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MC-14-2467Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972�J _ Inspection Number: INSP-223162 Permit Number: MC -11-14-2467 Scheduled Inspection Date: December 29, 2014 Permit Type: Mechanical - Residential Inspector: Perez, JlanPierre Inspection Type: Final Owner: PETERSEN, CARSTEN Work Classification: Addition/Alteration Job Address: 1209 NE 98 Street Miami Shores, FL Phone Number (305)807-2221 Parcel Number 1132050090230 Project: <NONE> Contractor: AIR SYSTEMS INNOVATIONS INC Phone: (954)793-6084 tiuuamg ueparltment comments INSTALLATION OF 1 4' GRILL W/FLEX Infractio Passed Comments 380CFM BATHROOM EXHAUST FAN AND 1 DRYER VENT I INSPECTOR COMMENTS False Inspector Comments Passed�� Failed Correction ❑ Needed Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. December 29, 2014 For Inspections please call: (305)762-4949 Page 7 of 26 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 BUILDING PERMIT APPLICATION ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑PLUMBING Ej MECHANICAL JOB ADDRESS: /207 IVC NOV 10 2014 FBC 2018 Master Permit No. 9c -(q- ?-/07 Sub Permit No.f ` c. I ey 64 --T ❑ REVISION ❑ EXTENSION ❑RENEWAL PUBLIC WORKS ❑ CHANGE OF CONTRACTOR if S7'_ ❑ CANCELLATION ❑ SHOP DRAWINGS City: Miami Shores County: Miami Dade Zip: 33/3f Folio/Parcel#: 4 . Is the Building Historically Designated: Yes NO Occupancy Type: �z- Load: Construction Type: V —A- Flood Zone: BFE: FFE: OWNER: Name (Fee Simple Titleholder): -.Q /L5 P�7/.f/ZSEA/ Phone#: Address: !Z ®q A4E- fk -5f City: ®"%/ m i4 Sh®P2,&s State: Zip: 33 13 & Tenant/Lessee Name: Email: CONTRACTOR: Company Name:kirz SAI C Phone#: 91!' I C11- (o ok/ Address: 6 3 1 N W 1. 5A A-V City: M OCf! H i e. State: t L Zip: v @ 63 Qualifier Name: , w;, Si ItA?' ne 7- Phone#: Cf q- T4 ` — 40SY State Certification or Registration #: e l' e- I jII S 1(a L Certificate of Competency #: DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit: $ 1.1-00-00 Square/Linear Footage of Work: Type of Work: ❑ Addition 2 Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: O 2 o' ®� 1 �`` P� L `� g 1 Le w Specify colorofcolor thru tile: Submittal Fee $ J �� Permit Fee $ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Notary $ Technology Fee $ Structural Reviews $, (Revised02/24/2014) Training/Education Fee $ Double Fee $ Bond $ TOTAL FEE NOW DUE $ F 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 s 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. Signature Signature Q-A�o OWNER or AGENT CONTRACTOR The foregoing instrument was acknowledged before me this day of lVv v, 20 1 )rC by who is personally known to me or who has produced identification and NOTARY PUBLIC: REYNA REYES MY COMMIS"',�EE206022 EXP1A'-' 1W 07 2016 " BondKc Inrouan I s i State Insurance Print: 'ICe9INA Y2sf Seal: :'`""'`� REYNAREYES MY COMMISSION *EE206022 q, EXPIRES: JUN 07, 2016 6or>ded MID* 1st State btsu **x**x**** ***900 APPROVED BY C\ U iY [ d I (RevisedO2/24/2014) The foregoing instrument was acknowledged before me this 6 day of IY®6� 20 /50 by JoS who is personally known to as me or who has produced identification and who di NOTARY PUBLIC: 4 Sign: Print: Seal: KYNA REYES MY COWSSION #EE206022 EXPIRES: JUN 07, 2016 1IG100 tiNouO Ist State bsurame as Plans Examiner Zoning Structural Review Clerk Miami shores Village Building Department 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 CONTRACTORS' REGISTRATION IF CONTRACTOR IS A FLORIDA STATE CERTIFIED CONTRACTOR: A. COPY OF QUALIFIER'S STATE LICENCES B. COPY OF LOCAL BUSINESS TAX RECEIPT C. COPY 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 CERTIFICE 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: Q -i R 5' 572 s ;/Irlo 11-d o aJ s �" G BUSINESS ADDRESS: & 3 / Nc4J tbs7t� 61 ve, CITY Mf�� Al STATE F& ZIP 33106.3 36 3 BUSINESS PHONE:9( . sy) 793 - 6 08 q FAX NUMBER( C)CY 910 -10 2,/ CELL PHONE (—qS-y) lam- Go�� QUALIFIER'S NAME:Sc QUALIFIER'S LIC NUMBER: C'Ne 1'e1S/ 6 L RICK SCOTT, GOVERNOR DEPARTI -opoirsies - T, he"CLASS AAIA CONDITIONING. CON' Named CERTIFIED.--- �f IS Ch r 489 FS. I a 8 N a -in. 6;r lider th U xpir , e PdrOtv,,!5iAo AUGU(3 31,211 -E '80on ,JIM E6NEZ, JQ Sr; A JR 831 W,65T-HAV ISSUED: 08/06/2014 KEN LAWSON, SECRETARY STATE OF FLORIDA ENT OF BUSINESS AND PROFESSIONAL REGULATION CONSTRUCTION-11NIJUSTRY LICENSING BOARD DISPLAY AS REQUIRED BY LAW SEQ L1408060001103 ®0 CERTIFICATE OF LIABILITY INSURANCE ( 11/7/2014 THI i CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON -THE CERTIFICATE HOLDER. THIS CEVTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVEhY 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 REF RESENTATIVE 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, §gbject to the terns and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the - Carl Mcate holder in lieu of such endorsement(s). PRODI CER A1�,RICAN QUALITY INSURANCE 3700 W.HILLSBORO BLVD DEi,RFIELD BEACH, FL 33442 CONTACT - PHONEF E)d: (954) 420-0093 AC,No:(954) 420-0083 ECM. ADDRESS: americanquality@bellSouth. net INSURER(S) AFFORDING COVERAGE NAICO INSURER A: CANOPIUS k' INSUR :D AIR SYSTEMS INNOVATION INSURER 8: PROGRESSIVE JOSE JIMENEZ INSURER C: INSURER D: PO BOR 938751 INSURER E: MARGATE, FL 33093 954-793-6084 INSURER F: COVI:RAGES CERTIFICATE NIIMRFR• REVISION NUMBER: THI i IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IND CATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEI.TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EX( LUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INsk SUSR WVO POLICY NUMBER L Y EFF MM/DD POLICY EXP MWDD LIMITS IENERAL LIABILITY EACH OCCURRENCE $ 1, 00,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100 ,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 A OUS009058683 1/14/141/14/15 PERSONAL&ADV INJURY $ 1,000,000 _ GENERAL AGGREGATE $ 2,000,000 iEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000_ POLICY E71 JERCOT LOC $ UTOMOBILE LIABILITY COMBINED SINGIT-nN0r_ Ea accident $ INJURY (Per person) $ 50,000 B _ _ AANYAUTO ALL LL OWNED SCHEDULED AUTOS R AUTOS NON -OWNED HIRED AUTOS AUTOS 07560526-3. 07/23/14 07/23/15 z BODILY INJURY (Per accident) $ 100,000 PROer PERTY ROPEERTY DAMAGE $ 25,000 III UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED 1 1 RETENTION $ $ VORKERS COMPENSATIONWC AD EMPLOYERS' LIABILITY YIN NY PROPRIETORPARTNERtExEcurnE �FFICERIMEMBER EXCLUDED? F7 I Mandatory in NH) ;'-': STATdU OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ .,. E.L. DISEASE - EA EMPLOYE $ yes, describe under IESCRIPTION OF OPERATIONS below E.L. DISEASE : POLICY LIMIT $ 7 DESCF IPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) LICENSE NUMBER CAC 1815166 v`_ CER-1FICATE HOLDER CANCELLATION MIAMI SHORES VILLAGE BLDG DEPT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 10050 NE 2ND AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MIAMI SHORES, FL 33138 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 198$-2 10 ACOR D.C600FUMIT rights reserved: ACOI tD25(2010/05) The ACORD name and logo are registered m rks of ACORD' JEFF ATWATER CHIEF FWMCIlU. OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL. SERVICES DIVISION OF WORKERS' COMPENSATION "" CERTIFICATE OF ELECTION TO 13E 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: $/26/2013 EXPIRATION DATE: 8/26/2015 PERSON: JIMENEZ JOSE A JR FEW: 205329943 BUSINESS NAME AND ADDRESS: AIR SYSTEMS INNOVATIONS P O BOX 938751 MARGATE FL 33093 SCOPES OF BUSINESS OR TRADE: HEATING, VENTILATION, AIR -GOND Pursuant to Chapter 440.05(14 F.S., an ofd of a copoattor who eIacte exemption from this chapterbyffihM a collikstsafekwilm ander this section may not recover beneft or comperssatim underthis chapter. Pumuent to Chapter 440.05(12 F.S., Cerfifcates of electior to be exempt.. appty ody ft si ' '' I of the business or #ads listed on the rrotke of electim► to be exempt Pursuant to Chapter 440.05(13). F.S., Notices ofel cdm to be exempt and des of eieadon too be exempt sired be suWd to reirogUom If, at anytime after the MV of the notice ar the kwuv= offt cerdcat% the person rrarrred an the notice or cer ifieate no 1cnW meets the requireneda of ttds section for issrraarce of a certifrrate. The departmard shag revoke a cerNicate at arry titre forfaiiure of the person named an the Oehl to to meet the req ".Mels of iht section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (860)413-1609 Miami S V11age 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. Corpora elect to be exempt if te officers or members of a limited liability company (LLC) in the construction industry may 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 maybe personallyliable for the worker com ensation in'uries of an erson allowed to work under this ermit. 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: Signature: State of Florida ) County of Miami -Dade ) Sworn to an subscribed before me 4s _ day of ��. , 20. B r, EEVES Y EXPIRES: JUN 07, 2016 (SEAL) " Bonded "h 1st State Insur, Tvve of Iden catron nro uce Contractor Print Name: ,J b S -L J 7 r,,, a ,n, e v Signature: State of Florida ) 10 County of Miami -Dade ) Sworn to and subscribed before me s I 0 day of , 20_J L. BY 1 "- REYES (SEAL) dant e.— '..RES aUN 07.2016 BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT 115 S. Andrews Ave., Rm. A-100, Ft. Lauderdale, FL 33301-1895 — 954831-4000 VALID OCTOBER 1, 2014 THROUGH SEPTEMBER 30, 2015 Receipt # DBA: :HEATING%AIRCONDITION CONT Business Name: AIR SYSTEMS INNOVATIONS INC Business Type: (CLASS A AIR CONDITIONING CONTR) Owner Name: JOSE A JR JIMENEZ Business Opened: o 9 / 12 / 2 0 0 6 Business Location: 631 NW 65 AVE State/County/Cert/Reg:CAC1815166 MARGATE Exemption Code: Business Phone: 954-793-6084 Rooms Seats Employees Machines Professionals 1 For Vending Business Only Number of Machines: Vending Type: 4 Tax Amount Transfer Fee NSF Fee Penalty, ,: Prior Years Collecti 27.00 0.00 0.00 0.00 0.00 i' qi on Cost Total Paid 0.00 27.00 f �f i' qi 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 s 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: JOSE A JR JIMENEZ Receipt #ICP -13-00013816; P 0 BOX 938751 Paid 08/27/2014 27.00 t; MARGATE, FL 33093 i; 2014 -2015 n.•.:;.,.,n:.,erAwx.:w.aum.,::sa,,,r.c. a.-.:.r..,.mw.: r:�rsuca::xc a._ s+m.:5;sa:=arx�ra.M.w�v; r„savR,tt5r: 5ttahi5i56��Se .,4cm.� eKad •i`aWa�"��ti..:.. SJd--:l+f. >:ie YT44:<:..e.;,, 2t,'dMr4�Y.rnte: •4s .... a. t`re