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MC-12-2397Miami 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: (303) 762.4949 BUILDING PERMIT APPLICATION FBC 20 Permit Type: MECHANICAL DEC 19 2, Permit No. Mc- Q_ -Z391 Master Permit No. OWNER: Name (Fee Simple Titleholder): k, Phone#: City: I N2VV''k �U 4 tl Q' State: _ a Zip: 169 1 Tenant/Ussee Name: Phone#: Email: JOB ADDRESS: �' - City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Flood Zone: CONTRACTOR: Company Name: « o4,-�v�u, "�� Phone#: Address: /I I City: Zip: Qualifier Name: Phone#: State Certification or Registration #: Certificate of Competency #.�M (oZ Contact Phone#: Email Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ 1 5- o o o -m Square/Linear Footage of Work: Type of Work: ❑Address ❑Alteration ❑New ,,❑Repair/Replace ❑Demolition Description of Work: �%�,. SII (� �'�P {,t�d Submittal Fee $ 0G Permit Fee $ �61, 20 CCF $ CO/CC $ Scanning Fee $ ?R f Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Double Fee $ Structural Review $ Technology Fee $ TOTAL FEE NOW DUE $ \vl?�' q4 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 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 file 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 appyty d and a reinspection fee will be charged Signature_ Signa Owner or Agent The foregoing instrument was acknowledged before me this day of _� , 20 1 Z by RMC6 R(yAW , who is personally known to me or who has produced As identification and who did take an oath. Contraci6r The foregoing instrument was acknowledged before me this day of 6 , 20 -11, by�`�5� ^�►a� who is p r nal y known me or who has produced as identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Structural Review Clerk (Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) FFRODUCER 123. 2013-11 :58AM.,_., WESTLAND SOUTH INS—, •••-No.2296_P1/1 �:lNI0-•• CERTIFICATE OF -lNSU ►1�iCL DATE(MM/DDIYY ' • % . .. 1 F,t3/?013 M►Wand South Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INF 3P-01 TION 2605 IV<fH 97th Ave ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MIAMI, PL M172 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR [Al TER THE COVERAGE AFFORDED BY THE POLICIES BELOW, (305)593.0630 _-.-•„•_,• COMPANIES AFFORDING COVER_A_G_E COMPANY INTEGON CASUALTY/GMAC INSURED A S®CO CONSTRUCTION,CORP COMPANY WESTERN WORLD 1439S SW 1:9 CCURT#101 ...... .. MIAM1,1FL,32ift COMPANY C COMPANY THIS IS TO L�RTIFY THAT TH; POLICIES OF INSURANCE LISTED BELOW ' HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY pERICD INDICATED, NOTWITNSTA{ND ING ANY REQUIRWENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH CERTIFICATE MAY BE ISSUE) OR MAY RESPECT TO WHcI4 THIS PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL TFE TERMS, EXCLUSfONS AND COSDITICNS OF SUCH POLICIES. LIMITS SHOW{) MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE I POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION GENERAL LIAXJTY DATE (MWODNY) DATE PUNDA” LIMITS ®ICOMMEvZCEAL GENERgf LIABILITY ! -• LI I NPP130$¢42 '1 ,�L�@dylaAOE �joccuR,I GENERAL AGGREGATE S 1/19/2013 1/19/2014 PRODUCTS - COMPIOPAGG. g Z000,0*0 4000 060 LM; OWNERS 8 C•3NTRAC-TOR'S PROT.; BLANKET Al PERSONAL &ADV INJURY $ 1,00Q,0110 R. �N_ �►�LV Fi ._S[DB.... - PER PROJECT EACH OCCURRENCE & 1000 AO FIRE DAMAGE (anyone Fue) S 100,000 AUTOMOBRE JABtL1TY MED EXP (Any one petscn) J> I ANY AU 0 OWMEL. AUTOS COMBINED SINGLE LIMIT S 1.000'mALL A ' ®- SCHEDLLE-D AUTOS I FLC 6052719BODILY INJURY $ 9/30/2012 9/30/2013 (Perperean) �®HIREDA,JTpS NON-OV'.1NE7 AUTOS BODILY INJURY (Pet 80CIti@nt) $ GARAGE LLAMUTY PROPERTY DAMAGE g ANY AUT© AUTO ONLY - EA ACCIDENT g. I (� OTHER TMAN AUTO ONLY: -- - - - F -ACM ACCIDENT S EXCESS LIANqJTy AGGREGATI; $ UMBRELLA FORM EACH OCCURRENCE g OTHER THAN UMBREL-A FOFM I AGGREGATE -- - .- ..•.•.._.. $ _.. WORKm CCLwFN$ATIONAND EMPLOYERS' -"LITY $ STATUTORY LIMITS 'E", D... : , THE PROPR#E-OFV PARTNERS�FEGJ7IVE ��•-7IjINCL .:*F -- FAGHp..!DENT , �Y •- OFFICERS ARE: �I £xCL! DISEASE - POLICY LIMIT $ OTHER DISEASE- EACH EMPLOYEE $ DESCRIPTION OF OFERATIONS/LCCATim"EHICLESI3PECULL 1' 2MS CERTIFICATE BOLDER IS ALSO N"ED AS AN ADDITIONAL INSURED IN REF TO GEN LIABILITY o T - MW fi SHORES VILL-NGE BUILDING DEPARTMENT 10050 NE 2 AVENUE MLAM SFIORES VILLAGE,FL,33138 FAX a 05.756.072 ar/ifltcssmr�L1I :.:. P :1:''1:: a,tg' SHOULD ANY OF THE ABOVE 'DESCRIRIlb POUCIES BE CANCELLED REPORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVCR TO MAIL 30 DAYS WRITTEN NOTICE TO 1144 CERTIRCATL HOLDER NAM6O TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LWB1uTY OF ANY IOND UPON THE COMPANY, ITS AGENTS OR F3WRE?,BENTATIVF$, AUTHORIZED REPRENTgTNE HOMERO LAVERNIA y NOTICE OF COMMENCEMENT A RECORDED COPY MUST BE POSTED ON THE JOB SITE AT TIME OF FIRST INSPECTION PERMIT NO.I 21_�e ✓ l TAX FOLIO NO. STATE OF FLORIDA: COUNTY OF MIAMI-DADE: THE UNDERSIGNED hereby gives notice that Improvements will be made to certain real property, and In accordance with Chapter 713, Florida Statutes, the following Information Is provided In this Notice of Commencement. CFN: 20130012288 BOOK 28431 PAGE 543 DATE:01/07/2013 12:58:37 PM HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY Space above reserved for use of recording office 1. Legal description pf propeerty and a address: u � �—`55- 57--41 40 JCC dV 2. Description of improvement: � e �� 5Z,- 3. Owner(s) name and address: 11 7AA AM Interest In property: Name and address of fee simple titleholder. 4. Cont or`s name, dressd phgne n ber- ii""�� 5. Surety: (Payment bond required by owner from contrac or, if any) Name, address and phone number Amount of bond $ ` 6. Lender's name and address: 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as,provided'b Section 713.13(1)(a)7„ Florida Statutes, Name, address and phone number: S. In addition to himself, Owners designates the following person(s) to,receive a copy of the Lienor's Notice ,as provided In Section 713. 1 3(1)(b), Florida Statutes. Name, address and phone number: 9. Expiration date of this Notice of Commencement: (the expiration date is 1 year from the date of recording undoes a different date is Specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER AFTER THE EXPIRATION OF THE NOTICE OF COMMENCEMENTARE CONSIDER IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN YOUR PAYING TWICE F IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE T FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WO s OR RECORDING YOUR NOTICE OF COMMENCEMENT. Signature(s) of Owner(s) or OAuthorized Offlcer/Director/Partner/Manager Prepared By Prepared By Print Name 0 -de t. Print Name Title/Office 5S Ger ✓IQNf Title/Office J STATE OF FLORIDA COUNTY OF MIAMI-DADE The for oln fns#pfinent was knowiedged before me this .�6 J� day of.... QC,i �d 7✓ G7 > �, BY ❑ Individually, or W as V. P. for ❑ Personally known, or ❑ produced the following type'of identificat v Signature of i 'Tt� EXPIRES: November lX 2014 E ,wao, co. Undor penalties of perjury, i declare that I hav that the facts stated in it are true, to the best of my knowledge and belief. Signature(s) of Owners er(s)'s Authorized Officer/Director/Partner/Manager who signed above: By By 123.01-W PM ano Miami Shores Village Building Department 10050 NX 2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795 2204 Fax: (305) 758.8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC' ® r� This form must accompany ALL air conditioning replacement p mdt 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): l 1.300 1UE 116`01 4r'� Q-404�v`� City: Miami Shores Village County: Mlami Dade Zip Code:.33/(O / 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 ❑ NOX ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ �vam -jo/uo /.si od4�00.ew s;Tudid 1. Minimum Circuit Ampacity (Wire Size): /eA 2. Maximum Overcurrent Protection (FuseBreaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Mean; Contractor's Company Name: cW/C=U 6e='7x66C,-rdYI <'1tY,�U Phonei �� State Certificate or Registration N, Certificate of Comps ency Signature - Date: /1 - If— /-1 tQuaaflers et�at+ue UNIT BEING REPLACED DATA JNEW UNIT MANUFACTURER AHU. or PKG. UNIT MODEL # 12S th COND. UNIT MODEL # KW HEAT NOM TONS AHU CU PKG 1 M:C.A AH CU PKG AHU CU PKG 2 M.O.P CU PKG jkl CU PKG / 3 VOLTS' CU G UNIT 1 1 PKG UNIT 1 I EERISEER CO ! YES NO. REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW CCONCRETE SLAB YES NO YES NO NEW ROOF STAND YES NO YES NO I NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacity (Wire Size): /eA 2. Maximum Overcurrent Protection (FuseBreaker Size): 3. Voltage of Circuit (208/240/480): 4. Size Disconnecting Mean; Contractor's Company Name: cW/C=U 6e='7x66C,-rdYI <'1tY,�U Phonei �� State Certificate or Registration N, Certificate of Comps ency Signature - Date: /1 - If— /-1 tQuaaflers et�at+ue Miami Shores village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tet: (305) 795.2204 Fax. (305) 756 8972 AIR CONDITIONING REPLACEMENT DATA PERMIT NUMBER: MC` This town must accompany ALL air conditioning replacement unit applications.?c�. h�rnust be on its own data sheet. Multiple units on single sheets are not acceptable. ;Ia""7 ./SS` Job Address (where the work Is being done): l 13100 NIF 2*"' F -N-Oe 6r-fS 10,,,4 q�,v'-' City: Mlaml Shores Village County: Mlamt Dade Zip Code:.3316 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 CONTRACTISREQUIRED WITH ALL;SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO ❑ ARHI Sheet Attachwl: YES ❑ NO ❑ Contract Attached: YES ❑ X&-A� /1:f -T 1. Minimum Circuit Ampacky (Wire Size): IV dT id!L® 2. Maximum Overcurrent Protection (FuselBreaker Size):, 3. Voltage of Circuit (208/2401480):- 4. Size Disconnecting Means: Contractxoes Company Name• Phone: oS) 97? 6142 3 State Certificate or Registration N, Certificate of Competency N. Clfe— C Slgnaiure QDate: (anme 's spam onv) UNIT BEING REPLACED DATA. NEW UNIT ^ MANUFACTURER 0.2 AHU.or PKG. UNIT MODEL # GOND. UNIT MODEL # Alif KW HEAT A/ q. co NOM TONS AHU CU PKG 1 MICA AHU CU PKG CU PKG 2 M.O.P AHU CU PKG AH CU PKG 3 VOLTS CU PKG PKG UNIT I i PKG UNIT / I EERISEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES NO YES NO NEW 4°CONCRETE SLAB YES NO YES NO NEIN ROOF STAND YES NO YES NO NEW RETURN PLENUM BOX YES NO 1. Minimum Circuit Ampacky (Wire Size): IV dT id!L® 2. Maximum Overcurrent Protection (FuselBreaker Size):, 3. Voltage of Circuit (208/2401480):- 4. Size Disconnecting Means: Contractxoes Company Name• Phone: oS) 97? 6142 3 State Certificate or Registration N, Certificate of Competency N. Clfe— C Slgnaiure QDate: (anme 's spam onv) 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 I This foam 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. /2?&V 4(/.,2/ C_eA0m i s Job Address (where the work is being done): / I ZOO ME '2he 4r Q-4 0'"9 City: Wami Shores Village County: Miami Dade Zip Code: 33/6 / ALL CONDENSING UNITS MUST BE ON A 4 INCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOMELEVATION A COPY OF THE CONTRACT.ItREQUIRED WITH ALL SUBMITALS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NO 0 ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ 1. Minimum Circuit Ampacity (Wire Size): 2 Mwftum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208!2401480): V 4. Size Disconnecting Means. Contradoes Company Name: Sf7dQ Ph"064-4 f) —374P-04-1-, 3 State Certificate or Registration N, Certificate of Competency N. C 147- C- Signature Date: (Qua6flers o UNIT BEING REPLACED DATA. NEW UNIT MANUFACTURER Gr/l2 047 AHU. or PKG. UNIT MODEL # Al ja COND. UNIT MODEL # IfM KW HEAT :NOM TONS AHU CU. PKG 1 KCA AHU CU PKG AIV CU PKG 2 M.O.P CU PKG U CU PKG 3 VOLTS AH CU PKG G UNIT I t UNIT I CQ 44— EERISEER 4. 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 Mwftum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208!2401480): V 4. Size Disconnecting Means. Contradoes Company Name: Sf7dQ Ph"064-4 f) —374P-04-1-, 3 State Certificate or Registration N, Certificate of Competency N. C 147- C- Signature Date: (Qua6flers o Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 796 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. R y,;o /511j Rh06 Llaz +l!�Y Job Address (where the work Is being done): l 1300 1W E '2 fA4 &'f -S 62,,4 a�,-v''-' City: MBami Shores Village County: WamI Dade ZIP Code: 33161 ALL CONDENSING UNITS MUST BE ON A 41NCH SOLID CONCRETE SLAB ALL UNITS MUST COMPLY WITH F.E.M.A MINIMUM FLOOD.ELEVATION A COPY OF THE CONTRACT -13 REQUIRED wrrH ALL suiimi LS ARI (AHRI) DATA SHEET REQUIRED Change Disconnecting means: YES ❑ NOW ARHI Sheet Attached: YES ❑ NO ❑ Contract Attached: YES ❑ 1. Minimum Circuit Ampacity (Wire Size): /01 2. Maximum Ovencurrent Protection (FuseBraker Size): e2 C7 %i rrl�0 3. Voltage of Circuit (208/2401480): 4. Size Disconnecting Mean: Contraceoes company Name: 37?- a State Certificate or Registration N, Certificate of Competency N. < _ fes-- _ 1621. �- I �✓ - Signature SL Date: 14A (Qtm6fle�s signature only) UNIT BEING REPLACED DATA _ NEW UNIT MANUFACTURER .- X asm AHU. or PKG. UNIT MODEL # 1.3 d- e. 3 Al* COND. UNIT MODEL # deza KW HEAT NOM TONS MU CU. PKG 1 M.CA AHU CU PKG MU CU PKG 2 M.O.P AHU CU PKG AHU CU PKG 3 VOLTS AHU CU PKG PKG UNIT I I PKG UNIT I I EERISEER YES NO REPLACING DUCTS YES NO YES NO REPLACING THERMOSTAT YES je NO YES NO NEW 4°CONCRETE SLAB YES N0 YES NO NEW ROOF STAND YES NO YES NO K. I NEW RETURN PLENUM BOX I YES NO 1. Minimum Circuit Ampacity (Wire Size): /01 2. Maximum Ovencurrent Protection (FuseBraker Size): e2 C7 %i rrl�0 3. Voltage of Circuit (208/2401480): 4. Size Disconnecting Mean: Contraceoes company Name: 37?- a State Certificate or Registration N, Certificate of Competency N. < _ fes-- _ 1621. �- I �✓ - Signature SL Date: 14A (Qtm6fle�s signature only) r,070"Imf7�, CONTRACTOR PRODUCTION REPORT ATTACH ADDITIONAL SHEETS IF NECESSARY) DATE ,,7, ` / 7 — / - / / CTT DL TION_�� Q.p �j(/� d REPORT NO CONTRACTOR SEICO Construction SUPNWE NDENT IQU AM NJEATHER MTFInR' ••�'G A F i MIN TEMP .7y, F WORK PERFORMED TODAY Schedule Acdft No. WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HRS WAS A JOB SAFETY MEETING HELD THIS DATE? JOB (RYha aambamorumff mm mka") SAFETY WERE THERE ANY LOST TIME ACCIDENTS THIS DATE? (RYES 0W*f0 mpeWd0SMMp0M AS C�IrRENCHINC4SCAFFOLDW ELECHGH AQRW HAZMAT WORK DONE? (RYESeitahsbmnedwdmddistshofthups.fimpofamet) WAS HAZARDOUS MATERIALIWASTE RELEASED INTO THE ENVIRONMENT? t YE s sm"b dmaipan af NdAent ena psp—d admy NO TOTALVWRKt1OURSON 408 StM TMOATE.INCLCCN'rSHEM Flys figNO f3t-. CULRRA7MTOTALCFW= ❑ YES M lO HouRSFROM PREhaoushRIMOhr TOTALMMMOURSFROM ❑ YES &NO START OF CONSTRUCTION F= Schedule LIST SAFETY ACTIONS TAKEN TODAYISAFETY INSPECTIONS CONDUCTED Adk* No, SAFETY REQUIREMENTS HAVE BEEN MET. EQUIPMENT04ATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (INDICATE SCHEDULE ACTIVITY NUMBER) Schedule I Subrhdttal hit Description of EqutpmentfMatedal Received Adift No. CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY. INDICATE HOURS USED AND SCHEDULE ACTIVITY NUMBElt Schedule Owner Dwalptlon of Conauddon Equlpment Used Today (Ind Make and Madel) HoursUsed Ad * No. Schedule REMARKS Activity No. r l2-l�-IZ CNTRACTORISLIP&INTENDENT DATE 42Wn (SM) 1 STATE OF •' D DEPARTMENT OF BUSINESS CONSTRUCTION INDUSTRY LICENSING BOARD y s� 0 ,j k NORTH rf. STREETTALLAHASSEE FL 32399-0783 SEIJAS, VICTOR FRANCISCO SEI< CORPORATION 14395 SW 139 CT APT#101MIAMI FL 33186 Congratulations! b'dtiia this license you become one of the nearty one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and busines range from architects to yacht broilers, from 1 boaters to barbeque restaurants, and they keep Florida's economy strong. Every day we wont to improve the way we do business in order to serve you beiter� For information about our services, please tog onto Wena+.i+5 oddaiicense,com. There you can find more information about our divisions and the regulations that ' impact you, subscribe to department newsletters and team more about the Departments initiatives. Our mission at the Department is: License Efficiently, Regulate Faidy. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! The i'sENE7?A?,+ : GQNTACT iR: . N'ameck below ..IS CE TIF' g33 Under thi provisions Of Chi Expiration date: AUG 21 92:rJAS. VTCTO. It`R&1$CIS 33186 DETACH HERE F es' ' Aim PRbi �t�A Oi1T COC1514 1200126b! $R fl on YS'CXRTIFundeztha : "tsicma ` 489 r'a ti2ot.04 .0 SEA RICK SCOTT GOVERNOR SECRETARY MM -AY AS REOutRED BY LAW Dale CERTIFICATE OF LIABILITY INSURANCE 10/9/2012 Producer: Lion Insurance Company This Certificate Is Issued as a matter of Information only and confers no rights 2739 U.S. Highway 19 N. Holiday, FL 34691 upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. 1 (727) 938-5562 Insurers Affording Coverage MAIC # Insured: South East Personnel Leasing, Inc. & Subsidiaries 2739 U.S. Highway 19 N. Holiday, FL 34691 Insurer A: Uon Insurance Company 11075 Insurers: Insurer C: Insurer D: Insurer E: Coverages The policies of insurance listed below have been Issued to the Insured named awve Tor the policy peIndicated. rgany reguireterm or condition ofarrycoraractor o0wilowmentwith respeltc Mch this certificate may be Issued or may pertain, to insivanoe afforded by the policies described herein Is stbject to all the terms, exclusions, and conditions of such policies. Aggregate limits shown may have been reduced by paid claims. NSR LTR ADDL NSRD Type of Insurance Policy Number Policy Effective Date Policy Expiration Date Limits (MM/DD)YY) (MM/DD/YY) GENERAL LIABILITY EachOuxuirence ti Commercial General Liability Claims Made 0 Occur Damage to rented premises (EA occurrenm) Med Exp Personal Adv Injury erreral aggregate limit applies per. Policy 1:1Project ❑ LOC General Aggregate Products - ComplOp Agg PUTOMOBILE LIABILITY Combined SingleUmit (FA Accident) Arr, Bodbphuy AD Owned Argos (Per Person) Sledded Au[os �� ti9uiY Hired Audi Non0med ALWs (PerAclder� Property Damage (Per Accident) EXCESSIUMBRELLA LIABILITY Eac'Ocu"anc Aggregate Occur ❑ Claire Made Deductible A Workers Compensation and Employers' Liability WC 71949 01/01/2012 01/01/2013 x WC Statu- I tory Limits I OTH- ER E.L. Each Accident $1,000,= Any proprietor/partner/executive officer/member E.L. Disease - Ea Employee $1,000,000 excluded? NO If Yes, describe under special provisions below. E.L. Disease -Policy Limits $1,000,000 Other Lion Insurance Company Is A.M. Best Company rated A- (Excellent). AMB # 12616 Descriptions of OperationafLocationslVehicles/Exclusions added by Endorsement/Special Provisions: Client ID: 82-65-001 Coverage only applies to active employee(s) of South East Employee Leasing Services, Inc. that are leased to the following "Client Company": Selco Construction Corp. Coverage only applies to injuries Incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s) , while working in Florida. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Name: ISSUE 10-09-12 (SD) n Date• 10 1 2009 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES BUILDING DEPARTMENT Shodd any of the above described policies be milled before the expirationdata t hared,, the Issuing insuaerw o endeavor to mail 30 days written notice to the certificate holder named to the left, but faihre to do so shell impose no obligation or liability of any Idnd upon to insurer, Its agents or representatives. 10050 NE 2ND AVE MIAMI SHORES, FL 33138 N't . 1 1 . M9 1 n - UAM Wd QTI AKIn Qf111TU 1 KIQ AI„ 1 71 A _ y ••••' ��, ,• V+IV 111 l IrV I1V' 1 1 1 7 I I W• ATE ADF TtA: D10/11I201 ) F ur ;CT-OF I:..:. ::.. FRaDUCER WeSdind South Insuranm THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 2608 NW 9ifh Ave ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE MIAMI, FL :'3172 HOLDER. THIS CERTIRCATE DOES NOT AMEND, EXTEND OR ALTER THE C17VCWA GE AFFORDED .BY THE POLICIES BELOW. COMPANIES AFFORDING COV>EMOE (305 593=06CF0 . • •••'.:.-_ _._...... COMPANY IIS TEGr:lN CASUALTY/GMAC A INSURED SEIC+:i CONSTRUCTION, --ORP COMPANY COMPANY WESTERN WORLD 14395 SW 139 COURT#1C1 MIAM I,FL,3:186 COMPANY C COMPANY D M. THIS IS TO CEF TIPY T! -AT THE POLICIES OF INSURANCE LISTED EELOW HAVE BEEN ISSUELQ TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOiW CHOTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI3 CERTIFICATE WAY BE !S$UED OR K#AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE) HEREIN IS SUBJECTTO ALL THE, TERMS, EXCLUSIONS AND CONDITIONS OF SVOH POLICIES. LIMITS SKONN MAY HAVE BEEN REDUCED BY PAID CLAIM& Go LT TYPE OF INSURANCE � POLICY NUMBER LTR POLICY EFFECTIVE POLICY EXPIRATION LlA rr$ DATE 001IpOIYY! DATE (MNII)D/YY: GENERAL LIAEOLITY I GENERAL AGGREGATE ;: 2,000,000 B I ® sCOMMERCKL GENWI, LIADILITY 1 �Ipp1302442 _ 1119/3012 IR9/2013 PRODUCTS-COMP/OP AG?. a 2,000,000 _.., 'r, � �LAI� MADE �J OCCIlRI •• _• L&ADV.INJURY 1,000,000 PERSONA ,.� .. .. —�1 O'WNEWS & CON7MTOR'S PRAT. { 3LANKET Al Fi OCCURRENCE 1 000 d00 �. WAIVER SUE. 'ER PROJECT FIRE DAMAGE (Anyone Mrs) g 100,000 MI=A EXP (Any one petsan) . 4. 5,000 AUTOMDBILE LIA'SlUn" ANY AUTO COMOINED SINGLE LIMIT g. 1,000,000 ALL OWNED AUTOS A ® SCHEDULED AUTOS =LC X2719 BODILY INJURY 7 9/30/2012 0/30/2013 ('w pamon). ®; H IRE) AUTCcS ! 119N-GN'NID AUTOS SC DILY INJURY (Per eocldent} S - ----� PFOPERTY DAMAGE $ GARAGE LIABILf-Y I ALTO ONLY - EAACCIDENT ANY AUTO OTHER THANAUTOONLY: EACH ACCIDENT g AGGREGATE L(ARIUrf EACH OCCURRENCE $ _EXCESS UMBRE"AFORM I AGGREGATE � OTHER THAN UMBRELLA FORM WORKERS C,IJII PENSATICN ANDSTATUTORY s_IMITS :t•:1 •�:; i. ri IWPLOYER6'LvUALITY ... _:...-. EACH ACCIQENT THE PROPRIETORt j INCL DISEASE PARTNeRSX-XE-C iTrVE - POLICY LIMIT g OFFICERS ARF: J EXCl DISEASE, EACH EMPLOYEE g OTHER DESCRIPTION OF OPERATION$t )0A'0ON N6H>CLE315REcIAL (TENTS CERTIFICATE HOLUM IS ALSO NAMED AS AN ADDITIONAL INSURED IN REF TO GEN LIASIUTY SHOULD ANY OF THE A DOVE DEWRIBED 'POLICIES BE CANCELLED 'KFOR€ Tilt; MIAMI SHOD VILLAGE jLDG DEPT EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10050 KE 2ND AVE 30 DAYS WRITTEN NOTICE TO TME CERTIFICATE 14OLMRNANtIEOTCTHE LEFT, MIAMI S1iORC `eFLr33938 I BUT FAILURE TO MAIL SUCH NOTICE SHA" I $E NO OBLIGATION OR LIABILITY OF ANY MND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. jAUTHORIYEb REPRF.SAWATIVE HOMERQ LAVEMIA SPATE OF FLORIDA DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395 1940 NORTH MONR.OE STREET WF TALLAHASSEE FL 32399-0783 HERNDON, JAMES MICHAEL SEICO CONSTRUCTION CORPORATION 8371 BUCKINGHAM ROAD FORT MYERS FL 33905 Congratulations! With this license you become one of the nearly one million Floridians licensed by the Department of Business and Professional Regulation. Our professionals and businesses range from architects to yacht brokers, from boxers to barbeque restaurants, and they keep Florida's economy strong. Every day we work to improve the way we do business in order to serve you better. For information about our services, please log onto vrwwr.myfloridalicense.com. There you can find more information about our divisions and the regulations that impact you, subscribe to department newsletters and learn more about the Department's initiatives. Our mission at the Department is: License Efficiently, Regulate Fairly. We constantly strive to serve you better so that you can serve your customers. Thank you for doing business in Florida, and congratulations on your new license! "C# 6310052 DETACH HERE ^-^ STATE OF FLORIDA AC#. G I LLQ 2 DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CAC1814962 08/28/12 128009031 CERTIFIED'AIR COND CONTR HERNDON, JAMES MICHAEL SEICO CONSTRUCTIONCORPORATION I$ CERTIFIED under the provisions of Ch.489 FS expiration date:AU(; 31. 2.014 L12082801244 j DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION INDUSTRY LICENSING BOARD SE L12082801244 ,mss„ ?W TE DA' 6ATCH?NUMBEIZ M. 128009031 i. .. . The CLASS A AIR CONDITIONING` CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2014 { HERNDON,, JAMBS MICHAEL SEICO CONSTRUCTION CORPORATION 8371 BUCKINGHAM ROAD FORT MYERS FL 33905 RICK SCOTT KEN LAWSON. GOVERNOR SECRETARY DISPLAY„AS„REQUIRED .BY LAW._........_..___.._ _. 707057-6 THIS IS NOTA BILL -DO NOT PAY NEW ""P60"'Ni RRi�`CT O sN' CORP 14395 SW 139 CT 33186 LININ DADE COUNTY FIRST-CLASS U.S. POSTAGE PAID IRA&. FL PERMIT NO. 231 RECEIPT NO 734829-5 STATE# CAC181496>2 OWNER SEICO CONSTRUCTION`CORP ' n. SAEC WORKER/S CHAKCAL CONTRACTOR 1 THIS IS ONLY A LCCAL BUSWESS TAX RECEIPT. IT DOES NOT PERIIRT THE HOLDER TO VIOLATE ANY EXB'TMG REGULATORY OR oR Ml NoRE DO NOT FORWARD ODES IT m Em THE HOLDERPR OAA YOTHEIi SEICO Pe�Rr OR ANY CONSTRUCTION CORP REQUIRED VICTOR REQUIRED13Y Law: THISPRES NOT A F SEIJAS THE �OF QUALMCP 14395 SW 139 CT MIAMI FL 33186 PAYMEWRECEMED COLLECTOR:COUNTY TAX 11/20/2012 02260071001 000075.00 SEE OTHER SIDE 12 ?� 1/2/2013 17:20 Southeast Personnel ;LION INSURANCE COMPANY-rSeico Construction Corp. 4/4 CERTIFICATE OF LIABILITY INSURANCE 1/2/2013 Producer: Lion Insurance Company This Certificate Is Issued as a matter of Information only and confers no rights 2739 U.S. Highway 19 N. upon the Certificate Holder. This Certificate does not amend, extend or alter Holiday, FL 34691 the coverage afforded by the policies below. . (727) 938-5562 Insurers Affording Coverage NAIC,# Insured: South East Personnel Leasing, Inc. & SubsidiariesnsurerLion Insurance Company 11075 B: 2739 U.S. Highway 1.9 N. Insurer B: Holiday, FL 34691 Insurer ,: Insurer D: Insurer E: Coverages The policies o insurance listed below ave been issued to the insured ramed above for the policy period indicated: otAi stan ing any requirement, term or condition of arry contract or other document with respect to which this certificate may be ssued or may pertain, the insurance afforded by the po'icies described herein is subject to all tha terms, exclusions, and conditions of such policies. Aggregate limits shown may have been reduced t paid claims INSR ADDL LTR 1143RD Type of Insurance Policy Number Policy Efffec,ve Policy Expiradon Date Date Limits (MM/DD/YY) (MM/DD/YY) GENERAL LIABILITY Each Occurrence Commercial General Liability Claims Made ® Occur Damage to rented premises (EA occurrence) Med Exp aggregate limit applies per:General Personal Adv Injury Aggregate Policy ®Project ® LOCProducts- Corrip/Op Agg Peral TOIMIOBILE LIABILITY combined single Limit Any Auto (EA Accident) $ Bodily Injury All Owned Autos Scheduled Autos (Per Person) Bodily Injury Hired Autos Non-Otamed Autos (Per Accident) Property Damage (Per Accident) Each Occurrence EXCESS/UMBRELLA LIABILITY I Occur ® Clalms Made Aggregate Deductible A workers Compensation and UVC 71949 01/012013 01/01/2014X UUC State- OTH- Employers' Llablllty to Limits ER E.L. Each Accident $1,000,000 Any pro prstor/partner/execufive officertmember excluded? NO E.L. Disease - Ea Employee $1,000,000 If Yes, describe under special provisions below. E.L. Disease- Policy Limb $1,040.000 Other, Lion Insurance Company is A.M. Best Company rated A- (Excellent): 'AMB # 12616 Descriptions of Operatlons/LocatlonslVehlcies/Excluslons added by Endorsement/Special Provisions: Client ID: 82 -65 -ODI Coverage only applies to active employee(s) of South East Employee Leasing Services, Inc. that are leased to the following "Client Company": Seico Construction Corp. Coverage only applies to injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s) , while working in Florida. Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity. A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562. Project Flame: ISSUE 10-09-12 (SD)Reissued 12/10/12 (SH) / REISSUE 01-02-13 (SD) Bealn Date: 10 1 009 CERTIFICATE HOLDER CANCELLATION MIAMI SHORES KILDING DEPARTMENT Should ary of the above described policies be cancelled before the expiration date thereof, the issuing insurerwill endeavor to mail 30 days written notice tete certificate holder named to the left, but to do so shell Impose no obligation or i;ebilityo` arry Iard upon the insurer, its agents or representatives 10060 NE 2ND AVE , MIAMI SHORES, FL 33136