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MC-14-10921q_ tr)q I Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-213168 Permit Number: MC -5-14-1092 Scheduled Inspection Date: April g9, 2015 Permit Type: Mechanical - Residential Inspector: Perez, JlanPierre Inspection Type: Final Owner: MAINADE, FRANK & KELARA Work Classification: Addition/Alteration Job Address: 925 NE 92 Street Miami Shores, FL 33138 - Project: <NONE> Phone Number Parcel Number 1132060060070 Contractor: FROSTY FROG A/C AND REFRIGERATION INC Phone: (305)967-0075 Building Department Comments INSTALL A/C UNIT mrra=0 rassea comments INSPECTOR COMMENTS False A t5i April 28, 2015 For Inspections please call: (305)762-4949 Page 1 of 33 Inspector Comments Passed LW Failed Correction Needed ❑ Re -Inspection ❑ Fee No Additional Inspections can be scheduled until re -inspection fee is paid. April 28, 2015 For Inspections please call: (305)762-4949 Page 1 of 33 Miami Shores Village ���� Building Department MAY 28 2014 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 ]BY: Tel: (305) 795-2204 Fax: (305) 756-8972 INSPECTION LINE PHONE NUMBER: (305) 762-4949 FBC 200 BUILDING Master Permit No.a. ISI, - 10 0`1 PERMIT APPLICATION Sub Permit No..Hr_ t `1. -- I OG 2 JOB ADDRESS: q�j W q q, S� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE:: � �jF�FE: OWNER: Name (Fee Simple Titleholder): rte., _ I r,���l-�. Phone#BF: w `4 5 W - 013 Address: I`� drJ C) 5- City: 1 10 YCe3— State: 1S* Zip: Tenant/Lessee Name: Phone#: Email: ��f ►/f nom, ��y CONTRACTOR: Company Name: v� ®�1 �C� "SII �s Phone#:305 ` & ` Address: U 5 City: State: foll Zip: 185, Tj Qualifier Name: ee— Phone#: State Certification or Registration M - Certificate of Competency M DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: fJ Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑]]Alteration ❑ New ElRepair/Replace ❑ Demolition Description of Work: --YID �T� L� Specify color of color thru tile: Submittal Fee $ _56,00 Permit Fee $ �11-7I lJ CCF $ CO/CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Technology Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ ❑BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION 0RENEWAL ❑PLUMBING MECHANICAL ❑PUBLICWORKS [:]CHANGE CONTRACTOR ❑ CANCELLATION ❑ SHOP DRAWINGS JOB ADDRESS: q�j W q q, S� City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: Is the Building Historically Designated: Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE:: � �jF�FE: OWNER: Name (Fee Simple Titleholder): rte., _ I r,���l-�. Phone#BF: w `4 5 W - 013 Address: I`� drJ C) 5- City: 1 10 YCe3— State: 1S* Zip: Tenant/Lessee Name: Phone#: Email: ��f ►/f nom, ��y CONTRACTOR: Company Name: v� ®�1 �C� "SII �s Phone#:305 ` & ` Address: U 5 City: State: foll Zip: 185, Tj Qualifier Name: ee— Phone#: State Certification or Registration M - Certificate of Competency M DESIGNER: Architect/Engineer: Phone#: Address: City: State: Zip: fJ Value of Work for this Permit: $ Square/Linear Footage of Work: Type of Work: ❑ Addition ❑]]Alteration ❑ New ElRepair/Replace ❑ Demolition Description of Work: --YID �T� L� Specify color of color thru tile: Submittal Fee $ _56,00 Permit Fee $ �11-7I lJ 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 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 posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the ab ce f ssuch�osted notice, the inspection will not be approved and a reinspection fee will be charged. �4' / Signature %� Signatures Owner or Agent �j The foregoinginstrument w s acknowledged before me this 1 day of 20 by �� N— �`Ta " who is personally known o me or who has produced As identification and who did take an oath. NOTARY PUBLIC: Si Print: My Commission Expires:ADYW MY COMMISSION ? q e'• � EXPIRES: March 10, 2018 T'- Notary Pubrb Underw , 1 Contractor r The f regoin instrument wascknowledged before me this 1 day of 20 by _K9 U&DA— who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: Stgn - Print: My Commission Expires ADYLENE RU2 = MY COMMISSION # FF 100079 � EXPIRES: March 10, 2018 BoWll PubAc Underwrde r; �k***�k�*�k�krkrkkakak�kflc***�ksk�k+k* APPROVED BY <7z)`✓ PI ns Examiner Zoning Structural Review Clerk RevisedO2/24/2014)(Revised 5/2/2012)(Revised 3/12/2012) )(Revised 06/10/2009)(Revised 3/15/09)(Revised 7/10/2007) 0 gORIE� t'hv� 'ALORID� 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. ,o�y 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: Signature: 62 State of Florida ) County of Miami -Dade) Q Sworn to an4 sybscribed before me thks(( day of 0 - ._ (SEAL) Type of Identification ADY[ENE RUIZ 'IRES: March 10, 2018 Tt" Wali POW Uftr wb, Contractor Print Name: Signature: State o Florida ) County of Miami -Dade ) Sworn to 4nosubscribed before me this day of ,_20 jT. Type of Identification FROSTY FROC AIC & REFRIGERATION INC9 { CAC 1815618 6551 S.W. 18 Terr - Miami, FI 33155 Cell: (305) 607-7289 - Fax: (305) 2641969 CC> JT2.dC7- u Witt (-Tc /s c) N, o N, -s ��c wl 2LA-� A-"� I X1 0 L Vt S 'H %I -4yPR-oJ&L- �X� l l auwe,2.. Cow�rac�a� Local Business Tax Receipt Miami—Dade County, State of Florida -THIS IS NOTA BILL - DO NOT PAY 6123251 BUSINESS NAME&OCATION FROSTY FROG A/C & REFRIGERATION INC 6551 SW 18 TERR WEST MIAMI FL 33155 13 1 RECEIPT NO. EXPIRES RENEWAL SEPTEMBER 30, 2015 6386114 Must be displayed at place of business Pursuant to County Code Chapter 8A - Art. 9 & 10 OWNER SEC. TYPE OF BUSINESS FROSTY FROG A/C & REFRIGETON INC 196 SPEC MECHANICAL CONTRACTOR PAYMENT RECEIVED CAC1815618 By TAX COLLECTOR Worker(s) 1 $45.00 07/28/2014 CREDITCARD-14-030184 This Local Business Tax Receipt only confirms payment of the Local Business Tax. The Receipt is not a license, permit, or a certification of the holders qualifications, to do business. Holdermust comply with any governmental or nongovernmental regulatory laws and requirements which apply to the business. The RECEIPT N0. above must be displayed on all commercial vehicles - Miami -Dade Code Sec 8a-276. For more information, visit www.miamidade.eovMaxcollector CONSTRUCTION INDUSTRY LICENSING BOARD LICENSE NUMBER The CLASS B AIR CONDITIONING CONTRACTOR Named below IS CERTIFIED Under the provisions of Chapter 489 FS. Expiration date: AUG 31, 2016 FIGUEROA, ALEX ROLANDO FROSTY FROG A/C AND REFRIGERATION INC 6551 SW 18TH TERRACE MIAMI FL 33155-1856 ISSUED: 09/03/2014 DISPLAY AS REQUIRED BY LAW SEQ # L1409030001907 t PLEASE CUT OUT CARD BELOW AND RETAIN FOR FUTURE REFERENCE 6551 SW 18 TERR MIAMI FL 33155 SCOPES OF BUSINESS OR TRA HEATING, VENTILATION, AIR-COND IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election 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 i subject to revocation if, 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. f DFS -F2 -DWG -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION `' F CONSTRUCTION INDUSTRY EXEMPTION Ip CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA I L WORKERS' COMPENSATION LAW D EFFECTIVE DATE: 12127/2013 EXPIRATION DATE: 12/2712015 PERSON: FIGUEROA ALEX R ! u FEIN: 260780541 4 E JE BUSINESS NAME AND ADDRESS: FROSTY FROG A/C AND REFRIGERATION INC IE 6551 SW 18 TERR MIAMI FL 33155 SCOPES OF BUSINESS OR TRA HEATING, VENTILATION, AIR-COND IMPORTANT Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election 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 i subject to revocation if, 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. f DFS -F2 -DWG -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 07-12 QUESTIONS? (850)413-1609 Miami Shores Village Building Department —F 10050 N.E.2nd Avenue tr-o-& --y 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, you may 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. i State of Florida ) County of Miami -Dade ) Sworn to and subscribed before me this day of 0 6019ti , 20_J_��_ ,;,;kES ivuvarr,uwr 09, 2015 Contractor a e: 10 R gna J W State f Florida ) Z Count f Miami -Dade ) Q co Sworn to and subscribed before me 4s y Zw, ay of 0X 4--01t'D- — ,, 20 2 x a m By -- -- :;�• � :`. NNEYANSI DE LGADO PRODUCER Insurance Professional Consult THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 10481 SW 88 St Ste. D-204 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Miami, FL 33176 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # Phone (305) 273-4530 Fax (305) 273-4409 INSURED Frosty Frog A/c &Refrigeration Inc. INSURER A: GRANADA INSURANCE COMPANY INSURER B:INSURER 6551 SW 18 Terrace Miami, FL 33155 License # CAC -1815618 C: INSURER D: INSURER E: COVERAGES INSURER F: THE POLICIES OF INSURANCE LISTED 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE WD11 ( POLICY EXPIRATION DATE MA) LIMITS GENERAL LIABILITY I EACH OCCURRENCE 2,000,000 ® COMMERCIAL GENERAL LIABILITY 0185FL00026856 06/06/14 06/06/15 DAMAGE TO RENTED 100,000 PREMISES Ea occurence MED EXP (Any one person) 5,000 ❑ ❑ CLAIMS MADE [j OCCUR A © ❑ PERSONAL &ADV INJURY 1,000,000 ❑ GENERAL AGGREGATE 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG 2,000,000 ❑ POLICY © PROJECT ❑ LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ❑ ANY AUTO (Ea accident) ❑ ❑ ALL OWNED AUTOS ElSCHEDULED AUTOS ❑ HIRED AUTOS El NON OWNED AUTOS (Per person) INJURY BODILY INJURY (Per accident) ❑ PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ❑ ❑ ANY AUTO OTHER THAN EA ACC ❑ AUTO ONLY: AGG EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE AGGREGATE ❑ OCCUR ❑ CLAIMS MADE ❑ ❑ DEDUCTIBLE ❑ RETENTION $ WORKERS COMPENSATION AND®WC EMPLOYERV LIABILITY STATU- ElOTH- TORY LIMIT EL EACH ACCIDENT ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER / MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS AIRCONDITIONING CONTRACTOR INSTALLATIONS, SERVICE AND REPAIRS. CONTRACTOR'S LICENSE:CAC1815618 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2001M) OF © ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL CITY OF MIAMI SHORES 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO 10050 NE 2ND AVE THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY MIAMI,FL 33138 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE FAX: 3057568972 JESSICA PEREZ ACORD 25 (2001M) OF © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) OF