: 305-852-5360
Miami, FL 331704
Alfredo Gonzalez
e. ExfJ I , Nor:
wtP
ADDRESS:
INSURERS) AFFORDING COVERAGE
HAW S
INSURER A: Bridgefleld Casualty Ins Co.
MOLDY
COMMERCIAL GENERAL LIABILITY
MIMED Cool- Breeze NC Corp
ID 712.801
13120 SW 130 Tarr
Miami, FL 33186
1141swRERS:Commerce & Industry ins Co
BK055846682
INSURER C:Ohio Security Insurance CO
0110112015
INSURER o : American Fire and Casualty Co
$ 1,000,000
INSURER E :
a 300,000
INSURER F •
$ 18,000
E.NUMBER:.
REVISION NUMBER:
IS 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 CONDmONsOF SUCH POLICIES. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TN
TYPE OF INSURANCE
INS,
,11 : -
POLICY MAWR
r
4 • • ► s
I YY;t �'° Al
LIMITS
0
GENERAL
--
X
MOLDY
COMMERCIAL GENERAL LIABILITY
BK055846682
01101/2014
0110112015
OCCURRENCE
$ 1,000,000
PR ra TaxxNxTAEaere rx)
a 300,000
M D EXP (Any two Noon)
$ 18,000
1 CIAIWIS.MACE
X
OCCUR
PERSONAL &ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP/OF AGO
$ 2,000,000
GENT. AGGREGATE UNIT APPLIES LIPER:
POLICY I— . —I LOC
$
10
X
X
O LI rrY
NY AUTO
� O9 OWNED
HIRED AUTOS
UM- 600,000
SRTE ED
NON-OWNED
UTOS EiI
BASb584b582
01/01/2014
01/0112016
aB )SINOIE t
$ 1,000,004
BODILY L )
$
BODILY INJURY (Per =ION)
$
I PROPBEFT tDANIAOE
$
$
B
X
UMBRELLA IAN
EXCESS LIAO
OCCUR
CUUMSMADE
0E020740608
01/01/2014
01/0112015
EACH OCCURRENCE
$ 5,000,000
AGGREGATE
$ 6,000,000
$
ow
ICO $
A
WORKERS
AND EMPLOYERS' LIABILITY'
OPRORPRETMBEREXRT r+�I
(Mandatory In NH)
IFIRCRIdrA OF OPERATIONS Wow
NIA
083044065
04/01/2014
04101/2015
X I'r'" 'rays s: I X 10a1.-
EL, EACH cDENR
1,000,000
E. DISEASE • EA EMPLOYEE
$ 1,000,000
E.L. DISEASE —POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATION$ I LOCATIONS) VEHICLES (Attach ACORD IC I, Additional Remarks Schedule, more space Is r red)
Air conditieon ng Services and Repairs
CERTIFICATE HOLDER
CANCELLATION
CITYMIS
City of Miami Shores Village
. 10050NE2Ave
Miami Shores Village, FL 33138
SHOULD ANY OF THE ABOVE DES' ' IBED POLICES BE CANCELLED. BEFORE
THE EXPIRATION DA 'THE- 0 < NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH EPOLI _VISIONS.
AUTHORIZED REP
Alfredo Gon
ACORD 26 (2010/05)
-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number. INSP- 211568 Permit Number: MC -4 -14 -868
Scheduled Inspection Date: July 02, 2014
Inspector: Perez, JanPierre
Owner: BENJAMIN JOHN & KRISTINA ROGERS,
QCAI I A SAIAI InLJAI 4 WDICTIIU A Dnf_`cDC
Job Address: 10618 NE 11 Avenue
Miami Shores, FL 33138-
Project: <NONE>
Contractor: COOL BREEZE AIR COND CORP
Permit Type: Mechanical - Residential
Inspection Type: Final
Work Classification: A/C Replacement
Phone Number
Parcel Number 1122320280630
Phone: 305 - 226 -2665
Building Department Comments
EXACT CHANGE OUT OF 3 TON SPLIT SYSTEM
Infractio Passed Comments
INSPECTOR COMMENTS
False
Inspector Comments
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
July 01, 2014
For Inspections please call: (305)762 -4949
Page 7 of 31