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MC-14-2039Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-219944 Permit Number: MC -9-14-2039 Scheduled Inspection Date: September 24, 2014 Inspector: Perez, JanPierre Owner: MARSH, TIMOTHY Job Address: 22 NW 103 Street Miami Shores, FL Project: <NONE> Permit Type: Mechanical - Residential Inspection Type: Final Work Classification: New A/C System Phone Number (786)897-8457 Parcel Number 1131010180010 Contractor: GUARDSMAN AIR PLUMBING CORP Phone: (954)478-4946 awlamg uepartment comments CENTRAL A/C WITH 10 KW HEAT Infractio Passed Comments INSPECTOR COMMENTS False TO CLOSE PERMIT#ME2003-19 Q6 7, I L l September 23, 2014 For Inspections please call: (305)762-4949 Page 14 of 25 Inspector Comments Passed TO CLOSE EXPIRED PERMIT ME2003-19 Failed Correction Needed ❑ Re -Inspection Fee No Additional Inspections can be scheduled until re -inspection fee is paid. September 23, 2014 For Inspections please call: (305)762-4949 Page 14 of 25 4 14 BUILDING PERMIT APPLICATION Miami Shores Village CEINTED Building Department SEP 18 2014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 2010 Master Permit No. NAO,- i Y -20 1cj Sub Permit No. ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING MECHANICAL [—]PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes Occupancy Type: Load: Construction Type: Flood Zone: BFFEE:�% FFE: OWNER: Name (Fee Simple Titleholder : /p f�'L� Phone#: + % M14 K4 Address: /4ts I-0til _ City: / Ul 114 W4 ' State: Tenant/Lesseee* chi 4,1 Email: �V' (-& lr t WIL %.VAvg L I CONTRACTOR: Company Name: � A.,,,- ott, L /N /��9. A �'2 � ��1?hone#: Address: �1 Lam' )( R u A k-4 a k R zy0f, __41-S91 City: IW l l tA. State: L- r Zip: Qualifier Name: i� �' l�- �1 A 7 A Phone#: (? 5 - Leg- el State Certification or Registration #: C I /5-C 03Certifiicate of Competency #: DESIGNER: Architect/Engineer: State: Zip: Value of Work for this Permit: $ U Square/Unear Footage of Work: Type of Work: ❑ Addition ��❑©© Alteration nN`ew ❑ Resp�aiirr-/pRReeplace ❑ Demolition Description of Work: CLO O �� �1°� 1T i� Specify color of color thru tile: Submittal Fee $ 1�;o v (n Permit Fee $ V� �`' CCF $ o 7_0 CO/CC $ jar r� Scanning Fee $ � d Radon Fee $ � , �� DBPR $ _ Notary $� co Technology Fee $ -5 , G® Training/Education Fee $ Double Fee $ Structural Reviews $ Bond $ TOTAL FEE NOW DUE $ (Revised02/24/2014) 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 Zi t, 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS, TANKS, 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 reinspection fee will be charged. ER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of 20, by day of 20 O , by who is personally known to AnC . who is personally known to me or who has produced HXZ geo�� �'�as me or who has produced A �s identification and who did take an oath. NOTARY PUBLIC: identification and who did take an oath. NOTARY PUBLIC: M 40 No, Nota P - - - . Notary Public State of Florida Seal: �° �� Notary Public State of Florida ro �; Joanna M Feliciano Joanna M Feliciano eVg�, My Commission FF 082753 �o� My Commission FF 082753 OFF►o1' Expires 01/12/2018 of FLA Expires 0l/12/2018 APPROVED BY "� Plans Examiner Structural Review (Revised02/24/2014) 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. ob Address (where the work is being done): ` I C)S' City: Miami Shores Village County: Miami Dade r,�61p 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 AHRI DATA SHEET REQUIRED Change disconnecting means: YES ❑ NO ❑ ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ 1. Minimum Circuit Ampacity (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: Ae /0• %P �hone: State Certificate or Registration No. �� / ����� °� Certificate of Competency No. ,. Signaturer./Date: Z117 4 (Qualifier's signature) (Revised02/24/2014) UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL # CON D. 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 (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Means: Contractor's Company Name: Ae /0• %P �hone: State Certificate or Registration No. �� / ����� °� Certificate of Competency No. ,. Signaturer./Date: Z117 4 (Qualifier's signature) (Revised02/24/2014) Miami shoresVillage Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CHANGE OF CONTRACTOR / ARCHITECT =Permit N. Owner's Name .(Fee Simple Title Holder : / rw ,1r°t fi Phone Owner's Address: /` I � � - City: ;lob Address (Of where work is being done):_ City: Miami Shores -Contractor's Company Name: CZCe State : Zip 2.2 A,12) t OS S7t State:_Florida Zip Code: t p 6 Address: % .3 Phone #:_ 0 �(Y - � ?V A 6 0� � 11 Q - city: 1e- State: Pe-, Zip Code:_ Qualifier's Name: k> A c -lee— Lic. Number. C-1 Architect/ Engineer of Record Name: Address: City: Describe Work: Phone #: State: Zip Code: I hereby certify that the work has been abandoned and/or the contractorlarchitect is unable or unwilling to complete the contract. I hold the Building Official and the Miami Shores harmless for all legal Involvement. Signature Signature Y 41A96nt �CorctororA,#Poect The foregoing ins men aknowled e e The foregoing instrument was aknowledged before me this LE day of 20�,*f �h ° this /? day of 2V% Who is personally known to me or who has produced who is personally known to me or who has produced 6490 —0 as indentiflcation. Ck_j as hderdcation. De. cy13c;)� September 17, 2014 Miami Shores Village Building Dept. 10050 NE 2nd Ave Miami Shores FL 33138 RE: 22 MN 103 Street, Miami Shores 33150 - Open Permits To whom it may concern: Please note that following our recent purchase of the above property out of foreclosure it is our intention to improve the home via the correct and legal channels, however we are unable to proceed at this time as there are two open permits dating back to 2003/4. The first for an aluminium fence which was not installed and the second for a new AC system which has not been closed out. We would respectfully request that they are both removed from the property records in order for us to begin the permitting process. As I am sure you are aware the longer the property remains vacant the higher the risk of break-ins and vandalism. Should we require an inspection please contact me urgently to arrange. Yours sincerely, Timothy Marsh 786-8-°��� STATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC 1815503 ISSUED: 06/22/2014 CERTIFIED AIR COND CONTR KAZAKOW, JACK GUARDSMAN AIR AND PLUMBING CORP IS CERTIFIED under the provisions of Ch.489 FS. Expiration date : AUG 31, 2016 L1406220000873 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954-831-4000 VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015 f DBA: Receipt#:183 -1711 HEATING/AIRCONDITION CONTRACTR Business Name: GUARDSMAN AIR & PLUMBING CORP Business Type: YP (AIR CONDITIONING CONTRACTOR) Owner Name: JACK KAZAKOW Business Opened:07/05/2007 Business Location: 1333 E HALLANDALE BCH BLVD 33]State/County/Cert/Reg:CAC 1815503 HALLANDALE Exemption Code: Business Phone: Rooms Seats Employees Machines Professionals 1 For Vending Business Only Numho�r of Marhinae• Vandina Tvnet Tax Amount Transfer Fee NSF Fee Penalty Prior Years Collection Cost Total Paid 27.00 0.00 0.00 0.00 0.00 0.00 27.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT This tax is levied for the privilege of doing business within Broward County and is non -regulatory in nature. You must meet all County and/or Municipality planning WHEN VALIDATED and zoning requirements. This Business Tax Receipt must be transferred when the business is sold, business name has changed or you have moved the business location. This receipt does not indicate that the business is legal or that it is in compliance with State or local laws and regulations. Mailing Address: JACK KAZAKOW 1333 E HALLANDALE BCH BLVD 333 HALLANDALE, FL 33009 2014 -2015 Receipt #30B-13-00002810 Paid 08/27/2014 27.00 09/17/2014 11:17 954-616-1888 Matthew Roebuck Page 1/1 OP ID: MGR 'A4k `r r CERTIFICATE OF LIABILITY INSURANCE D0917/2014Y) TYPE OF INSURANCE 09/17/2014 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(les) 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 Roebuck Associates Insurance Exchange LLC 5599 S University Drive, # 301 Davie, FL 33328 Roebuck Associates NCT PHONE FAX A/ No): E-MAIL ADD C P s;R I #. GUARD4 INSURERS AFFORDING COVERAGE NAIC # INSURER A : Federated National Ins. Co. INSURED Guardsman Air & Plumbing Corp. 8880 Sunrise Lakes 131vd., # 20 Sunrise, FL 33322 INSURER B: ENSURER C : 07/10/2015 INSURER D: PREMISES Ea occurrence $ 100,00 INSURER E: PERSONAL & ADV INJURY $ 1,000,00 F !INSURER nn�ra-new�c. W �,��V1V 1VV I:PK 11F11.O 1 F MI 1MKFV• f�Grh71V11% 114JIYI 2=M; 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 SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER 61 Y EFF POLICY EXP UNITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR GLOS0401086301 07/10/2014 07/10/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 100,00 MED EXP (Any one n) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN•L AGGREGATE LIMITAPPLIES PER; POLICY JECT F1 PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ (PER ACCIDENT) HIRED AUTOS NON -OWNED AUTOS S $ UMBRELLA UAB EXCESS UAB HWIMSMADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATIONWC AND EMPLOYERS' LILIABILITILITY YIN ANY PROPRIETOR/PARTNF_R/F�CUT71/E OFFICERIMEMBER EXCLUDED? J (Mandatory In NH) If yyes destriHe under DESGtRIPTION OF OPERATIONS bebw N / A $ STATU-MITS OTH 7QRXLI jR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DER".11 ION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, AddMonal Remarks Schedule, N more space Is raquI eM Air Conditioning Operations Only. CFRTIFIPATF YA1 noo Miami Shores Village 1DOSO NE 2nd Ave Miami Shores, FL 33138 ACORD 25 (2009/09) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1WHU-21Joe ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Pfy 08-07-2013 JEFF ATWATER STATE OF FLORIDA CHIEF FINANCIAL OFFICER 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: 07/29/2013 PERSON: KAZAKOW FEIN: 203250071 BUSINESS NAME AND ADDRESS: GUARDSMAN AIR AND PLUMBING CORP 8880 SUNRISE LAKES BLVD SUNRISE FL 33322 SCOPES OF BUSINESS OR TRADE: 1- HEATING, VENTILATION, AYR -GOND EXPIRATION DATE: 07/29/2015 JACK IMPORTANT: Pursuaat to Chapter 440 . 05(14), F.S., as 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 440.05112), 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 al 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 any time for failure of the person named on the certificate to meet the requirements of this section. OWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 01-11 QUESTIONS? (850) 4 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW 'd EFFECTIVE: 07/29/2013 EXPIRATION DATE: 07/29/2015 PERSON: JACK KAZAKOW FEIN: 203250071 BUSINESS NAME AND ADDRESS - GUARDSMAN AIR AND PLUMBING CORP 8880 SUNRISE LAKES BLVD SUNRISE, FL 33322 SCOPE OF BUSINESS OR TRADE: 1- HEATING, VENTILATION, AIR-COND IMPORTANT OPursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of electior L under this section may not recover benefits or compensation under t D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be H exempt.. apply only within the scope of the business or trade listed Rthe notice of election to be exempt E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exeml and certificates of election to be exempt shall be subject to revocat 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 i the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413-1 CUT HERE * Carry bottom portion on the job, keep upper portion for your records. Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers jn the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees, including the owner, must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if 1. The officer owns at least 10 percent of the stock of the corporation, or in the case of an LLC, a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State, Division of Corporations; and 3. The corporation is registered and listed as active with the Florida Department of State, Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption. In these circumstances, Miami Shores Village does not require verification of workers' compensation insurance coverage from the contractor's company. Therefore, you may be personally liable for the worker compensation injuries of any person allowed to work under this permit Please check with your insurance carrier since most property jnsurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Owner Contractor Print Name: �vi-- l� Print Name: ' -0 Signature: 2. m� Signature: �4 C /L mil d�2 \� x o 0 o�oq a'C0 ) State of F;and a o State of Florida) m z County omi-Dade) 6 County of Miami -Dade) �+. 3 m Sworn tobscribed before me this o N o. Sworn to and subscribed before me this -d cy da of , 20 O co d' day of -n t By cop � ` ;3 N j x -n 9.� By c� �° o W o m �Z ; (SEAL) _ (SEAL)