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MC-14-1401V BUILDING PERMIT APPLICATION Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 I JUN 3 0 014 FBC 20 ('D Master Permit No. xA %-A ! I I Sub Permit No. ❑ BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL [--]PLUMBING ETMECHANICAL F] PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 6 y S C Cit : Miami Shores Folio/Parcel#: Occupancy Type: Load: OWNER: Name (Fee Simple Title er): Aririracc• (n d S /!:;,I City: the Building Historically Designated: Yes NO Type: Flood Zone: BFE: FFE: State: 9— C- Zip: Tenant/Lessee Name: Phone#: Email: 33r'?, CONTRACTOR: Company Name: 9 -i/ Phone#: 3®�' ©� "'? �0 Address: 1? 7 IV /0 q= City: State: if— L Zip: 3 3D -2 f Qualifier Name: t 0_a4 -6-L &i�4'tzi(.j'0 Phone#: -3 92S" °-4' OO?- 7 71 of State Certification or Registration #: C -A-60 $ V 5_V _5_ Certificate of Competency M DESIGNER: Architect/Engineer: Address: Value of Work for this Permit: $ Type of Work: ❑ Addition❑Alteration / Description of Work: ` / e 4 --7—o T' State: Zip: Square/Linear Footage of work: El New L -J Repair/Replaacc}e El Demolition 41 Specify color of color thru tile: V` Submittal Fee $ � . ) Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Training/Education Fee $ Structural Reviews (Revised02/24/2014) Double Fe $ Bo TOTAL FEE NOW DUE $ LA 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 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 QTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TON,�'11. PROPERTY. IF YOU INTEND F. TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR MATITV,RNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charge r Signature OWNER or AGENT The foregoing instrument was acknowledged before me this f J3 day of 20 ` by !�',1 HRi�e�►' Ham", who is personally known to me or who has produced V::�t- X, as identification and who did take an o�kl`��iiiii�i�ui��,,,�r� NOTARY PUBLIC: Sign: Print: Seal: /��i�ruii►t�,��"`'`� '"` Signature CONTRACTOR The f`o-rregoing instrument was acknowledged before me this day 0` n' 20 by who is personally known to r IGO A4L fy� "v-� me or who has produced 45j-- as identification and who did take a$*I uiai�u�+r� NOTARY PUBLIC: L Sign: — v Print: Seal: APPROVED BY Plans Examiner Zoning t Structural Review Clerk (Revised02/24/2014) 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): & 0 , & d.A.tL, 6&f/�l -e City: Miami Shores Village County: Miami Dade Zip Code: 3 3 13 oQ 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 PARHI SHEET REQUIRED Change disconnecting means: YES❑ NOet Attached: YES [:]NO ❑ Contra ttached: YES ❑ 1. Minimum Circuit Ampacity (Wire Size): # 6 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): c- 4- 4. Size Disconnecting Means: WC 4W Contractor's Company Nam 194-,yeo �' Phone: S wog Z ? I State Certificate or Re ' n No S—OS Certificate of Competency No. Signature Date: (Revised02/24/2014) UNIT BEING REPLACED DATA NEW UNIT MANUFACTURER AHU or PKG. UNIT MODEL # 1214 /T-(- /f "14 GOND. UNIT MODEL # / 4L Aj�14-0 r "(0 KW HEAT ( D NOM TONS AHU CU PKG 1) M.C.A AHU 60CU PKG AHU CU PKG 2) M.O.P AHU dV CU PKG AHU CU PKG 3) VOLTS AHUt.?WCU PKG PKG UNIT / / PKG UNIT EER/SEER %fp YES NO REPLACING DUCTS YES YES NO REPLACING THERMOSTAT NO YES NO NEW 4"CONCRETE SLAB YES YES NO NEW ROOF STAND YES YES NO NEW RETURN PLENUM BOX YES O 1. Minimum Circuit Ampacity (Wire Size): # 6 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208/240/480): c- 4- 4. Size Disconnecting Means: WC 4W Contractor's Company Nam 194-,yeo �' Phone: S wog Z ? I State Certificate or Re ' n No S—OS Certificate of Competency No. Signature Date: (Revised02/24/2014) 06/30/2014 14:12 3526749037 ALLIN ONE INSURANCE PAGE 01/01 stco �0 CERTIFICATE OF LIABILITY INSURANCE 6/30/ oi4 ' 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 OELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHOR990 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 cuN W o t NAME; ALL IN ONE INSURANCE PHONE E>a: (352) 674-9015 AJC.N :(352) 6749037 526 N VS Hwy 441/27 AODREss:bsabotka@bellsouth.net Lady Lake, FL 32159 wsuRERls) AFFORDING COVERAGE NAICX INSURER A: QBE SPECIALTY INSURANCE INSURED WWCO AIR, INC INSURER, B! PROGRESSIVS EXPRESS NS COMPANY DBA FLORIDA SOLAR AC INSURER C: 4314 NW 120Th AVE INSURER D; CORAL SPRINGS, FL 33065 INSURER E 561-901-7641 INSURER F; COVERAGES CFRTIMCATE flftIIURER• REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PFRIOD 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 70 ALL. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSD y,ND POLICY NUMBERMM/DDNYYY AUTHORIZED REPRESENTATIVE ZWWW�LIMITS A X COMMBReIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR SCL0002634 10/15/1310/x.5/14 y EACH OCCURRENCE S_1 000 000 PREMISES 6a occurrence S 1.00 000 MED EXP (Any One Person) $ 5 DO O PERSONALIADVINJURY s 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY El 4ECT LOC OTHER: i GENERAL AGGREGATE s 2F000,000! PRODUCTS - COMPIOP AGG S 2,000,000 $ B AUTOMOBILE xa LIABILITY ANYAUTO ALL OWNED I SCHEDULED AUTOS AUTOS D HIRED AUTOS AUTOS 08213365-2 06/23/13 08/23/14 Ee 8Cpd6^t S 5INMnMT 1 , OOO , 000 BODILY INJURY (Per person) $ BODILYINJURY(Peraccident) b Per eGCidoM s S UMBRELLA LIABOCCUR EXCESS I" HDED CLAIMS•MADE EACH OCCURRENCE S AGGREGATE s RETENTIONS $ WORKERS COMPENSATION AND EMPLOYERS' 1,1ABILITY YIN ANY PROPRI@YORIPARTNERIEXECGTNE OFfICEMN113J BER MLUDFA'I ❑ (WridauHy In NH) If ea, descr)be under 0>SGRIPTION OF OPERATIONS below NIA STATUTE ER E. L. EACH ACCIDENT S E.L. DISEASE - );A EMIPLOYEE S E.L. DISEASE -POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may by attached IF more apace E required) 2004 DCX SPRINTER 2500 4X2 WD2PD644745613873 2000 AVEN 'TRAILER 4T6FB0817YXO14134 Air Conditioning Contractor I;Laensa number CAC058505 VILLAGE OF MIAMI SHORES 10050 NE 2ND AVEENUE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN MIAMI SHORES FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. FAX:305-756-8972 AUTHORIZED REPRESENTATIVE ` L ®1E66-ZU13 AE;UKU UVWORATIVN, All rlgntS reServed. ACORD25(2013/04) The ACORD name and logo are registered marks of ACORD 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: 6/26/2014 EXPIRATION DATE: 6/25/2016 PERSON: MANNO MICHAEL FEIN: 651041543 BUSINESS NAME AND ADDRESS: MANCO AIR INC 197 NW 104 AVENUE CORAL SPRINGS FL 33071 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR -GOND Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of electiion under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates 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 to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation it, 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. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 Miami Shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tet: (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 in 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, youmay 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 insurance policies DO NOT cover this type of liability. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. j� Owner Print Name: Signature: State of Florida ) County of Miami-Dade)�� Sworn t2japd subscribed before me this day of , 20 B (SEAL) AS Type of Identification vrodu&fl•T T® _ ®� CC z 11 1 dM- e, State of Florida) County of Miami -Dade ) Sworn to and subscribed before me this 1?0 day of cS: , 20 l BY *�ti 4,t � S *c •• iii (SEAL) Type of Identification produced t a t B %n