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MC-13-2783Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 KO 15 4:-,— -T Inspection Number: INSP-224144 Permit Number: MC -12-13-2783 Scheduled Inspection Date: December 01, 2014 Permit Type: Mechanical - Residential Inspector: Perez, JanPierre Inspection Type: Rou Owner: POZO, JAMES AND YAMILETH Work Classification: Additionh& Iteration Job Address: 11028 NW 2 Avenue Miami Shores, FL 33168-4304 Phone Number Parcel Number 1121360020260 Project: <NONE> Contractor: AA MASTERS MECHANICAL AIR MOVING AND ENGINEERIN ' Phone: (305)559-7004 Building Department Comments INSTALL A NEW EXHAUST FAN IN BATHROOM 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. November 26, 2014 For Inspections please call: (305)762-4949 Page 26 of 27 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 DEC 12 2013 FBC 20 Permit No. (i_ j 3 Master Permit No.pvl Permit Type: MECHANIC` tAL e JOB ADDRESS: 110 26 K vV 2- TiVW-V1 V e City: Miami Shores County: Miami Dade Zip: �g Folio/Parcei#: Is the Building Historically Designated: Yes NO Flood Zone: OWNER: Name (Fee Simple Titleholder): ZlAkS-5 A*J D yA44 1 L6'AAone#: Address: ii ''t 10 a X11 W Q- .4 Vle-K4�. M City: �t,a m i S�w res State: -FL Zip: 3313 Tenant/Lessee Name: Phone#: Email: CONTRACTOR _Company Name: _ o a &ffin'C Ae-&O,+N\Cy Phone#:-�O10 1�1-1 Acs Addn City: Qualifier Name: �V (A406. Phone#: -IqG W11-0665- State 11-0665State Certification or Registration #:C 2C.05-10 „ ro Certificate of Competency #: Contact Phone#: 3�` 06cEmail Address: DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ t00-00 Square/Linear Footage of Work: Type of Work: ❑Address OAlteration l3New ORepair/Replace 13Demolition Description of Work: I ✓lS W I a )low 12.X WAA" at TAA . Submittal Fee $ �0 Permit Fee $� i OD CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ Bonding Company's Name (if applicable) Bonding Company's Address City State Mortgage Lender's Name (if applicable) Mortgage Lender's Address zip 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 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 the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be p ed at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence ofi p b inspection will not be approved and a reinspection fee will be charged. (17w"" l Signature mo;z, a'ZC . Owner or Agent The foregoing instrument was acknowledged before me this _( day of tk%Q k6or , 20 t.3 by ,. 0,W,LS' po zo , who i personally known o me or who has produced As identification and who did take an oath. NOT Sign: Print: My C Signature_ The foregoingYnstrument was acknowledged before me this05 day of Lq . 20 ,6 , by Af ,j,, wew0. , who is personally known to me or who has as identification and NOTARY PUBLIC: Sign: Print: �U My Commission IM take an oath. ,cs ucw& 18, 2017 Tft to* Notary imices APPROVED BY glans Examiner zoning Structural Review Revised 3/12/2012)(Revised 07/10/07)(Revised 06/10/2009)(Revised 3/15/09) 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): I I ® tl9 �J � � 4WV k City: Miami Shores Village County: Miami Dade Zip Code: r 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 ❑ NO ❑ Contract Attached: YES ❑ 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 (Wire Size): 2. Maximum Overcurrent Protection (Fuse/Breaker Size): 3. Voltage of Circuit (208!2401480): 4. Size Disconnecting Contractor's Company, State Certificate odRWis Signature Certificate of Competency N Phone: i�(O 3 — d(45 . l% _"'� _�rr� CERTIFICATE OF LIABILITY INSURANCE ` DATE /YYYY) 100107!1/07/14 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, 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 WANED, 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 andorsement(s). PRODUCER Usa General Insurance 5841 S.W. 137th Ave. Miami, FL 33183 Phone (305) 386-3305 Fax (888) 330-1123 CONTAE:CT GRETELL GONZALEZ NAM PHONE , (305) 386-3305 Fax N„ (888) 330-1123 'MAILADDRESS: greteligonzalez@yahoo.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: GRANADA INSURANCE COMPANY INSURED AA MASTERS MECHANICAL AIR MOVING & ENGINEERING SYSTEMS CO 15591 SW 105 TERR #525 CONTRACTOR LICENSE #: CFC 1426169 Miami, FL 33196 (305) 244-0667 1 INSURER B: PROGRESSIVE AUTO INSURANCE COMPANY INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. ILNSSR TYPE OF INSURANCE ADD INSR UBR I WVD POLICY NUMBER POLICY EFF MM/DD/YY POLICY EXP MM/DONYYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ❑ F1CLAIMS-MADE0 OCCUR N N 0185FL00045507 05/06/2014 05/06/2015 EACH OCCURRENCE $ 1,000,000.00 DAMAGE(RENTED 100 000.00 PREMISESS Ea occurrence) $ MED EXP (Any one person $ 5,000.00 PERSONAL & ADV INJURY $ 1,000,000.00 ❑ _ GENERAL AGGREGATE $ 2,0 0,000-00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PRO- JECT ❑ LOC PRODUCTS - COMP/OP AGG $ 2,000,000.00 $ B AUTOMOBILE LIABILITY ❑ ANYAUTO ALL ❑ AUTOS OWNED AUTOSULED ❑HIRED AUTOS NON -OWNED ❑ AUTOS ❑ ❑ N N 01321884 01/22/2014 01/22/2015 COMBINED SINGLE LIMIT Ea acc dent BODILY INJURY (Per person) $ 10,000.00 BODILY INJURY (Per accident $ 20,000.00 PROPERTY DAMAGE $ 10,000.00 Per accident $ ❑ UMBRELLA LIAR ❑ OCCUR ❑ EXCESS LIAR ❑ CLAIMS -MADE EACH OCCURRENCE $ _ AGGREGATE $ T ❑ DED 0 RETENTION $ $ WORKERS COMPENSATION❑ AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) ElE.L. If yes, describe under DESCRIPTION OF OPERATIONS below NIA WC YTATU- ❑ OTH- — ER E.L. EACH ACCIDENT $ DISEASE - EA EMPLOYE $ — — E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it mare space Is required) PLUMBING - RESIDENTIAL OR COMMERCIAL AIR CONDITIONING EQUIPMENT- INSTALLATION, SERVICING, OR REPAIR CERTIFICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPARTMENT 10050 NE 2ND AVE MIAMI SHORES FL 33138 ACORD 25 (2010105) OF 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 ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 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. Owner Print Name: �Pj �t Signature:���' State of Florida ) County of Miami -Dade) 411, Sworn to and spbscribed before me .this OF day of , 20. •�'�� AR By ` ;ire ,, ''L �.'• (SEAL) 9;`'Y x,11678 ,� Aru a ata SanW Tvpe of Identification- produced Contractor Print Nam�� czsf Signature: State of Florida ) County of Miami -Dade ) Sworn to and subscribed before day of Qg, F&N * * My I( By EXPIR 'Tear ��' (SEAL) r Tvne of Identificatio c