MC-15-356J
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FIL l�
Phone: (305)795-2204 Fax: (305)756-8972 ="
Inspection Number: INSP-229828 Permit Number: MC -2-15-356
Scheduled Inspection Date: April 06, 2015 Permit Type: Mechanical - Commercial
Inspector: Perez, JanPierre Inspection Type: Final
Owner: , Work Classification: Addition/Alteration
Job Address: 650 NE 88 Terrace
Miami Shores, FL 33138 -
Phone Number (305)868-8203
Parcel Number 1132060110190
Project: <NONE>
Contractor: RIGHT BTU SERVICES INC Phone: (954)444-3059
Building Department Comments
DUCTWORK Infractio Passed Comments
INSPECTOR COMMENTS False
Inspector Comments
Passed CREATED AS REINSPECTION FOR INSP-229266. CALL IF ANY
QUESTIONS 7862855740 work not per plans and existing nail salon w/o
permits, hole in fire wall
Failed
Correction ❑ L
Needed
Re -Inspection ❑
Fee
No Additional Inspections can be scheduled until
re -inspection fee is paid.
April 06, 2015 For Inspections please call: (305)762-4949 Page 15 of 40
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC
F-IPLUMBING MECHANICAL
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
FBC 20(0
Master Permit No. Ct,t 4404
❑ ROOFING ❑ REVISION ❑ EXTENSION/ ❑ RENEWAL
r-1 PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR _ DRAWINGS
10B ADDRESS: CIE
City Miami Shores ounty Miami Dade Zip: �3 ( '
Folio/Parcel#: 11- 3"Z O 6 0 ®1 1 ' ®i c
i ® Is the Building Historically Designated: Yes NO
Occupancy Type: Load:
OWNER: Name (Fee Simple
City: d 1imk-VXL41 11
Tenant/Lessee Name:
Email:
CONTRACTOR: Company Name:
Address: 161L�'� N V
City:
Construction Type: Flood Zon)e:� BFE: FFE:
4
Stat �- Zip: ��3 0`-
A
C
Phone#:
sem- a
Zip:
Qualifier Name: ��_J 11 �1 W Phone#:
State Certification or Registration #: Certificate of Competency #:
DESIGNER: Architect/Engineer: Phone#:
Address: City: State: Zip:
Value of Work for this Permit: $ U. Square/Linear Footage of Work:
Type of Work: ❑ Addition Q Alteration � ❑New
❑Repair/Replaces ❑Demolition
Description of Work: / /'"," `"P' `V"""`�
::Do gj-7 UK)eK'
Specify color of color thru tile: <21 �
Submittal Fee $ �� • � Permit Fee $ 15 0 � CCF $ CO/CC $
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $
Structural Reviews $
Training/Education Fee $
Double Fee $
Bond $ '^7
TOTAL FEE NOW DUE $ ' i
(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
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 attachmen�nlS(7)
o, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs sdays after the building permit is issued. In the absence of such posted notice, the
inspection will not be apl, roved and a reection fee will be charged.
OWNER or AGENT
The foregoing instrument was acknowledged before me this
'>ICI day of20 by
who is personally known to
me or who has produced
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
* MY COMMISSION # EE 642217
EXPIRES: October 10, 2016
� ThruNomry �Is�
as
Signatu
CONTRACTOR
The foregoing instrument was acknowledged before me this
day of 0,6�-2& J by-
o is personally known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
00
Sign:
Print:
m>r L.Orl V. Norrl:.i
Seal: #EE21t;753)COMMmsloN
EXPIRES:AUG.05,2016
aWWW AMONNouRY=m
APPROVED BYans Examiner Zoning
Structural Review Clerk
(Revlsed02/24/2014)
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
ec r0,oz-
City: Miami Shores Village County: Miami Dade Zip Code: _�,_Z=,
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: Phone: _
State Certificate or R istration"NNe _. Certificate of Competency No.
Signature Date:
ualifier's '
(Revised02/24/2014)
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 (208/240/480):
4. Size Disconnecting Means:
Contractor's Company Name: Phone: _
State Certificate or R istration"NNe _. Certificate of Competency No.
Signature Date:
ualifier's '
(Revised02/24/2014)
Miami shores Village
Building Department
CONTRACTORS' REGISTRATION
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR:
A. PY OF QUALIFIER'S STATE LICENCES
B. Y OF LOCAL A BUSINESS TAX RECEIPT
C.PY OF LIABILITY INSURANCE*
D. COPY OF WORKERS COMPENSATION INSURANCE*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit)
IF CONTRACTOR HAS A MIAMI DADE COUNTY CERTIFICATE OF COMPETENCY:
A. COPY OF CERTIFICATE OF COMPETENCY OF QUALIFIER
B. COPY OF LOCAL BUSINESS TAX RECEIPT
C. COPY OF STATE REGISTERED CONTRACTOR LICENSE OR MIAMI DADE COUNTY MUNICIPAL
CONTRACTOR'S TAX RECEIPT.
D. COPY OF LIABILITY INSURACE*
E. COPY OF WORKERS COMPENSATION INSURANCE*
(Workers Compensation EXEMPTION must have NOTICE TO OWNER Affidavit)
*YOUR INSURANCE COMPANY MUST ISSUE A CERTIFICATE AS FOLLOW:
Certificate Holder:
MIAMI SHORES VILLAGE BLDG DEPT
10050 NE 2ND AVE
MIAMI SHORES, FL 33138
Certificate must specify the description of operations or contractor license number.
BUSINESS NAME:
BUSINESS ADDRESS: 16 Z3:7 &AL) Z' j1 CI 14
BUSINESS PHONE: 14—�
CELL PHONE ( )
QUALIFIER'S LIC NUMI
STAT ZIP 93
to
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 taw.
EFFECTIVE DATE: 8/19/2014 EXPIRATION DATE: 8/18/2016
PERSON: DEL VILLAR DOMINGO J
FEIN: 571188179
BUSINESS NAME AND ADDRESS:
RIGHT BTU SERVICES INC
16297 NW 18TH STREET
PEMBROKE PINES FL 33828
SCOPES OF BUSINESS OR TRADE:
HEATING, VENTILATION,
AIR -GOND
003503
GERMCATE OF INSURANCE I ISSUE DATE 12/1912014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY A10 CONFERS NO RIGHTS UPON THE CERTIFICATE HODSTHIS CERTIFICATE DOES NOT.
AFFIRMATIVELY OR NEGATIVELY AMEND, WXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES
NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sh AUTHORMED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: IF THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(1W MUST BE ENDORSED. N SUBROGATION IS WAIVED, SUBJECT TO THE
TERMS AND CONDITIONS OF THE POLICY, CERTAIN PONGEES MAY REQUIRE AN ENDORSEMENT. A STATEMENT ON THIS CERTIFICATE DOES NOT CONFER
RIGHTS TO THE CERTIFICATE HOLDERIN LIEU OF SUCH ENDORSEMENTM
PRODUCER
INSURER(S) AFFORDING COVERAGE
INSURER A. Canopius US Insurance, Inc.
Northeast Agencies, Inc.
6467 Main Street - Suite 104
INSURER B: N/A
Williamsville, NY 14221
INSURED
INSURER C:
INSURER D:
Right BTU Services, Inc
16237 Northwest 18th Street
INSURER E: N/A
Pembroke Pines, FL 33028
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LSM 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 TERNS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAV HAVE BEEN REDUCED -BY
PAID CLAWS.
INSR
TYPE OF
POLICY
POLICY
POLICY
LIMITS
LTR
INSURANCE
NUMBER
EFFECTIVE DATE
IRATION DATE
A
GENERAL LIABIUTY
OUS009071128
10/16/2014
10/16/2015
GENERAL AGGREGATE
600,OW
300,
PRODUCTS-COMIOP AGG.
300,000
PERSONAL & ADV. INJURY
300,000
EACH OCCURRENCE
i00,000
DAMAGE PP"RENTED TO YOU
5,000
MED EXPENSE (Anyone person)
B
PERSONAL LIABILITY
COMBINDED SINGLE LIMIT
MEDICAL PAYMENTS TO OTHERS
C
EXCESS LIABILITY
EACH OCCURRENCE
AGGREGATE
D
E
PROPERTY
BUILDING
CONTENTS
BUSINESS INCOME
THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS LINES
CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA GUARANTY ACT TO THE EXTENT OF ANY RIGHT OF RECOVERY
FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER.
SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED 13Y ANY FLORIDA REGULATORY
AGENCY_
DESCRIPTION OF OPERATIONS / SPECIALTY ITEMS
Heating or Combined Hea ft & Air Corbii6oninng Systems or Equipment dealers or distributors & Installation, servlcing or repair no fiqueflef petrola n gas (LPG) equipment sales
SURPLUS LINES AGENT VIRGINIA CLANCY LICENSE# A20MS
13577 FEAT HERSOUND DRIVE PO BOX 17M CLEARWAT ER, FLORIDA 33762
CERTIFICATE HOLDER
CITY OF MIAMI SHORES
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
ORE THE EXPIRATIONDATE THEREOF, NOTICE WILL BE DELNERE04M
ACCORDANCE WATT THE POLICY PROVISIONS.
BUILDING DEPT
10050 NE 2ND AVE
AUTHORIZED SIGNATURE
Miarrti, FL 33138
i'
Notice to Owner — Workers' Com
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
nsation 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
f:
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 and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors..
Therefore, you may be personally liable for the worker compensation iniuries 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. I
Signature:
County of Miami -Dade
The fbregoiqg-wp acknowledge
who is
as
Notary:
SEAL:
or
1`7
Lori C. Norris
r^ 4!SS10N#EE218753
05, 2016
retractor
Signature:Al A 60
State of Florida
County of Miami -Dade
Sye foreg ' vdacknowledge bg a 's -o
who is persona1Lv3&own tome or has produce
as identification. o°°°'Y Lori C. Norris
=COMMISSION # EE 218753
Notary: ��' ';= EXPIRMAUG. 05, 2016
SEAL: Flsnnm°` ON OTARY.com